Impaired self-awareness and theory of mind: An fMRI study of mentalizing in alexithymia
Introduction
Alexithymia is a disturbance in both affective and cognitive functioning characterized by difficulty in describing or recognizing the emotions of the self. Alexithymia was originally described by Sifneos (1972) in patients with psychosomatic disorders. Subsequently, alexithymia was regarded as an impairment of emotion self-regulation that is found in a broad range of physical and psychiatric disorders (e.g., alcoholism, drug addiction, and post traumatic stress disorders; see Taylor et al., 1997). At the present time, alexithymia is not considered a discrete disorder but rather a personality characteristic that is expressed with variable intensity in the general population.
Although alexithymia refers to a deficit in emotional self-awareness, Bydlowski et al. (2005) reported that high alexithymic patients with eating disorders showed impairment in the ability to describe the emotional experiences of others in hypothetical situations. Thus, emotional self-awareness seems to be closely related to sensitivity to the emotions of others. Furthermore, the capacity to differentiate the emotions of the self from those of another person in a given context appears to be crucial for managing a variety of emotional states (Bydlowski et al., 2005). Lane and Schwartz (1987) noted that as the level of emotional awareness increases, the differentiation of self from other increases. In the absence of such differentiation, emotions remain global and undifferentiated, leading to a relative inability to use one's own emotions to guide the selection of adaptive behavior.
Understanding that others have beliefs, desires, and intentions different from the self is a cognitive skill known as “Theory of mind” (ToM) or ‘mentalizing’ (Frith and Frith, 2003). Autistic spectrum disorders, including Asperger's syndrome, are characterized by an impairment of ToM (Baron-Cohen et al., 1985, Baron-Cohen et al., 1997). Asperger's syndrome is associated with high alexithymia scores (Berthoz and Hill, 2005, Frith, 2004, Hill et al., 2004). This suggests that the ability to describe the mental states of self and other is related. Alexithymia was also associated with impairment in the ability to identify emotions from facial expressions (Pandey and Mandal, 1997, Parker et al., 2005, Lane et al., 1996). Alexithymia has been related to certain psychiatric disorders characterized by a deficit in the ability to know what others are thinking and feeling or a lack of empathy, for example, schizophrenia (Cedro et al., 2001, Maggini and Raballo, 2004a, Maggini and Raballo, 2004b, Stanghellini and Ricca, 1995, Todarello et al., 2005, van 't Wout et al., 2004), and borderline (Guttman and Laporte, 2002) and psychopathic personality disorders (Haviland et al., 2004). Thus, disorders characterized by ToM impairment are also associated with alexithymia.
It would therefore appear likely that individuals with alexithymia have an impaired ability to know the minds of others, which might contribute to difficulties in emotion regulation and interpersonal relations. However, the relation between alexithymia and mentalizing has only been sparsely investigated (for example, see Wastell and Taylor, 2002), and its neural basis remains to be examined.
We therefore investigated neuronal activation in individuals with high and low alexithymia during a ToM task using functional magnetic resonance imaging (fMRI). We hypothesized that alexithymia would be associated with decreased neuronal activity in the medial prefrontal cortex (MPFC), the temporo-parietal junction (TPJ), and the temporal pole (TP), a neuronal activity pattern characteristic of subjects who are known to have a deficit in the capacity for mentalizing, such as patients with Asperger's syndrome (Castelli et al., 2002, Frith and Frith, 2003).
Section snippets
Subjects
We screened 310 college students (105 males and 205 females) for alexithymia using a self-administrated questionnaire, TAS-20 (Taylor et al., 2003, Komaki et al., 2003). Individuals with high or low TAS-20 total scores (n = 20, score > 60 and n = 18, score < 39, respectively) were selected to obtain two groups that were maximally divergent on alexithymia. This yielded 38 volunteers (30 females, 8 males; 19 to 22 years of age, mean age = 20.4 years, SD = 0.938). All subjects gave written
Behavioral measures
There was no difference between the groups in the ratio of male to female subjects (13 alexithymia females to 3 alexithymia males and 12 non-alexithymia females to 2 non-alexithymia males; χ2 = 0.168, Fisher's Exact probability = 1.00, two tailed), so scores for men and women were combined (see Table 2). The alexithymia group scored significantly lower than the non-alexithymia group on ToM intentionality, appropriateness, IRI perspective taking and empathic concern, and scored significantly
Discussion
Our study demonstrates differences between individuals in behavioral and neural responses to a mentalizing task as a function of alexithymia. Alexithymia, a disturbance in self-awareness, was associated with impairment in mentalizing and the related empathic ability of perspective taking, the ability to see things from the point of view of another person. Neural activity in the medial prefrontal cortex was decreased in alexithymics, and activity in the same region was closely related to
Conclusion
Our findings demonstrate that alexithymia, a deficit in the ability to identify and describe the feeling states of the self, is related to impaired mentalizing (comprehending the mind of others), which in turn is associated with hypoactivity in the MPFC. The deficit in mentalizing that we observed is associated with impairment in the higher cognitive ability to take a perspective different from the self, a skill that may be essential for the comprehension of the mental states of both self and
Acknowledgments
This study was supported by the Research Grant (17A-3) for Nervous and Mental Disorders from the Ministry of Health, Labour and Welfare, Japan.
We thank Dr. Uta Frith for her generous donation of the animation to the project.
