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ORIGINAL ARTICLES |
From the Departments of Psychiatry (R.D.L., D.E.S., A.W.K.) and Psychology (R.D.L., L.S., D.E.S., A.W.K.), University of Arizona, Tucson, AZ; and Department of Psychology (R.R.), Troy State University, Troy, AL.
Address reprint requests to: Richard D. Lane, MD, PhD, Department of Psychiatry; P.O. Box 245002, Tucson, AZ 85724-5002. Email: lane{at}u.arizona.edu
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ABSTRACT |
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 TOP ABSTRACT INTRODUCTIONMETHODSRESULTSDISCUSSIONACKNOWLEDGMENTSREFERENCES |
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METHODS: Three hundred seventy-nine subjects completed the 20-item Toronto Alexithymia Scale, the Levels of Emotional Awareness Scale, the Marlowe-Crowne Scale (a measure of repressive defensiveness), the Bendig Short Form of the Taylor Manifest Anxiety Scale, and the Perception of Affect Task. The Perception of Affect Task consists of four 35-item emotion recognition subtasks: matching sentences and words, faces and words, sentences and faces, and faces and photographs of scenes. The stimuli in each subtask consist of seven emotions (happiness, sadness, anger, fear, disgust, surprise, and neutral) depicted five times each. Recognition accuracy results were collapsed across subtasks within each emotion category.
RESULTS: Highly alexithymic subjects (for all, p < .01) and those with low emotional awareness (for all, p < .001) were consistently less accurate in emotion recognition in all seven categories. Highly defensive subjects (including repressors) were less accurate in the detection of anger, sadness, fear, and happiness (for all, p < .05). Furthermore, scores on the Levels of Emotional Awareness Scale accounted for significantly more variance in performance on the Perception of Affect Task than scores on the Marlowe-Crowne Scale (p < .01).
CONCLUSIONS: The results indicate that alexithymia and the repressive coping style are each associated with impairments in the recognition of both pleasant and unpleasant emotions and that the two styles of emotional self-regulation differ more in the magnitude than in the quality of these impairments.
Key Words: alexithymia • repression • repressive coping style • emotion recognition • deficit
Abbreviations: LEAS = Levels of Emotional Awareness Scale, MC =Marlowe-Crowne Scale; PAT = Perception of Affect Task, TAS-20= Twenty-Item Toronto Alexithymia Scale; TMAS = Taylor Manifest AnxietyScale.
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INTRODUCTION |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONACKNOWLEDGMENTSREFERENCES |
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Leading conceptualizations of alexithymia place primary emphasis on the deficit in symbolization of emotion, consistent with the name selected for this clinical phenomenon (7). According to this view, the experience of alexithymic individuals does not differ from that of nonalexithymic individuals; rather, they differ in the meaning given to the experience and the knowledge of what is being felt. We note, however, that there are numerous direct and indirect indications that alexithymia, as originally conceived, is associated with either a deficit in or an absence of conscious emotional experience and that the views of the originators of the alexithymia construct remain unchanged by our alternative view. In 1970, Nemiah and Sifneos (1) wrote, "These patients manifested either a total unawareness of feelings or an almost complete incapacity to put into words what they were feeling." In 1975, Nemiah (8) wrote that alexithymic individuals "... appear to have little or no awareness of their internal life of feelings," describing a feature of the disorder as an "absent or diminished awareness of feelings" and noting that "the individual ... experiences no conscious awareness of feelings." In 1994, Sifneos (9) pointed out that "... language cannot be used to express an absent feeling." In 1996, Sifneos (10) wrote, "... the diminution or absence of one of the most striking human characteristics, the ability to experience feelings, is evidence of their alexithymia."
These clinical descriptions of alexithymia also discussed the deficit in the capacity to symbolically represent emotion, but the examples above illustrate that the original descriptions of alexithymia included deficits in the conscious experience of emotion. We have theorized elsewhere that the way emotion is symbolically represented influences the nature of emotional experience (11). According to our model, the lowest level of emotional awareness involves undifferentiated experience with a focus on somatic sensation, not the consciously experienced emotions or feelings typical of individuals who do not have such developmental deficits. Thus, this alternative conceptualization of alexithymia involves a shift in emphasis rather than a radical departure from traditional views.
