Emotion processing deficits in alexithymia and response to a depth of processing intervention
Introduction
In spite of receiving substantial clinical interest, the construct of alexithymia, introduced by Sifneos (1972) to describe the difficulty of psychosomatic patients to verbalize inner states, remains elusive. Research has since indicated that alexithymic deficits extend beyond the verbal expression of emotion (e.g. Lane et al., 1996, Wagner and Lee, 2008) to difficulties in distinguishing affect-related arousal from other bodily sensations, describing feelings, limited fantasy and daydreaming, and externally oriented thinking (Taylor, Ryan, & Bagby, 1985). It mostly characterizes older, low SES males, which suggests that it may be contextually controlled, and is associated with various psychiatric disorders (Bankier, Aigner, & Bach, 2001), symptom reporting and treatment seeking (De Gucht & Heiser, 2003).
Despite extensive research, few well-controlled experimental studies exist to specify alexithymic deficits and clarify whether these pertain to the physiological, the subjective or the behavioral component of emotions, or if the deficit relates to a disorganization of these systems (Luminet et al., 2004, Roedema and Simons, 1999, Peasley-Miklus and Vrana, 2004 are some exceptions). The present study, using a well-established experimental paradigm, examines differences between individuals high and low in alexithymia at all of the three major emotion output systems (Lang, 1979) of emotional response (physiological, behavioral-expressive and cognitive-experiential), as well as differences in the concordance among these components.
Numerous investigations have attempted to map the physiology of alexithymic affective responding, using a variety of emotion materials (e.g. pictures, stressors, films) but resulted in conflicting findings. Some evidence (e.g. Eastabrook et al., 2013, Friedlander et al., 1997, Stone and Nielson, 2001) supports what is known as the hyper-arousal theory, according to which alexithymics demonstrate exaggerated physiological responses (e.g. increased heart rate response among those high in Difficulty Describing Feelings; Luminet et al., 2004) to emotional stimuli or chronic (tonic) hyper-arousal (Lane et al., 1997, Lumley, 2000). However, contradictory findings also exist, suggesting that physiological reactivity is similar to that of controls or even attenuated (Bausch et al., 2011, Connelly and Denney, 2007, Linden et al., 1996, Neumann et al., 2004Peasley-Miklus and Vrana, 2004, Pollatos et al., 2011, Roedema and Simons, 1999), especially during negative emotions. Such findings have led to a converse, hypo-arousal hypothesis. Hence although some type of autonomic arousal deficit characterizes this population, the direction of the difference is uncertain, as is whether differences pertain to resting physiology or to specific emotions.
Inconsistent results with regards to the physiological emotion response system in alexithymia can in part be attributed to methodological variations between studies. For example, studies differ in the stimuli used to elicit emotion; some have used stressors (e.g. Friedlander et al., 1997, Näätänen et al., 1999), whereas others have used films and pictures. Findings about responses to stressors may not generalize to processing of other emotions such as fear or joy elicited by visual stimuli. Furthermore, some studies using films elicited specific emotion categories such as fear only (Stone & Nielson, 2001), whereas other studies using pictures compared positive to negative emotional conditions. The absence of systematic examination of emotion categories across studies, and inconsistent manipulation of aspects of emotion such as valence and arousal, makes it difficult to draw conclusions that can generalize beyond single investigations, which themselves may have been methodologically solid. Also different dependent measures of physiological reactivity have been used, including skin conductance response, heart rate, muscle tension, etc. Since each of these systems may be best suited for the assessment of different aspects of emotion processing, for example sympathetic versus parasympathetic autonomic nervous system activity, appropriate dependent measures need to be selected to answer specific research questions.
Studies have so far focused mainly on autonomic arousal, which provides an index of the global mobilization of the organism in the face of a significant event (emotion, action disposition). Autonomic responses, however, do not adequately differentiate between emotional states of different valences. The combined dimensions of valence and arousal explain most of the variance in emotion descriptions (Mehrabian & Russell, 1974) and are linked to differential aspects of approach and defense systems (e.g. Bradley, 2009). It is, therefore, difficult to conclude if alexithymic deficiencies in emotional processing are general for all emotions or valence-specific (observed only during positive or negative emotional situations, which are matched on other dimensions such as arousal). Research should aim to more clearly differentiate the affective context relevant to alexithymic difficulties and to specify the response systems in which deficits become apparent.
Additionally, most studies have compared emotion responses in high and low alexithymia individuals. Those studies that broke down the construct into the constituent factors measured by the TAS, however, suggest that these may show differential patterns of associations with specific emotion response systems (e.g. Luminet et al., 2004). Therefore the role of specific TAS sub-factors also needs to be taken into consideration.
It is possible more-over that alexithymic deficits do not pertain so much to the physiological, and specifically autonomic response system but to the behavioral or subjective-experiential systems of emotion: Reporting subjective experiences by labeling emotions (see review by Grynberg, Chang, et al., 2012) or rating them on different emotional dimensions, as well as the non-verbal facial expression of emotion may be compromised (e.g., Luminet et al., 2004, Roedema and Simons, 1999), as initially suggested by the clinical descriptions of alexithymics during clinical interviews (Sifneos, 1972). Results addressing this prediction have also been mixed, with some studies finding decreased reports of specific emotions, or of affective arousal and valence among alexithymics (Vanman, Dawson, & Brennan, 1998), when others found no differences from controls or even higher reports of arousal (Grynberg et al., 2012b, Roedema and Simons, 1999). With regards to facial expressions, many studies have found decreased facial responses in alexithymics (e.g., McDonald and Prkachin, 1990, Troisi et al., 1996), but others have not corroborated these findings (e.g. Näätänen et al., 1999, Roedema and Simons, 1999), perhaps due, once more, to varied methodologies to induce and measure emotion and the aspects of alexithymia considered.
