Psychoanalysis Alexythimia

Journal of the American Psychoanalytic Association
http://apa.sagepub.com/ Psychoanalysis and Empirical Research : The Example of Alexithymia

Graeme J. Taylor and R. Michael Bagby J Am Psychoanal Assoc published online 23 January 2013 DOI: 10.1177/0003065112474066 The online version of this article can be found at: http://apa.sagepub.com/content/early/2013/01/23/0003065112474066
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Graeme J. Taylor / R. Michael Bagby
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PSYCHOANALYSIS AND EMPIRICAL RESEARCH: THE EXAMPLE OF ALEXITHYMIA

An extensive body of research on the alexithymia construct is reviewed to show how various empirical methodologies can be used to evaluate the validity and increase our understanding of theoretical and clinically derived psychoanalytic concepts. The historical background of alexithymia and the theoretical framework in which the construct was formulated are presented, after which measurement- and experiment-based approaches to construct validation are described. This is followed by a review of empirical investigations that have yielded evidence that alexithymia is a dimensional personality trait associated with several illnesses of interest to psychoanalysts. Empirical research also supports clinical observations and impressions that individuals with high degrees of alexithymia principally employ primitive defenses, have a limited capacity for empathy, exhibit deficits in mentalization, and do not respond well to traditional interpretive psychotherapies. Also reviewed is empirical research that implicates genetic and environmental/developmental factors in the etiology of alexithymia, in particular childhood trauma and insecure attachments, factors generally associated with deficits in affect development and affect regulation. The clinical relevance of the empirical research findings is discussed in the final section.
n an essay on biology and the future of psychoanalysis, published more than a decade ago, the Nobel laureate Eric Kandel (1999) remarked that a most disappointing aspect of psychoanalysis is its failure to evolve and progress scientifically, specifically its failure to develop objective methods for testing the ideas it formulates. Psychoanalysis,
Graeme J. Taylor, Professor of Psychiatry, University of Toronto and Mount Sinai Hospital, Toronto; faculty, Toronto Institute for Contemporary Psychoanalysis. R. Michael Bagby, Professor of Psychology and Psychiatry, University of Toronto; Senior Scientist, Centre for Addiction and Mental Health, Toronto. The authors thank Morris N. Eagle for comments made on an early draft of this paper. Submitted for publication April 3, 2012.
DOI: 10.1177/0003065112474066
G r a e m e J . Ta y l o r / R . M i c h a e l B a g b y
he asserted, has traditionally been far better at generating ideas than at testing them (p. 506). The importance of empirical research for the enrichment and ongoing development of psychoanalysis, and especially for strengthening its position among other sciences, has been emphasized in recent years by Cooper (2005) and Kernberg (2006), who note that such research has been limited by the isolation of psychoanalytic institutes from university departments of psychiatry and psychology, and by the ambivalence or opposition of many psychoanalysts who argue that empirical research does not address the complexity of clinical phenomena. A growing awareness of the need to increase the quantity and quality of research in psychoanalysis has led several psychoanalytic institutes and organizations to teach basic research methods to candidates and interested psychoanalysts, and to encourage collaborative studies with other disciplines (see Hauser 2005). Yet more effort is needed for psychoanalytic researchers to inform practicing analysts about the nature and relevance of their research, as well as the methodologies they employ. As Masling (2000) and Luyten, Blatt, and Corveleyn (2006) point out, research groups have for many years been using empirical methods to test psychoanalytic hypotheses. Much of this research, however, remains unknown or unacknowledged by many psychoanalysts. An area of research that has expanded immensely over the past twenty years, yet remains little known among psychoanalysts, involves the use of empirical methods to validate, and increase our understanding of, the alexithymia construct. Coined by Sifneos (1973) from the Greek (a = lack, lexis = word, thymos = emotion), the term alexithymia refers to a cluster of clinically observable characteristics including difficulty identifying and describing subjective feelings, a restricted fantasy life, and an externally oriented thinking style. The construct was introduced during the early 1970s and initially was of interest primarily to psychoanalysts investigating and treating patients with classic psychosomatic diseases.1 As alexithymia theory advanced, however, the construct moved beyond the field of psychosomatics and became incorporated into the broader field of research on emotional processing and affect pathology, a field important to psychoanalysts generally. Although many practicing psychoanalysts are
The classic psychosomatic diseases are the seven conditions investigated by Franz Alexander and colleagues during the 1950s and 1960s. However, the idea that there exists a specific group of psychosomatic diseases was discarded several decades ago. Moreover, many of the seven diseases were subsequently found to be heterogeneous, both physiologically and psychologically (Taylor, Bagby, and Parker 1997).
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PSYCHOANALYSIS AND EMPIRICAL REASEARCH
familiar with the features of alexithymia through clinical experience, acquiring knowledge of the theoretical advances and findings from empirical research on the construct can help clinicians develop more effective therapeutic approaches for patients with high degrees of alexithymia. Empirical research can provide clinically relevant information about (a) the nature of the deficits and defenses associated with the construct; (b) whether alexithymia is a graded or an all-or-none phenomenon; (c) its relations with other psychological and psychoanalytic constructs concerned with aspects of emotional processing; (d) the etiopathogenesis of alexithymia; and (e) the types of psychoanalytic interventions that have been found most effective in reducing alexithymia. Nearly two decades ago, Taylor (1995) outlined briefly the historical background and clinical features of the alexithymia construct, and reported findings from a program of measurement-based empirical research that provided preliminary support for the validity of the construct and its association with four common psychiatric disorders. In this paper we provide a more detailed description of the historical background and also outline the theory underlying alexithymia. We then update the earlier review by describing more recent empirical research that has yielded additional support for the validity of the construct and its association with various somatic and psychiatric disorders. We also review studies that have examined relations between alexithymia and other clinically important constructs, focusing especially on the similarities and differences between alexithymia and the concept of mentalization, but also relations with ego defense mechanisms, empathy, and attachment styles. We later review investigations aimed at identifying genetic factors and the role of early trauma in the etiology of this personality trait. Finally, we review studies that have examined the influence of alexithymia on treatment outcome, and consider how knowledge gained from the larger body of alexithymia theory and research can inform the psychoanalytic approach to these patients. Although all of these research studies have been published elsewhere, we provide an overview in this paper in the hope that it will offer a template for other researchers who wish to use empirical methods to validate psychoanalytic constructs.
