Neuroscience and Biobehavioral Reviews 68 (2016) 10061020

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Neuroscience and Biobehavioral Reviews

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Commentary

Whats in the name alexithymia? A commentary on Affective

agnosia: Expansion of the alexithymia construct and a new
opportunity to integrate and extend Freuds legacy.
Graeme J. Taylor a, , R. Michael Bagby b , James D.A. Parker c
a
Department of Psychiatry, University of Toronto and Mount Sinai Hospital, 600 University Avenue, Toronto, Ontario M5G1X5, Canada
b
Departments of Psychology and Psychiatry, University of Toronto, 1265 Military Trail, Sy-131, Toronto, Ontario M1C1A4, Canada
c
Department of Psychology, Trent University, 1600 West Bank Drive, Peterborough, Ontario K9J7B8, Canada

a r t i c l e i n f o a b s t r a c t

Article history: The recent proposal of a new type of agnosia termed affective agnosia extends Freuds legacy and cap-
Received 6 January 2016 tures the concept of not knowing ones own emotions. This concept links well with the theory of levels of
Received in revised form 20 April 2016 emotional awareness and maps onto a hierarchical model of neural substrates of emotional experience,
Accepted 23 May 2016
but does not encompass the pense opratoire component of the alexithymia construct. Moreover, iden-
Available online 24 May 2016
tifying agnosia and anomia subtypes, which connotes a categorical conceptualization of alexithymia, is
inconsistent with the dimensional nature of the construct. We describe a more widely accepted deni-
Keywords:
tion of alexithymia, and argue that although aptly descriptive, the concept of affective agnosia does not
Alexithymia
Anomia
advance the theory, measurement, and treatment of alexithymia. A review of alexithymia literature indi-
Agnosia cates that impairment in the mental representation of emotions has been a central aspect of alexithymia
Emotional awareness theory since the concept was introduced, and guided the development of the Toronto Alexithymia Scale
Mentalization and other measures of the construct. Moreover, techniques to enhance mentalization of emotions have
Primal repression been used by psychotherapists for several decades.
Psychotherapy 2016 Elsevier Ltd. All rights reserved.
Toronto Alexithymia Scale
Trauma

1. Introduction of alexithymia, and having conducted research on this construct

In a recent article in this journal Lane et al. (2015a) propose
a new type of agnosia, which they name affective agnosia and
describe as an impairment in the ability to mentally represent
or know what one is feeling (p. 594). They note that affective
agnosia is closely related to the alexithymia construct, which was
introduced by Nemiah and Sifneos (1970) (Nemiah et al., 1976) in
the early 1970s and has since generated a large body of empirical
research. Whereas the term affective agnosia captures the concept
of not knowing ones own emotions, Lane et al. point out that the
term alexithymia when taken literally (lack of words for emotion)
refers to a type of anomia. They propose a continuum between
severe forms of alexithymia (the agnosia version) and mild forms
of alexithymia (the anomia version), and suggest that the concept
of affective agnosia advances the theory, measurement, and treat-
ment of alexithymia. As the developers of three different measures
for more than thirty years, we found Lane et al.s (2015a) ideas
interesting and worthy of attention; however, their review of the
alexithymia literature was notably selective with several signi-
cant omissions and oversights. In addition, we believe that their
proposal of subtypes of alexithymia conicts with their conceptu-
alization of a continuum construct and is more likely to generate
confusion rather than advance the eld. In this Commentary we
offer an alternative perspective on the theory, measurement, and
treatment of alexithymia, and attempt to correct some potential
misconceptions about the construct. In particular, in Section 6, we
address the various issues Lane et al. (2015a) raise in their critical
review of the use of the self-report 20-item Toronto Alexithymia
Scale (TAS-20) in alexithymia research.
2. Agnosia, anomia, and agnostic aphasia

We commend Lane et al. for drawing attention to Freuds (1891)

Corresponding author. much neglected treatise On Aphasia and for extending his legacy
E-mail addresses: graeme.taylor@utoronto.ca (G.J. Taylor), by integrating his concept of agnosia into the eld of alexithymia.
rmichael.bagby@utoronto.ca (R.M. Bagby), jparker@trentu.ca (J.D.A. Parker). In so doing they have added to contributions by other authors

http://dx.doi.org/10.1016/j.neubiorev.2016.05.025
0149-7634/ 2016 Elsevier Ltd. All rights reserved.
 G.J. Taylor et al. / Neuroscience and Biobehavioral Reviews 68 (2016) 10061020
(e.g., Miller, 1991; Rizzuto, 1989; Stengel, 1954) who extended
Freuds legacy by recognizing that many of the ideas he presented in
his treatise anticipated some of his later psychoanalytic concepts;
these include his theoretical construct of a speech apparatus as an
antecedent of the psychic apparatus, his application of Hughling
Jacksons ideas of neurobehavioral regression to the aphasias and
later to mental processes (further on we discuss the application of
the concept of regression to alexithymia), and his concept of repre-
sentation. Whereas Finkelnburg (1870) called disturbances in the
recognition of objects asymbolia, Freud proposed the term agnosia
because he considered asymbolic a more appropriate designation
for the relation between the word (re)presentation and the object
(re)presentation rather than for the relation between the object
and the object (re)presentation.1 As Lane et al. (2015a) indicate,
Freud described asymbolic aphasia (anomia) as a type of aphasia
in which the associations between the word (re)presentation and
object (re)presentation are disturbed.2 They point out also that a
failure of naming necessarily occurs as part of the impaired recog-
nition in individuals with agnosia; however, they fail to mention
that Freud gave the name agnostic aphasia to this combination of
agnosia and anomia. When applied to emotions, individuals who
are unable to adequately represent and recognize the meaning of
visceral/somatic emotional reactions (i.e., agnosia) will also mani-
fest difculty nding words for feelings (i.e., anomia).
It is Lane et al.s (2015a) impression that the distinction between
anomia and agnosia has not previously been made or considered in
relation to alexithymia or affect. Although other authors may not
have made the same distinction, it should be acknowledged that the
idea of alexithymia being a form of agnosia has been suggested pre-
viously. We draw attention to articles indicating that Sifneos (1967,
1994, 1996) initially contemplated the concept of agnosia, but later
suggested that alexithymia may be a type of anomia. In the late
1960s, Sifneos (1967) reported his preliminary clinical observations
on randomly selected patients with classic psychosomatic diseases;
the most striking characteristic was a marked difculty many of the
patients had in nding appropriate words to describe their feelings,
as though they did not understand the meaning of the word feeling.
Although Sifneos (1967) did not refer to Freuds treatise On Aphasia,
he wondered if these patients suffer from emotional agnosia sim-
ilar to the visual agnosia observed by Klver and Bucy in monkeys
(p. 8). Many years later, inuenced by a review article on aphasia
by Damasio (1992), Sifneos (1994, 1996) hypothesized that alex-
ithymic individuals, who are unable to link limbic emotions with
cognitive activity in the form of images, fantasies, and thoughts, are
suffering from a feeling aphasia. Since Damasio (1992) had dened
aphasia as an interruption in the ability to convert the sequences of
nonverbal mental representations that constitute thought into the
symbols and grammatical organizations that constitute language
(p. 531), a feeling aphasia suggests a type of anomia even though
the decient cognitive activity referred to by Sifneos involves more
than labeling emotions with words. If Sifneos had combined his
proposal of a feeling aphasia with his earlier proposal of an emo-
1
Freud used the German word Vorstellung, which has been translated variously
into English as presentation, idea, concept, and representation. For example,
Strachey (1957) referred to word and object presentations; Stengels translations
were word concept and idea of the object. According to the Edinburgh Interna-
tional Encyclopedia of Psychoanalysis (Skelton, 2009), Lacan showed that Freud
borrowed the term Vorstellung (translated as representation) from philosophy to
mean, broadly speaking, the elements within the mind from which a world of expe-
rience is constructed (p. 403).
2
Strachey (1957) notes that what Freud called object presentation in his treatise
On Aphasia he calls thing presentation in his paper The Unconscious; and what he
called object presentation in The Unconscious denotes a complex made up of the
combined thing presentation and word presentation, a complex that is not given
a name in his treatise.
1007
tional agnosia, he might have described alexithymia as an affective
agnostic aphasia.
Although Lane et al. cite Prinzs (2004) book Gut Reactions, they
do not credit him for characterizing alexithymia as an analogue of
associative agnosia. Prinz suggested that rather than alexithymia
being a verbal disorder, it is more likely to be an inability to recog-
nize emotions (p. 217). They also overlook an article by Primmer
(2013), who offers a slightly different perspective. Like Lane et al.s
(2015a) idea of a continuum, Primmer conceptualizes alexithymia
as a dimensional construct; but whereas Lane et al.s conceptu-
alization of severe alexithymia as an affective agnosia seems to
include apperceptive agnosia and/or associative agnosia depend-
ing on the level of decit, Primmer considers severe alexithymia
analogous only to apperceptive visual agnosia and regards mild
alexithymia as analogous to blindsight (i.e., an associative visual
agnosia).3 Although Primmer employs a bodily theory of emo-
tion, she bases her argument on evidence from some experimental
studies that individuals with severe alexithymia are poor at rec-
ognizing facial expressions of emotion; she presumes that they
respond with low levels of physiological arousal when viewing
such expressions and proposes that they are therefore unable to
develop accurate percepts of this type of emotional elicitor (for a
more detailed discussion see Primmer, 2015). Primmer acknowl-
edges that being poor at identifying other peoples emotions is not
one of the salient components of the alexithymia construct, but
suggests that as a secondary feature it may help in determining the
severity of alexithymia. She is not concerned about the meaning of
the term alexithymia, but takes for granted that it refers to a decit
in the processing of emotional information. Since emotional aware-
ness is not a categorical construct, Primmer (2013) argues against
the idea of dening subtypes of alexithymia, and says it is more
likely that there exist various degrees of alexithymia (p. 115), just
as there are various degrees of emotional awareness ranging from
mere awareness of bodily sensations to full-blown awareness (p.