In addition to possible deficiencies in specific emotion response systems, another potential source of alexithymic difficulties is the concordance among these. Somewhat more consistency characterizes studies documenting this particular deficit named “alexithymic decoupling” (Martin & Pihl, 1986). A cognitive deficit involving poor mental representation of emotions has been suggested as the cornerstone of alexithymia (e.g. Luminet et al., 2006, Suslow and Junghanns, 2002); alexithymic difficulties are believed to lie in how easily specific aspects of emotion are accessed, once other components have been activated within the associative network in memory. Physiological aspects of emotions may not be strongly linked with their symbolic representations, including emotion labels and subjective experience, and are thus misinterpreted as signs of illness (Taylor & Bagby, 2004; see also Mériau et al., 2006 for brain imaging support). This hypothesis is in line with findings from other patient groups who over-report symptoms compared to their objective arousal such as panic disorder patients (Lang & McTeague, 2009), who are believed to demonstrate “loose” emotions associative networks in memory (Lang, 1993).
To summarize, alexithymic deficiencies have been identified at multiple emotion response systems, including physiology, subjective-experiential and behavioral (non-verbal expression of emotions) but have not been replicated consistently. Deficits have also been identified in the form of discordance between these emotion output systems. The present study attempts to delineate where alexithymic deficits are mostly localized by measuring all aspects of emotion responses. The study also aims to specify if difficulties generalize to emotions of varied valences or are specific to positive or negative emotions. To this end, a validated experimental paradigm is used with standardized emotional imagery scripts, to manipulate emotional valence while keeping constant the dimension of arousal.
In this study we further examine whether deficits can be remediated. Clinical evidence, not yet systematically subjected to controlled, experimental verification, focuses on how specific interventions can rehabilitate alexithymic difficulties. Specifically, guided, deep emotional processing, which presumably alexithymic individuals do not spontaneously engage in, has been found to reduce alexithymia (Baikie, 2008, Lumley, 2004, Páez et al., 1999). Therefore, high alexithymia individuals may be able to process emotion appropriately if trained to do so. Studies unrelated to alexithymia have shown that deep processing of emotion influences physiological responses like the startle reflex (Herbert & Kissler, 2010), and brain activity (Hariri, Bookheimer, & Mazziotta, 2000). In one of the few studies relating deep processing to alexithymia, Luminet et al. (2006) found no effects of processing depth on memory of emotional words. Vermeulen, Toussaint, and Luminet (2011), using the same depth manipulation found more affective priming in alexithymics compared to controls, suggesting interactions between alexithymia and depth of processing.
Here we used the tone-cued imagery paradigm (Panayiotou, Brown, & Vrana, 2007) to induce emotion, which has been used effectively with alexithymics (Bausch et al., 2011, Peasley-Miklus and Vrana, 2004) and incorporated an emotional depth of processing manipulation. The startle reflex was included, along with autonomic measures and measures of facial expression as added indices of affective valence and defensive system activation. Physiological and self-report responses to both positive and negative emotions are examined, extending past findings, which mostly focus on negative affect. Self-report measures included subjective valence and arousal, as well as the dimension of dominance, the third most important dimension in affective descriptions (Mehrabian & Russell, 1974). Dominance may be relevant for alexithymia, which has been previously linked to less internal locus of control and less confidence in the ability to exert control over life and the environment (Hexel, 2003). Alexithymia has also been linked to experiential avoidance and poor emotion regulation (e.g. Panayiotou et al., in press, Venta et al., 2013), which suggests that some of the emotion difficulties in alexithymia pertain to a sense that emotions are unwanted and out of control. It was therefore of interest to examine whether high alexithymia individuals differ in experienced dominance during specific emotions.
In sum, we have the following aims: Aim (1) To study if high alexithymic individuals differ from controls in (a) general physiological arousal levels, (b) physiological reactivity to emotional imagery, (c) the facial expression of emotion and (d) labeling emotions and self-report of emotional dimensions (valence, arousal and dominance). Aim (2) To examine if the degree of association between self-reported emotion and physiological response systems differs between high alexithymia individuals and controls. Aim (3) To investigate if instructions for deep emotion processing would alleviate any observed alexithymic deficits.
Section snippets
Sample
Students (N = 466; 122 male, Mage = 21.28, SDage = 3.51, age range = 17–49) from two Cyprus universities were screened with the Toronto Alexithymia Scale-20 (TAS-20; Parker, Taylor, & Bagby, 2003). The scale, adapted and validated into Greek by Anagnostopoulou and Kossieoglou (personal communication, October 2007), assesses on a 5-point Likert scale three factors, namely Difficulty Identifying Feelings (DIF), Difficulty Describing Feelings (DDF) and External-Oriented Thinking (EOT). The total score is
Manipulation checks
First, as manipulation checks for appropriate emotion induction and to examine group differences in the effectiveness of emotional imagery, repeated-measures ANOVAs were conducted with planned contrasts (i.e. baseline vs. joy, fear and neutral) with HR, SCL, facial EMG and startle reflex (baseline vs. joy and fear) as dependent variables. Also, repeated measures ANOVAs on the raw HR, SCL, facial EMG scores and startle responses during imagery and affect ratings were computed to verify that the
Discussion
This study examined differences between high and low alexithymic individuals in emotion responses and the effects of a deep emotion processing intervention. It aimed to reconcile past findings through a controlled experiment, using the well-established tone-cued imagery paradigm. All emotion response systems were assessed to clarify the systems where alexithymic deficits appear. Manipulation checks verified the effectiveness of experimental procedures. Also, high and low alexithymia
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These authors contributed equally to this paper.