HISTORICAL BACKGROUND
Psychoanalysts and psychotherapists have long observed that some patients are deficient in certain psychological capacities and consequently 3
do not respond well to psychoanalysis or interpretive forms of psychotherapy. In the early 1950s, Horney (1952) and Kelman (1952) found that some psychiatric patients came to an impasse in psychoanalytic psychotherapy because of limited emotional awareness, a paucity of inner experience, minimal interest in dreams, concreteness of thinking, and an externalized style of living in which behavior is guided by rules, regulations, and the expectations of others rather than by ones feelings, wishes, and personal values. These patients were prone to developing somatic symptoms and often engaged in binge eating, alcohol abuse, or other compulsive behaviors, seemingly in an attempt to regulate distressing inner states. Although regular in their attendance at analytic sessions, these patients were not really engaged in the analytic process; unaware of an inner life, they tended to fill each analytic session with a chronological recital of events [that] transpired since the last hour (Kelman 1952, p. 20). A proneness to somatic disorders and substance abuse had been suggested a few years earlier by Ruesch (1948), who described a similar affective and cognitive disturbance among patients with posttraumatic states or various somatic diseases. Ruesch hypothesized that this disturbance was due to a developmental arrest, possibly a result of traumatic events in early childhood. Since these patients emotions were not well connected with verbal symbols, Ruesch thought they were expressed directly through physical actions or bodily channels. An association between externalized living as an over-all modus vivendi (Kelman 1952, p. 17) and vulnerability to somatic illness was suggested by Marty and De MUzan (1963), who described a utilitarian thinking style and a conspicuous absence of fantasy observable in many physically ill patients. They referred to this cognitive style as pense opratoire (operative or mechanical thinking), which Marty (1991; Fain and Marty 1964) attributed to a deficiency in mentalization, a concept he and his colleagues introduced in the early 1960s to refer principally to an individuals representational and fantasy activity (Aisenstein 2008). In the early 1970s, Nemiah and Sifneos (1970) conducted systematic investigations on patients with classic psychosomatic diseases and observed that many of these patients had a marked difficulty in describing subjective feelings, an impoverished fantasy life, and a cognitive style that is literal, utilitarian, and externally orientated. As noted earlier, the term alexithymia was coined to denote this cluster of characteristics. It was Sifneoss impression (1973) that alexithymic characteristics are not 4
specific to psychosomatic patients. Indeed, other psychoanalysts were describing similar characteristics among patients with severe posttraumatic states (Krystal 1968), drug dependence (Krystal and Raskin 1970), or eating disorders (Bruch 1973). In that the internal arousal during panic attacks is expressed directly via somatic pathways with no modification by higher-order psychic processes, Nemiah (1984) later suggested that alexithymia might also be associated with panic disorder. Based on their clinical research findings, Nemiah, Freyberger, and Sifneos (1976) formulated alexithymia as a testable hypothetical construct with the following salient features: (1) difficulty identifying feelings, differentiating among the range of common affects, and distinguishing between feelings and the bodily sensations of emotional arousal; (2) difficulty finding words to describe feelings to other people; (3) constricted imaginal processes, as evidenced by a paucity or absence of fantasies referable to drives and feelings; and (4) a thought content characterized by a preoccupation with the minute details of external events (i.e., an externally oriented cognitive style). The latter two features correspond to Marty and de MUzans concept of pense opratoire.2 Consistent with the experience of Horney and Kelman, psychoanalysts have continued to report that patients with a high degree of alexithymia make little progress in psychoanalysis or psychoanalytic psychotherapy. McDougall (1972, 1984) referred to these patients as anti-analysands and used the word disaffected to describe their affect pathology; she warned of the potential for prolonged periods of stagnation if they were taken into analysis. And Krystal (19821983) concluded that alexithymia is possibly the most important single factor diminishing the success of psychoanalysis and psychoanalytic psychotherapy (p. 364). There was general agreement that the communicative style of alexithymic patients often evokes feelings of dullness, boredom, and frustration in the therapist.
2 Some readers may regard alexithymia as a descriptive psychiatric construct rather than a construct originating in psychoanalytic observations. As is evident from this historical review, however, and as emphasized also by Weinryb (1995), the psychoanalytic literature has long described patients who are unable to symbolize their emotions and talk about psychologically meaningful events. Rubins (1980) notes that Sifneos completely ignored the precedent set by Horney (1952) when he labeled these patients alexithymic.
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T H E O R E T I C A L C O N S I D E R AT I O N S
Although derived from clinical observations, the alexithymia construct was formulated within a theoretical framework for the cognitive processing and regulation of emotions. In conceptualizing this framework, Nemiah and Sifneos were careful to define their understanding of the concept of affects. Like Freud (19161917), who described affects as highly composite experiences including in the first place particular motor innervations or discharges and secondly certain feelings (p. 395), Nemiah, Freyberger, and Sifneos (1976) recognized that affects have both biological and psychological components; they defined emotion as the neurophysiological and motor-expressive component, and feelings as the subjective, cognitive-experiential component. They considered affect a more general term, and indicated that emotions must be represented mentally to be experienced consciously as feelings, a process that Nemiah (1977) referred to as the psychic elaboration of emotions.3 He described several elements to this process, including a refinement and delineation of raw emotions into a variety of qualitatively different nuances that have the potential for conscious experience as feelings; a linking of the feelings with words to describe them; the production of images and fantasies expressive of the feelings; and the arousal of memories and associations related to the feelings. It was assumed that an awareness of feelings, together with the thoughts, fantasies, and memories they elicit, facilitates regulation of the emotional arousal induced by affect-evoking stimuli. Nemiah suggested that alexithymia could occur as a result of a failure in one or more of the elements of psychic elaboration, such that the activity of the biological component of affect would be unregulated by cognitive processes and lead to somatic symptoms or be discharged through actions. Within this theoretical framework, Sifneos (1994) and Taylor, Bagby, and Parker (1997) proposed that the features comprised in the alexithymia construct reflect a deficit in the cognitive processing of emotions. This proposal and Nemiahs description of the psychic elaboration of emotions (1977) place the alexithymia construct within the broad field of
The same conceptual distinction between emotions and feelings has been emphasized more recently by Damasio (2003), who states that emotions play out in the theater of the body. Feelings play out in the theater of the mind (p. 28). He points out that emotions precede feelings and that it is through our feelings that we know what is happening with our emotions.
