Sensitivity & alexithymia

This post is based on an email consultation (service no longer offered), which the consultee gave permission to post so more people may benefit from the information. Thank you!

The first of 3 related questions she asked was:

What tools and techniques help with the balance between sensitivities and alexithymia? (not recognizing our feelings or sensitivities or suppressing them)

Sensitivities & alexithymia

There is an interesting relationship between sensitivities on the one hand, and alexithymia on the other. Because although alexithymia can desensitize us in many ways, it does nothing to prevent sensory overwhelm, for instance. This results in an interesting mix between hypersensitivity and hyposensitivity. One example is an experience I had which I call “a panic attack without panic”, where I felt all the physical sensations of a panic attack, but mentally I stayed calm and rational. Read more about that in the post below.

The experience of overwhelm

So rather than hypersensitivity and alexithymia being polar opposites that ought to be balanced against each other, they actually both interact with each other in such a way that we experience more anxiety. Let’s look at some research to clarify this.

A study from 2008 by Miriam Liss, Jennifer Mailloux, and Mindy J. Erchull shows something interesting about the relationships between three factors of sensory processing sensitivity:^[1]The relationships between sensory processing sensitivity, alexithymia, autism, depression, and anxiety (Liss, Mailloux, & Erchull, 2008)

• Ease of excitation (a tendency to become mentally overwhelmed by internal or external stimuli) and low sensory threshold (a tendency to experience unpleasant arousal in the face of external stimuli) were related to autism symptoms, alexithymia, anxiety, and depression.
• Aesthetic sensitivity (a greater awareness and appreciation of beauty) was related to attention to details (a symptom of autism) and anxiety but not to depression.
• Aesthetic sensitivity was also negatively related to externally-oriented thinking (a symptom of alexithymia).

The research shows that ease of excitation and difficulty identifying feelings (alexithymia) together predict anxiety. In other words, being both easily excited by stimuli and unable to identify one’s feelings is particularly anxiety-provoking.

And the more anxiety we experience due to our sensitivities, the greater our alexithymia potentially becomes; it acts as a defense mechanism. After all, what better way to cope with sensitivities than to cut off access to the experience of those sensitivities? The problem, however, is that alexithymia prevents us from processing our feelings, and as a result, those feelings get suppressed and stored in the body through a process called somatization. This leads to various bodily symptoms, including pain^[2]Somatization and Bodily Distress Disorder (de Greck, 2018) and the emergence of conditions like fibromyalgia. Various papers have established a clear relationship between pain and alexithymia in fibromyalgia patients.^[3]Relationships Between Physical Symptoms, Emotional Distress, and Pain Appraisal in Fibromyalgia: The Moderator Effect of Alexithymia (Martínez et al., 2014)^[4]Pain experience in Fibromyalgia Syndrome: The role of alexithymia and psychological distress (Di Tella et al., 2016)

Also note that ignoring sensitivities—as well as the anxiety that results from it—leads to suppression, which sustains alexithymia. Research from 2009 shows that alexithymic individuals are more prone to suppressive emotion regulation strategies rather than reappraisal strategies (cognitively reframing an event to reduce its negative impact).^[5]Dealing with Feelings: Characterization of Trait Alexithymia on Emotion Regulation Strategies and Cognitive-Emotional Processing (Swart, Kortekaas, & Aleman, 2009)

Alexithymia is a fairly stable construct related to emotion regulation, but research from 2005 by Moïra Mikolajczak and Olivier Luminet shows that situational stress increases anxiety, obsessions, and somatization.^[6]Is alexithymia affected by situational stress or is it a stable trait related to emotion regulation? (Mikolajczak & Luminet, 2005)

And since alexithymia and hypersensitivity together increase anxiety, you can see how this, in turn, leads to greater attempts to ignore and suppress sensitivities. It’s a vicious circle of sensitivity and desensitization! Although I have not been able to substantiate with research that anxiety and somatization have an effect on alexithymia and sensitivity as well, I think the diagram above is a fairly accurate representation of that vicious circle.

Deficit of awareness

It has been suggested that alexithymia is a deficit of awareness or of emotional representations in working memory.^[7]A processing theory of alexithymia (Frawley & Smith, 2001) Why is this problematic? After all, alexithymia is an adaptation that helps us cope with perpetual overwhelm (read more about that in the Defense mechanism section of the post below).

Alexithymia & autism guide

The problem is that this deficit of awareness causes certain feelings to build up inside us without us necessarily being (fully) aware of those feelings until they reach a climax. So yes, it desensitizes and postpones the experience of negative feelings. But then our feelings escalate, and not being aware of them, we can’t address them until they reach a certain threshold. And what do you think the experience of escalated feelings is like? Right—it feels very intense! People with alexithymia can be seemingly unfazed by anything, but ultimately they can become explosive “out of nowhere”.

Maybe that is more characteristic of PTSD, but PTSD and alexithymia often co-occur, and PTSD is moderately associated with alexithymia, in particular difficulties with identifying feelings.^[8]Posttraumatic stress and alexithymia: A meta-analysis of presentation and severity (Edwards, 2019)

When I was very high in alexithymia, I was generally quite non-reactive, but over a period of months feelings would build up, until finally, I had a big release of emotions in the form of a meltdown or crying. It actually felt like such a big relief to cry and let it all out. It felt like I was resetting, after which I could take on the world for another few months.

