THE AMERICAN JOURNAL OF PSYCHIATRY

Alexithymia: Concept, Measurement, and Implications

for Treatment

Graeme J. Taylor, M.B. Ch.B., [Link].

characteristics have now been reported among patients

Alexithymia refers to a specific disturbance in with a wide range of medical and psychiatric disorders
psychic functioning characterized by difficulties in the and have even been considered “possibly the most
capacity to verbalize affect and to elaborate fantasies. important single factor diminishing the success of
Although initially described in the context of psychoanalysis and psychodynamic psychotherapy”
psychosomatic illness, alexithymic characteristics (3). Furthermore, alexithymia has challenged develop-
may be observed in patients with a wide range of mental theorists to extend our understanding of how
medical and psychiatric disorders. The author early physiological experiences and bodily sensations
reviews the concept of alexithymia, including its acquire mental representation as feelings and thoughts
historical background, clinical and demographic that eventually result in a language for expressing the
f eatures, and possible etiology. He critically evaluates emotions.
the different methods used to measure alexithymia This paper reviews the concept of alexithymia and
and discusses the important implications it has for the different hypotheses that have been proposed to
medical and psychiatric treatment. explain its etiology. In addition, the methods for
(Am J Psychiatry 141:725-732, 1984) measuring alexithymic characteristics are critically
evaluated and several implications that the disturbance

A lexithymia,
(from the Greek;
a term coined
a=lack,
by Sifneos
lexis=word,
( 1 ) in 1972
thymos
has
cussed.
for medical and psychiatric treatment are dis-

emotion), refers to a cognitive-affective disturbance

that affects the way individuals experience and express THE CONCEPT OF ALEXITHYMIA
their emotions. Despite some initial controversy over
the concept of alexithymia, it has captured the interest Historical Background
of considerable numbers of clinicians, theoreticians,
and researchers in various countries of the world, who The concept of alexithymia has evolved from clinical
have described the clinical characteristics with remark- observations that were initially made on patients with
able consistency (2). In an earlier review, Lesser (2) classical psychosomatic disorders. As early as 1948
concluded that “the alexithymic concept has much to Ruesch (4) noted a disturbance of verbal and symbolic
offer heuristically” even though it is not yet an estab- expression in psychosomatic patients whom he labeled
lished entity. In fact, the usefulness of the concept has “infantile personalities,” and he considered this the
extended far beyond the context of psychosomatic “core problem in psychosomatic medicine.” Shortly
illness in which it was initially described. Alexithymic thereafter MacLean (5), who was developing his con-
cept of the “triune brain,” noted that many psychoso-
matic patients show an apparent intellectual inability
Received March 28, 1983; accepted June 3, 1983. From the to verbalize emotional feelings. He speculated that
Department of Psychiatry, University of Toronto; the Consultation- instead of being relayed to the neocortex and finding
Liaison Service, Mount Sinai Hospital, Toronto; and the UCLA expression in the symbolic use of words, these emo-
Neuropsychiatric Institute, Los Angeles. Address reprint requests to
tions found immediate expression through autonomic
Dr. Taylor, Rm. 933, 600 University Ave., Toronto, Ont., Canada
MSG 1XS. pathways and were translated into a kind of “organ
Copyright © 1984 American Psychiatric Association. language.” Freedman and Sweet (6) referred to pa-