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emotion theory and research. Indeed, Nemiahs formulation anticipated several contemporary conceptualizations of how emotions are processed and organized in the mind, in particular Buccis multiple code theory (1997a), which postulates three modes or systems of representing and processing emotional information. According to this theory, emotion schemas are made up of components from all three modes: the nonverbal subsymbolic mode (patterns of sensory, visceral, and kinesthetic sensations and motor activity experienced during states of emotional arousal), the nonverbal symbolic mode (images), and the verbal symbolic mode (words). Whereas the subsymbolic mode constitutes the affective core of the schema, it is linked to the other two modes by a referential process: analogically processed subsymbolic representations are chunked into functionally equivalent classes of representation that lead to the construction of discrete prototypical images, thereby connecting subsymbolic information with nonverbal symbolic representations; once language is acquired, images can then be connected to verbal symbols. As Bucci (1999) explains, this is not a transformation from one modality to another, but a translation of dominant representations from the nonverbal modes into logically organized speech; this allows for a transformation of the meanings represented in the nonverbal modes, which is necessary for self-reflection and for the verbal communication of subjective experience. Bucci proposes that if the referential process is disrupted (e.g., by conflict or trauma) or fails to develop adequately, the verbal and nonverbal systems within the schemas are dissociated, thereby affecting the organization of the schemas, the regulation of emotional arousal, and the construction of emotional meanings. The idea of dissociation within the emotion schemas can be applied to alexithymia; without linkages to images and words, the individual is unable to symbolize emotional states (Bucci 1997b). Moreover, activation of the subsymbolic system without symbolic connections may result in poorly regulated states of emotional arousal, which may contribute to the pathogenesis of the various disorders with which alexithymia has been associated. It has been hypothesized, for example, that the alexithymic deficit in the cognitive processing of emotions leads to a focusing on, and amplification of, the somatic sensations accompanying emotional arousal, and/or to physical action as an immediate response to unpleasant arousal (Taylor, Bagby, and Parker 1997). This is thought to explain the proneness to somatization among high-alexithymia individuals, as well as their tendency to regulate tension
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through compulsive behaviors such as smoking, binge eating, and abuse of alcohol or drugs; such behaviors are risk factors for disease. Recognizing that the features of the alexithymia construct reflect deficits in emotional processing, Graham (1988) used Bions ideas about the transformation of emotional experience (1962) to propose a metapsychological formulation; he attributed the impaired imagination and symbolic thinking of alexithymic patients to a failure of alpha function so that emotions tend to be experienced as sensual impressions, things in themselves (beta elements), that cannot be transformed into alpha elements that can be used in dreams, fantasies, thinking, and learning from experience. According to Bions theory, when there is a lack of alpha function, beta elements have to be expelled by means of projective identification and mindless actions, or evacuated into the body, resulting in somatic symptoms. These and other metapsychological concepts can be extremely useful clinically, as they provide ways of conceptualizing and describing the nature of the alexithymic patients psychopathology and may help analysts develop therapeutic interventions for these patients (Taylor 1984, 2012). However, metapsychological concepts are not empirically verifiable; and as Lesser and Lesser (1983) point out, a conceptual fallacy is introduced when empirical and metapsychological concepts are used interchangeably (p. 1306).
E M P I R I C A L VA L I D AT I O N
As emphasized by Lesser and Lesser (1983), empirical validation of new psychological constructs is essential, especially for those originating within psychoanalysis, as they are easily reified and once entrenched are difficult to evaluate objectively and so may lead to a false sense of understanding. There are two main empirical methodologies for validating a construct: measurement-based methods and experiment-based methods. In the case of alexithymia, measurement-based methods can be used to evaluate the hypothesis that the clinically observable descriptive features of alexithymia are interrelated and form a coherent construct; experiment-based methods can evaluate the theoretical proposal that deficits in the cognitive processing of emotions underlie the descriptive features of the construct.
A Measurement-Based Approach
The first step in evaluating the validity of a psychological construct is to determine whether it can be empirically operationalized. Although 8
this is a widely used method of construct validation in the field of personality research (Clark and Watson 1995), the development of a reliable and valid instrument for measuring a construct is seldom pursued within the field of psychoanalysis. As outlined by Taylor (1995), this was accomplished for alexithymia through development of the self-report 20-item Toronto Alexithymia Scale (TAS-20), which has three factor scales that assess difficulty identifying feelings (DIF), difficulty describing feelings to others (DDF), and externally oriented thinking (EOT) (Bagby, Parker, and Taylor 1994; Bagby, Taylor, and Parker 1994; Parker, Taylor, and Bagby 2003). Of particular interest to psychoanalysts and psychotherapists, the TAS-20 correlates negatively with measures of psychological mindedness, need for cognition (the tendency to engage in and enjoy analytical thought), affective orientation (the extent to which individuals are aware of and use affects to guide communication), and openness to experience (one of the dimensions in the well-known and widely applied five-factor model of personality, which includes openness to fantasy and receptivity to feelings) (see Taylor 1995). Among the factor scales of the TAS-20 the strongest correlations were with EOT, with the exception of the affective orientation measure, which correlated most strongly with DDF. The TAS-20 has been translated into more than twenty languages, and its three-factor structure, which maps onto the theoretical conceptualization of alexithymia, has been cross-validated by confirmatory factor analysis in Western, Eastern European, East Asian, and Middle Eastern countries (see, e.g., Taylor, Bagby, and Parker 2003; Zhu et al. 2007). These findings indicate that the structure of the construct is equivalent across many cultures, thereby supporting the view that alexithymia is a universal trait rather than a culture-bound construct that merely reflects the emphasis of Western psychoanalysis and psychotherapy on psychological mindedness. Although the TAS-20 has become the most widely and frequently used measure of alexithymia, all methods for assessing psychological constructs have some shortcomings. For example, a possible limitation of the TAS-20 is that individuals with a high degree of alexithymia may not be able to assess reliably and accurately their own deficits in affect awareness on a self-report scale. To address this potential shortcoming, personality psychologists recommend using a multimethod approach to measurement (Eid and Diener 2006). With this in mind, Bagby et al. (2006) developed the Toronto Structured Interview for Alexithymia
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(TSIA). This instrument includes a factor for assessing imaginal processes, as well as factors for assessing the other three facets of the construct. The four-factor structure has been replicated in different samples and different languages (e.g., Caretti et al. 2011). The TSIA surmounts the potential limitation of the TAS-20, as it includes prompts and probes for each question and the interviewer is required to request examples to amplify responses to the questions. The TAS-20 and its three factor scales have been shown to correlate significantly with the TSIA in both clinical and nonclinical samples (Bagby et al. 2006; Caretti et al. 2011).4 The psychometric properties of the TAS-20 and the TSIA provide support for the validity of the alexithymia construct. For both instruments, significant correlations among the factors validate Nemiah, Freyberger, and Sifneoss description of alexithymia as a coherent but multifaceted construct.
Experimental Studies
One experimental approach to assessing whether alexithymia reflects deficits in the cognitive processing of emotions is to compare individuals receiving high or low scores on the TAS-20 or other measures of alexithymia in their ability to identify and label verbal and nonverbal expressions of emotion. In one such study, individuals recruited from the community were asked to complete a series of tasks that require matching verbal emotional stimuli (e.g., words or sentences) or nonverbal ones (e.g., scenes or faces) with verbal or nonverbal emotional responses (Lane et al. 1996). The TAS-20 correlated negatively with the performance on each verbal and nonverbal task; in addition, individuals with high TAS-20 scores had significantly lower accuracy rates than did individuals with low TAS-20 scores on all of the tasks.5
4 There is evidence that the TAS-20 and its three factor scales also correlate significantly with other non-self-report measures of alexithymia, including a performance-based measure (Porcelli and Mihura 2010) and an observer-rated measure (Bagby, Taylor, and Parker 1994), suggesting that research findings are most likely not compromised in studies using the TAS-20 alone to assess the construct. 5 Rather than analyzing alexithymia scores as continuous data, most of the experimental studies compare research participants with either high or low degrees of alexithymia, who were either preselected for the study or categorized into groups for purpose of the analyses. This method increases statistical power by creating greater variability of alexithymia scores. Many psychological constructs, including intelligence and personality traits, are distributed dimensionally, yet cutoff scores are defined to determine groups of individuals with very high or very low degrees of the construct being measured.