115).
If we have followed Lane et al.s (2015a) reasoning correctly,
their understanding of the perceptual decit in apperceptive affec-
tive agnosia is different from Primmers view as they are concerned
with the perception of ones own emotions rather than the emo-
tional expressions of others. Consistent with their theoretical
model of levels of emotional awareness, and applying Marrs model
of stages in visual perceptual processing to emotion, Lane et al.
(2015a) propose that at the lowest level an individual might have
discrete somatic complaints such as stomach pain and muscle ten-
sion, but not perceive these complaints as related (i.e., parts of a
coherent bodily reaction) (p.600). At an intermediate level of rep-
resentation an individual will experience coherent patterns of his
or her entire bodily state, and also manifest facial and other bodily
expressions of emotion, but may not recognize these experiences
as emotional experiences and use their emotional meaning, i.e., an
associative agnosia.
We agree with both Primmer (2013) and Lane et al. (2015a) for
including apperceptive agnosia as well as associative agnosia in
their conceptualizations of alexithymia, but we question Primmers
assumption that severe alexithymia is associated with low physi-
ological arousal when viewing emotional facial expressions since
investigations of this relation have yielded inconsistent ndings
(Grynberg et al., 2012). Although Primmer and Lane et al. share the
view that different degrees of alexithymia (i.e., differences in sever-
ity) reect differences in the structure of the cognitive schemata
used to process emotional information, Lane et al. (2015a) declare
3
As noted by Lane et al. (1997, 2015a), blindsight is the ability of a blind person to
perceive visual stimuli, but without conscious awareness of the experience because
of lesions in area V1 of the primary visual cortex.
1008 G.J. Taylor et al. / Neuroscience and Biobehavioral Reviews 68 (2016) 10061020
that The tendency to jump to the explanation that alexithymia is a
continuum obscures a critical issue and prevents the important dis-
tinction between anomia and agnosia from being made (p. 607).
Given that ndings from taxometric investigations using data from
several different samples support a dimensional conceptualization
of alexithymia (Mattila et al., 2010a; Parker et al., 2008), we are
in agreement with Primmer that it is preferable to conceptualize
different degrees of alexithymia, rather than dene subtypes.
3. Freuds concept of primal repression
Lane et al. (2015a) raise the question of why Freud did not con-
nect agnosia to affective experience, and suggest that perhaps he
did not use it in his psychoanalytic writings because he focused
almost exclusively on mental contents that had been previously
mentally represented which were once known but were disguised
or barred from consciousness due to defenses such as repression
(p. 606). However, as noted by many psychoanalytic authors (e.g.,
Cohen and Kinston, 1983; Dorpat, 1985), Freud (1915) described
two phases in the operation of repression. The rst phase, which he
called primal repression, denies entrance of instinctual and affective
representatives into consciousness. In the second phase, referred to
as repression proper, instinctual, emotional, and other experiences
have been mentally represented and gain entry into the conscious
mind, but are then excluded from it. Although Freud focused more
on instinctual drives than emotions and conceptualized primal
repression in different ways at different times, it is clear from his
descriptions that the elements under primal repression exist in a
form that does not include verbal symbols (see editorial note in A.
Freud, 1981). For example, infantile experiences that precede the
development of the preconscious system in Freuds topographical
model of the mind are primally repressed and thus are not mentally
represented. This primitive defense is not limited to early experi-
ences, but occurs in children and adults when higher level mental
capacities are overwhelmed by the impact of trauma (Cohen, 1985;
Frank, 1969). Freud (1926) linked primal repression with psychic
trauma when he stated that it is highly probable that the imme-
diate precipitating causes of primal repressions are quantitative
factors such as an excessive degree of excitation and the break-
ing through of the protective shield against stimuli (p. 94). We
elaborate further on the association between trauma and primal
repression in Section 9; but here we propose that Freuds con-
cept of primal repression is analogous to affective agnosia since
it encompasses emotions and instinctual states that are not recog-
nized by the individual as they are not linked with verbal symbols
and thereby mentally represented.
Our proposal is supported by the formulations of several
other authors. Basch (1977), for example, anticipating Lane
and Schwartzs (1987) cognitive developmental theory of levels
of emotional awareness, employed Piagets model of cogni-
tive development and proposed that primal repression involves
sensorimotor schema which have never been given symbolic rep-
resentation, that is, which have not participated in preoperational
transformations (p. 260). Dorpat (1985) regards primal repression
as a primitive form of denial and proposes that it results in an arrest
in the cognitive processing and construction of mental represen-
tations of perceived stimuli. In contrast to Freud, who based his
concept of denial (or disavowal) on the mistaken belief that all per-
ception is conscious, Dorpat emphasizes unconscious perception
and argues that primal repression or denial affects the perceptual
process after a person has registered a threatening object or situ-
ation, but before the person constructs a conscious percept of the
object. He notes that the failure to construct a verbal representation
of the stimulus object, and thereby provide meanings, is similar to
what occurs in individuals with associative visual agnosia where
there is a defect not in the registering of sensory information but
in the conceptual stage of perception. Dorpats theory could apply
to states of arousal whether they arise in response to an external
stimulus or internally without any such provocation.
4. Whats in the name alexithymia?
Lane et al. (2015a) suggest that affective agnosia may be a more
proper label as the original denition of alexithymia involves a lack
of words for emotions. We argue against this suggestion because
there is more to the name alexithymia than it may seem. Let us
briey review the origins of the term and its use by clinicians and
researchers over the past 40 years.
Three years after Sifneos (1967) reported his preliminary clin-
ical observations, Nemiah and Sifneos (1970) conducted a more
systematic examination of previously tape-recorded interviews of
patients with two of the following classic psychosomatic diseases
(duodenal ulcer, bronchial asthma, rheumatoid arthritis, ulcera-
tive colitis, atopic dermatitis); in addition to a marked difculty in
describing their feelings, many of these patients showed a thought
content consistent with Marty and de MUzans (1963) concept
of pense opratoire (operative thinking), including a nearly total
absence of fantasy or other material related to their inner mental
life of thoughts, attitudes and feelings, and a recounting of details of
external events. Sifneos (1973) states that for lack of a better term,
he proposed the word alexithymia (from Greek stems a = lack,
lexis = word, and thymos = emotion, mood, or feeling) to denote the
specic difculty in nding appropriate words to describe feelings.
A few years later, he told attendees at the 11th European Confer-
ence on Psychosomatic Research (ECPR) that The word was simply
used to describe certain clinical observations that were made over
very many years. I tried appropriately to use a Greek word or a
pseudo-Greek word for descriptive purposes (Sifneos, 1977; pp.
368369). Sifneos et al. (1977) had reported the clinical observa-
tions in a presentation earlier at the conference; the characteristics
they described included more than a difculty nding appropriate
words to describe feelings). In some of his later articles, Sifneos
(1994, 1996) made clear that the term alexithymia refers to an
affect decit that encompasses all of the characteristics that he
and Nemiah had described in 1970, the most salient characteris-
tics being difculty identifying feelings, differentiating among the
range of common affects, and distinguishing between feelings and
the bodily sensations of emotional arousal (i.e., not knowing what
one is feeling); difculty nding words to describe feelings to other
people; constricted imaginal processes as evidenced by a paucity or
absence of fantasies referable to drives and feelings; and a thought
content characterised by a preoccupation with the minute details of
external events (the last two characteristics correspond to pense
opratoire) (Nemiah et al., 1976). These characteristics comprise
what came to be referred to as the alexithymia construct (Lesser,
1981; Taylor et al., 1991). Thus, although the literal meaning of the
term alexithymia implies a type of anomia, for Sifneos and Nemiah
and for most clinicians and researchers inspired by their contri-
butions, it is the name of a multifaceted construct that involves
more than a difculty nding words for emotional feelings. Lane
et al. (2015a) state that Although alexithymia has often been
assumed to be something more than a simple lack of words, it
has been challenging to nd a more suitable term and concep-
tual framework to describe and measure it (p. 595). As we have
just shown, the something more is not an assumption but is
actually included in the denition of the construct. Later in this
Commentary, we describe a conceptual framework that has guided
clinicians and alexithymia researchers for many years, including
psychotherapists and developers of several instruments for mea-
suring alexithymia.
 G.J. Taylor et al. / Neuroscience and Biobehavioral Reviews 68 (2016) 10061020
From time to time the term alexithymia has been challenged
or different descriptive labels have been used to denote the clus-
ter of characteristics that comprise the construct. Responding to
questions and criticisms of the concept at the 11th ECPR, Sifneos
(1977) was adamant that alexithymia is here to stay, whether we
like it or not and it is going to be with us for the rest of our lives
(p. 369). The term alexithymia has not only outlived Sifneos and
many of the attendees at that conference, but is widely accepted
and has become the lingua franca for clinicians and researchers in
countries throughout the world. Although some authors may occa-
sionally overlook the multifaceted nature of the construct and apply
the term alexithymia to only one facet, we think that changing the
name is ill-advised. The term alexithymia is now deeply entrenched
in the scientic literature, and also listed in the Shorter Oxford
English Dictionary (Trumble, 2007), and thus available for general
public use. The OED denes alexithymia as An affective disorder
characterised by an inability to recognize and express emotions (p.
50), a denition that clearly encompasses both the agnosia (inabil-
ity to recognize) and the anomia (inability to express) aspects of
the construct.