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tients who could not describe their emotions as “emo- of himself. Nemiah (18) has distinguished the alexithy-
tional illiterates.” mic individual from the individual with hysterical
In 1963 a group of French psychoanalysts (7, 8) personality or obsessional personality in the following
described a utilitarian thought style and conspicuous way: The absence of affect and fantasy in the hysteric
absence of fantasy in a mixed medical and psychoso- “is limited to the area of psychological conflict” and
matic patient population. Quite independently, Ne- the obsessional patient “reveals a richness of endoge-
miah and Sifneos (9) examined transcribed interviews nous fantasy that indicates the existence and nature of
with 20 patients who had two psychosomatic illnesses the underlying, isolated drives and affects.”
and found that 16 of them showed “a marked difficul- As already indicated, the observations that led to the
ty in verbally expressing or describing their feelings concept of alexithymia were initially made on patients
and an absence or striking diminution of fantasy” (p. with classical psychosomatic disorders. This led to the
28). Unaware of this work, Krystal and Raskin (10, 11) premature and erroneous assumption that there exist-
were describing similar characteristics in patients with ed a specific etiological relationship between alexithy-
severe posttraumatic states and with drug dependence. mia and psychosomatic illness. Not all psychosomatic
Against this historical background, the clinical con- patients exhibit alexithymic characteristics, and alex-
struct of alexithymia was more precisely defined at the ithymia does not answer the question of the choice of
1 ith European Psychosomatic Research Conference disease. In a recent study Smith (19) found that 30% of
held in Heidelberg in 1976 (12). the medically ill patients referred to a consultation-
liaison service were alexithymic, but an association
Clinical and Demographic Features between alexithymia and classical psychosomatic dis-
orders was not supported. Weiner (20) regards alexi-
Alexithymia denotes a specific disturbance in an thymia as one of several possible “general onset situa-
individual’s psychic functioning that is manifest pri- tions or risk factors that seem to increase the suscepti-
manly in his or her communicative style. This commu- bility to disease which is specified by other variables.”
nicative style is characterized by markedly reduced or Perhaps of more relevance for the psychiatrist is the
absent symbolic thinking so that inner attitudes, feel- frequent presence of alexithymic characteristics in
ings, wishes, and drives are not revealed (13). Thinking patients with somatoform disorders (21-23), psycho-
is literal, utilitarian, and concerned with the minutiae genic pain disorders (24-26), substance use disorders
of external events, a characteristic that Marty and de (11, 17, 27), and posttraumatic stress disorders (10,
M’Uzan (7) called pensee operatoire (operative think- 17). Alexithymia has also been described in patients
ing). Alexithymic individuals report few dreams and with masked depressions (24), character neuroses (3,
have a paucity of fantasies (9). When dreams are 28, 29), and sexual perversions (30). Although Langs
recalled they either contain explicit archaic mental (31) did not use the term “alexithymia,” he described a
content or are of the secondary process type and lack very similar nonsymbolic communicative style in many
the color, bizarreness, and symbolism characteristic of patients with narcissistic personality disorders. Alex-
primary process dreams. ithymia is not an all-or-none phenomenon, and all
Alexithymic individuals show a striking difficulty in people seem to have the capacity to shift at times to a
recognizing and describing their own feelings, and they communicative style that is less symbolic. However,
have difficulty discriminating between emotional states certain individuals manifest this as a predominant trait
and bodily sensations (14). As Nemiah (15) has mdi- (31), which has led to Freyberger’s distinction (32)
cated, they occasionally have outbursts of rage or between primary and secondary alexithymia. Some
tearfulness, but when questioned they are unable to investigators have suggested that alexithymia is related
elaborate further on what they are feeling. Superficial- to lower socioeconomic class (21, 33, 34) and to
ly, alexithymic individuals often seem well adapted increasing age (35), but the prevalence of alexithymic
and show a high degree of social conformity, but in characteristics in the general population is not yet
McDougall’s opinion (16) this is a “pseudonormality,” known. In a study of undergraduate students, Blan-
for on closer inspection they have little contact with chard and associates (36) found that 8.2% of the men
their own psychic reality. They follow a robot-like and 1.8% of the women were within the alexithymic
existence, going through life in a mechanical way, range, but the instrument the authors used to measure
almost as if they are following an instruction book. alexithymia is of questionable validity and reliability.
Their constricted emotional functioning and inner
psychic life are sometimes revealed by a stiffness of Etiological Theories
posture and lack of expressive facial movements (15,
17). In their interpersonal relationships Krystal (17) There have been attempts to explain the etiology of
has described an impaired capacity for empathy, which alexithymia from many points of view including genet-
is not surprising in view of the difficulty alexithymic ic (37, 38), neurophysiological (39-43), social learning
individuals have in recognizing and using their own (34, 44), developmental (45), and psychodynamic (3,
feelings as signals to themselves. This impairment may 16, 17, 30, 46, 47). Since most of the research studies
also be discerned in the doctor-patient relationship, in of alexithymia can be faulted on methodological
which the patient experiences the doctor as a duplicate grounds, these etiological explanations remain theoret-