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Other experimental approaches have employed methodologies and techniques from cognitive psychology to evaluate the assumption that the features of the alexithymia construct reflect a deficit in the cognitive processing of emotion. In one study, individuals with high TAS-20 scores compared with those with low scores showed a delay in making lexical decisions to emotion words after being primed by related emotion situations (Suslow and Junghanns 2002). This effect is compatible with the theoretical view that in alexithymia the elements of emotion schemas are not well integrated. In another study, individuals with high TAS-20 scores did not differ from individuals with low scores in their ability to recall both emotion and non-emotion (neutral) words at a shallow level of processing in which the focus is on the physical attributes (e.g., size, color) of the word stimuli. At a deep level of processing, however, in which thinking about the meaning of the word stimuli is central, individuals with high TAS-20 scores evidenced lower recall of emotion words than did individuals with low scores (Luminet et al. 2006). Another approach is to evaluate emotion schemas by investigating the quality of linkages between the subsymbolic and symbolic elements within the schemas. This can be done with a method developed by Bucci et al. (1992) in which thematic units of a transcribed narrative are scored along four linguistic dimensions using referential activity scales. Taylor (2003) used as narrative protocols the dream reports collected from students with either high or low TAS-20 scores when they were awakened in a sleep laboratory from REM sleep. The students with high alexithymia scores had a significantly lower mean overall referential activity score than did students with low scores. Although this finding needs to be replicated with continuous texts from psychoanalytic or psychotherapy sessions, and using a more recently developed computerized measure of referential activity, it is consistent with the view that alexithymia involves a decoupling of states of emotional arousal from images and words. Experimental methods have also been used in research exploring the neurobiology of alexithymia. Studies using functional brain imaging techniques have been conducted to determine whether alexithymia is associated with differences in regional brain activation in response to emotion-inducing stimuli such as autobiographical recall of emotional events, or the viewing of facial emotional expressions or pictures or films that evoke emotion. Although a few studies have yielded inconsistent
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findings (which may possibly be attributed to the use of different methodologies), the overall findings suggest that alexithymia is associated with reduced activation in the anterior cingulate cortex (ACC), the right medial prefrontal cortex (mPFC), and the anterior insula (AI), as well as with increased or decreased activation in several other regions of the brain (see, e.g., Bird et al. 2010; Frewen et al. 2008; Moriguchi et al. 2006). Although the ACC, the surrounding mPFC, and the AI are associated with a wide range of emotion-regulatory processes and other functions, there is accumulating evidence that these regions of the brain are involved in the ability to be aware of ones own and others emotional feeling states (Craig 2009; Lane et al. 1998; Ochsner et al. 2004; Singer, Critchley, and Preuschoff 2009). The association between alexithymia and decreased activation in these networks during exposure to emotioninducing stimuli provides some support for the view that alexithymia reflects impaired processing of emotions. There is also experimental evidence that putting feelings into words (lexithymia) enhances emotion regulation, partly by reducing autonomic arousal. In a recent study, affect labeling, relative to other forms of encoding, was found to diminish activity in the amygdala and other limbic regions in response to viewing negative emotional images (Lieberman et al. 2007).
T H E D I M E N S I O N A L N AT U R E O F A L E X I T H Y M I A
One common misunderstanding among psychoanalysts is the assumption that alexithymia is an all-or-none phenomenon and therefore defines a type of person. Categorizing patients as alexithymic or nonalexithymic rather than placing them on a dimension of severity may influence treatment decisions, including suitability for psychoanalysis or psychoanalytic psychotherapy; it also has implications for understanding the etiology of the construct, which we discuss later. Nemiah and Sifneos were somewhat unclear as to whether they considered alexithymia categorical or dimensional. Krystal (19821983), however, declared that it varies in intensity not only from one patient to another, but sometimes also within the same individual, albeit in response to highly stressful situations such as development of a serious illness; he thereby conceptualized alexithymia as a personality trait, but with some potential state variation. In recent years, the empirical method of taxometric analysis (Waller and Meehl 1998) has been used to investigate whether alexithymia is a categorical or a dimensional construct. Using the three factor scales of 12
the TAS-20 as indicators, Parker et al. (2008) applied various taxometric procedures to large English-speaking community and undergraduate student samples and to a smaller sample of psychiatric outpatients in Canada. The results across the various procedures and the different samples provided strong support for conceptualizing alexithymia as a dimensional construct. A second study with a large sample from the general population in Finland yielded similar results (Mattila et al. 2010).
ALEXITHYMIA AND ILLNESS
Numerous empirical investigations have been conducted to determine the extent to which alexithymia is present among patients with disorders in which the features were initially observed and that led to formulation of the construct. In the earlier review, Taylor (1995) cited studies that provided empirical evidence that high degrees of alexithymia are common among patients with substance abuse disorders, eating disorders, panic disorder, and posttraumatic stress disorder. Recent studies of patients with physical illnesses have found high levels of alexithymia among patients with functional gastrointestinal disorders; contrary to the clinical observations of Nemiah and Sifneos (1970), however, with the exception of essential hypertension, lower levels have been reported among patients with so-called classic psychosomatic diseases (Taylor 2004). Of relevance to psychotherapists, in a sample of almost three hundred patients admitted to an intensive psychotherapeutic inpatient setting, 27 percent scored in the high alexithymia range (Grabe et al. 2008); this contrasts with rates of around 10 percent that have been reported for large general population samples (Franz et al. 2007; Mattila 2009). It is likely, however, that the prevalance rates of high degrees of alexithymia found in clinical populations would have been lower had the assessment been made before onset of the disorders. Other studies have evaluated the clinical impression that individuals with high degrees of alexithymia are prone to somatize. For example, in a large nationally representative sample in Finland, alexithymia (especially the difficulty-identifying-feelings facet) was associated with somatization independently of somatic diseases, anxiety, and depression, and potentially confounding sociodemographic variables (Mattila et al. 2008). There is empirical evidence that the difficulty-identifying-feelings facet of alexithymia is associated also with impulsive aggression (Fossati et al.