References (91)
- et al.
Does the autistic child have a “theory of mind”?
Cognition
(1985) - et al.
The validity of using self-reports to assess emotion regulation abilities in adults with autism spectrum disorder
Eur. Psychiatry
(2005) - et al.
A PET investigation of the attribution of intentions with a nonverbal task
NeuroImage
(2000) - et al.
Movement and mind: a functional imaging study of perception and interpretation of complex intentional movement patterns
NeuroImage
(2000) - et al.
Dissociable temporal lobe activations during emotional episodic memory retrieval
NeuroImage
(2000) - et al.
The impact of individual differences on the neural circuitry underlying sadness
NeuroImage
(2003) - et al.
What does the frontomedian cortex contribute to language processing: coherence or theory of mind?
NeuroImage
(2002) - et al.
Other minds in the brain: a functional imaging study of “theory of mind” in story comprehension
Cognition
(1995) - et al.
How many subjects constitute a study?
NeuroImage
(1999) - et al.
Reading the mind in cartoons and stories: an fMRI study of ‘theory of mind’ in verbal and nonverbal tasks
Neuropsychologia
(2000)
Attachment-style differences in the ability to suppress negative thoughts: exploring the neural correlates
NeuroImage
Alexithymia, empathy, and psychological symptoms in a family context
Compr. Psychiatry
The reliability and factorial validity of the Japanese version of the 20-item Toronto Alexithymia Scale
J. Psychosom. Res.
Neural circuitry underlying voluntary suppression of sadness
Biol. Psychiatry
Reduced activation of posterior cingulate cortex during imagery in subjects with high degrees of alexithymia: a functional magnetic resonance imaging study
Biol. Psychiatry
General and specific contributions of the medial prefrontal cortex to knowledge about mental states
NeuroImage
Dementia: the estimation of premorbid intelligence levels using the New Adult Reading Test
Cortex
The assessment and analysis of handedness: the Edinburgh inventory
Neuropsychologia
Alexithymia and depression: a 1-year follow-up study in outpatients with major depression
J. Psychosom. Res.
Against simulation: the argument from error
Trends Cogn. Sci.
People thinking about thinking people. The role of the temporo-parietal junction in “theory of mind”
NeuroImage
Acquired theory of mind impairments in individuals with bilateral amygdala lesions
Neuropsychologia
The 20-Item Toronto Alexithymia Scale: IV. Reliability and factorial validity in different languages and cultures
J. Psychosom. Res.
Emotional processing in a non-clinical psychosis-prone sample
Schizophr. Res.
Mind reading: neural mechanisms of theory of mind and self-perspective
NeuroImage
Do triangles play tricks? Attribution of mental states to animated shapes in normal and abnormal development
J. Cogn. Dev.
Structure and measurement of empathy: Japanese version of Davis's Interpersonal Reactivity Index (IRI-J)
Psychol. Rep. Sophia Univ.
Development of the Structured Interview by the Modified Edition of Beth Israel Hospital Psychosomatic Questionnaire (SIBIQ) in Japanese edition to evaluate alexithymia
Jpn. J. Psychosom. Med.
Another advanced test of theory of mind: evidence from very high functioning adults with autism or Asperger syndrome
J. Child Psychol. Psychiatry
Neural correlates of conscious self-regulation of emotion
J. Neurosci.
An fMRI study of intentional and unintentional (embarrassing) violations of social norms
Brain
Effect of impaired recognition and expression of emotions on frontocingulate cortices: an fMRI study of men with alexithymia
Am. J. Psychiatry
Using the interpersonal reactivity index to assess empathy in violent offenders
Int. J. Forensic Psychol. Issue
Emotion-processing deficits in eating disorders
Int. J. Eat. Disord.
Autism, Asperger syndrome and brain mechanisms for the attribution of mental states to animated shapes
Brain
Alexithymia in schizophrenia: an exploratory study
Psychol. Rep.
Measuring individual differences in empathy: evidence for a multidimensional approach
J. Pers. Soc. Psychol.
Empathy: A Social Psychological Approach
The functional architecture of human empathy
Behav. Cogn. Neurosci. Rev.
Overlap between alexithymia and Asperger's syndrome
Am. J. Psychiatry
Attachment and borderline personality disorder
J. Am. Psychoanal. Assoc.
The role of the prefrontal cortex in self-consciousness: the case of auditory hallucinations
Philos. Trans. R. Soc. London, Ser. B Biol. Sci.
Emanuel Miller lecture: confusions and controversies about Asperger syndrome
J. Child Psychol. Psychiatry
Interacting minds—A biological basis
Science
Development and neurophysiology of mentalizing
Philos. Trans. R. Soc. London, Ser. B Biol. Sci.
Cited by (306)
Adverse childhood experiences differently affect Theory of Mind brain networks in schizophrenia and healthy controls
2024, Journal of Psychiatric ResearchThe emotional pathway to parenthood: Parental mentalizing mediates the association between alexithymia and parental emotion regulation in the transition to parenthood
2023, Journal of Affective Disorders ReportsA feeling difficult to identify: Alexithymia is inversely associated with positive body image in adults from the United Kingdom
2023, Journal of Affective DisordersNo feelings for me, no feelings for you: A meta-analysis on alexithymia and empathy in psychopathy
2022, Personality and Individual DifferencesThe Cerebellum as an Embodying Machine
2024, Neuroscientist