Emotional processing

At its core, alexithymia is difficulties with emotional processing.^[9]A processing theory of alexithymia (Frawley & Smith, 2001) Brain regions involved in alexithymia are the corpus callosum, the cingulate cortex, the insula, and the amygdala and the orbitofrontal cortex appear to be implicated as mediators, because of their broader involvement in emotional processing and executive control.^[10]The neurocognition of alexithymia: evidence from neuropsychological and neuroimaging studies (Wingbermühle et al., 2012)

One of the issues of dysfunction in emotion centers in the brain such as the orbitofrontal cortex is that it leads to interference with the processing of somatic or emotional signals.^[11]The role of emotion in decision-making: Evidence from neurological patients with orbitofrontal damage (Bechara, 2004) This is evidenced especially by people who have sustained head injury, leading to indecisiveness.^[12]Deficits in decision-making in head injury survivors (Salmond et al., 2005)^[13]Orbitofrontal cortex and its contribution to decision-making (Wallis, 2007) This is also particularly relevant to alexithymia since organic alexithymia (a subtype of secondary alexithymia) is caused by brain damage.

This interference with the processing of somatic and emotional signals causes us to loop information in the brain, so sensitivities are no longer processed. Neither is trauma, and as such alexithymia and PTSD are sustained.

Solution

The solution, thus, isn’t really about finding a balance between sensitivities and seeming lack thereof. Instead, you need to focus on two things:

• Connect with and process your feelings
• Decrease your alexithymia

Fortunately, the two are correlated, so I suppose it’s really one thing you need to focus on; your objective is to decrease alexithymia, which you do by connecting with your feelings. And I know, that can feel scary and frustrating, for two reasons:

• Feelings can be overwhelming, which is exactly why you have alexithymia to better cope. Wouldn’t decreasing alexithymia open the flood gates so to speak?
• Due to alexithymia, certain feelings are not readily accessible to us, and at least in my experience, being urged to focus on them, identify them, and describe them has been frustrating, agitating, and at times triggering.

To the first point, I would say that there is not going to be a sudden switch. By digging deeper into your emotional experience, and connecting those with bodily sensations, with frequent practice, you will get better at it. And each time you do it—triggering as it may be—you will more readily process your emotions rather than somatize them. Provided you are in a safe environment, decreasing your alexithymia will not make your emotional experience overwhelming, because your emotionality will grow in accordance with your ability to process your emotions and self-regulate. For example, when I decreased my alexithymia, I went from crying twice per year to crying several times per week or even daily. But I wasn’t more upset or depressed, or any less happy. Instead, I was just more in tune with my emotions. I would cry for a minute, and then the feelings are processed and everything is fine. I continued doing that for quite a while as I dealt with all the emotions I locked up in my body over the years.

The process of getting in tune with your emotions can be frustrating and exhausting in the beginning. Natalie would ask me how I’m feeling, and my initial response would be “I don’t know”. After she asks a second time, I find my brain actually starts looking for a meaningful response, and explores my inner emotional experience. It’s interesting how my initial response actually evades genuinely looking at that. That’s why it’s so helpful to have a partner or friend who urges you to look at your emotions rather than ignore and suppress. Usually after I am asked about my emotional experience a second time, I do have a better answer. And the more we did this, the better my answers became as I was able to report more on my internal experience.

But sometimes, feelings would remain difficult to access, and I found I would sometimes respond with anger. That is one of the defense mechanisms you will likely experience. Just stay with your emotions, and don’t fight it. If you find you are getting angry and frustrated, explore those feelings, too. Ask yourself why you are having this reaction, and just focus on the somatic experience of that frustration. Where in your body do you feel that emotion? In the image below, based on research from 2014, you can see a mapping of where emotions are felt in the body.^[14]Bodily maps of emotions (Nummenmaa et al., 2014) For those with anxiety, for example, it should not be a surprise that anxiety is felt in the chest, and indeed somatizes there as well. Having alexithymia, I joked how I cannot tell the difference between feeling anxious and feeling proud. For more information on this, listen to our talk on alexithymia: Mini-lecture: alexithymia

So by decreasing alexithymia, you can process emotions earlier in the process without leading to escalation, and without suppression and somatization. Below are a few more tips when it comes to processing your emotions.

• Use logic. You need your emotions online to make rational decisions.
• Identify emotions > feel emotions in your body (somatic experience) > mobilize action in your head.
• Ask yourself, “Is the feeling/emotion connected to the present or the past?”
• Alexithymia is all about safety. Ask yourself, “Am I safe? Are people around me safe?”
• We want to be seen for who we are, and provided we are in a safe environment where we can be ourselves, we have to honor who we are, without evasion or suppression.
• Anticipate challenges.
• Practice reappraisal. By practicing reframing events to reduce their impact and finding the benefits of past events, experiences, and challenges, you can strengthen your reappraisal ability. As a result, you are more likely to confront challenges and process the emotions that come up, instead of evading and suppressing them.

Facing feelings as awareness

Lastly, let me leave you with a video by Rupert Spira, which I found to be very helpful to promote awareness and mindfulness, and to focus on the somatic experience without overidentifying with your emotions.

In a future post, I will talk more about specific therapeutic approaches that deal with alexithymia.