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2009), which is consistent with Nemiah, Freyberger, and Sifneoss observation that alexithymic patients may exhibit explosive flashes of destructive rage . . . [that are] without premonitory affect or fantasy (1976, p. 432). The range of disorders with which alexithymia is most strongly associated is consistent with the theoretical view that unsymbolized emotion can generate a variety of bodily symptoms or mindless actions that are secondary to unregulated activation of visceral and/or motoric systems. It is important to emphasize, however, that the findings from the various clinical studies are correlational only and that no causal inferences can be drawn. Indeed, it is quite possible that alexithymia is a state reaction to the presence of illness. To determine if alexithymia is a risk factor for illness, longitudinal studies are needed, with alexithymia measured before the onset of any psychiatric or medical disorder. Although the alexithymia associated with PTSD can be considered secondary to dissociation among the symbolic and subsymbolic elements within emotion schemas as a result of psychic trauma (Bucci 1997a, 2008), studies are currently under way to determine whether individuals with trait alexithymia are more vulnerable to developing PTSD.
R E L AT I O N S B E T W E E N A L E X I T H Y M I A AND EGO DEFENSES
Several psychoanalysts have suggested that alexithymia is a defense against anxiety and neurotic conflicts, rather than a type of affect deficit as Nemiah (1977) and Sifneos (1994) had proposed. Knapp (1983), for example, suggested that denial, repression, displacement and reaction formation fit the clinical facts better, but he acknowledged that when emotions and fantasies emerge they are often terrifying in their primitivity (p. 23). Krystal (19821983), by contrast, argued that alexithymia is a defense in the teleological sense only. We are dealing here with a regression in affective and cognitive development or an arrest in it (p. 375). As we elaborate later, Krystal attributes this regression or arrest to the effects of trauma. McDougall (19821983, 1989) points out that the defense theory of alexithymia and the deficit/developmental arrest theory are not mutually exclusive. She relates alexithymia to deficits in the mental representation of emotions and to early trauma, but also conceptualizes alexithymia as a massive defense against primitive terrors and inexpressible pain rather than neurotic anxieties. 14
Given these considerations, one would predict that individuals with a high degree of alexithymia would employ mostly immature (primitive) defenses in their attempts to manage distressing or overwhelming affects. To investigate this predication empirically, it has proven useful to employ measures that organize ego defenses hierarchically in relation to their overall adaptiveness. The 88-item revised Defense Style Questionnaire (DSQ), for example, provides three factor scales that separately assess mature defenses (e.g., sublimation, humor, suppression), neurotic defenses (e.g., undoing, reaction formation, idealization), and immature defenses (e.g., denial, projection, acting out, splitting, somatization) (Andrews, Singh, and Bond 1989). In studies with several nonclinical samples and with a psychiatric outpatient sample, the TAS-20 correlated moderately with the immature defense factor of the DSQ, and weakly with the neurotic defense factor; in several of the samples, the TAS-20 also correlated weakly but negatively with the mature defense factor (Helmes et al. 2008; Kooiman et al. 1998; Parker, Taylor, and Bagby 1998). There is evidence that these associations between alexithymia and defense styles still hold after controlling statistically for anxiety and depression (Kooiman, Raats, and Spinhoven 2008). The finding that individuals with a high degree of alexithymia rely primarily on immature defenses to regulate affects is consistent with the view that alexithymia reflects a lower level of functioning in contemporary models of affect development (see, e.g., Lane and Schwartz 1987) and also in models of self-organization. This lower level of functioning involves deficits in ego development, including impaired symbolization, as well as a limited capacity to employ higher-level defenses and other cognitive capacities to regulate affects. As Grotstein (1986) notes, there are deficits not only in the capacity to regulate affects by way of mature ego defenses, but also in the capacity to mythicize primitive affects and drives into dreams or fantasies. Instead, immature defenses are employed in an attempt to organize the internal chaos that accompanies intense but unsymbolized and poorly differentiated affective and drive arousal.
A L E X I T H Y M I A A N D E M PAT H Y
Clinicians generally report a lack of empathy in patients with high degrees of alexithymia (Krystal 1979). Lacking knowledge of their own emotional experience, these patients cannot readily imagine themselves
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in another persons situation and consequently are ineffective in appreciating the emotional states of others. Indeed, it is common for individuals with high degrees of alexithymia to seek treatment because of pressure from a discontented spouse. Empirical investigations have supported these clinical observations by demonstrating a negative relation between measures of alexithymia and empathy. For example, in a large community sample, the TAS-20 and its three factor scales correlated negatively with the empathy subscale of the BarOn Emotional Quotient Inventory (Taylor and Bagby 2000). Several other studies with samples of parolees, university students, or healthy adults assessed empathy with the Interpersonal Reactivity Index; alexithymia was related negatively to subscales assessing empathic concern and perspective taking (Bekendam 1997; Moriguchi et al. 2007; Sonnby-Borgstrm 2009). Experimental methods have also been used to evaluate the ability of individuals with a high degree of alexithymia to empathize with the emotional states of others; such methods improve the quality of alexithymia research, as they measure implicit emotional responses. For example, using pictures of facial expressions as the emotional stimuli, and monitoring facial muscle activity, Sonnby-Borgstrm (2009) demonstrated that individuals with high TAS-20 scores are less able to automatically imitate facial expressions of negative emotion than are individuals with low scores, and are thus less able to transpose themselves into the other persons emotional state. Although findings from correlational studies on alexithymia and empathy do not permit inferences of causality, the results from Sonnby-Borgstrms study are consistent with the view that an individuals emotional experience and awareness are influenced by proprioceptive information from facial muscle activity.
