Magazine article Clinical Psychiatry News

Alexithymia Requires Persistence, Empathy

Magazine article Clinical Psychiatry News

Alexithymia Requires Persistence, Empathy

Article excerpt

Alexithymia is known as a patient characteristic that can have a negative outcome on psychotherapy (Compr. Psychiatry 2005;46:206-13). But many of our patients have difficulty understanding and describing their emotions, and as a result, their anxieties often are expressed as somatic distress. What techniques have you used that have proved effective in working with alexithymic patients?

Boost Suspicion Index

My experience with such patients is that they use a somatic metaphor for communication, thus avoiding dealing with developmental issues (rape, incest, physical trauma, etc.) that continue to be of great emotional significance. Such patients also avoid emotionally laden material such as spousal abuse. This as may produce negative feelings in the therapist.

Many of these patients eventually develop somatization disorders or polysubstance addiction, frequently iatrogenically induced. Many undergo multiple surgical procedures that culminate in the development of a depressive disorder, the focus of which then becomes the physical issue itself. The psychodynamic material is once again avoided.

Therapists should have a high index of suspicion of these patients to help them avoid unnecessary surgical and medical interventions. A nonjudgmental therapeutic alliance is the best modality. Occasionally, it is necessary to work with the family as well.

Ronald Turco, M.D.

Beaverton, Ore.

Flexibility Is the Key

Patients whose "anxieties are expressed as somatic distress" include those who present with complaints such as headaches, stomach aches, back pain, or dyspareunia, and have usually been referred by another physician who has been unable to relieve their discomfort. Many of these patients have an associated diagnosed physical illness. I find it helpful to be a supportive and sympathetic listening presence, to help the person understand the role that the somatic symptoms play in his life, and to be there as long as the patient finds it useful.

A flexible approach is key. If a patient's pain or fatigue makes it impossible to get to my office, I offer him a phone session. A young adult with chronic back pain recently had difficulty sitting through the session, so we went outside and talked while we walked. Such a patient is also particularly appreciative of my communicating with his or her internist, rheumatologist, or ob.gyn.

Gerald P. Perman, M.D.

Washington

Give Voice to Minimal Emotions

Slight or minimal emotional reactions, revealed by minute changes in facial expression, tone of voice, or bodily movements, can prove revealing. Using sensitivity, I give voice to the probable underlying emotion, especially in context of the patient's narrative. In time, the patient gains help in recognizing his own emotions, and so speaks them with increasing depth of feeling. In the process, I imagine that new neural pathways are being laid down in the process--between the cortex and the deeper centers of emotion.

Victor Bloom, M.D.

Grosse Pointe, Mich.

Dr. Fink replies:

Alexithymia is a complex symptom--not a diagnosis--characterized by three core issues: difficulty identifying feelings; difficulty communicating feelings; and externally oriented thinking. The concept is not one that we hear outside of academic circles, although psychiatrists who do psychotherapy are very familiar with patients who have one or more of these dimensions of affect deficiency in their presentation.

I first became acquainted with the term more than 30 years ago through John Nemiah, M.D., one of the most important figures in 20th century psychiatry. He was a former editor of the American Journal of Psychiatry and a Harvard professor. He characterized alexithymia as occurring when a patient seemed either devoid of, or would not express, his or her feelings.

As I began to think of how I could try to pigeonhole this symptom, I found several diagnoses that contain some element of this symptom that is not often labeled as alexithymia. …

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