To the extent that alexithymia is conceptualized in this way, a natural question is how it differs from repression. The alexithymia construct arose in the context of attempts to validate the role of repression in psychosomatic diseases (1). Instead of confirming that specific repressed conflicts were associated with specific psychosomatic diseases (12), Ruesch (13), and later Nemiah and Sifneos (1, 2) among others, observed that patients with these disorders have a pervasive deficit in the capacity to experience and describe emotions. This pattern contrasted with the more discrete effect of repression, which was thought to be associated with the exclusion from conscious awareness of specific conflicts and the associated emotions.
Attempts to test such hypotheses empirically are limited by the inability to objectively verify the contents of subjective experience. Thus, the closest approximation to an objectively verifiable test of interoceptive awareness is a test of exteroceptive awareness. According to this view, if the alexithymic individual’s experience of emotions is undifferentiated, there should be an associated lack of differentiation in the perception of exteroceptive emotional cues.
Current evidence is in fact consistent with this hypothesis. In healthy subjects, Parker et al. (14) and Mann et al. (15) observed that higher alexithymia scores were associated with impaired recognition of facial expressions. Although Mann et al. (16) failed to find such an association when their study sample was extended to include patients who were substance abusers, this study involved a relatively small sample with one test of emotion recognition (facial recognition). In a much larger community sample with multiple tests of emotion recognition, we demonstrated that alexithymic individuals were impaired in both verbal and nonverbal emotion recognition (4). Thus, the expected association between alexithymia and decreased accuracy in emotion recognition is supported by current evidence. A question that remains to be answered is whether this deficit is pervasive or is restricted to emotions of a particular type.
Research on repression has been hampered by the lack of a valid measure of it (17). An alternative strategy is to measure the repressive coping style, which is thought to involve the exclusion of discrete distressing emotions from conscious awareness (18, 19). Individuals who strongly manifest the repressive coping style are called "repressors." Repressors have been shown to recall fewer childhood memories that are threatening to the self and to take longer to recall negative memories (20). Another study found that repressors also recalled fewer positive childhood memories than nonrepressors (21), but a subsequent study by another group found that repressors recalled fewer negative, not fewer positive, childhood memories (22). In response to distressing films, repressors summon positive memories more readily than negative memories and spontaneously have positive associations, whereas nonrepressors do not (23). Repressors, compared with nonrepressors, manifest more discrete and less complex emotional ratings of childhood memories (24) and less complex ratings in the emotional appraisal of faces (25). Current evidence therefore suggests that repressors more readily respond positively to distressing stimuli and are less able to recall negative information because it is less likely to be encoded as such during the initial appraisal process. These findings suggest that performance on emotion recognition tasks may be quite relevant to the essential features of the repressive coping style.
Although the repressive coping style involves a deficit in the processing of negative emotional information, alexithymia, as noted above, can be conceptualized as a trait condition that involves a deficit in the capacity to be aware of emotions of all types (7). Despite this clear distinction, to our knowledge there have been no previous studies comparing emotion recognition ability in alexithymic individuals and repressors using a variety of types of emotional stimuli.
We therefore examined whether alexithymia and the repressive coping style are associated with deficits in the recognition of emotions of particular types. We tested the following hypotheses: 1) Alexithymia is associated with a deficit in the capacity to recognize emotions of all types, 2) the repressive coping style is associated with deficits in the recognition of negative emotional stimuli only, and 3) the correlation in the population between repressive defensiveness and the recognition of positive emotional stimuli is zero.
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METHODS |
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2 = 0.319, df = 1, p = .572; 2 = 0.354, df = 2, p = .838; and 2 = 4.047, df = 4, p = .400, respectively). Subjects were required to be native English speakers and were excluded if they had a self-reported history of serious psychiatric disorder, substance abuse, or cognitive impairment. No systematic attempt was made to objectively confirm the self-reported absence of clinical abnormality. Subjects gave informed consent and were paid $10 for their participation. They completed the questionnaires in a quiet setting with an examiner present to answer questions and to ensure no contact between subjects.