5. Alexithymia theory
5.1. Early formulations
Lane et al. (2015a) propose that the concept of affective agnosia
advances the theory of alexithymia. Although affective agnosia
is an aptly descriptive label, in our opinion the concept will not
advance alexithymia theory because impairment in the ability
to mentally represent or know what one is feeling is already
encompassed in current alexithymia theory. Derived from clinical
observations, the alexithymia construct was formulated initially
without an underlying theoretical framework. In contrast to how
most personality traits are conceptualized, Nemiah et al. (1976)
did not postulate a latent variable (viz., alexithymia) that causes
and exists apart from the clinically observable features; rather,
they formulated what is essentially a mereological construct with
the various components assumed to interact with and reinforce
one another.4 Nonetheless, from the outset, Nemiah and Sifneos
(1970) (Nemiah et al., 1976) suggested some possible explana-
tions for the observable features including not only an arrest in
development as proposed much earlier by Ruesch (1948), but also
psychodynamic and neurophysiological hypotheses. And within a
short time, they placed alexithymia within a theoretical framework
that Nemiah (1977) conceptualized for understanding the cogni-
tive processing of emotions. Whereas Lane et al. (2015a) point out
that Emotion has traditionally been equated with the subjective
experience of emotional feelings (p. 608), Nemiahs theoretical
framework reects a distinction that he and Sifneos made between
emotions and feelings. Recognizing that affects have both biologi-
cal and psychological components, they dened emotions as the
neurophysiological and motor-expressive component of affects,
and feelings as the subjective, cognitive-experiential component
(Nemiah et al., 1976; Sifneos, 1975). This distinction is consistent
with Freuds (19161917) description of affects as highly com-
posite experiences including in the rst place particular motor
innervations or discharges and secondly certain feelings (p. 395); it
is also consistent with a contemporary view expressed by Damasio
(2003) that emotions play out in the theater of the body. Feelings
play out in the theater of the mind (p. 28). Although the distinc-
4
Mereology refers to the study of the relations of parts to a whole as well as the
relations between the parts within the whole (Stanford Encyclopedia of Philosophy,
2003).
1009
tion between emotions and feelings is overlooked in parts of Lane
et al.s (2015a) article,5 they acknowledge on page 606 that it is crit-
ical and parallels the distinction they make between implicit and
explicit processes.
Lane et al. (2015a) believe that The current view that alex-
ithymia may include a decit in mental representation of emotion,
not just in naming it, was ushered in by neuroimaging ndings
that suggested an impairment in emotional awareness rather than
in emotional naming (p. 608). But this view existed long before
neuroimaging studies were conducted; the contribution of such
studies was to explore neural correlates of alexithymia and emo-
tional awareness (Lane et al., 1998a; Van der Velde et al., 2013).
It is evident in Nemiahs (1977) theoretical framework for emo-
tional processing that emotions must be mentally represented to be
experienced consciously as feelings. In conceptualizing the frame-
work, Nemiah outlined the internal processes that normally occur
in individuals in response to an affect-provoking external event. In
addition to there being a perception and cognitive appraisal of the
elements of the event, he indicated that the somatic components of
affect are aroused and undergo a process of psychic elaboration. In
formulating this process, he was probably inuenced by Sandlers
(1972) discussion of emotion and the building up of a representa-
tional world at a Ciba Foundation Symposium in 1972, which he
and Sifneos attended. As we have reviewed elsewhere (Taylor and
Bagby, 2013a), Nemiah (1977) described several elements to the
process of psychic elaboration, including a renement and delin-
eation of the raw emotion into a variety of qualitatively different
nuances that have the potential for conscious experience as feel-
ings; a linking of the feelings with words to describe them; the
production of images and fantasies expressive of the feelings; and
the arousal of a network 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 stim-
uli. 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 biologic component of affect would be unreg-
ulated by cognitive processes and lead to somatic symptoms or be
discharged through actions.
Formulated a decade after Nemiahs conceptual framework was
published, Lane and Schwartzs (1987) theory of levels of emo-
tional awareness provides a more detailed and elaborate model for
understanding the psychic elaboration of emotions and individual
differences in affect awareness. Like Nemiah, Lane and Schwartz
rst adopt the generally accepted view that emotion is preceded
by cognitive appraisal of the environment (Smith and Ellsworth,
1985), and then focus on the structure of emotional experience
once an emotional response to a stimulus has been activated.
Their central thesis is that what is experienced as emotion is
the consequence of a subsequent cognitive processing of emo-
tional arousal and that the cognitive process itself undergoes a
sequence of structural transformations during development which,
in turn, determines the structure of subsequent emotional experi-
ence (p. 134). Lane and Schwartzs theory not only modies and
expands Nemiahs theoretical framework for the psychic elabora-
tion of emotion, but as we indicated many years ago (Taylor and
Bagby, 2000; Taylor et al., 1991, 1997), it also extends earlier contri-
butions of Schur (1955) and Krystal (1974), who conceptualized an
epigenetic sequence for affect development involving a progressive
desomatization, differentiation, and verbalization of emotions as
5
On pages 595 and 600, for example, Lane et al. (2015a) refer to an inability
to experience emotion, whereas in a different paragraph on page 595 they refer
to a diminution or absence of the basic human ability to experience feelings. We
comment further on the experiencing of emotions versus feelings in Section 6.3.
1010 G.J. Taylor et al. / Neuroscience and Biobehavioral Reviews 68 (2016) 10061020
cognitive capacities mature. Along with this process Krystal (1979)
described the development of a capacity for affect tolerance, and
an increasing ability to use affects as signals to ones self.
It is surprising that Lane et al. (2015a) do not mention Krys-
tals contributions even though he reported characteristics similar
to those described by Nemiah and Sifneos at around the same
time and before becoming aware of their work. Moreover, Krystal
(1968) (Krystal and Raskin, 1970) observed these characteristics
among patients with severe post-traumatic states and patients
with substance use disorders, thereby setting the stage for extend-
ing the concept of alexithymia beyond the eld of psychosomatic
medicine. On the basis of his clinical observations, Krystal (1979,
1982/83, 1997) proposed that alexithymia is a consequence of
an arrest in affect development due to psychic trauma in early
childhood. And using the concept of regression, he proposed that
alexithymia can also result from a regression of affect involving ded-
ifferentiation, deverbalization, and resomatization of affects, which
may occur secondary to major trauma in adulthood. As noted ear-
lier, Freud (1891) derived the concept of regression from Hughling
Jacksons doctrine of functional retrogression in the central ner-
vous system, and thereafter used it to describe a reversion to a
level of mental functioning that was characteristic of an earlier
stage of ones development. Krystal (1982/83, 1988) noted that
the application of the concept of regression to alexithymia per-
mits an understanding of why this construct varies in severity
from one person to another and sometimes within the same indi-
vidual; compared to developmental arrests, regressions are more
spotty, irregular, uctuating and reversible (Krystal, 1979; p. 25).
Given these ideas, it is possible that patients with alexithymia
secondary to psychic trauma in adulthood (e.g., patients with post-
traumatic stress disorder) may show changes in their level of
emotional awareness as they shift back and forth on the continuum
between affective agnosia and anomia proposed by Lane et al. Most
importantly, Krystal (1988) observed that patients with severe
alexithymia do not understand the meaning of their emotions;
because their emotions are undifferentiated and poorly repre-
sented mentally, they are experienced predominantly as somatic
reactions that only call attention to themselves rather than to what
they signal (p. 264).
5.2. Interplay of decit and defense
Guided by the above overlapping theories, we proposed that
the features comprising the alexithymia construct reect a decit
in the cognitive processing and regulation of emotions (Taylor, 2000;
Taylor et al., 1991, 1997). Sifneos (1994) also referred to alex-
ithymia as a decit in the cognitive processing of emotions
(p.194). Similarly, Vanheule (2008) conceptualized alexithymia as
a difculty in processing and regulating affective arousal by means
of mental representations (p. 332). Some authors (e.g., Knapp,
1983) regard alexithymia as a defense against neurotic conict
rather than an affect decit. But this is a false dichotomy. As we
have outlined elsewhere (Taylor and Bagby, 2013a; Taylor et al.,
1997), a decit/developmental arrest theory of alexithymia does
not exclude a role for defenses. Nemiah (1977) included both decit
and defense in his theoretical formulations of alexithymia; Krystal
(1982-83) employed the defense mechanism of regression and the
idea of developmental arrest in his conceptualizations of alex-
ithymia, but considered alexithymia a defense in the teleological
sense only (p. 375); McDougall (1982-83) related alexithymia to
decits in the mental representation of emotion, but also concep-
tualized severe alexithymia as a massive defense against primitive
terrors and inexpressive pain. Recognizing primitive denial or pri-
mal repression as the rst phase in the process of repression, Dorpat
(1985) argues that primal repression is associated with or brings
about developmental decits, and that there is interaction between
decits and defenses in all psychopathology. Along similar lines,
we noted that as with other types of psychic decit, the presence
of alexithymia is likely to both initiate conict [and defense] and
intensify ordinary developmental conicts (Taylor et al., 1991; p.
156).
As one would predict, several empirical investigations with both
clinical and nonclinical samples have demonstrated that severe
alexithymia is associated most strongly with immature defenses
(such as denial, splitting, somatization), weakly with neurotic
defenses (such as reaction formation, idealization), and negatively
with mature defenses (such as suppression, sublimation). More-
over, there is evidence that these associations still hold after
controlling for anxiety and depression (see Taylor and Bagby, 2013a
for a review).