A L E X I T H Y M I A A N D M E N TA L I Z AT I O N
There is some overlap of alexithymia with the concept of mentalization, a concept that has gained interest among psychoanalysts in recent years, as it bridges attachment theory with psychoanalytic theory and is associated with the representation and regulation of affects, especially with the capacity to reflect on and give meaning to affective experiences (Jurist 2005). As noted earlier, the concept of mentalization was introduced by French psychoanalysts in the early 1960s (Fain and Marty 1964) to refer to representational and fantasy activity. It was adopted more than three decades later by Fonagy and Target (1997; Fonagy et al. 2002), who 16
conceptualized mentalization more broadly as the capacity to be aware of and to think about feelings and other mental states (e.g., beliefs, intentions, desires) in oneself and others. This definition is similar to Gardners concepts of intrapersonal intelligence (the capacity to access ones own feeling life, to discriminate among ones feelings and enmesh them in symbolic codes, and to use them to understand and guide ones behavior) and interpersonal intelligence (the capacity to read the moods, intentions, motivations, and desires of others), from which the construct of emotional intelligence was derived. Gardner (1983) deemed symbolization to be essential for the personal intelligences and conceptualized them as dimensional constructs. Similarly, Lecours and Bouchard (1997) conceptualize a hierarchy of levels of mentalization, with the higher levels involving greater symbolization as bodily excitations become linked with images and words. There is empirical evidence that alexithymia is strongly and inversely related to emotional intelligence and to its intrapersonal and interpersonal components (Parker, Taylor, and Bagby 2001). More recently, Fonagy, Bateman, and Luyten (2012) have described mentalization as a multifaceted construct and acknowledged its close relation to several other constructs, including alexithymia, emotional intelligence, empathy, psychological mindedness, and theory of mind. Although mentalization is usually measured with the Reflective Functioning (RF) Scale, given the conceptual overlap with other constructs it has recently been recommended that different facets of mentalization may be assessed with measures of alexithymia, emotional intelligence, empathy, and psychological mindedness (Luyten et al. 2012). As noted earlier, the TAS-20 correlates negatively with measures of these other constructs. Moreover, it is possible that deficits in the affective processing of an individual patient may be more adequately assessed with the TAS-20 or TSIA, as there is some evidence that the RF Scale is more sensitive to a subjects quality of affect elaboration in others rather than of self, which is consistent with the theory of mind aspect of mentalization (Bouchard et al. 2008, p. 60). Yet there is empirical evidence that alexithymia is related negatively also to theory of mind; in an investigation with college students, those with a high degree of alexithymia scored significantly lower on a theory of mind task than students with a low degree (Moriguchi et al. 2006). And just as mentalization and reflective function are affected by individual differences in attachment, there is empirical evidence (described below) that alexithymia too is related to attachment status. 17
Notwithstanding the empirical relations of alexithymia with several facets of mentalization, alexithymia is a more narrowly defined construct concerned specifically with emotional self-awareness and the ability to symbolize and regulate ones own emotional states. It corresponds most closely with a specific aspect of mentalization that Fonagy et al. (2002) have labeled mentalized affectivity, which includes identifying, processing, and communicating affects (Jurist 2005). Alexithymia does not encompass the cognitive aspects of mentalization, such as thinking about thinking and understanding that others have thoughts, feelings, beliefs, and desires that are different from ones own (Allen, Fonagy, and Bateman 2008). In further distinguishing between the two constructs, Fonagy, Bateman, and Bateman (2011) emphasize that in contrast to alexithymia, mentalization is not a static and unitary skill or trait. . . . [but] a dynamic capacity that is influenced by contextual factors such as stress and arousal, particularly in the context of specific attachment relationships (p. 105). As mentioned earlier, it was Krystals clinical impression (19821983) that the severity of alexithymia may sometimes vary within the same individual; however, such variations are generally associated with mood changes or highly stressful life events rather than with acute states of arousal. Indeed, several studies have shown that alexithymia scores are influenced by the presence of anxiety or depressive symptoms, and therefore lack absolute stability, yet the relative differences in alexithymia scores among individuals remain the same over time (relative stability) (see, e.g., Luminet, Bagby, and Taylor 2001; Luminet et al. 2007). These empirical findings demonstrate that although alexithymia is a trait, it shows some state variation in response to gradual changes in an individuals affective state; this is consistent with other personality traits such as neuroticism and extroversion (Santor, Bagby, and Joffe 1997). In general, an individuals degree of alexithymia is fairly constant in clinical situations and other interpersonal contexts, whereas the capacity for mentalization can change abruptly, especially in the transference and other emotionally intense relationships. Some of the differences between alexithymia and the broader construct of mentalization are illustrated by the following clinical vignettes.
Case 1: Mary
Mary, a twenty-three-year-old graduate student, was referred for psychotherapy because of a six-month history of pain and feelings of numbness in her face and arms for which no organic cause had been 18
found. Although she has never been anorexic or prone to purging, she describes frequent binge eating since adolescence and a habit of strenuous dieting whenever she becomes excessively overweight. Quite often Mary complains also of abdominal discomfort, bloating, and altered bowel habits, which her physician attributes to irritable bowel syndrome. In her sessions, Mary has considerable difficulty identifying and describing subjective feelings; she reports no fantasies or dreams, and her thought content is characterized by a preoccupation with her somatic dysfunctions and details of external events. She is unable to relate the tingling sensations in her body and episodes of binge eating to any life events or inner conflicts. When the therapist asks Mary how she is feeling, she usually replies that she is upset or nervous and is unable to elaborate further on her affective experience. In describing what being upset is like for her, she says, It is like fretting and then I revert to eating. Mary reports that being upset or feeling nervous usually prompts an eating binge, but she then proceeds to describe details of recent changes in her body weight or lists the various foods she consumes during a binge. On occasion, Mary is aware that her impulsive bingeing is triggered by emotional arousal: I feel agitated and then become selfdestructive, she says; Its as if I cant eat enough. Unable to link the agitation with images or words that would allow her to identify specific affects that she could begin to think about, Mary aborts the arousal by mindless acting-out behavior: All I know is that I feel agitated and reach for a bag of cookies and then not feel agitated again. Mary denies feeling depressed; in fact, she says that she doesnt know what depression is. She recently took up sports to work off tension. Although she is distant in her interpersonal relationships and slow in forming an emotional attachment to the therapist, she appreciates his efforts to help her learn about her emotions and feelings and does not misconstrue his intentions and interventions.
Case 2: Sylvia
Sylvia, a twenty-one-year-old undergraduate student with a borderline personality disorder, was referred for psychoanalytic psychotherapy because of recurrent suicidal threats, fear of her own violent impulses, and affective instability. For several years she has engaged in selfmutilating behavior, especially when overwhelmed by feelings of abandonment, rage, or intense despair. Although she displays a wide range of intense and unregulated emotions during therapy sessions, she is able to 19
name the various feelings, including anger, shame, guilt, disgust, love, hate, sadness, and helplessness. Sylvia reports many fantasies and dreams, which usually reflect aspects of childhood emotional trauma and a wish to find refuge in an imaginary safe world. However, she tends to relive these past traumas in actuality in the transference. She frequently misperceives aspects of the therapists nonverbal behavior, or misconstrues his questions or comments. For example, she sometimes accuses him of mocking her when he has a slight smile on his face, of looking at her in a lustful way, and of hating or betraying her if he is slightly late or needs to change an appointment to a different day. She is unable to consider alternative explanations at these times. Although Sylvia is sometimes receptive to the therapists attempts to understand the instability in her interpersonal relationships, she more often loses her capacity to reflect and think about his comments, and then viciously accuses him of attacking her. Feeling abandoned at the end of sessions, she sometimes flees to the washroom, where she screams for several minutes.
Discussion
Whereas Mary shows a high degree of alexithymia, Sylvia knows what she is feeling and has no trouble identifying different affects and expressing them. However, both patients have difficulty regulating states of emotional arousal; they engage in action-based modes of expression and have a limited capacity to reflect on the meaning of their mental states. Having a dismissing attachment style and only a vague awareness of her feelings, Mary is prone to functional somatic symptoms and compulsive bingeing or physical activity to regulate the bodily tension associated with emotional arousal. Sylvia, by contrast, displays disorganized attachment; she is overwhelmed by too much affect and attempts to alleviate her distress and down-regulate the intensity of arousal through self-mutilating and other impulsive behavior. Further, and again in contrast to Mary, Sylvia misinterprets emotional facial expressions and manifests marked deficits in cognitive aspects of mentalization; equating her thoughts and misperceptions with reality, she suspends the as if dimension of thinking and consequently misreads the mental state of her therapist, including his intentions and feelings. Because of these failures in mentalizing, Sylvia becomes suspicious, antagonistic, and impulsive in most of her interpersonal relationships, which results in further affective instability. The differences between these two patients are consistent with Fonagy, Bateman, and Batemans observation (2011) that patients may 20
show impairment in some components of mentalization, but not necessarily in others.

