Do You Have Words For Your Feelings?
Alexithymia: Signs, Diagnosis, and Healing
Alexithymia is something you can heal from. Trapped under an alexithymic exterior is an excruciatingly sensitive and empathic soul. If you give yourself a chance, and courageously embark on the path to reclaim your emotional sensitivity and intensity, the reservoir of aliveness is within grasp.
Being able to feel and express emotions are your birthrights. From the moment you came into this world, you feel a myriad of emotions in response to life circumstances. Some of these feelings are pleasant, some unpleasant, some confusing, and some frightening. If you have emotionally available and attuned caregivers, you will learn to regulate yourself, and grow to be an adult who can tolerate a wide range of emotions. In an ideal scenario, even emotions that are often deemed as ‘negative’ or tabooed by our culture and society, such as anger, sadness, and regrets, are given healthy channels to be expressed. Ultimately, it is only when you can be honest with yourself about your feelings could you have a solid sense of self, and it is only when you have room to express authentically could a relationship be sustainably fulfilling.
What happens, then, if the channel via which you feel, and express emotions is blocked? You may end up feeling empty, confused, disconnected, and alone. This is the world someone with ‘Alexithymia’ dwells in. Don’t be too surprised if you have not heard of this term, as even many mental health professionals are not aware of this condition and understand the invisible pain it generates.
It may seem paradoxical that someone who is innately emotionally sensitive and intense can also be emotionally ‘blocked’, but it is more common than you think. An understanding of the trauma pathway will help us make sense of alexithymia’s relationship to emotional intensity.
“Anyone who has a continuous smile on his face conceals a toughness that is almost frightening.”
What is Alexithymia?
Alexithymia literally means ‘no emotions for words’ in Greek. When you have Alexithymia, you have difficulty identifying and describing feelings and have to rely on what is known as ‘external oriented thinking’ (Nemiah and Sifneos 1970, Taylor et al., 1997), meaning you use external signals to make sense of the world rather than following your inner guidance.
What might have happened was that due to an early trauma too painful to bear, you have unconsciously cut off from your feelings. This ‘trauma’ may not be a typical ‘shock trauma’, but ‘cumulative developmental trauma’ (CDT), also known as early relational trauma (Isobel et al., 2017). This type of trauma happens when you were trapped in a situation where your boundaries were violated repeatedly, cumulatively, over a period of time in which you had no route to escape (Sar, 2011).
It may also not be what your caregivers did, but more so, what was missing. All children need to be attended to, to be shown that they matter and are cared for. Prolonged childhood neglect, or when you had to deal with emotionally unstable, blank, or cold caregivers, could be as traumatic if not more traumatic than being physically beaten.
As a result of your relational trauma, the feeling world has become something frightening; so instead you focus your mind on ‘external facts’ that on the surface seem more tangible, predictable, and reliable. (Chung et al., 2016; Kupchik et al., 2007) This was a strategy you have adopted to feel safer and gain some sense of control in a precarious world in which you were unprotected. Unfortunately, however, this is not a sustainable strategy. Unprocessed feelings will inevitably accumulate in your body, causing physical and neurological symptoms that seem disconnected from their sources (Pennebaker and Beall, 1986; Martino et al., 2019). You may have frequent headaches, fatigue, get panic attacks, without knowing why.
“My feelings are too loud for words and too shy for the world.”
What it is like to live in a world without Emotions
With Alexithymia, you may come across as socially awkward to others as you do not automatically appear jolly in a ‘happy’ occasion. Your difference may cause you to be socially anxious and find gatherings unappealing. When unfortunate events happen to you, you may seem unusually stoic, and fail to receive the sympathy and empathy others offer you. This, however, does not mean you don’t feel things— at least physiologically, you do. You may have physical symptoms or even suicidal ideations, but the sources of your distress remain a mystery to you.
Some Inner Signs of Alexithymia:
You are out of touch with your feelings. When you try to feel into your heart, you feel blocked.
Most of the time, you don’t get emotional nuances. You can only tell if you are feeling ‘good’ or ‘bad’, ‘happy’ or ‘unhappy’, and not much more beyond that.
You cannot tell what others are thinking or feeling just by their body language and facial expressions.
In interactions, you don’t feel connected to other people, as though there is a wall blocking you and them.
You feel alienated from your own body; you may have physical symptoms of panic attacks that seemingly come from nowhere.
You do not usually feel emotional but suddenly, you can become flooded with anxiety or burst out in rage.
While you crave intimacy, you find the prospect of close relationships daunting. They make you feel like you are losing control and put you too far outside of your comfort zone.
You may have lost your drive and motivation. You procrastinate at work and do not find much joy in any hobbies. Every day feels like a grind, simply getting through the day is difficult.
You are not interested in things that have to do with imagination or fantasy and prefer the concrete and practical.
You are confused about your identity and lack a sense of self.