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 GRAEME J. TAYLOR

ical and speculative (2). As Nemiah (45) has pointed posing a genetic view of affects, Krystal (3, 17) attrib-
out, multiple factors must play a role in the develop- uted alexithymia to an arrest in affect development
ment of such a complex phenomenon. following infantile psychic trauma or to a regression in
Lesser (2) criticized two Norwegian twin studies sug- the affective-cognitive function after catastrophic trau-
gesting a strong hereditary component in alexithymia: ma in adult life. Krystal’s theoretical contributions are
A small number of twins was studied (only 33 pairs), consistent with the Kleinian concept of fixations at or
and since the twins were raised in their own families, regressions to the paranoid-schizoid position of mental
they were exposed to similar environmental influences. functioning in which the capacity to form symbols is
There is also no experimental evidence to support absent, since this ego function is linked with the later
Nemiah’s hypothesis (39, 45) of a neurophysiological depressive position (57). Rickles (58) related the alex-
defect affecting modulation by the striatum of input ithymic patient’s impaired capacity for play and syrn-
from the limbic system to the neocortex. However, bolization to early developmental disturbances inter-
studies of hemispheric specialization (48), including fering with the creation of a transitional object. Some
how the brain integrates affective and propositional evidence for the etiological role of a disturbed mother-
language (49), may eventually elucidate the neural infant relationship may be found in the well-known
organization underlying different communicative styles. case of Monica, who, as a young woman, manifested
Flannery and I (SO) have attempted to integrate alexithymic characteristics (59). McDougall (46) and I
some recent neurobiological findings with psychoana- (47) have described how some alexithymic patients
lytic concepts and have proposed that alexithymic make extensive use of projective identification to dis-
individuals, with their paucity of fantasies and their charge unbearable mental states into others-a com-
concrete thinking, may show left cerebral lateraliza- municative mode that corresponds to Langs’ type B
tion. Hoppe’s observation (Si) of the appearance of field (31). Patients who are more severely alexithymic
alexithymic characteristics in patients who had surgi- make little use of projective identification and may
cal commissurotomies for intractable epilepsy sup- have experienced disturbances during the autistic
ports our hypothesis, as does a study by Kaplan and phase of development. Their nonsymbolic communica-
Wogan (42) in which painful sensation was reduced by tive style corresponds to the type C field described by
continued fantasizing-the mobilization of fantasy Langs (31), in which language is used to create impene-
correlated with right hemisphere activation as mea- trable barriers that seal off meaningful mental contents
sured by the EEG. Furthermore, the finding of a and destroy links with other people. Both type B and
greater prevalence of alexithymia among men in the type C fields can evoke countertransference boredom,
studies by Blanchard and associates (36) and Smith which is typically experienced during psychotherapy
(19) may be related to less hemispheric specialization with alexithymic patients (iS, 47).
and the greater neural plasticity reported among worn- In addition to intrapsychic factors, styles of commu-
en (52, 53). Hemispheric studies using EEG techniques nication are influenced by sociocultural factors, family
or observation of conjugate lateral eye movements patterns of discourse, and intelligence. For instance,
have not yet been done with alexithymic patients. To Leff (60) found that people in developed countries
further investigate the neurophysiology of alexithyrnia, show a greater differentiation of emotional states than
Flannery and I (SO) also suggested that alexithymic people in developing countries and that some lan-
patients be studied in sleep laboratories, since a prelim- guages impose constraints on the expression of emo-
mary study of “super-stable” eczema patients by tion. Using interviews and psychological tests, Borens
Brown and Kalucy (54) had found greatly reduced and associates (34) found that psychosomatic patients
slow-wave sleep and few or no reported dreams when of lower socioeconomic status used fewer affect words
these patients were awakened after long periods in and had fewer fantasies. Thus, multiple factors must
REM sleep. More recently, Tantarn and associates (55) be considered in research on the etiology of alexithymia.
found that alexithyrnic patients with skin disorders
showed a trend toward less REM sleep and a signifi-
cant lack of involvement in their dreams. THE MEASUREMENT OF ALEXITHYMIA
From a psychoanalytic viewpoint, Nemiah (39, 45)
and Sifneos (56) have argued that neurotic defense Alexithymia is a difficult concept to operationalize,
mechanisms such as denial, repression, and isolation and no sufficiently reliable and valid instrument for
do not adequately explain the phenomenon of alexi- measuring it has been developed. Observer-rated and
thymia. McDougall (30) attributed alexithymia to self-assessment questionnaires, as well as projective
disturbances in the mother-infant relationship and tests and the content analysis of speech samples, have
proposed a very early preneurotic pathology in which been used. More recently a grapho-projective test has
the mechanisms of splitting and projective identifica- been devised to measure symbolic function directly.
tion predominate. In McDougall’s view (46), “alexi-
thymia is an uncommonly strong defense against prim- Questionnaires
itive terrors,” which the patients also seek to bypass
through somatization or by resorting to addictive The most widely used instrument for quantifying
substances and perverse sexual behaviors. After pro- alexithymia is the Beth Israel Hospital Psychosomatic