5.3. A multiple code theory
More recently, we argued that the conceptualization of a decit
in the cognitive processing of emotion places alexithymia in the
broad eld of emotion theory and research (Taylor and Bagby,
2013a). We gave as an example Buccis (1997a, 2002, 2008) multiple
code theory, which was developed in the context of work in cog-
nitive science, emotion theory, and neuroscience. Bucci postulates
three modes or systems of representing and processing emotional
information; these are the nonverbal subsymbolic, nonverbal sym-
bolic, and verbal symbolic modes. According to the theory, emotion
schemas are comprised of components from all three modes, and
develop on the basis of repeated interactions with others from the
beginning of life. The nonverbal modes develop rst and include
subsymbolic processes (patterns of sensory, visceral, and kines-
thetic sensations and motor activity experienced during states of
emotional arousal), and symbolic imagery. The verbal symbolic
mode develops later and is organized according to the symbolic
format of language. According to Bucci, the verbal and nonverbal
components within emotion schemas are connected, to varying
degrees, by a referential process; the connections are most distant
for subsymbolic representations such as sensory experiences and
patterns of autonomic arousal, which may require connections with
specic images within the nonverbal domain before they can be
connected to language in the verbal domain. As with Lane and
Schwartzs (1987) theory of levels of emotional awareness, the link-
ing does not transform one modality into another, but allows for
a transformation of the meanings represented in the nonverbal
modes and for translation into logically organized speech. Bucci
(1997a) proposes that if the referential process is disrupted (e.g.,
by conict 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 emo-
tional arousal, and the construction of emotional meanings.
Applying her multiple code theory to alexithymia, Bucci (1997b)
suggests that the dissociation within and between modes when
connections are disrupted or fail to develop is far more complex
than being without words for emotions; in some emotional-somatic
disorders, the patient is without symbols for somatic states (p.
165). As Bucci explains, the dissociation between subsymbolic
and symbolic components within the emotion schemas may allow
physiological activation to occur during emotional arousal without
a corresponding cognitive activation. Moreover, without a sym-
bolic focus and regulation, the activation is likely to be prolonged
and repetitive, and the ultimate effects on physiological systems to
be more severe (Bucci, 1997b; p. 165). Depending on the degree
of dissociation between somatic and motor patterns of activation
and symbolic representations, and also on the interaction with
constitutional and other vulnerability factors, a range of somatic
 G.J. Taylor et al. / Neuroscience and Biobehavioral Reviews 68 (2016) 10061020
disorders of varying seriousness may occur, from somatic symptom
disorders to medical illnesses and diseases. It has been hypoth-
esized, for example, that the alexithymic decit in the cognitive
processing of emotions leads to a focusing on, and amplication of,
the somatic sensations accompanying emotional arousal, and/or to
physical action as an immediate response to unpleasant arousal
(Barsky and Klerman, 1983; Lane and Schwartz, 1987; Taylor et al.,
1997). This is thought to explain the proneness to somatization
among high alexithymia individuals (De Gucht and Heiser, 2003;
Nakao et al., 2002), as well as their tendency to regulate tension
through compulsive behaviors such as binge-eating and abuse of
alcohol or drugs (Kauhanen et al., 1992; Pinaquy et al., 2003); such
behaviors are risk factors for disease. However, it is primarily the
difculty identifying feelings facet of alexithymia that is associated
with somatization (Mattila et al., 2008), whereas the externally ori-
ented thinking facet is associated more with lower attention to
internal bodily states (Davydov et al., 2013). When it is simply
the primary object of the emotion schema that has been dissoci-
ated (e.g., conict over intense anger toward an abusive spouse),
the mind may try to repair the dissociation by using a part of the
body to organize the schema, thereby creating a conversion symp-
tom with symbolic meaning. Thus, in the same year that Lane et al.
(1997) proposed the blindsight model of alexithymia, and focused
attention on the vertical axis of the brain to address the physiologi-
cal dysregulation that may link alexithymia and adverse medical
outcomes, Bucci (1997b) proposed that the failure to symbolize
emotions at a cognitive level results in physiological dysregula-
tion that might link alexithymia with illness and disease. One of
us (Taylor, 1992) had earlier formulated a dysregulation model of
disease in which prolonged emotion dysregulation as a result of
psychological conict or decits in the mental representation of
emotions may cause perturbations and changes over time in the
rhythmic functioning of other biological subsystems; if sustained,
such changes might initiate a transition from health to illness or dis-
ease. Buccis proposal that the connections between words, images,
and subsymbolic elements in emotion schema can be disrupted by
trauma, and thereby permit prolonged physiological activation, is
consistent with Krystals hypothesis that alexithymia and increased
vulnerability to somatic disorders may result from affect regression
induced by psychic trauma.
6. Measurement of alexithymia in empirical research
As indicated by Lane et al. (2015a), much of the empirical
research on alexithymia has measured the construct with the TAS-
20, which was developed by us more than two decades ago (Bagby
et al., 1994a,b) and is currently the most widely used measure
of alexithymia. In Section 3 of their article, however, Lane et al.
question whether this scale is a valid measure of alexithymia in
individuals who resemble those described by Nemiah and Sifneos.
They raise the following issues: First, they doubt that individu-
als with impaired affect awareness can accurately rate themselves
on this lack of awareness on a self-report scale. Second, because
the TAS-20 correlates positively with self-reported negative affect,
they argue that this clearly conicts with the original description
of alexithymia as a severe affective decit including a decit in
the description of affective distress (p. 596). Third, they declare
that most studies using the TAS-20 involve healthy individuals.
And fourth, they speculate that some limitation of the TAS-20 is
leading to a failure to detect an association with adverse medical
outcome that actually exists (p. 597). These assertions about mea-
surement of alexithymia with the TAS-20 are quite misleading as
some relevant studies have been omitted. We now comment on
the four issues, but rst make some general comments about the
development of the TAS-20.
1011
6.1. Development of the TAS-20
Lane et al. (2015a) assert that the creation of the TAS-20 was
guided by the theory that alexithymia is a problem in the verbal
description (readout or report) of experience (Taylor et al., 1997),
analogous to an anomia that reects a continuum in the population
(p. 597). This is incorrect. To the contrary, when we developed the
TAS-20 and its earlier 26-item version, we were guided primar-
ily by Nemiah et al.s (1976) description of the features they had
observed among patients in clinical interviews, which we outlined
in Section 4, and were mindful also of the distinction they made
between emotions and feelings. It is obvious from an examination
of the three factor scales of the TAS-20 that the items were writ-
ten to assess salient components of the alexithymia construct, and
certainly not to assess proneness to experience negative affect. The
items on the rst factor, Difculty Identifying Feelings (DIF), assess
the level of mental representation of affects (e.g., I am often puzzled
by sensations in my body; I have feelings that I cant quite iden-
tify). The items on the second factor, Difculty Describing Feelings
(DDF), assess the ability to nd words to express feelings to others
(e.g., It is difcult for me to nd the right words for my feelings;
I am able to describe my feelings easily (negatively keyed)). The
items on the third factor, Externally Oriented Thinking (EOT), assess
operative thinking, including the level of interest in ones inner
emotional life (e.g., I prefer to analyze problems rather than just
describe them (negatively keyed); I prefer talking to people about
their daily activities rather than their feelings (negatively keyed)).
Although the original 26 item TAS included a factor for assessing
the capacity for fantasy and other imaginal activity (Taylor et al.,
1985), subsequent evaluation of the scale revealed that the items
on this factor, plus some additional items we wrote to assess imag-
inal processes, showed a social desirability response bias and/or
low magnitude corrected item-total correlations and were there-
fore eliminated in the process of revising the scale. Nonetheless,
the EOT factor correlates with other measures of fantasizing (Bagby
et al., 1994b; Taylor and Bagby, 2013b; Tibon et al., 2005), which
suggests that this factor indirectly assesses the impaired imaginal
processes facet of the alexithymia construct. Thus, if we think of
the measurement of alexithymia in relation to Lane et al.s (2015a)
proposed concept of affective agnosia, the DIF factor of the TAS-
20 assesses the agnosia aspect of alexithymia, and the DDF factor
assesses the anomia aspect; but in addition, the EOT factor assesses
the operative thinking (pense opratoire) aspect of the construct.
6.2. Self-rating of alexithymia and a multimethod assessment
approach
It is possible that the self-report TAS-20 alone may not ade-
quately assess capacities that individuals with severe alexithymia
may not know they lack. As we have acknowledged elsewhere
(Taylor and Bagby, 2004; Taylor et al., 1997, 2000), however,
alexithymia research is enhanced by the use of a multi-method
approach to measuring the construct.6 Sifneos (1973) developed
the observer-rated Beth Israel Hospital Psychosomatic Question-
naire (BIQ) for assessing alexithymia, but this instrument lacked
adequate interrater reliability. Following suggestions of Sriram
et al. (1988) for enhancing the psychometric properties of the BIQ,
we developed a modied version with six items that assess affect
awareness (AA) and six items that assess operative thinking (OT)
(Taylor et al., 1997). The modied BIQ is administered as a semi-
structured interview, except by Japanese researchers who use a
6
We also use a multimethod approach for assessing alexithymia in our clini-
cal work, including the TAS-20, a clinical interview, and measures of emotional
intelligence and openness to experience.
