Psychosomatics 39:554-555, December 1998
© 1998 The Academy of Psychosomatic Medine
Disorders of Affect Regulation: Alexithymia in Medical and Psychiatric Illness
Edited by G.J. Taylor, R.M. Bagby, J.D.A. Parker, Cambridge, UK, Cambridge University Press, 1997, 359 pages, ISBN 0-521-45610, $85
James L. Griffith, M.D.
Key Words: Book Review
Alexithymia—the notion that patients who somatize lack ability to understand or express emotions with language—has provided much of the impetus over the past two decades for studying how the neurobiology of emotion may relate to unexplained physical symptoms. The basic idea for this condition has been refined since the 1970s, when Peter Sifneos and John Nemiah first proposed alexithymia as a possible explanation for somatization.
The current concept of alexithymia is a relative difficulty (not total) in using language to understand the emotional states of self and others, rather than Freudian ideas about libido discharged into bodily organs when it cannot be expressed in words. It is as a dimensional trait spread throughout the population. Alexithymia, when prominent, creates difficulties by robbing a person of the ability to use language to regulate affects. This failed access to emotional language means a person must live without the buffering of distress that concerned family members, friends, and other relationships can provide when mobilized.
In this book, Taylor, Bagby, and Parker tell the story of alexithymia—its origins as a construct, the research efforts to validate it, and the extension of efforts to use it beyond somatization to understand substance abuse, eating disorders, depression, panic disorder, and posttraumatic stress disorder. Their writing is admirably clear and well-organized, so that their topic, which thus far has been more intriguing in theory than in clinical innovation, nevertheless keeps the reader musing about potential applications to clinical treatment. They accomplish this, in part, by providing not only an account of alexithymia, but also lucid current summaries of the neurobiology of emotion, attachment theory, and affect regulation.
The first chapter provides an overview of theories of emotion and normal affect development. They propose possible relationships between affect regulation and early life relationships, emphasizing the roles that ambivalent and avoidant attachments in early life may play in poor affect regulation later in life. The second chapter outlines salient features of the alexithymia construct as currently understood: first, difficulty identifying feelings and distinguishing between feelings and bodily sensations of emotional arousal; second, difficulty describing feelings to other people; third, constricted imaginal processes; and fourth, a stimulus-bound, externally oriented cognitive style. This perspective views alexithymia as an arrest at, or regression to, a preconceptual (sensorimotor) level of emotion organization. Individuals identified as highly alexithymic often appear anhedonic, with a limited capacity for experiencing joy, happiness, and love, and the authors illustrate these features in an interview transcript of an alexithymic patient. These alexithymic features are attributed to putative disturbances in the regulation of affects, which the authors believe to be a psychopathological mechanism for a broad range of serious psychopathologies and poor physical health.
The third and fourth chapters summarize evidence supporting the validity of the alexithymia construct and its relationship to prior research on personality factors and coping styles. They outline the historical development of methods for quantitating alexithymia and the reliabilities of these instruments are discussed, with a detailed discussion of the Toronto Alexithymia Scale–20. Chapter Five begins with an overview of the neurobiology of emotion, emphasizing the roles of the two cerebral hemispheres in the perception, expression, and regulation of affects. This chapter is one of the most interesting ones because of its clarity in summarizing succinctly not only findings from research studies of alexithymia, but also the broader discussion of affect regulation in the central nervous system.
Chapters Six through Ten discuss consecutively how impaired affect regulation may help generate somatoform disorders, anxiety and depressive disorders, substance abuse disorders, personality disorders, eating disorders, and medical diseases. The authors propose a reconceptualization of the somatoform disorders as disorders of affect regulation, citing research findings that link a tendency to develop medically unexplained symptoms with limited ability to modulate negative affects. They view anxiety and depressive disorders as arising from loss of ability to use anxiety or depression as signal affects, so that emotions that might otherwise have prompted adaptive changes when "unread," instead become sources of agitation. While acknowledging the multifactorial etiologies of substance abuse and eating disorders, the authors argue that impaired affect regulation underlies both disorders, accounting for treatment relapses when ingestion of substances or restricting/bingeing/vomiting food are used to buffer affects that are intolerable. In such medical disorders as coronary artery disease and cancer, they show how such disease risk factors as type A behavior and repressive coping styles might be understood in terms of poor regulation of affects.
Treatment methods that derive specifically from an alexithymia construct appear to be limited at present. The authors advocate a stronger focus on education and therapist modeling, which has been customary for most psychodynamic psychotherapists. They recommend efforts to help patients find language for experience that has been previously inchoate. As a deficit model, it is expected that patients will be most symptomatic when attempting to manage more emotion that floods limited capacities for coping. Hence, medications that attenuate depressive or anxiety states, as well as cognitive and life-style strategies for buffering affective intensity, are recommended. Most of these recommendations, however, do not diverge greatly at this point from recommendations according to other clinical paradigms.
The limits of the alexithymia construct are likely to be found in its research focus on the individual human being. Can any phenomenon so obviously social as the perception and expression of emotion be understood adequately without locating more of its major processes outside the individual and in the social domain? Laurence Kirmayer, for example, has observed that, outside Europe and North America, somatic symptoms as expressions of distress are the worldwide norm, suggesting that they can be regarded as normative social communications rather than forms of psychopathology. To their credit, the authors discuss Kirmayer's and other competing paradigms, although less fully than they present their refutations. The text is best read within the context of the more expansive literature on somatization, in which few final conclusions as yet can be drawn.
This book is useful reading for clinicians and researchers studying any of the clinical disorders for which the authors have implicated affect dysregulation in the pathogenesis. The book is a well-written summary of alexithymia research and a well-articulated argument for alexithymia as an explanatory construct in psychiatric and medical disorders.
FOOTNOTES
Dr. Griffith is Professor of Psychiatry and Neurology and Director of Consultation-Liaison Psychiatry, The George Washington University Medical Center, Washington, DC.
Get information about faster international access.
Privacy Policy
Copyright © 1998
Academy of Psychosomatic Medicine.
All rights reserved.
Home
| Search
| Current Issue
| Past Issues
| Subscribe
| All APPI Journals
| Help
| Contact Us
|