Measures
Twenty-Item Toronto Alexithymia Scale.
The TAS-20 (26, 27) is a self-report measure that involves rating each of 20 items using a five-point Likert scale for a maximum score of 100. The 20 items are divided into three subscales: 1) difficulty identifying feelings, 2) difficulty describing feelings, and 3) externally oriented thinking.
Subjects were allowed to leave any item blank on this and any other scale. Subjects with fewer than 17 (85%) scorable responses were excluded from the analysis. Scores were prorated if subjects had fewer than 20 but more than 16 responses. Ten subjects had one missing item, and two subjects had two missing items. Cronbach’s 
for the TAS-20 was 0.84 (N = 368). A complete summary of findings with the TAS-20 and previous versions of this scale can be found in a recent review by Taylor et al. (7).
TAS-20 data were examined in two ways, consistent with the categorical and dimensional interpretations of alexithymia. First, we used previously established cutoff scores on the TAS-20 to assign subjects to alexithymia groups (4). The cutoff scores were as follows: nonalexithymic, 
51; intermediate, 52 to 60; and alexithymic, 
61. Second, the mean ± 1 SD (46.07 ± 11.79) was used to define low ( 34), intermediate (35 to 57), and high (58) alexithymia groups.
Levels of Emotional Awareness Scale.
The LEAS (28) is a written behavioral measure that asks the subject to describe his or her anticipated feelings and those of another person in each of 20 scenes (vignettes) described in two to four sentences. Highly reliable structural scoring criteria are used to evaluate the degree of differentiation and integration of the words denoting emotion attributed to the self and to the other person. Higher scores reflect greater differentiation in emotions, greater awareness of emotional complexity in the self and others, and relative absence of alexithymia.
In previous research, the LEAS score has been shown to correlate positively with scores on two cognitive-developmental measures, the Sentence Completion Test of Ego Development (29, 30) and the cognitive complexity of the description of parents (31). The LEAS score also correlates positively with the degree of right hemispheric dominance in the judgment of facial emotion (32) and the degree of blood flow in the anterior cingulate cortex during film- and recall-induced emotions (5). In clinical studies, patients with borderline personality disorder were observed to score significantly lower on the LEAS than age-matched control subjects (33), and the LEAS score was inversely correlated with nonspecific somatic symptoms in patients with fibromyalgia (34). Both sets of clinical findings are consistent with predictions. Interrater reliability of the total LEAS score is consistently high: intraclass r = 0.84 (28) and Pearson product-moment r = 0.97 (32).
One scene is presented per page, and two questions ("How would you feel?" and "How would the other person feel?") are written at the top of each page. Subjects write their responses on the remainder of each page. They are instructed to use as much or as little of the page as needed to answer the questions. Eight subjects left one item blank, and one subject left two items blank. Scores were prorated for these subjects. Responses are scored separately for each scene. The response for each scene receives a score of 0 to 5; these scores correspond to the underlying cognitive-developmental theory of five levels of emotional awareness. The maximum total score is 100. Each response receives separate scores for the emotion described for the self and the other person. The lowest score (level 0) is for nonemotional responses in which the word "feel" is used to describe a thought rather than a feeling. Level 1 reflects an awareness of physiological cues (eg, "I’d feel tired"). Level 2 consists of words that are typically used in other contexts but are frequently used to convey relatively undifferentiated emotion (eg, "I’d feel bad") or use of the word "feel" to convey an action tendency (eg, "I’d feel like punching the wall"). Level 3 responses involve use of one word conveying typical, differentiated emotion (eg, happy, sad, or angry). A glossary of commonly used words at each level was created before this study to guide scoring. The highest score for the self and the other person, level 4, is given when two or more level 3 words are used that convey greater emotional differentiation than either word alone. Each subject thus receives separate scores of 0 to 4 for the self and other responses. In addition, a third "total" score is given; this score is equal to the higher of the self and other scores, except when both responses receive level 4 scores. Under these circumstances, a total score of level 5 is given for the scene if the emotions for the self and other person can be differentiated from one another. Only results using the total score are reported. Thus, the ratings are based entirely on structure, involve no inference of the meaning of words (except in rare instances), and do not require any rating for appropriateness of the response.