1012 G.J. Taylor et al. / Neuroscience and Biobehavioral Reviews 68 (2016) 10061020
structured interview method, and it correlates positively with the
TAS-20 (r ranges between 0.26 and 0.53) (Arimura et al., 2002;
Bagby et al., 1994b; Lumley et al., 2005; Martnez-Snchez, 1996;
Meganck et al., 2011). We later developed the Toronto Structured
Interview for Alexithymia (TSIA; Bagby et al., 2006), which also
correlates positively with the TAS-20 in a variety of samples (r
ranges between 0.31 and 0.68) (Bagby et al., 2006; Caretti et al.,
2011; Grabe et al., 2009; Inslegers et al., 2013). In addition to factor
scales for assessing DIF, DDF, and EOT, the TSIA contains a factor
scale that assesses fantasizing and other imaginal processes (IMP);
the DIF and DDF factors form a higher-order AA factor, and the
EOT and IMP factors form a higher-order OT factor. Although a
structured interview method proved more reliable than self-report
questions for assessing the imaginal processes facet of the alex-
ithymia construct, the items may not adequately capture wish
fulllment fantasies and fantasies referable to instinctual drives
and feelings, which was the content emphasized by Krystal (1988)
and Nemiah et al. (1976). An alternative method for assessing imag-
inal capacity is a performance measure, such as the Rorschach
Reality-Fantasy Scale (RFS), which assesses the adaptive use, cre-
ation, and preservation of the psychoanalytic concept of potential
space between reality and fantasy (Tibon et al., 2005). In a sample of
92 patients with inammatory bowel disease (IBD; which is one of
the classic psychosomatic diseases), the mean RFS score correlated
positively with the TAS-20 total score (r = 0.60) and with scores on
all three factor scales (r ranged between 0.43 and 0.64), which sup-
ports the restricted fantasy and concrete reality-oriented cognitive
style components of alexithymia. The TAS-20 also correlates posi-
tively with the Rorschach Alexithymia Scale (in a combined IBD and
psychiatric outpatient sample, r = 0.78), which uses three variables
from the Rorschach Comprehensive System that are theoretically
consistent with the alexithymia construct (Porcelli and Mihura,
2010). Positive correlations have also been reported between the
TAS-20 and the Observer Alexithymia Scale (r ranged between 0.23
and 0.41) (Dorard et al., 2008; Lumley et al., 2005; Meganck et al.,
2011).
The ndings that the TAS-20 correlates positively with struc-
tured interview, observer-rated, and performance-based measures
of alexithymia, as well as evidence that the total scale and its
three factor scales all correlate negatively with measures of closely
related constructs (including psychological mindedness, need-
for-cognition, affective orientation, emotional intelligence, and
openness to experience) (Bagby et al., 1994b; Parker et al., 2001;
Taylor and Bagby, 2000), provide strong support that the TAS-20
captures an impairment in experiencing and describing emotions
and is a valid measure of the alexithymia construct.
6.3. Relations between alexithymia and negative affect
Lane et al. (2015a) refer to a study by Leising et al. (2009), who
found that participants with higher TAS-20 scores reported more
emotions (particularly negative ones) and more different emo-
tions during interviews than those with lower alexithymia scores.
They overlook opposite ndings from a later study by Wotschack
and Klann-Delius (2013), who conducted interviews that included
questions about emotion knowledge for six emotion terms (e.g.,
What is joy for you? How do your recognize joy in yourself and
others?), autobiographical narratives about recent positive and
negative events in the persons life, and oral administration of form
B of the Levels of Emotional Awareness Scale (LEAS; Lane et al.,
1990). In this study, individuals with high scores on both the TAS-
20 and the self-report Bermond-Vorst Alexithymia Questionnaire
(BVAQ; Vorst and Bermond, 2001) produced fewer negative and
positive emotion words, fewer different types of emotion words,
fewer synonyms for a target emotion (e.g., joy, fear, anger), and
fewer physiological-expressive terms to describe emotions during
the interviews than individuals with low alexithymia scores.
Lane et al. (2015a) also refer to a study by Marchesi et al. (2014),
who found that differences in TAS-20 scores observed between var-
ious psychiatric patient groups and a nonpatient group disappeared
after controlling for the effect of anxiety and depression severity.
They seem to concur with Marchesi et al.s conclusion that the TAS-
20 appears to be a measure of psychological distress. A contrasting
view is offered by Lumley (2000), who opines that because of the
limited ability of alexithymic individuals to regulate and resolve
negative emotions stemming from stressful or conicting events,
the negative affect remains unmodulated yielding a chronic, yet
undifferentiated dysphoria (p. 52). Lumley notes that although
negative affect may contribute to some score elevation, in particular
on the DIF and DDF factor scales, the TAS-20 can be differentiated
from measures of negative affect, and that this alexithymia scale
is not simply a proxy for negative affect. Indeed, Luminet et al.
(1999) have shown that alexithymia is not merely equivalent to
the construct of neuroticism, but is represented by a cluster of
traits across the domains of the ve-factor model of personality.
Although some researchers report signicant positive associations
between the TAS-20 and measures of anxiety and depression (e.g.,
Makino et al., 2013), others have found nonsignicant correlations
between the TAS-20 (or original 26-item TAS) and measures of anx-
iety and/or depression (e.g., Carton et al., 2008; Zunhammer et al.,
2015). In several other studies, in which the investigators were
mindful of the ostensible association between negative affective
states (i.e., depression, anxiety) and alexithymia, measures of neg-
ative affect were modelled into the statistical equations in which
TAS-20 scores were used to predict a variety of dependent variables,
partialling or removing their shared variance with alexithymia
from the model. Despite the removal of this variance, positive and
statistically signicant associations were found between TAS-20
scores and a number of outcomes, including a decit in remember-
ing emotion words (Luminet et al., 2006), presence of Parkinson
disease (Assogna et al., 2012), and dimensions of health-related
quality of life (Mattila et al., 2010b).
Furthermore, even though TAS-20 scores may be moderately
inated by negative affect and thus lack absolute stability, there
is strong evidence of relative stability, which is a true indicator
of whether a personality construct is a stable trait and not simply
reective of distress. For example, in an investigation of outpatients
with major depression, Luminet et al. (2001) demonstrated a high
degree of relative stability of TAS-20 scores by signicant corre-
lations between scores at treatment initiation and after 14 weeks
of pharmacotherapy, and also by hierarchical regression analyses,
which indicated that variance in follow-up TAS-20 scores could be
predicted from scores at baseline over the effect contributed by
baseline and follow-up depression scores. Similar ndings were
reported in an investigation of women with breast cancer (Luminet
et al., 2007); and also in an investigation of alcoholic inpatients
undergoing alcohol withdrawal even though there were large
decreases in anxiety and depression (de Timary et al., 2008). In
another study, relative stability of TAS-20 scores was demonstrated
over a six month treatment period in a group of outpatients with
functional gastrointestinal disorders; moreover, the stability of the
alexithymia scores could not be accounted for by their associations
with anxiety and depression scores (Porcelli et al., 2003). Lane et al.
(2015a) also overlook a study in Finland in which Mattila et al.
(2008) sought to answer the question of whether alexithymia is
an independent determinant of somatization in the general popula-
tion. With a large nationally representative sample comprising both
young and old adults, alexithymia measured with the TAS-20 was
associated with somatization independently of anxiety, depression,
somatic diseases, and potentially confounding sociodemographic
 G.J. Taylor et al. / Neuroscience and Biobehavioral Reviews 68 (2016) 10061020
variables. The strongest association was between the DIF factor of
the TAS-20 and somatization.
Based on the ndings in the studies by Leising et al. (2009) and
Marchesi et al. (2014), Lane et al. (2015b) suggest in another recent
article that the TAS-20 is a measure of distress, not an impairment
in the ability to experience and express distress (p. 399). This is
a confusing statement as it ignores the distinction that Nemiah
and Sifneos made between emotions and feelings. As Lane et al.
would surely agree, individuals with high degrees of alexithymia
are impaired in their ability to experience and express distressing
and other subjective feelings, but that does not mean that they do
not experience emotional distress. The distress may be commu-
nicated as somatic sensations or symptoms (Taylor et al., 1992),
or expressed through impulsive behaviors such as substance use
(Kauhanen et al., 1992) or bingeing on food (Pinaquy et al., 2003),
which may serve to downregulate emotional arousal. Indeed, it is
evident from Sifneos and Nemiahs descriptions of patients affec-
tive experience that the decit in affect awareness is not an absence
of emotions or a total failure to speak of feelings, but an inability
or difculty in elaborating feelings. Sifneos (1967) noted that these
patients commonly mention anxiety and complain of depression,
and may also talk about nervousness, agitation, restlessness, irri-
tability, and tension (i.e., negative affects). Nemiah et al. (1976)
also reported that Although many individuals may initially speak
of being nervous, or sad, or angry, if they are pressed to describe
their feelings further and to tell the examiner what being sad or
nervous or angry feels like, it rapidly becomes apparent that they
are totally unable to do so (p. 431). Nemiah and Sifneos (1970)
(Sifneos, 1967) described patients who, when asked if they were
upset or angry, gave responses such as I have a tight sensation
in my throat; a dead feeling through my stomach; and I could
see my muscles twitching. They observed also that alexithymic
patients on occasion have sudden outbursts of rage or crying with-
out any premonitory feeling or fantasy (Nemiah et al., 1976). We
have made similar observations to those of Sifneos and Nemiah
in our own clinical work, and in earlier contributions we pro-
vided some examples of alexithymic patients who spoke of feeling
upset, nervous, agitated, lonely, furious, or emotionally distressed,
but were unable to elaborate further on their affective experience
(Taylor, 1994; Taylor and Bagby, 2013a; Taylor et al., 1997).
In our view, alexithymic patients are capable of experiencing
emotions and of being distressed by their emotions, but they lack
adequate mental representations to experience them as feelings
they can easily identify and describe to the examiner. Sifneos (1967)
suggested that perhaps as these patients grow older, and have
become aware of their difculties communicating with people, they
may try to overcome them by describing physical sensations when
they are asked how they feel. Similarly, Krystal (1979) observed
that like the color-blind person, many of these patients are aware
of their difculty in recognizing and describing feelings, and use
somatic sensations and other clues by which they infer what they
cannot discern. It is therefore not surprising that measures of alex-
ithymia would correlate positively with measures of neuroticism
or negative affect, which typically include items that ask if the
respondent experiences bodily sensations of emotion or unelabo-
rated feelings such as nervousness, restlessness, agitation, tension,
jitteriness, a lump in the throat, feeling depressed, upset, or scared.
Pandey and Mandal (1996) demonstrated that the strength of the
association between the TAS-20 and a measure of neuroticism was
signicantly reduced after controlling for the contribution of per-
ceived autonomic arousal.