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Questionnaire (6 1), which is a 1 7-item forced-choice projective tests that offer standardized methods of
questionnaire completed by the interviewer. Eight of scoring. In addition, test records can be subjected to
the items are derived from the clinical construct I have operationalized and highly reliable linguistic analyses.
outlined. Although Apfel and Sifneos (62) reported However, since there are no normative data, most
good interrater reliability with this instrument, others studies using projective test measures have compared
have found that scoring is highly dependent on the groups of psychosomatic patients with groups of psy-
experience, bias, and style of the interviewer (63-65). choneurotic patients or some other control group on
Kleiger and Jones (66), who used the Beth Israel the assumption that psychosomatic patients are more
Q uestionnaire to assess alexithymic characteristics in alexithymic. Using selected cards of the Thematic
patients with chronic respiratory illness, reported high Apperception Test (TAT), Defourny and associates
interrater reliability. However, instead of a compari- (74) demonstrated alexithymic characteristics in type
son of ratings from separate interviews, audiotapes of A coronary-prone patients. In our own studies (67,
single interviews were rated independently by three 75), my associates and I found that a group of
judges. My colleagues and I (67) used separate inter- psychosomatic patients with inflammatory bowel dis-
views to rate patients with inflammatory bowel disease ease were less verbally productive and used fewer
and found unacceptable interrater reliability with the affect words in response to TAT cards than did a
Beth Israel Questionnaire. Lolas and associates’ find- suitably matched group of psychoneurotic patients.
ing (63) that ratings on this questionnaire were affect- The difference in verbal-emotional expressiveness was
ed by the experience of the interviewer also indicates independent of the level of psychopathology. ln re-
that wider reliability studies are needed with this sponse to the Rorschach, our psychosomatic patients
instrument. were less able to modulate their emotions (significantly
The Schalling-Sifneos Personality Scale (62) is a 20- lower percent of responses using both form and color,
item self-report questionnaire that bypasses the inter- where form was the primary determinant), but the
actional problems associated with the Beth Israel human movement scores did not indicate less fantasy
Q uestionnaire but produces erratic results (62, 67). formation in the patients with inflammatory bowel
Nevertheless, as stated earlier, Blanchard and asso- disease than in the psychoneurotic patients. However,
ciates (36) used this questionnaire in their study of also using the Rorschach test, Vogt and associates (76)
undergraduate students and reported that scores were found significant differences in fantasy formation be-
higher among men and were independent of scores on tween groups of psychosomatic and psychoneurotic
other measures of psychopathology. patients, and Safar and associates (77) showed a lack
The Interoceptive Awareness Subscale of the Eating of fantasy life in patients with essential hypertension.
Disorder Inventory developed by Garner and asso-
ciates (68) is a 10-item self-report measure for assess- Verbal Content Analysis
ing alexithymic characteristics. It has established reli-
ability and validity but was designed only for patients Since alexithymia is essentially a communicaftve
with anorexia nervosa or bulimia. disorder, it has also been studied through the content
The 22-item MMPI alexithymia scale developed by analysis of speech. Speech samples may be interaction-
Kleiger and Kinsman (69) standardizes the informa- al (usually the first 1,000 words of a psychoanalytical-
tion collected from patients and is reported to have ly oriented interview) or monadic (responses to select-
impressive stability over time and an 82% success rate ed TAT cards or having the patient talk for S minutes
when predicting alexithymia scores on the Beth Israel about any interesting or dramatic life event). Using the
Q uestionnaire. However, this instrument lacks face Gottschalk-Gleser method (78), which has been exten-
validity and was derived on the basis of correlations sively validated, von Rad and Lolas (79) found signifi-
with the Beth Israel Questionnaire, which itself has not cant differences in the expression of affect (anxiety and
been adequately validated. Doody and I (70) found hostility) between psychosomatic and psychoneurotic
that the MMPI alexithymia scale correlates inversely patients with interactional speech samples but not with
with abstract intelligence and measures personality monadic speech samples. Since these findings indicate
features involving social overconformity; however, it that verbal affective expression can be influenced by
does not correlate with measures of the ability to situational factors, the investigators favored a “situa-
express feelings verbally or the capacity for fantasiz- tion-dependent state” concept rather than an “organis-
ing, both of which are central to the construct of mic subject-dependent trait” view of alexithymia.
alexithymia. Despite these limitations, this instrument Doody and I (80) also found no differences between
was confidently used in several studies that measured matched groups of psychosomatic and psychoneurotic
alexithymia in asthmatic patients (35, 71-73) and patients when we analyzed monadic speech samples
chronic pain patients (25). with the Gottschalk-Gleser method. However, when
we employed a simple frequency count of different
Projective Tests affect words (the affect vocabulary score), we found
significant differences. This measure is consistent with
Several investigators have measured patients’ verbal the construct that alexithymic patients have a more
affective expression and capacity for fantasizing with limited emotional vocabulary. Furthermore, in our

