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When you think of the personality traits in psychology with the greatest importance, you may be likely to regard them as fitting into the well-established framework of the Five Factor Model (FFM). According to the FFM, personality fits neatly into the five categories of conscientiousness, openness to experience, agreeableness, extraversion, and neuroticism (also thought of as the opposite of emotional stability). There is a vast body of research supporting the FFM, along with studies showing how its sub-categories, or facets, change over the course of the adult years. FFM research also examines the relationship of its five factors and facets to various health-related behaviors and outcomes. Some even believe the FFM traits to be genetically determined.

Enter a long-known-but-underappreciated personality trait as a distinct entity in its own right. The personality trait of alexithymia was identified over four decades ago by Boston psychoanalyst John Nemiah and colleagues (1976). Intended to capture the personality of people seen in therapy who fit the profile of what they call the “boring” patient, alexithymia literally translates from the Greek to mean “no words for emotions.” The reason people with alexithymia are so "uninteresting" in therapy is precisely because they have so much difficulty expressing their emotions. They may enter treatment for symptoms such as disordered eating or a host of physical complaints, but because they can’t put their feelings into words or even describe their dreams (an obvious concern in psychoanalysis), the conversation with them is likely to run out of steam very quickly. In a 2018 APA Convention presentation, R. Michael Bagby, of the University of Toronto, provided an impressive 50-minute summary of the large body of work generated in the study of this trait.

The most well-established measure of alexithymia is the 20-item Toronto Alexithymia Scale (TAS-20), which Bagby and colleagues published in a landmark book (1994). Now translated into multiple languages and used in literally thousands of studies, the TAS-20 captures the 3 interrelated elements of difficulty identifying feelings in the self (DIF), difficulty describing feelings (DDF), and externally oriented thinking style (EOT) in which people don’t attend to their own emotions or inner states. As stated by Edith Cowan University (Australia)’s David Preece and colleagues (2018), people with alexithymia rarely pay attention to their emotional states (EOT), and have difficulty appraising what those states are (DIF, DDF). Their emotional regulation is disturbed in that they tend toward experiential avoidance, but they also suffer from difficulties, because they don’t have a good internal tracking system for identifying emotional states.

Research conducted since the original conceptualization of this trait confirms that people high in alexithymia are poor candidates for psychotherapy, while at the same time having higher risk for a variety of psychological disorders. Scores on the TAS-20 correlate with feelings of psychological distress and difficulties in regulating emotions. Additionally, TAS-20 scores are related to emotional intelligence, particularly in the component of intra-personal intelligence (Onur et al. 2013).

The Australian authors believed that, while the TAS-20 has certainly gained widespread use, it is not clear whether it best breaks down into three factors (vs. four), nor is it clear that the structure of the TAS-20 is the same for people who do and do not have a psychological disorder. Finally, the sub-scales of the TAS-20 are reported to be somewhat lower than acceptable testing standards. The Preece et al. study was intended to determine if it is possible to improve the scale’s ability to measure alexithymia in a valid and reliable manner.

The 428 non-clinical online participants in the Australian study and 156 clinical patients in the psychiatric sample completed a set of psychological tests that included the TAS-20. Examples of items on the TAS-20 scales include: “I am often confused about the emotion I am feeling” (DIF); “It is difficult for me to find the right words for my feelings” (DDF); and “Being in touch with emotions is essential” (EOF, reversed-scored). Participants rate their agreement with each item on a five-point scale.

Statistical analyses revealed that the original three-scale structure of the TAS-20 fit the patterns of scores for both the clinical and non-clinical samples. However, the EOT sub-scale did not meet appropriate standards, and therefore, although it appears to tap into some aspects of alexithymia, the authors believe it does not do so in a robust manner.

These technical issues aside, what do we now know about alexithymia 40 years after its initial identification? Even though EOT may not be appropriately measured with the TAS-20, the combination of avoidance of strong feelings along with an inability to understand the nature of one’s own feelings can clearly lead to difficulties when individuals high in overall alexithymia are involved in close relationships. They will stay away from emotionally laden experiences, both good and bad, and they will also be unable to express themselves clearly to their partners.

Alexithymia may also be damaging to an individual’s health. Michela di Trani and colleagues (2018), of Sapienza University (Rome, Italy), compared older hypertensive patients with college students on measures of alexithymia, including an interview assessment and a questionnaire that focuses specifically on an individual’s ability to provide labels to such inner states as bodily experiences, verbal imagery, and affect. As the authors note, people high in the quality they call Referential Ability (RA) use “language that is vivid, specific, full of imagery, and evocative,” compared to people on the alexithymia dimension whose language is “abstract, vague, general and diffuse.”

Trani and her collaborators used a discourse analysis program to provide RA scores from audio recordings of the alexithymia interviews. Overall, participants with hypertension indeed had higher TAS-20 scores than did the healthy college controls. For both groups, people with higher alexithymia scores also had lower scores on the component of the interview measuring sensitivity to somatic sensations. The most significant feature marking the individuals with hypertension was a tendency to show wide fluctuations between no feeling awareness at all and an extreme spike in emotional activation. As the authors concluded, “lack of contact with emotions and emergence of emotions in a very intense and unregulated way” (p. 244) tend to alternate. In people low in alexithymia, emotional expression rises and falls more gradually, so that their inner awareness of their emotions and their ability to express those emotions are in sync. If they get angry, they are aware of their anger and express it accordingly. People high in alexithymia may be more likely to explode all of a sudden.

The physical toll taken by people with high alexithymia shown in the Italian study adds one more piece to the puzzle of understanding why this trait can have such negative consequences. Given the focus on the “Type A” behavior pattern of hostility, impatience, and competitiveness, it may be worth examining the contributing role of alexithymia to the personality-health relationship. 

To sum up, being aware of your emotional state and then being able to put those feelings into words can become an important contributor to physical and psychological problems in ways you may not otherwise recognize. Although the original psychodynamic view of this trait stemmed from observations of “boring” patients in psychotherapy, the renewed interest in alexithymia may provide therapeutic approaches specifically aimed at helping these individuals gain fulfillment through a healthier awareness of their emotions.

References

Nemiah, J. C., Freyberger, H., & Sifneos, P. E. (1976). Alexithymia: A view of the psychosomatic process. In O. Hill (Ed.), Modern trends in psychosomatic medicine, Vol. 3 (pp. 430–439). London, UK: Butterworths. 

Bagby, R. M., Parker, J. D., & Taylor, G. J. (1994). The twenty-item Toronto alexithymia scale—I. Item selection and cross-validation

of the factor structure. Journal of Psychosomatic Research, 38, 23–32.

Preece, D., Becerra, R., Robinson, K., & Dandy, J. (2018). Assessing alexithymia: Psychometric properties and factorial invariance of the 20-item Toronto Alexithymia Scale in nonclinical and psychiatric samples. Journal of Psychopathology and Behavioral Assessment, 40(2), 276-287. doi:10.1007/s10862-017-9634-6

Onur, E., Alkın, T., Sheridan, M. J., & Wise, T. N. (2013). Alexithymia and emotional intelligence in patients with panic disorder, generalized anxiety disorder and major depressive disorder. Psychiatric Quarterly, 84(3), 303-311. doi:10.1007/s11126-012-9246-y

Di Trani, M., Mariani, R., Renzi, A., Greenman, P. S., & Solano, L. (2018). Alexithymia according to Bucci's multiple code theory: A preliminary investigation with healthy and hypertensive individuals. Psychology and Psychotherapy: Theory, Research and Practice, 91(2), 232-247. doi:10.1111/papt.12158