6.4. Variety of samples in alexithymia research
Although Lane et al. (2015a) are correct that many studies using
the TAS-20 have been conducted with student or healthy adult
1013
samples, they fail to acknowledge that a large number of studies
have also been conducted with medical or psychiatric patient sam-
ples in which alexithymia was measured with either the TAS-20
or the original 26-item version of the scale. As reviewed in earlier
contributions (Taylor and Bagby, 2012; Taylor et al., 1997), these
studies included samples of patients with essential hypertension
(Jula et al., 1999), functional gastrointestinal disorders (Porcelli
et al., 2003), chronic pain disorders (Cox et al., 1994), eating dis-
orders (Bourke et al., 1992), substance use disorders (Taylor et al.,
1990), panic disorder (Galderisi et al., 2008), or posttraumatic stress
disorder (Frewen et al., 2008c), a large proportion of whom had high
alexithymia scores, just as groups of patients with some of these
disorders in later studies cited by Lane et al. (2015a) had lower
LEAS scores than some comparison groups.
6.5. Prediction of medical outcomes
Contrary to Lane et al.s (2015a) assertion, several studies have
demonstrated that the TAS-20 can predict medical outcomes. For
example, in the above mentioned investigation of patients with
functional gastrointestinal disorders (Porcelli et al., 2003), baseline
depression and TAS-20 scores emerged as signicant predictors of
treatment outcome; however, alexithymia was the stronger predic-
tor. And in an investigation of patients who underwent laparoscopic
cholecystectomy for treatment of gallstones, preoperative TAS-
20 scores predicted the persistence of gastrointestinal symptoms
more strongly than did psychological distress, even after control-
ling for preoperative gastrointestinal symptoms (Porcelli et al.,
2007). In a recent investigation of women who had undergone
surgery for breast cancer and were followed for up to 12 months,
the TAS-20 predicted the development of persistent postsurgical
pain independently of anxiety and depression (Baudic et al., 2016).
Lane et al. (2015a) mention a prospective study with 2000 middle-
aged Finnish men in which the 26-item version of the TAS predicted
all-cause mortality over a period of 5.5 years, particularly violent
death (Kauhanen et al., 1996). Even though alexithymia theory pos-
tulates that emotions that are not represented mentally may be
expressed somatically and through actions, Lane et al. (2015a) are
critical because the study does not disentangle whether the TAS
captured a problem in actions (behavior) or organs (pathophys-
iology) (p. 597). They seem unaware that the mortality rate of
the sample was examined subsequently over an average follow-
up period of 20 years. After adjusting for biological, behavioral, and
psychosocial factors, the risk of death from cardiovascular disease
increased by 1.2% for every 1-point increase in scores on the TAS
(Tolmunen et al., 2010).
7. The levels of emotional awareness construct
7.1. Affect awareness and pense opratoire
As we indicated in Section 3, and have outlined in previous
publications (Taylor, 2000; Taylor et al., 1997), we nd Lane and
Schwartzs (1987) conceptualization of stages in normal affect
development helpful for understanding individual differences in
affect awareness. But in our opinion, Lane et al.s (2015a) empha-
sis on the levels of emotion awareness construct actually limits the
theory, measurement, and treatment of alexithymia. The concept
of affective agnosia certainly links well with the developmental
model of levels of emotional awareness, which in turn maps onto
Lane et al.s (2015a) hierarchical model of the neural substrates of
emotional experience. And their hypothesis that affective agnosia
involves a failure to engage areas of the medial prefrontal lobe, in
particular the rostral anterior cingulate cortex (rACC), the dorsal
ACC, and the dorsomedial prefrontal cortex, is supported partly by
ndings from some (but not all) studies suggesting that the neural
1014 G.J. Taylor et al. / Neuroscience and Biobehavioral Reviews 68 (2016) 10061020
correlates of alexithymia include reduced activation in the ACC and
the right medial prefrontal cortex when responding to emotion-
inducing stimuli (e.g, Frewen et al., 2008a; Moriguchi et al., 2006).
However, as we outlined above, the alexithymia construct includes
a restricted imagination and an externally oriented cognitive style,
and is therefore a broader construct than the levels of emotional
awareness construct. This difference is emphasized by Lumley et al.
(2005) who point out that Emotional awareness includes attend-
ing to, identifying, and correctly labeling emotions in oneself and in
others, but it does not include the cognitive components included
in the broader construct of alexithymia (p. 331).
Lane et al. (2015a) are well aware that the development of
emotional awareness in infancy and early childhood requires the
assistance of another person, who is usually the primary caregiver
(most often the mother). They consider emotional awareness to
be a separate line of development from other domains of cogni-
tion. However, they fail to give attention to the childs capacity
for imagination, which develops in tandem with the develop-
ment of emotional awareness and also plays an important role in
affect regulation. And like emotional awareness, the development
of the imaginal capacity is dependent on the childs interactions
with affectively engaged primary caregivers. As we outlined almost
two decades ago (Taylor et al., 1997), normal affect development
requires attunement of the mother to the behavioral emotional
expressions of her infant, the mothers containment and regulation
of the infants emotional states, and transformation of the infants
sensations and primitive emotions through her own cognitive pro-
cesses into meaningful affects and other aspects of experience
that can be conveyed back to the infant. With the emergence of
symbolization and language during the second year of life, the
childs level of subjective awareness gradually increases as the par-
ents teach words and meanings for their childs somatic emotional
expressions and other bodily experiences. The line of development
of an imaginal capacity proceeds from the infants formation of
images of the mother (which become linked to subsymbolic sen-
sory experiences),7 to the creation of a transitional object (such
as a soft toy or blanket, which is a sensation-dominated object
before it comes to symbolically represent the mother), to the 5-
year-olds creation of fantasy play that reects his own subjective
world and his understanding of the concepts of mental states and
mind (Mayes and Cohen, 1992; p. 41). Fantasies, dreams, play,
and interests involve affects and serve some of the affect regula-
tory functions initially provided by the primary caregivers; they
play an important role in personality development and in the self-
regulation of affects throughout life. Imaginative play has been
described as one of the most important developmental processes
through which children learn to integrate affect, cognition, and
action (Izard and Kobak, 1991). Indeed, as the philosopher Susanne
Langer argued, the capacity for imagination allows humans to cre-
ate explicit meanings out of emotions and thereby defer immediate
action (Browning, 2006). Children who are unable to engage in
imaginative play show degrees of failure in integrating cognitions
with emotions, as well as disturbances in the symbolic function
of fantasy and an inability to identify with the feelings of others
(Galenson, 1984). It is not surprising that arrests in affect develop-
ment are invariably accompanied by arrests in the development of
the imaginative capacity, and that alexithymic individuals mani-
fest both types of decit. Furthermore, the failure to link feelings
with fantasies and to reect on inner experience pushes the mind
toward a preoccupation with the details of external events, which
is characteristic of pense opratoire (Krystal, 1979).
7
Bucci (1998) considers images pivotal in linking words with subsymbolic ele-
ments within emotion schemas.
7.2. The levels of emotional awareness scale
Although the LEAS (Lane et al., 1990) may adequately assess
the levels of emotional awareness construct and the continuum
between affective agnosia and anomia, it was not created as a
measure of alexithymia per se (Lane et al., 1998b, p. 382), and was
recently described simply as a performance measure of the abil-
ity to put emotions into words (Lane et al., 2015b; p. 399). Thus
researchers such as Subic-Wrana et al. (2001) are incorrect in refer-
ring to the LEAS as a new alexithymia test (p. 176). The scoring
system of the LEAS evaluates the structure of experience and not its
content, and assigns scores based on the use of words that convey
the degree of differentiation of emotion. One could infer that the
respondents imagination is involved in thinking about his or her
anticipated feelings and those of another person in each of the 20
scenes in the test, but there is no direct scoring of the respondents
imaginal capacity or tendency toward an externally oriented style
of thinking.
Notwithstanding low correlations reported between the TAS-
20 and the LEAS (around r = 0.20), theoretically alexithymia and
emotional awareness are overlapping constructs. Indeed, several
studies that have used both the LEAS and the TAS-20 (or TAS-26)
have reported similar ndings for the two measures. For example,
higher alexithymia scores and lower emotional awareness scores
have been reported in cigarette smokers seeking help for cessa-
tion (Carton et al., 2008), and are associated with reduced accuracy
on verbal and nonverbal emotion recognition tasks (Lane et al.,
1996). In another study, patients with chronic somatoform pain
disorders had signicantly lower emotional awareness scores and
higher alexithymia scores than a matched healthy control group
(Zunhammer et al., 2015), In separate studies, but with the same
sample of patients with posttraumatic stress disorder, Frewen et al.
(2008b,c) reported higher alexithymia scores and lower emotional
awareness scores than in a non-psychiatric control group. How-
ever, despite the negative relation between the TAS-20 and the
LEAS, both measures correlated negatively with activation in the
ventral ACC during trauma-script imagery (Frewen et al., 2008b,c).
Divergent ndings have also been reported in some other studies
that suggest that the TAS-20 and LEAS measure different aspects
of emotional functioning. Whereas patients with generalized anx-
iety disorder (GAD) score higher on the TAS-20 than individuals
without GAD (Mennin et al., 2005), contrary to predictions, Novick-
Kline et al. (2005) found that patients with GAD scored signicantly
higher than controls on the LEAS. And whereas in a sample of
pregnant women alexithymia was associated with low relationship
satisfaction (Taylor et al., 2014), Croyle and Waltz (2002) found
that a higher level of emotional awareness was associated with
lower relationship satisfaction in women. Frewen et al. (2008b)
and Novick-Kline et al. (2005) offer some possible explanations for
these discrepant ndings, including method variance, social desir-
ability response bias, the possibility that the LEAS measures being
skilled at emotional verbiage rather than at awareness of ones
emotions, and that high levels of emotional awareness may not
always be adaptive. These authors also refer to a study by Lundh
et al. (2002), who in a sample of undergraduate students observed
two subgroups that scored inconsistently on the TAS-20 and LEAS;
one group scored low on both measures, and the other group scored
high on both measures.