T H E E T I O LO G Y O F A L E X I T H Y M I A
From a clinical perspective it is important to know whether alexithymia is an inherited trait, is acquired through adverse childhood experiences, or results from interactions between environmental/developmental factors and a temperamental disposition. Nemiah (1977; Nemiah, Freyberger, and Sifneos 1976) speculated that both genetic factors and early life experiences contribute to the etiology of alexithymia; Krystal (1988) proposed that psychic trauma resulting in an arrest in affect development in childhood, or inducing affect regression in adolescence or adulthood, is the main etiological factor. A multifactorial etiology is strongly suggested by the evidence we reviewed earlier in considering the dimensional nature of alexithymia. As Haslam (1997) explains, a dimensional latent structure of a personality construct is incongruent with single gene effects and with single discrete environmental effects, but could implicate a combination of genetic and environmental factors. Findings from two recent twin studies provide some support for an etiological model of alexithymia that involves both genetic and environmental factors. In a study with a population-based sample of 8,785 Danish twin pairs with an age range of twenty to seventy-one years, Jrgensen et al. (2007) demonstrated that genetic factors accounted for 30 to 33 percent of the variance in TAS-20 scores, with non-shared, and to a lesser extent shared, environmental influences accounting for the remaining proportion of the variance. In a subsequent study with a sample of 729 Italian twins aged twenty-three to twenty-four years, Picardi et al. (2011) found that genetic factors accounted for 42 percent of the individual differences in alexithymia, but that this heritability estimate fell to 33 percent when depression was included as a covariate in the genetic models; as with the Danish study, unshared environmental factors accounted for most of the variation in alexithymia. Given the growing body of evidence that early experience and specific environments influence the expression of genes (Rutter 2006), it is most likely that the genetic and environmental factors contributing to alexithymia do not influence affect development independently, but rather involve gene-environment interactions. Fonagy et al. (2002) argue that it is not the actual environment that regulates gene expression, but 21
the way the child experiences, processes, and interprets the environment. These authors place particular importance on the childs experience of early attachments, which are influenced by the sensitivity, attunement, and mentalizing capacities of the parents, and also by the temperament and genetic characteristics of the child. It is well established that attachment experiences in early childhood influence the development of emotion schemas, imagination, and other cognitive skills involved in affect regulation (Cassidy 1994; Fonagy and Target 1997). Since a creative imagination and effective emotion-regulating skills and other mentalizing abilities are more likely to emerge in the context of secure attachment relationships (Fonagy et al. 2002; Meins, Fernyhough, and Russell 1998), one would expect alexithymia to be associated with insecure patterns of attachment. Several studies with samples of adults have yielded empirical support for this speculation. One study used the Adult Attachment Interview Q-sort, which assesses mental representations of attachment that reflect prevailing modes of affect regulation that have been internalized during childhood; alexithymia was associated positively with dismissing and deactivating attachment and negatively with secure attachment (Scheidt et al. 1999). In studies that used self-report measures of attachment, alexithymia was associated predominantly with a dismissing/ avoidant style, but in some studies also with a preoccupied and/or fearful style of insecure attachment (see, e.g., Bekendam 1997; De Rick and Vanheule 2006; Montebarocci et al. 2004; Troisi et al. 2001). Some caution is needed when considering these findings, as self-report measures of adult attachment assess conscious attitudes toward current close relationships rather than mental representations based on childhood relationships with parents, and correlations between these measures and the AAI are generally low (Ravitz et al. 2010). There is also no consensus on whether individuals should be assigned to attachment style categories, or rated on various dimensions of attachment attitudes and behaviors such as discomfort with closeness and preoccupation with relations. Moreover, an individual may manifest different patterns of attachment in different relationships. Although investigators should heed these concerns when planning studies on alexithymia and attachment, the present findings suggest that during childhood, individuals with a high degree of alexithymia experienced serious deficiencies in their caregivers responsiveness to distressing affects; a nonspecific pattern of caregiver behavior would account for the development of different insecure attachment styles as strategies for regulating emotions. As noted above, however, 22
inherited temperamental characteristics of the child may also interact with and influence the caregiving style of the parents. Closely linked with the findings from attachment research, empirical evidence is accumulating for Krystals proposal (1988) that psychic trauma plays an important role in the etiology of alexithymia. In several studies with either clinical or nonclinical samples, alexithymia or its difficulty-identifying-feelings facet were associated significantly with retrospectively reported experiences of emotional and/or physical neglect during childhood, or with childhood sexual or physical abuse (see, e.g., Berenbaum 1996; Frewen et al. 2008; Goldsmith and Freyd 2005; Paivio and McCulloch 2004; Zlotnick, Mattia, and Zimmerman 2001). The findings from these studies are likely influenced by the age of the children at the time of the abuse, the duration and severity of the abuse, and whether or not the children developed PTSD. Other studies have demonstrated associations between alexithymia and traumatic experiences during adult life. For example, levels of alexithymia were significantly higher in combat veterans with PTSD, individuals with PTSD related to motor vehicle accidents, and victims of rape (especially multiple rapes) than in comparison groups (Frewen et al. 2008; Taylor 2004; Zeitlin, McNally, and Cassiday 1993). Moreover, there is evidence that alexithymia is associated positively with both hyperarousal and emotional numbing symptoms and that these two symptom clusters are positively rather than negatively correlated in PTSD populations (Frewen et al. 2008). These findings are consistent with Buccis proposal (2008) that traumatic events can disrupt the referential connections within emotion schemas such that symbolic and subsymbolic elements in the schemas become dissociated, thereby contributing to unregulated states of emotional arousal in victims of trauma.
