When asked about her sex life, Maureen told me with no apparent regret that her partner was impotent and that they had had sex only a few times during their marriage, though they still shared some lesser intimacies. How did Maureen feel about this lack of sex in her life? "I got used to it," she said nonchalantly. She insisted she was "very happy" in her marriage and that she had no complaints about her husband.

Maureen readily volunteered that her first sexual experience occurred at 15 years of age, and that she had had six or seven sexual partners before marrying. She reported these facts almost clinically, as if speaking about someone else. As she told me this, sitting upright on a gurney in tan, cuffed shorts, bare legs unself-consciously displayed, making good eye contact and talking in a pleasant, round tone, I was not convinced Maureen had made as good an accommodation to living a sexless life as she would have herself and me believe.

I regret not asking Maureen if she had been involved with another man (or a woman) at any time during her 15-year marriage, if she had wanted to be or if she was frustrated by her own efforts, past or present, to be involved. Her answers could have given some hint of what was underneath a story that had no words for feelings so painful she was at "rock bottom," saw no hope of feeling better and had gone to two different ERs in two days.

Maureen had severe headaches (not migraines, her doctor told her) and abdominal pain. Several years earlier, she had a total hysterectomy for endometriosis and was taking Premarin (estrogen). Hoping to get a better sense of how much pain Maureen's body caused her, I asked her to rate that pain on a scale of one to six (the somatic concern item on the Brief Psychiatric Rating Scale [BPRS]). Quickly, she answered four. If Maureen had no words for her emotional pain, at least she could be quantitative about her physical pain! Perhaps she was one of those alexithymic patients who had somatic symptoms related to her inability to discharge negative emotions and neutralize the physiological concomitants of prolonged emotional arousal. Kisha, on the other hand, acknowledged only those somatic symptoms related to the physical injuries she inflicted on her body.

Maureen was in considerable emotional distress, but she did not need to be hospitalized. I referred her to a psychiatrist committed to doing intensive outpatient psychotherapy. The ER attending wrote a prescription for venlafaxine (Effexor) (the "different antidepressant" Maureen had come for) and suggested she stop fluoxetine, which seemed to have done little for her after two years. Unlike many medications that need to be tapered to prevent rebound effects, fluoxetine can be discontinued without tapering because of its long half-life and that of its active metabolite, norfluoxetine.

Although not fully empirically validated, alexithymia is a useful clinical construct. For Kisha and Maureen, this word, so descriptive in its Greek roots, specifies a real phenomenon and identifies a deficit of self. Neither woman shut down or clammed up just for their ER interviews; the disconnect between feeling and words was part and parcel of their daily experience. Both women were personable, outgoing and articulate-except about what they felt. Neither showed any sign of schizoid personality disorder, a diagnosis that needs to be considered when patients seem detached from their feelings and lack insight. Being able to say that Kisha and Maureen had no words for their feelings is a major first step in identifying what is pathological about their worlds. How could anyone who cannot discharge negative emotions over a long time not be depressed? Or have any number of other emotional, as well as somatic, problems?

Identifying a patient as alexithymic opens a door to that person's pathological world and creates a fertile field for exploration in therapy. A workable identity can develop only after the elements of a person's life coalesce into a minimally satisfactory story. Paraphrasing Winnicott, a "good enough" identity requires a "good enough" story. It is the therapist's job to help the alexithymic patient convert a nonstory into a story that is at least partially authentic, so a more authentic identity can evolve from that story.
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