Protocols were identified only by subject number; each scene was coded independently of the others for all subjects. All protocols were scored by one rater. In addition, 120 items (6 of each of 20 scenes) were randomly chosen from the entire sample and scored independently by a second rater. Interrater reliability for the self, other, and total scores was high: intraclass r (N = 118) = 0.93, 0.94, and 0.96, respectively. Intratest homogeneity for self, other, and total, measured by Cronbach’s , was 0.84, 0.83, and 0.88, respectively (N = 371). The mean ± 1 SD (61.79 ± 10.83) was used to define the low (50), intermediate (51–72), and high (73) emotional awareness groups.
Taylor Manifest Anxiety Scale (Bendig version).
This abbreviated version of the TMAS (35) asks the subject to rate 20 statements describing symptoms of anxiety or distress as true or false.
Marlowe-Crowne Scale.
The MC (36) is a 33-item true/false scale. Fifteen items keyed false are probable but socially undesirable (eg, "I am sometimes irritated by people who ask favors of me"), and 18 items keyed true are improbable but socially desirable (eg, "No matter who I’m talking to, I am always a good listener"). The validity of the MC scale as a measure of the repressive coping style is based on psychophysiological (37), psychopathological (38), and psychosomatic evidence (39).
Four groups were defined on the basis of quartile splits of the MC and TMAS scores (repressors defined as those with an MC score 21 and a TMAS score 3). These cutoff scores yielded 36 repressors (9.5%). The MC cutoff score was somewhat higher than that previously used in student samples because of the age distribution of this sample and the positive correlation between MC score and age (38). The four groups were repressors (high MC, low TMAS), truly low anxious (low MC, low TMAS), defensive high anxious (high MC, high TMAS), and truly high anxious (low MC, high TMAS). Defining the four groups in two other ways yielded results comparable to those presented in Table 1: 1) Use of median splits of the MC (median = 16) and TMAS (median = 7) scores yielded 31% repressors; and 2) based on the estimate that repressors constitute 10% to 20% of the population, a quartile split of the MC scores in combination with the TMAS cutoff score used by Myers (40), ie, <6 (42nd percentile), yielded 15% repressors. In addition, the MC mean score ± 1 SD (15.79 ± 6.25) was used to define the low (9), intermediate (10–22), and high ( 23) defensiveness groups. The second, standardized approach permitted comparison of TAS-20, LEAS, and MC scores in a common metric.
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The stimuli in subtask 1 are sentences depicting a specific emotion that do not include words denoting emotion, eg, "The man looked at the picture of his recently departed wife" (choose the emotion that the man felt). The response to each item is selected from a list of seven words denoting emotion. The stimuli in subtask 2 are photographs of faces with an emotional expression. The response options (words) are the same as in subtask 1. The stimuli in subtask 3 are the same sentences as in subtask 1. The response to each item is selected from a page displaying each of the seven facial expressions presented as stimuli in subtask 2. The stimuli (faces) in subtask 4 are the same as in subtask 2. The response to each item is selected from a page displaying photographs of scenes without human faces depicting each of the seven emotions. Thus, subtask 1 (sentences-words) is verbal-verbal, subtask 2 (faces-words) is nonverbal-verbal, subtask 3 (sentences-faces) is verbal-nonverbal, and subtask 4 (faces-scenes) is nonverbal-nonverbal. Item content was selected to achieve comparable difficulty across subtasks in a previous study. Scores for each subtask were prorated if no more than 5 of 35 items were missing. Otherwise, subjects were excluded from the analysis. Cronbach’s (and the number of subjects with no missing data) for each subtask and for the total PAT score are as follows: 1 = 0.74 (N = 354), 2 = 0.75 (N = 363), 3 = 0.83 (N = 346), 4 = 0.88 (N = 362), and total = 0.93 (N = 304).