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study the affect vocabulary score correlated with mea- tional states, alexithymic individuals often communi-
sures of fantasy activity, whereas the Gottschalk- cate inner psychic distress by means of physical com-
Gleser scores did not. In fact, the Gottschalk-Gleser plaints. As Flannery (22, 86) has pointed out,
scales were developed to measure immediate, labile physicians tend to mistake these physical symptoms
emotional states rather than stable traits (81). for undetected organic pathology, which results in
When Lolas and von Rad (82) subsequently ana- overinvestigation and overtreatment and frequently
lyzed dyadic speech by means of a computerized adds an iatrogenic complication to the patient’s disor-
analysis system using one version of the anxiety topics der. Since alexithymic patients are usually not overtly
dictionary, they found significant differences between psychiatrically ill, their physicians regard them as
psychosomatic and psychoneurotic patients for only psychologically normal and they are referred for psy-
one out of four meaning categories. Weintraub’s meth- chiatric consultation late or not at all. Considering the
od (83) of verbal content analysis (which uses monadic high prevalence of iatrogenic illness, an important task
speech samples) has not been employed to study for the liaison psychiatrist is to help physicians appre-
alexithymia, but Weintraub has shown that binge- ciate that these patients are ill but do not necessarily
eating women and alcoholic women tend to use more have an organic disease. Even when there is an organic
expressions of feeling than normal subjects but less disease, alexithymia may contribute to lengthy or more
than depressed patients. The results obtained from frequent hospitalizations, as has been shown for asth-
verbal content analysis seem to be influenced not only matic patients (71, 72). Brown and associates (73)
by the situation used for collecting speech samples but have shown that alexithymic asthmatic patients also
also by the method of measurement. In addition to a minimize their reporting of physical and emotional
lack of normative data, verbal content analyses, like difficulties during respiratory distress, thereby falsely
projective tests, are extremely time-consuming proce- reassuring their physicians into prescribing less effec-
dures and therefore not practical methods for measur- tive treatment. The liaison psychiatrist can also trans-
ing alexithymia. late for medical and nursing staff the meaning and
function of the unusually bland mental state (second-
The SAT9 Test ary alexithymia) that sometimes appears in dialysis
and organ transplant patients and in those faced with
A more promising instrument for quantifying alex- life-threatening illness in intensive care units (32).
ithymia is the archetypal 9 test (AT9), which was Alexithymic patients with psychophysiological
recently introduced by Demers-Desrosiers (84). It is a symptoms or classical psychosomatic disorders are
grapho-projective test with a quantitative scoring sys- generally not good candidates for psychodynamic psy-
tern (SAT9) (85) and provides a direct measure of chotherapy, and as Sifneos (87, 88) has pointed out,
symbolic function that is inhibited in alexithymic they may become worse as a result of anxiety-provok-
individuals. In preliminary studies, Demers-Desrosiers ing psychotherapeutic interventions. Sifneos (88) and
and her colleagues (26, 85) demonstrated acceptable Freyberger (32) have both recommended supportive
interrater reliability with the SAT9 and found that it and educational approaches for these patients. Group
correlates with the Beth Israel Questionnaire but not therapy has also been used (89, 90) and has a long
with the MMPI alexithymia scale. Using the SAT9, tradition of being helpful to psychosomatic and other
Demers-Desrosiers and associates (26) found various medically ill patients (91). Flannery (86) has recom-
degrees of inhibited symbolic function in chronic pain mended low doses of major tranquilizers, such as
patients. In a current study we (G.J. Taylor, M. perphenazine, for alexithymic patients with unex-
Bourke, A.H. Crisp) are assessing the symbolic func- plained somatic distress. However, if a masked depres-
tion of patients with anorexia nervosa and will exam- sion is suspected or the patient has a pain-prone
ine possible correlations among SAT9 scores, body disorder, Blumer and Heilbronn (24) have advocated a
weight, verbal and abstract intelligence, and scores on trial of antidepressant medication. Behavioral tech-
the Interoceptive Awareness Subscale of the Eating niques such as relaxation training, autogenic training,
Disorder Inventory. Further experience with the SAT9 meditation, guided imagery, and hypnosis (92) may all
is likely to refine the instrument and lead to improved help the alexithymic patient acquire better control over
studies of the demographic and other variables associ- his psychophysiological responses to stress and in-
ated with alexithymia. crease his awareness of relationships between bodily
sensations and environmental events. Rickles (58, 93)
has used biofeedback as an adjunct to psychotherapy
IMPLICATIONS FOR TREATMENT with somatizing alexithymic patients, but he stressed
the importance of evaluating the difficult transference
Consultation-Liaison Psychiatry problems that usually arise. He has conceptualized the
biofeedback machine as a transitional object that in a
Alexithymia has important implications for treat- very nonthreatening way helps some patients acquire a
ment in both medical and psychiatric settings. Because greater capacity for symbolization. For other patients
of their difficulty in verbalizing feelings and distin- the biofeedback machine may be experienced as a
guishing between bodily sensations and different emo- “fetish-like object,” and Rickles (58) has described the