You feel empty and numb, as though you are just an observer of your own life. You know you are missing out on life but you don’t know how else you can live.
Outward Signs of Alexithymia
You have blank facial expressions and do not smile or frown when it is ‘socially appropriate’ to do so.
You can find no words when you try to express emotions. If someone asks ‘how are you feeling?’ You either reply with generic terms like ‘fine’ or ‘okay’. If someone specifically asks what you are feeling, you draw a blank.
You appear cold and unfeeling. Others may think of you as arrogant or aloof.
Others may think you lack humor.
You use nervous laughter to fill in the gap, silence makes you uncomfortable.
As you struggle to express your needs and desires, others do not understand what you want and become frustrated.
When speaking you go into endless descriptive details without any personal feelings. Your speech may be monotonous, dry, and hard to follow.
It’s important to note that having Alexithymia does not mean you are apathetic. You may still feel things deep inside, but you struggle to feel connected to your feelings or express them to others.
While not inherently dangerous, alexithymia can lead to a myriad of interpersonal and relationship issues. In school and at work, you feel left out. In relationships and marriages, you are misunderstood as distant and disengaged. People you love are not able to feel your affection. You may also suffer from a lack of sex drive. Sadly, the inability to express affection also means you are more likely than others to end up with broken relationships. Being excluded and misread on all fronts can lead to a very lonely existence.
On the surface, alexithymia can seem like a ‘convenient’ strategy to deal with life. You may be able to temporarily ‘erase’ painful feelings, but by wiping away the lows, you also leave behind the highs. Without emotions, you will not be able to build positive memories with your loved ones, feel energetically charged with a passion, or intimately connected to someone. You remain a clinical observer of your life, watching it goes by without enjoying it.
“Sometimes loneliness makes the loudest noise.”
The Diagnosis of Alexithymia
Alexithymia is not recognized as a mental disorder on its own. It was first introduced into the lexicon of psychiatry by Peter E. Sifneos, a psychiatrist and professor emeritus of psychiatry at Harvard Medical School in the year 1976. Yet even today, there is a lack of information on the underlying causes and recommended therapies.
What makes matters more difficult is the inability of the alexithymic to ‘tell their story.’ You may act out (by anger, self-harm, and even suicide attempts) without being able to offer any explanation for your actions. In the absence of a first-hand account of what happens, diagnosis becomes difficult.
Certain social demographic factors are more likely to put a person at risk of Alexithymia. While it’s estimated that 13 percent of the population suffers from Alexithymia, the prevalence among men is almost twice that of women.
Alexithymia can occur at two levels – as a primary trait and as a secondary state. Primary Alexithymia implies that the individual is born with a genetic defect that hampers the ability to feel and express emotions and empathize. It’s also linked to brain damage, particularly to the anterior insula (responsible for the visceral sensory and motor responses and somatic sensory reactions, especially in the face, tongue, and upper limbs). The brain defect can be a congenital condition or the result of an injury that occurs later in life.
Much of the research available, however, is focused on secondary Alexithymia, which is usually a response to traumatic life events as a child or adult.
Alexithymia can be perpetuated by the presence of a host of other conditions, such as;
· Obsessive-compulsive disorder
· Binge eating disorder
· Substance abuse
· Childhood neglect and emotional abuse
· Life-altering illnesses
Alexithymia and Autism
A stereotypical understanding of the autism spectrum disorder (ASD) is the lack of empathy, which has been largely debunked. An alexithymic person’s failure to recognize the intense feelings (such as confusion or danger) in others and their lack of expression of emotions means that Alexithymia is often misinterpreted as autism.
While individuals on the autism spectrum are much more likely also to exhibit traits of Alexithymia, research on the correlation between the two conditions is inconclusive. The existing consensus seems is that Alexithymia often occurs with autism and is not caused by autism.
Alexithymia and Depression
People who suffer from major depressive disorders and postpartum disorders are more likely to suffer from Alexithymia. A person with Alexithymia is twice as likely also to experience depression. But at the same time, research shows that symptoms of alexithymia decline with a reduction of symptoms of depression. Therefore, it is not possible to say whether Alexithymia is a cause or consequence of depression.
Alexithymia and Trauma
People who experience PTSD are more likely to develop Alexithymia. A study of Vietnam veterans with post-traumatic stress disorder revealed that 41 percent of them were alexithymic. A similar survey of holocaust survivors revealed that those with PTSD had significantly higher scores when tested for Alexithymia than those without PTSD.
Alexithymia and Neurological Disease
Patients with neurological diseases and conditions such as traumatic brain injury, stroke, dystonia, Huntington’s disease, multiple sclerosis, Parkinson’s disease, and epilepsy are more likely to have Alexithymia.
Alexithymia and Early Childhood Emotional Abuse and Neglect
Alexithymia is most likely the outcome of a combination of both biology and the environment. In other words, some might be born more prone to alexithymia than others, and then experience traumatic events or relational wounds as the final triggers.