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RESULTS |
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2 = 6.80, df = 1, p < .01), indicating that the two correlations were not equal) (42). A similar comparison between the TAS-20 and MC was not significant (2 = 1.63, df = 1, NS). Next we examined the nature of recognition errors on the PAT as a function of alexithymia and the repressive coping style. There was no particular tendency for subjects scoring high on the MC or TAS-20 or low on the LEAS to view negative emotions as positive. The overall accuracy rate on the PAT for the entire sample, 84.6%, yielded an expected error rate of 15/6 (2.5%) per error category, thus limiting the possible error rate in any given category.
To further explore the overlap of findings, we examined the relationship between independent variables. The TAS-20 score correlated positively with the TMAS score (r = 0.32, N = 379, p < .001) but did not correlate with the MC score (r = -0.05, N = 379, NS). TAS-20 scores differed across the four groups defined by the MC and TMAS (F(3,375) = 7.76, p < .001). Scores were lower in the repressor and truly low anxious groups than in either the high anxious or defensive high anxious group, but repressors did not differ significantly from the other three groups on the TAS-20 in post hoc comparisons. The TMAS score correlated negatively with the MC score (r = -0.34, N = 379, p < .001) but did not correlate with the LEAS score (r = 0.07, N = 379, NS). Correlations between LEAS and MC scores (r = -0.22, N = 379, p < .001) and between LEAS and TAS-20 scores (r = -0.19, N = 379, p < .001) were negative (as expected) and of comparable low magnitude.
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DISCUSSION |
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To the extent that recognition of exteroceptive stimuli is a valid index of the recognition of interoceptive stimuli, the present findings suggest that alexithymic subjects have a decreased capacity to identify their own negative and positive emotional responses. The findings also suggest that individuals with alexithymia have a greater deficit in their capacity to experience emotional feelings than do those with the repressive coping style. Results from a functional brain imaging study demonstrating a positive correlation between LEAS scores and activity in the dorsal anterior cingulate cortex during emotional arousal (5) are consistent with the conclusion that the LEAS is a valid measure of interoceptive emotional awareness. In light of the strong positive correlation between LEAS and PAT scores in all emotion categories in this study, this relationship between interoceptive and exteroceptive capacity may be reasonable. This is also consistent with the theory that the same schemas are used to process internal and external sources of emotional information (11). In the context of interoception, a deficit in perceptual discrimination could be associated with a deficit in the capacity to experience discrete emotional states. In addition, the inability to differentiate between exteroceptive emotion cues is likely to be associated with an internal state that is itself undifferentiated. In severe cases, such a deficit in interoceptive capacity could be associated with a total unawareness of feelings.
As noted above, it is well established that repressors have a decreased capacity to attend to and recall negative emotional states. Their difficulty in discriminating between negative emotional stimuli in the current study was therefore predicted. However, the association between alexithymia and negative affect is more complex. On the one hand, the original descriptions of alexithymia described decreased awareness of negative emotions. On the other hand, positive correlations between TAS-20 scores and those of measures of negative affect have typically been observed (43, 44), as they were in this study. How can these differing accounts be reconciled?
The discrepancies may arise because of differences in the severity of alexithymia in the two contexts. The consistent positive correlations between negative affect and TAS-20 scores may reflect the fact that most subjects in such studies do not score in the alexithymic range or meet other independent criteria of alexithymia as a clinical entity. It is reasonable to hypothesize that the ability to accurately discern the difference between different internal negative affects permits use of the information inherent in a given emotional response to address and potentially modify the environmental circumstance (or the interpretation of it) that led to that emotional response. Thus, the less alexithymic someone is, the more she or he can take action to prevent the persistence of negative affective states. In contrast, the original descriptions of alexithymia reported observations in patients who described little or no negative affect. Early descriptions of alexithymia did include reports of occasional intense motor expressions of emotion, such as intense crying (1). Such motor expressions of emotion are not inconsistent with a deficit or absence of emotional experience. For example, pseudobulbar palsy is a neurological condition with just such a dissociation (45).