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emergence of primitive rage or frightening depressive development of the patient’s own capacity for “play-
feelings when some patients’ primitive defenses were ing” with thoughts, ideas, and images.
breached. Controlled studies that consider communi- Several therapists (30, 31, 47, 97, 98) have described
cative style and other variables need to be done to eval- the use of their countertransference responses to gain
uate and compare the effectiveness of these different access to the primitive mental life of those alexithymic
treatment modalities for alexithymic medical patients. patients who make extensive use of projective identifi-
cation. Like a mother who is “the thinking apparatus
Psychotherapy and Psychoanalysis of her baby,” the therapist “contains” the patient’s
projective identifications and transforms them into
Alexithymic patients who are being treated with symbolic thoughts that may form the basis of interpre-
psychoanalytic psychotherapy or psychoanalysis for tations subsequently given to the patient. The therapist
various psychiatric disorders present major technical should also repeatedly interpret the way the patient
difficulties for their therapists. Whereas a typical neu- uses language to discharge unbearable psychic states
rotic patient communicates symbolic material in the and, as Grotstein (99) has stressed, investigate with the
form of thoughts, feelings, fantasies, and dreams, the patient why he could not “contain” these states him-
nonsymbolic communicative style of alexithymic pa- self. The patient’s own capacity to tolerate affect and
tients provides few analyzable derivatives and quickly fantasy and use symbolic thoughts is expected to
evokes countertransference feelings of dullness, bore- gradually increase. Severely alexithymic patients who
dom, frustration, and sleepiness (15, 31, 47, 56). use language to destroy meaning and to prevent relat-
Overbeck (94) studied quantitative aspects of the edness make very little use of projective identification,
language of individual psychotherapy sessions and and access to their intrapsychic worlds is extremely
found that in comparison with neurotic patients, alex- difficult. As Langs (3 1) has recommended for patients
ithymic patients spoke less, were far less spontaneous with type C communicative fields, the therapist must
in speech production, and were silent more, thus wait patiently for opportunities to point out the mas-
forcing the therapist into greater activity. Therapeutic sive defensive function of their nonmeaningful corn-
impasses quickly develop, and there is a high risk for munications and should only offer hints as to the
countertransference acting out. Furthermore, these pa- nature of the underlying contents. In fact, McDougall
tients frequently resort to addictive behaviors, includ- (30) has warned of serious risks to severely alexithymic
ing perverse sexual activity, or they complain of so- patients unless therapists “treat [their] defensive prison
matic symptoms when the therapist expects them to with considerable caution.”
experience psychic distress. Premature termination of Krystal (3) has suggested that even with modified
treatment is not uncommon, but according to McDou- techniques, it is probable that only patients with mild
gall (95), lengthy analyses are sometimes conducted and secondary types of alexithymia will be able to use