From a developmental perspective, alexithymia is a result of the disruption in one’s emotional development as a child. It may be that your parents were depressed, cold, and distant, and were not able to mirror your feelings back to you or attune to you. Or, they might be afraid of emotions themselves and therefore punish you for expressing them. They may lack a language of feelings, and had never modeled for you what it means to be emotionally literate.
If as a sensitive and intense child you were repeatedly belittled, blamed, or scapegoated for your natural expressions, alexithymia would be a natural outcome. Perhaps it had never felt safe for you to express yourself. The message you received was that if you ever expressed anything that was ‘inconvenient’ to the adults, such as disappointment or anger, you risk being rejected, abandoned, or punished. In some households, even joy and excitement were discouraged. With your intensity, your natural exuberance might be deemed as ‘too much’ and therefore was shut down.
For some time it was thought that emotional neglect was the only child maltreatment uniquely associated with Alexithymia. However, other research has shown that a history of abuse is also linked to alexithymia (Berenbaum, 1996; Joukamaa, et al., 2008). This makes sense— imagine being punished every time you express emotion. Eventually, you will learn to stop crying or speaking up just to stay safe.
Several questionnaire tests are being used to help patients and therapists identify Alexithymia. The most popular among them is Toronto Alexithymia Scale 20 (TAS-20, Bagby, Parker & Taylor, 1994) that assesses Alexithymia in adults. There is also a version that can be administered to children. Depending on the initial assessment, an MRI may be suggested to assess any damage to the insula in the brain.
“One can be the master of what one does, but never of what one feels.”
Coming out of Alexithymia
The treatment approach for Alexithymia itself may have to be different from typical therapy approaches because we are working with someone who cannot even identify or name their feelings. For instance, research shows that psychoanalysis where the therapists’ ‘blank-screen’ could be too confrontation or threatening is not a good match. (Lesser, 1981; Sifneos, 1975; Taylor, 1984) But because Alexithymia often occurs along with other mental disorders, the treatment of those conditions can help reduce the Alexithymia.
As discussed, having alexithymia does not mean you do not feel, or are cold and need no human connection. It does not mean you are a bad person or never empathize with others. All it is is a blockage in your feeling channel, coupled with a form of ‘emotional illiteracy’. Therefore, one of the biggest milestones in your journey to healing is in finding a language for your feelings. This is known as ‘building emotional literacy’. A tool that can be useful in this process is the ‘emotional wheel’. Developed by psychologist Robert Plutchik, this vis handy tool allows you to learn about emotions in varying degrees of complexities and nuances. With some training, you can slowly build up a set of vocabularies and link them to your inner states. There are plenty of online resources on the emotional wheel, like this one.
Other than that, there are other tools you can use to find a connection with your inner world. For example, researchers have found expressive writing, especially when practiced every day, can help you build internal-awareness and bridge your feelings with words. Reading novels that involve a personal narrative will help you to get out of the rut of monotonous narrating. Expressive arts therapies such as art-making, dance, and music can be good ways to express yourself in ways other than words.
In my experience, the biggest healing when it comes to Alexithymia happens in a relationship. Since the original wound likely happened in a relational context, it must also be healed in a relational way. It maybe a relationship with an enlightened friend, or a therapist/ coach. Ideally, your therapist or coach will create an environment where you — both the adult you and your inner child— genuinely feel safe enough to feel and express emotions. Where words are lost, they can gently guide you by providing vocabularies or model authentic expressions of their own emotions. Some degree of self-disclosure on their side, showing that they, too, feel things, can help you feel safer and empowered to do the same. Wherever appropriate, they should encourage you to name your feelings, though this does not mean arbitrarily forcing you to do things you cannot do.
One important juncture in the process is when you feel or have to express feelings that are hard for your therapist/ coach to receive. If you have been shut down in the past, feelings such as anger or disappointment in another person can be very difficult for you. It is critical that they do not, due to their own fears or vulnerability, punish you for expressing these ‘negative’ feelings towards them. If they do, they are simply repeating what your early caregivers had done to you. Therefore, it is important that you work with someone who ideally has worked on themselves, are genuinely emotionally mature, and not just hiding behind a ‘professional facade’. It can be life-changing for you to experience, maybe for the first time in your life, a genuine, trusting, and lasting relationship in which all expressions are allowed. The experience you have with a professional can then be brought to and generalized to other aspects of your life, such as in your friendships and intimate relationship.
Alexithymia is not something you cannot change. This may be counter-intuitive, but more likely than not what is trapped under an alexithymic exterior is an excruciatingly sensitive and empathic soul. Shutting down emotionally was never your conscious choice; it was what you were pushed to do to survive painful situations.
If you give yourself a chance, and courageously embark on the path to reclaim your emotional sensitivity and intensity, the reservoir of aliveness is within grasp.
“What happens when people open their hearts?”
“They get better.”