The subjects in this study had no history of psychiatric or major medical disorders and gave informed consent to participate in a study dealing with personality and emotion. Alexithymic subjects in clinical settings, in contrast, tend to avoid situations that are emotionally challenging and tend to avoid dealing with psychological issues. It is likely that more severe alexithymia occurs in clinical populations compared with the nonclinical sample in this study. As such, it is possible that more pronounced effects than those obtained in this study would be observed in alexithymic subjects drawn from clinical contexts. Therefore, the differences between alexithymic subjects and those with a repressive coping style observed in this study need to be replicated, and future research should be extended to clinical contexts. In addition to measures such as the TAS-20, which rely on self-reported assessments of alexithymia, observer-rated measures of alexithymia (46, 47) may be needed to identify individuals at the most severe end of the alexithymia continuum who lack awareness of their own emotions and may be unable to accurately rate this lack of awareness on the TAS-20. Such replication studies should ideally include other measures of the repressive coping style, such as the Weinberger Adjustment Inventory (48).
How the complex relationship between alexithymia and self-reported negative affect is handled will influence the conclusions drawn about the degree of similarity between alexithymia and the repressive coping style. Newton and Contrada (49) and Myers (40) observed that repressors scored lower on the TAS-20 than nonrepressors, data which suggest that there is little overlap between alexithymia and the repressive coping style. As just noted, the TAS-20 score correlated positively with measures of negative affect in this and other studies (43, 44). The repressive coping style is defined on the basis of low scores on measures of negative affect. In addition, the MC score is inversely correlated with factors 1 and 2 of the TAS-20 (50), perhaps consistent with the inverse correlation between scores on the MC and measures of negative affect (51). Therefore, by virtue of how the repressive coping style is defined and the characteristics of the TAS-20, a reciprocal relationship between the repressive coping style and alexithymia is likely. However, if alexithymic subjects are chosen in a manner consistent with the original description (lack of awareness of emotional feelings), it is possible that more similarities would be observed between alexithymia and the repressive coping style. In this context, it is notable that scores on the LEAS did not correlate with those on the TMAS in this study or with other measures of negative affect in other studies (unpublished). Therefore, comparisons between alexithymia and the repressive coping style should ideally be made using measures of dependent and independent variables that do not preordain the outcome, as in the current study.
With regard to positive affect, an association between anhedonia and alexithymia is well documented (52). In contrast, the repressive coping style is typically associated with preferential access to positive emotional states, as noted above. How can these observations be related to the present findings and the associated interpretation that decreased recognition of positive stimuli is associated with decreased experience of positive emotion?
The answer may be related to a preferential association between the repressive coping style and the internal rather than the external generation of positive affect. A growing body of evidence indicates that self-generated actions yield diminished sensory experiences compared with those produced by externally produced stimuli (53). For example, it has been suggested that an "efference copy" of a motor command is associated with a predicted sensory outcome that attenuates the sensory consequences of a given action, thus permitting greater discrimination between intentional and unexpected events (54, 55). Blakemore et al. (53) showed that a self-induced tickle sensation was perceived as less "tickly" (people cannot tickle themselves very well) (56) and was associated with decreased activity in several brain areas, including sensorimotor cortex, compared with an externally induced tickle sensation. In an analogous manner, it may be speculated that self-induced positive affect in repressors produces a diminished feeling compared with the externally induced positive affect typically observed in nonrepressors. The decreased intensity of positive feelings may decrease the opportunities for and thus one’s overall skill at perceiving them. Alternatively, the efference copy associated with the intentional induction of positive affect may itself generate a message that renders unnecessary the detection of positive affect through the usual interoceptive mechanisms. In either case, a deficit of positive feeling may be present in repressors as in alexithymic individuals, but to a lesser extent. Compared with alexithymics, repressors are far more adept (perhaps too adept) at emotional self-regulation and have superior reservoirs of positive affect from which to draw. The preference for self-induced relative to externally induced positive affect may account for the at-times false or "façade" quality of the positive affect of repressors.