despite evident stagnation. psychoanalytic psychotherapy. However, he stressed
Pierloot and Vinck (33) compared patients who that the concept of alexithymia is of value to all
were randomly assigned to short-term psychodynamic psychotherapists and psychoanalysts, since neurotic
psychotherapy or behavior therapy (systematic desen- and characterologically disturbed patients may also
sitization) and found that the dropout rate with the show this cognitive-affective disturbance at different
former treatment was related to the presence of alex- times.
ithymic characteristics. Krystal (3, 17) has devised
some modifications of technique for making psycho-
therapy more helpful and useful to alexithymic pa- CONCLUSIONS
tients. He has shifted the focus of therapy from the
content to the form of the patient’s communications The clinical construct of alexithymia defines more
and has recommended that the therapist first “help the precisely the phenomenological characteristics of pa-
patient to observe the nature of his alexithymic distur- tients who were previously labeled “not psychological-
bances.” The patients are then helped to develop affect ly minded” (100) and dismissed without further inves-
tolerance and taught “to recognize their emotions as tigation of why they had this state of mind. Although
signals to themselves which are self-limited in duration much of the research on alexithymia can be faulted on
and intensity.” Like a parent teaching a child, the methodological grounds, studies that have objectively
therapist helps the patient to accurately label and quantified symbolic activity, fantasy formation, or the
gradually verbalize his emotions. This is a slow and verbal expression of affect support the view that
tedious process and, as Krystal (3, 17) has indicated, alexithymia is a valid entity. The extent to which
patients may begin to use more affect words but alexithymia represents a developmental defect or a
denude them of their intrinsic emotional significance. dekense against primitive anxieties remains unclear,
McDougall (46) has also cautioned that “the therapist bui the consequences of having this cognitive-affective
must not be fooled by the devitalized use of vital disturbance are beginning to be realized. As etiological
words.” Using Winnicott’s notion (96), the therapist explanations are sought, important questions need to
who engages “playfully’ with his patient may expand be answered about the neural mechanisms and interac-
the patient’s imaginative life by prompting further tional experiences in early life that account for the

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transformation of physiological experiences into psy- 18. Nemiah JC: Psychology and psychosomatic illness: reflections
chological representations and result in a capacity for on theory and research methodology. Psychother Psychosom
22:106-111, 1973
symbolization and eventually acquisition of a language 19. Smith GR Jr: Alexithymia in medical patients referred to a
for expressing emotions. Psychophysiological studies consultation/liaison service. Am J Psychiatry 140:99-101,
of alexithymic patients may help clarify some of the 1983
relationships among bodily sensations, perception, 20. Weiner H: Contributions of psychoanalysis to psychosomatic
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