While Lane et al. (2015a) focus their attention on the low asso-
ciations typically found between the LEAS and TAS-20 scores, it
is important to note that the LEAS also tends to correlate weakly
with other alexithymia measures. Lumley et al. (2005), for exam-
ple, not only found the TAS-20 to be unrelated to the LEAS, but
the LEAS was also not related to the Observer Alexithymia Scale
(Haviland et al., 2000) and the Modied BIQ (Bagby et al., 1994b),
with correlations that ranged from 0.20 to +0.08 across the var-
 G.J. Taylor et al. / Neuroscience and Biobehavioral Reviews 68 (2016) 10061020
ious alexithymia scales and subscales. A similar pattern of results
has also been reported for the related construct of emotional intel-
ligence (EI). Lumley et al. (2005) found low or non-signicant
correlations between the LEAS and both self-report and perfor-
mance measures of EI. Ciarrochiet al. (2003), using an earlier version
of the same performance measure of EI, found a very low correla-
tion (r = 0.15) between the total LEAS and total EI scores. A more
recent study, using youth versions for the LEAS and the perfor-
mance measure of EI (Veirman et al., 2011), found non-signicant
to low correlations between the LEAS and the various EI scales and
subscales (r = 0.02 to 0.19).
For a scale that was developed to assess individual differences
in emotional awareness, it is also peculiar, from a construct validity
perspective, that the LEAS does not correlate with the dimen-
sional traits located in basic universal models of personality. As
we have noted in detail elsewhere (Taylor and Bagby, 2013b), indi-
vidual differences in identifying and differentiating feelings should
be expected to be related to some basic personality dimensions.
Although Lane et al. (1990) reported a positive association between
the total LEAS and an openness to experience inventory, Ciarrochi
et al. (2003), for example, found no signicant correlations between
total LEAS and any of the dimensions in the ve-factor model of
personality. Veirman et al. (2011) report similar results, with non-
signicant or low correlations (r =0.01 to 0.17) between the LEAS
and the ve-factor personality dimensions.
Clearly further empirical investigations are needed to illuminate
the relation between the alexithymia construct and the levels of
emotional awareness construct. It would be important to use mul-
tiple measures of alexithymia and to include a measure of imaginal
functioning. In a recent study with a university student sample, for
example, the LEAS correlated weakly with the TAS-20 (r = 0.20),
but more strongly with the TSIA (r = 0.47) (Lichev et al., 2014);
future research should also focus on using clinical samples.
8. Alexithymia and the concept of mentalization
Lane et al. (2015a) argue that scientic developments since the
1970s, including the concept of theory of mind or mentaliza-
tion, and new knowledge about the brain and emotion, make it
not only possible, but even necessary, to expand the alexithymia
construct. In their view these advances lead to a formulation that
permits a shift to a perspective that verbal behavior is an indi-
cator of the problem rather than the primary problem itself (p.
596). Although we fully agree that scientic developments have
increased and will continue to advance our understanding of alex-
ithymia, in our opinion the verbal behavior aspect of alexithymia
has always been considered an indicator of a problem rather than
the primary problem itself; examples of this are Sifneoss (1967)
speculation that difculty nding appropriate words to describe
feelings might reect an emotional agnosia, and our conceptual
idea that alexithymia reects a decit in the processing and regu-
lation of emotions by means of mental representations (Taylor et al.,
1997). Vanheule et al. (2011) also have emphasized that this con-
ceptualization of the construct means that alexithymia is a marker
of an underlying process, from which it should never be separated
(p. 88).
In discussing theory of mind or mentalization, Lane et al.
(2015a) note that these concepts were introduced six years after
the term alexithymia was coined. The concept of mentalization
was actually introduced in the 1960s by French psychoanalysts
in an attempt to understand the role of pense opratoire in psy-
chosomatic illness (Fain and Marty, 1964; Luquet, 1981; Marty,
1991). Mentalization referred to the linking of somatic affect and
drive excitations with mental representations, and is thus a process
similar to Buccis (1997a) concept of referential activity, provided
1015
one recognizes that the subsymbolic system in Buccis model
operates with its own organizing principles and does not have
to be transformed to become part of psychic life (Bouchard and
Lecours, 1999; Bucci, 1999). In the late 1990s, Lecours and Bouchard
(1997) extended the contributions of Marty and other French ana-
lysts by proposing a hierarchical conceptual model with levels of
mentalization of increasing complexity; this model shows some
similarities with Krystals (1974) theory of affects and Lane and
Schwartzs (1987) hierarchical model of levels of emotional aware-
ness. It was around that time that Fonagy and Target (1997) (Fonagy
et al., 2002) adopted the concept of mentalization and dened it
more broadly as the capacity to be aware of and to think about
feelings and other mental states (e.g., beliefs, desires, intentions)
in oneself and others. Fonagy (2000) indicated that he preferred
the term mentalization (or reective function) to theory of mind.
More recently, Fonagy et al. (2012) described mentalization as a
multifaceted construct with cognitive and affective components,
and indicated that mentalizing is not a static and unitary skill,
but a dynamic capacity that is inuenced by stress and arousal,
particularly in the context of specic attachment relationships (p.
19). Fonagy et al. (2012) also described mentalization as a form
of social cognition, which they dened as the imaginative mental
activity that enables us to perceive and interpret human behavior
in terms of intentional mental states (e.g., needs, desires, feelings,
beliefs, goals, purposes, and reasons) (p. 4).
Clearly Fonagy et al.s (2012) understanding of mentalization,
and the way it is applied by Lane et al. (2015a), is very different from
how it was conceptualized originally by French psychoanalysts
(Fain and Marty, 1964; Luquet, 1981; Marty, 1991). As we outlined
in another contribution (Taylor and Bagby, 2013a), alexithymia is
a much narrower construct that corresponds most closely with
one specic component of mentalization, which involves iden-
tifying, processing and communicating affects and is referred to
as mentalized affectivity (Fonagy et al., 2002; Jurist, 2005). We
emphasized that the alexithymia construct does not encompass
the cognitive aspects of the broad mentalization construct, such
as thinking about thinking and understanding that others have
thoughts, feelings, beliefs, and desires that are different from ones
own. Experimental investigations of the role of theory of mind
in alexithymia, including Lane et al.s (2015b) recent investigation
of patients with somatoform disorders and medical controls, use
theory of mind tasks that test the ability to detect mental states in
others, not in oneself. Lane et al. (2015a) refer to that recent study
and note that after controlling for self-reported positive and neg-
ative affect, the LEAS correlated positively with several measures
of theory of mind whereas the TAS-20 did not. Some individu-
als with a high degree of alexithymia might be impaired in their
ability to read the intentions, desires, and emotional states of oth-
ers, but measures of alexithymia were not designed to assess this
ability as it is not included in the denition of the alexithymia con-
struct. Nonetheless, several investigations have found associations
between alexithymia and poor empathic abilities (e.g., Grynberg
et al., 2010; Moriguchi et al., 2007; Taylor and Bagby, 2000), which
is consistent with clinical observations (Krystal, 1979) and suggests
that impaired empathy is an important correlate of alexithymia.
There is empirical evidence also that alexithymia negatively affects
the quality of interpersonal relationships (Foran and OLeary, 2013;
Humphreys et al., 2009; Vanheule et al., 2007).
9. Treatment of alexithymia
Lane et al.s (2015a) proposal that the concept of affective
agnosia advances the treatment of alexithymia seems based on a
mistaken impression that the usual psychotherapeutic approach
has been simply to help patients put emotions into words. They
1016 G.J. Taylor et al. / Neuroscience and Biobehavioral Reviews 68 (2016) 10061020
assert that a variety of treatment methods that have been
created in recent years that promote mental representation of
emotion. . .. . . have not been applied to the alexithymia context
to date (p. 606). They suggest that techniques used in dialecti-
cal behavior therapy, mentalization-based therapy, and emotion
focused therapy are potentially applicable to the treatment of alex-
ithymia/affective agnosia as they promote the ability to know
what one is feeling (p. 606). They also refer to new approaches
used by therapists in Germany to engage implicit emotional pro-
cesses, such as art therapy, dance therapy, massage and other
body-based treatments. In our view, these opinions reect a failure
to review and integrate the existing literature on the treatment of
alexithymia.
The unsuitability of the classic psychodynamic model of drive
and defenses for treating patients with alexithymia was pointed
out rst by Sifneos (1975) and Nemiah et al. (1976); they therefore
recommended supportive psychotherapy. Krystal (1979), how-
ever, developed a modied form of psychodynamic psychotherapy,
which includes techniques for helping patients to both recognize
and verbalize their emotions. We described these techniques and
some additional strategies in detail almost two decades ago (Taylor
et al., 1997), so there is no need to repeat them in this Commen-
tary. We indicated that In general, these modications focus on the
form, rather than on the content of the patients communications,
and they attempt to enhance the patients awareness of decits in
the way they process and experience emotions (Taylor et al., 1997;
p. 250). Moreover, consistent with Lane and Schwartzs (1987)
development model of levels of emotional awareness, we empha-
sized that The therapeutic approach for alexithymia patients
attempts to elevate emotions from the level of perceptually bound
experience (a world of sensation and action) to a conceptual repre-
sentational level (a world of feelings and thoughts) where they can
be used as signals of information, thought about, and sometimes
communicated to others (Taylor et al., 1997; p. 252). This approach
corresponds to enhancing mentalization in the way this concept
was dened by Marty (1991) and other French psychoanalysts (Fain
and Marty, 1964; Luquet, 1981).