As noted above, we propose that alexithymia consists of a deficit in the capacity to consciously experience emotional feelings in the context of autonomic activation indicative of emotional arousal (6). A fundamental assumption of this construct is that the emotional response that is not experienced is associated with heightened or dysregulated autonomic activation (7). In fact, this assumption has not yet been confirmed in empirical research. Alexithymia has been associated with increased physiological arousal at baseline (57–61), increased physiological reactivity relative to self-reported reactivity (57, 62, 63), and delayed physiological recovery after exposure to emotion-evoking stimuli (63). However, decreased physiological reactivity associated with either decreased (59, 64) or increased (49) self-reported reactivity has also been reported. A view that is gaining some empirical support is that alexithymia is associated with decreased physiological arousal in response to emotion-evoking stimuli (65).
The present results raise the possibility that standard emotion induction procedures that involve the perception and response to emotion cues may not be perceived or appreciated as well by severely alexithymic subjects as they are by other subjects. Consistent with this, one study found that the heart rate response to viewing emotional and neutral pictures was significantly less deceleratory in alexithymic subjects, suggesting that these subjects devote less attention to the processing of affective stimuli (65). Thus, the failure to observe autonomic activation may be due, at least in part, to a failure to adequately induce emotion in these subjects because of their deficit in exteroceptive detection of emotion cues. Although either the exaggerated or diminished autonomic activation model of alexithymia is consistent with the present results, it is important to distinguish between them to determine the developmental origin of this deficit and to establish a physiological basis for a possible link between alexithymia and systemic medical disorders (66). The variable findings in psychophysiological studies of alexithymia may be related to the possibility that samples vary in the extent to which they include subjects who lack awareness of their own emotional states as in the original descriptions of alexithymia.
Attempts to make sharp distinctions between alexithymia and the repressive coping style are hampered by the ambiguity of the phenomena in question. The absence of a valid measure of repression means that the exact nature of the phenomenon and the component processes that contribute to it have not been clearly delineated. Although repression is often considered an unconscious defense mechanism, Freud accepted that repression could be under voluntary control and used the term interchangeably with suppression (67). Modern scholars who have considered the phenomenon carefully tend to view repression from the perspective of cognitive science, eg, transformation of schemas to facilitate the construction of memories congenial to the sense of self (ie, that enhance or preserve self-esteem) (17, 68). One could extend this to include the nature of the schemas involved in the construction of emotional states (eg, more vs. less complex) (11). Alexithymia and the repressive coping style, therefore, involve variations in the attention to and the appraisal, encoding, and recall of interoceptive and exteroceptive emotional stimuli. From this perspective, and in light of the current findings, alexithymia and the repressive coping style each involve alterations in the cognitive processing of internal responses and external emotional cues in a way that influences the content of emotional experience. An important issue for future research is to dissect the similarities and differences between the alterations in cognitive processing of emotional information associated with these two styles of emotion self-regulation. Quantitative differences in the deficits observed in alexithymia and the repressive coping style may relate to the number of component processes that are implicated, the severity and duration of their involvement, as well as the total number and quality of the contexts in which these deficits are manifested.
For clinical purposes, it has been recommended that psychotherapy for alexithymic individuals begin with teaching them about the nature of their deficit (69). The current findings suggest that useful learning can occur early on in psychotherapy by focusing on the identification of emotions in others, distinguishing present from absent and positive from negative emotions. A key question for future research is whether this type of learning will facilitate the development of interoceptive awareness. Although resistance to exploring and experiencing negative emotions is often based on an apparent fear of being overwhelmed by the emotions in question, the current findings suggest that as the ability to experience and discriminate between negative emotions improves, so too will the ability to experience positive emotions. Thus, the prospect of enhancing the experience of positive emotion may be a counterintuitive benefit and may enhance the motivation for fully attending to and experiencing negative emotions.
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ACKNOWLEDGMENTS |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONACKNOWLEDGMENTSREFERENCES |
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Received for publication February 19, 1999.
Revision received December 16, 1999.
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONACKNOWLEDGMENTSREFERENCES |
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 M. Kano, S. Fukudo, J. Gyoba, M. Kamachi, M. Tagawa, H. Mochizuki, M. Itoh, M. Hongo, and K. Yanai Specific brain processing of facial expressions in people with alexithymia: an H215O-PET study Brain, June 1, 2003; 126(6): 1474 - 1484. [Abstract] [Full Text] [PDF]
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