A L E X I T H Y M I A A N D P S YC H O A N A LY T I C T H E R A P Y
Despite the widely acknowledged difficulty in treating patients with alexithymic characteristics, at the time of Taylors review (1995) there were no empirical studies evaluating the effect of alexithymia on the process and outcome of insight-oriented therapies, or any studies evaluating the efficacy of specific psychotherapeutic approaches for reducing alexithymia that had been suggested by Krystal (1979, 19821983). Although there are still no studies investigating the influence of alexithymia on the outcome of psychoanalysis or long-term psychoanalytic psychotherapy, 23
there is now some empirical evidence that alexithymia is associated with less improvement in both supportive and interpretive forms of short-term individual and group psychotherapy (Ogrodniczuk, Piper, and Joyce 2011). And consistent with clinicians reports of experiencing feelings of dullness, boredom, and frustration when attempting to treat alexithymic patients, empirical investigations in the context of group therapy have found that higher levels of alexithymia evoke negative reactions in therapists, and that these reactions partly contribute to poor treatment outcome (Ogrodniczuk, Piper, and Joyce 2011). Although these negative findings might suggest that alexithymia is a contraindication for psychoanalytic therapy, it can be argued that knowledge gained from the larger body of alexithymia theory and research can guide therapists toward achieving better treatment outcomes. Indeed, given that alexithymia involves impaired symbolic mental functioning and is frequently associated with histories of emotionally traumatic experiences from childhood, psychoanalytic therapy may be the only therapy that can enable these patients to symbolize and contain the unmentalized emotions associated with trauma. Since emotional trauma or neglect is thought to interfere with the development of referential links between subsymbolic and symbolic elements within emotion schemas (Bucci 2008), interventions aimed at strengthening referential activity and enhancing symbolic mental functioning are of primary importance in the treatment of alexithymic patients. This requires supportive rather than interpretive interventions, including the various psychoeducational strategies that Krystal (1979, 19821983) described for increasing affect awareness and affect tolerance, and for enhancing the patients capacity for affect-related fantasy and imagery. These strategies include focusing attention on the meaning of bodily sensations and other nonverbal manifestations of emotions, and teaching patients the signal function of affects and how to label and differentiate the various affects.6 Similar strategies are used in metacognitive interpersonal therapy (MIT), a recently developed modality that shares some of the components of mentalization-based treatment, which has proved useful for patients like Sylvia who have borderline personality disorders and severe affect dysregulation (Allen, Fonagy, and Batemen 2008). As Fonagy, Bateman, and Bateman (2011) point out, MIT was designed specifically for patients with poor emotional
6 These supportive interventions differ from the short-term supportive individual and group therapies reviewed by Ogrodniczuk, Piper, and Joyce (2011), which used guidance, advice, and problem solving to foster more adaptive modes of behavior.
24
awareness; it would therefore be suitable for patients like Mary, as the interventions include helping patients recognize that arousal shifts are correlated with emotions, and find affect words to match their bodily states; they are also guided to become aware of how and why they think, feel, and act (Dimaggio et al. 2011). There are preliminary empirical evidence and occasional case reports showing that psychotherapies that incorporate these and other strategies can reduce the degree of alexithymia (Beresnevaite 2000; Dimaggio et al. 2011; Grabe et al. 2008; Melin, Thulesius, and Persson 2010; Taylor 2012; Tulipani et al. 2010). As Lecours (2007) points out, the use of supportive interventions by psychoanalysts does not imply an abandonment of the analytic stance. He argues that supportive interventions need to be employed deliberately for patients with alexithymia or other mentalizing impairments in order to transform their nonsymbolic in-session experiences into symbolic mental functioning. Once patients learn to identify, consciously experience, and communicate their subjective feelings, analysts must be prepared for considerable turmoil in the therapeutic relationship as further analytic work begins to reactivate intense trauma-related emotions that need to be linked with imagery and words so they can be integrated and gradually contained by the patient (Taylor 2012). It is important also for psychoanalytic therapists to identify the subtypes of insecure attachment associated with alexithymia, as these influence the nature of the transference and may require different therapeutic interventions. Whereas patients with a dismissing style have difficulty reexperiencing painful emotions and acknowledging the analysts importance to them, those with a preoccupied style will manifest displays of unregulated and poorly differentiated affect, and often become dependent and demanding (Slade 2000). Therapists should also anticipate that alexithymic patients will employ primitive defenses and engage in maladaptive coping behaviors to regulate affects, which may also be expressed through medically unexplained somatic symptoms. Since the feelings evoked by alexithymic patients may influence treatment outcome, it is important to closely monitor and reflect on countertransference feelings, as these may provide clues as to what is going on in the patient. Taylor (1984) and McDougall (19821983) suggest that the countertransference feelings and images evoked by these patients often represent primitive affects and fantasies that have been split off and projected into the therapist, who may use them to better understand the patients early traumatic experience and to gradually facilitate symbolic representation and expression. 25
CONCLUDING COMMENTS
The example of alexithymia shows how the development of a reliable and valid instrument for measuring a psychoanalytic construct not only provides support for the validity of the construct, but also provides opportunity for a wide range of other empirical investigations that can yield clinically relevant findings. These investigations may include correlational studies that clarify the nature of relations with other psychoanalytic constructs, experimental studies that evaluate theoretical proposals about underlying deficits, brain-imaging studies that identify neural correlates of the construct, twin studies that determine the extent to which a construct can be explained by genetics, and treatment studies that evaluate the efficacy of different therapeutic interventions. Various statistical procedures, such as confirmatory factor analysis and taxometric analysis, can be used to determine whether the defining features of a construct are likely to be present among patients across cultures, and whether patients vary in the extent to which they manifest these features. The findings from empirical research on alexithymia are of value to psychoanalytic therapists, as they provide greater understanding of patients who are difficult to treat because they have limited awareness of their feelings, are prone to somatic symptoms and action-based behavior, seem resistant to exploration of their unconscious inner world, fail to interact emotionally with their therapist, and often evoke feelings of frustration, boredom, and depletion in the therapist. The research links these characteristics to deficits in the capacity to symbolize emotions, and shows that alexithymia is a fairly stable trait. Therapists can anticipate that patients with a high degree of alexithymia will manifest a predominance of primitive defenses and impairments in empathy and mentalizing, especially in the affective dimension of mentalization. Listening carefully to the patients narrative will identify an operative mode of thinking with low referential activity, which helps the therapist understand the negative feelings evoked in him or her. As with the patients other relationships, the transference will usually be influenced by an insecure attachment style, which will also alert the therapist to the need to explore the likelihood of childhood emotional trauma and/or limited affect attunement and mentalizing by the patients parents. Although long-term outcome studies are required, the existing research suggests that these patients are likely to benefit from supportive interventions guided by a theoretical understanding of the impaired symbolization associated with alexithymia, rather than from interpretive interventions. 26
Although we wrote this paper to exemplify the use of empirical methods for examining psychoanalytic constructs, it is important to emphasize that systematic clinical observations are also necessary for the advancement of psychoanalytic knowledge. We believe that using both clinical and empirical methods strengthens the position of psychoanalysis in the broader scientific community. Psychoanalytic case studies generate hypotheses that need to be evaluated through systematic empirical research (Eagle and Wolitsky 2011); but clinically derived constructs can also generate many other research ideas that bring psychoanalysis into closer relation with other scientific disciplines that have the similar aim of advancing knowledge of the human mind and its relations with the brain and body. This is evidenced by the example of alexithymia, which has inspired a diverse range of collaborative investigations that have not only supported many clinical observations and impressions, but also contributed to a greater understanding of the basis for, and consequences of, deficits in emotional processing.
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PSYCHOANALYSIS AND EMPIRICAL RESEARCH: THE EXAMPLE OF ALEXITHYMIA

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