Most clinicians treating alexithymic patients with psychother-
apy employ some or all of the techniques described by Krystal
(1979), or similar techniques adapted from cognitive-behavioral,
mentalization-based, or emotion-focused therapies. There are sev-
eral single case reports of patients whose alexithymia was reduced
using these approaches (e.g., Dimaggio et al., 2011; Kennedy and
Franklin, 2002; Taylor, 2012; Vanheule et al., 2011). In addition,
there is empirical evidence from some preliminary studies that
the level of alexithymia can be reduced by modied group psy-
chotherapy. In one of these studies, which was conducted with
post-myocardial infarction patients, the reductions in alexithymia
were maintained over a 2-year follow-up period; and during those
two years, patients with decreased alexithymia following group
therapy experienced fewer cardiac events (re-infarction, sudden
cardiac death, or re-hospitalization for rhythm events or severe
angina) than patients whose alexithymia remained unchanged
(Beresnevaite, 2000). In another study, even after controlling for
the inuence of changes in depressive symptoms, alexithymia, par-
ticularly the DIF facet of the construct, decreased in psychiatric
outpatients who participated in a comprehensive group therapy
program that was predominantly guided by cognitive-behavioral
theory, but included participation in groups with various orien-
tations including psychodynamic and interpersonal therapy that
focused on a range of different topics (Ogrodniczuk et al., 2012).
As described by the researchers, The groups [were] co-led by one
dedicated group leader (e.g., a psychoanalytically-trained psychia-
trist for the psychodynamic group) and one trainee (e.g., a mental
health nurse) (p. 282). The decreased alexithymia in these psychi-
atric patients was associated with improvements in interpersonal
problems.
Given their proposal that affective agnosia constitutes a
supramodal agnosia consisting of dysfunction in the activation
and/or use of high level mental representations of emotional states
and their meaning, Lane et al. (2015a) conclude that clinical
intervention should place special emphasis on using emotional
information as opposed to only expressing emotions in words (p.
608). Clinicians and psychotherapy researchers are well aware that
Alexithymia involves an impaired capacity to construct mental
representations of emotions (Ogrodniczuk et al., 2005; p. 211),
and that interventions need to focus not only on developing that
capacity but also on increasing patients ability to use emotional
information to guide thinking and behavior (Krystal, 1979; Taylor
et al., 1997). This ability is assessed by a negatively keyed item on
the EOT subscale of the TAS-20 (I nd examination of my feel-
ings useful in solving personal problems.), and by several items
on the EOT subscale of the TSIA (Do you nd examining your feel-
ings useful when attempting to solve personal problems?; Do you
often rely on your feelings to help guide your actions?; Do you
think about past emotional experiences to help you cope with more
recent emotional problems?; Do you learn much about yourself on
the basis of your feelings?). As Lane et al. (2015a) note, the ability
to use emotional information is one of the components of the emo-
tional intelligence construct. In a study with a young adult sample,
the TAS-20 correlated negatively with the Using Emotions subscale
of a measure of ability emotional intelligence (r = 0.32, p < 0.001,
N = 140), whereas the LEAS failed to correlate (r = 0.02, ns, N = 140)
(Lumley et al., 2005). Although these results need to be repli-
cated with clinical samples, they suggest that assessing levels of
emotional awareness alone may not sufciently inform therapists
about their patients capacity to use emotions to guide thinking and
behavior. Indeed, in contrast to the TAS-20 and the TSIA, the LEAS
does not include scoring for the ability to use emotions.
We agree with Lane et al. (2015a) that art therapy and body-
based approaches may be useful in making alexithymic patients
more aware of their emotions and for facilitating the conscious
experiencing of feelings that can be labeled and described to oth-
ers. Such approaches are not new, but have been recommended and
used by some therapists for several decades. More than thirty years
ago, Taylor (1984) suggested several behavioral techniques, such as
relaxation training, autogenic training, meditation, guided imagery,
and hypnosis, that might help alexithymic patients increase their
awareness of relations between the bodily sensations of emo-
tions and environmental triggers; he also referred to the use of
biofeedback as an adjunct to psychotherapy with somatizing alex-
ithymic patients. Moreover, as part of group therapy in the above
mentioned study with post-myocardial infarction patients, partic-
ipants were taught Jacobsons technique of progressive relaxation
to help focus their attention on inner experience; participated in
role playing and nonverbal communication (e.g., mimicry and eye
communication) to improve their ability to identify and commu-
nicate subjective feelings; and listened to music while in a relaxed
state to enhance imaginal activity (Beresnevaite, 2000). Although
Lane et al. (2015a) briey mention that Ruesch (1948) posited
trauma as one potential cause of the impaired mental representa-
tion of emotion in psychosomatic patients, their failure to consider
Krystals (1979,1988) contributions to the eld results in a major
omission in their discussion of implications of the concept of affec-
tive agnosia for treatment. As we indicated in Section 5.1, Krystal
attributed alexithymia to early childhood trauma that interrupts
the normal development of affects, or to catastrophic adult trauma
that triggers a regression of affects to a preconceptual level of
organization. Because the mind of the infant or young child is not
sufciently developed to mobilise psychological defenses to mod-
erate the impact of psychic trauma, and the adults defenses are
 G.J. Taylor et al. / Neuroscience and Biobehavioral Reviews 68 (2016) 10061020
overwhelmed by the intensity of the traumatic event, traumatic
experiences and the associated intense emotions are not repre-
sented mentally, but are managed by primal repression as opposed
to repression proper (Freud, 1915). Whereas repression proper
is a defensive process that rejects from the conscious mind emo-
tional, instinctual, and other representations, primal repression, as
we indicated in Section 3, forecloses traumatic experience from the
mind and thus prevents the formation of mental representations
of the experience (Cohen and Kinston, 1983; Kinston and Cohen,
1986, 1988). These unmentalized emotional experiences are often
associated with alexithymia (Cohen, 1991; Krystal, 1990), and are
increasingly seen as having an important role in psychopathol-
ogy and somatic illness (Busch and Sandberg, 2014; Mitrani, 1995;
Taylor, 2010). As several authors point out, trauma-related emo-
tions are encoded on a sensorimotor, enactive level rather than
in a semantic and linguistic way, but their presence is manifest
through somatic symptoms, physiological reactions, or mindless
actions such as compulsive drug abuse and bingeing on food (Cohen
and Kinston, 1983; Krystal, 1988; Taylor et al., 1997).
Although Freud gave greater attention to conicts over instinc-
tual drives than to traumatic emotions in psychopathology, as we
outlined in Section 3, his concept of primal repression is analogous
to affective agnosia since the traumatic emotions are not repre-
sented psychically and are therefore inaccessible to consciousness,
and their meaning is unknown to the person. It is perhaps because
of primal repression that some authors conceptualize alexithymia
both as a massive defense against unbearable emotions and as a
decit in the mental representation of emotions (see, Taylor and
Bagby, 2013a). As psychotherapy of the alexithymic patient pro-
ceeds, there is potential for activation of intense trauma-related
emotions, which can be overwhelming for the patient as they
emerge from primal repression (Taylor, 2012). If this phase of treat-
ment is reached, it requires a relationship in which the therapist
contains and helps the patient tolerate the emotions, and aids the
patient in linking them with images and words and understanding
their meaning.
10. Conclusion
The concept of affective agnosia is a reminder that alexithymia
is not simply a difculty in nding words for feelings, but involves
an impairment in the mental representation of emotions, which
limits the capacity to regulate emotions through cognitive pro-
cesses. Deciding whether a patient has the anomia or the agnosia
version of alexithymia, however, implies a categorical conceptual-
ization, which is inconsistent with Lane et al.s (2015a) description
of different levels of emotion representation with different degrees
of organization and complexity. Nemiah and Sifneos may have
regarded alexithymia as a categorical construct, but Krystal (1979)
reported that Most patients are able to experience some feelings
some of the time and declared that alexithymia is not an all
or nothing phenomenon (p. 24). The results of empirical inves-
tigations support a dimensional conceptualization of alexithymia
(Mattila et al., 2010a; Parker et al., 2008), and therefore the view
that it is preferable to conceptualize different degrees of alex-
ithymia, rather than dene subtypes.
Following Krystals (1988, 1997) ideas about the impact of
trauma on affect development and affect regression, the degree of
alexithymia in any person is likely to reect the extent of trauma
experienced by the person during childhood or as an adult, and
whether or not an attachment gure was available to contain and
modulate the persons distress. Milder degrees of alexithymia likely
reect deciencies in the parents attunement and responsiveness
to the childs affects; severe degrees of alexithymia may reect
more catastrophic traumas such as parental neglect, physical or
1017
sexual abuse, and exposure to military combat or natural disasters.
Janet (1889) believed that it is the vehement emotions that accom-
pany extreme experiences that makes them traumatic. Although
Freuds concept of primal repression is seldom used by psychoana-
lysts, it is an adaptive response that keeps such emotions from being
represented, while they continue to exert an indirect effect on the
persons body and mental life. The application of primal repres-
sion to alexithymia (Cohen, 1991; Krystal, 1990) is consistent with
Buccis (1997a, 1997b) conceptualization of trauma-induced disso-
ciation within and among the symbolic and subsymbolic elements
of emotion schemas, and directs clinicians to consider patients
constricted cognitive functioning and somatic or behavioral symp-
toms as possible manifestations of trauma. Primal repression thus
has implications for treatment beyond those of the concept of
affective agnosia. It should not reduce attention to the anomia
aspect of alexithymia, however, as there is experimental evidence
from studies with healthy individuals that putting feelings into
words (lexithymia) enhances emotion regulation, partly by reduc-
ing amygdala activation in response to emotional stimuli (Burkland
et al., 2014; Lieberman et al., 2007).
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