Once the distortions are cleared away, most patients who come to the emergency room tell stories that seem to grow out of the problems they claim to have and the pain they claim to feel. These stories reverberate with emotions congruent to their themes. But occasionally, patients who clearly have problems and are in great emotional pain tell noncongruent stories. They will insist that they have no problems, that life is fine and that they have no idea what is wrong. Their story is that they have no story. These patients seem unable to find the words necessary to describe their feelings.
In 1972, Peter Sifneos introduced to psychiatry the term alexithymia, which (derived from the Greek) literally means having no words for emotions (a=lack, lexis=word, thymos=emotions). Alexithymia is not a diagnosis, but a construct useful for characterizing patients who seem not to understand the feelings they obviously experience, patients who seem to lack the words to describe these feelings to others. Identifying this deficit in expressivity is important because doing so gives the clinician a leg up in making a diagnosis and charting a therapeutic course.
Many individuals with alexithymia have somatic complaints. Considerable empirical evidence links prolonged states of emotional arousal, and the concomitant physiological arousal, with susceptibility to certain somatic disorders. Clearly, someone who cannot verbally express negative emotions will have trouble discharging and neutralizing these emotions, physiologically as well as psychically. All feelings, whether normal or pathological, are ultimately bodily feelings. Those with alexithymia lack a lived understanding of what they experience emotionally.
From the perspective of development, alexithymia implies a glitch in the process that permits the expression of feelings in words that capture the body's involvement in these feelings. Perhaps the child's mother failed to sufficiently encourage a language of feelings (surely excluding her from the pantheon of Winnicott's "good enough" mothers). Alternatively, emotional trauma later in life may compromise the connection between what is felt and what can be grasped about this feeling and can be put into words, particularly if that link were tenuous to begin with.
If a patient has no story to tell a clinician, even at a time when emotions are stirred high enough to prompt an ER visit, it seems a good bet that person has no story to tell themselves either. Having no story almost certainly implies an impaired identity: Who we know ourselves to be depends heavily on the story we tell ourselves about who we are. The inability to express emotions verbally implies a deficient interior life. Inevitably, those who cannot match words to feelings will live out that deficit in their contacts with others as well. To have no words for one's inner experience is to live marginally, for oneself and for others.
"Kisha," 16, was brought to the ER by her mother after she held a curling iron to the outside of her upper left arm, causing a large, painful burn. Kisha had just started her junior year in high school and also worked as a cashier in a convenience store. She was an average student, but her mother assured me she was one of the most popular girls in her class. Kisha lived with her parents, two sisters and brother. She had never used illicit drugs or abused alcohol. "I'm a virgin," she said easily and proudly when I asked if she had a current boyfriend, which she did not. Kisha denied physical and sexual abuse, and her mother later corroborated her denial. Asthma, occasional bronchitis and seasonal allergies were her only concessions to good health.
Kisha acknowledged feeling depressed recently, although she did not admit to having any of the symptoms of a major depressive episode. Her appetite had not changed, and she was sleeping up to 10 hours a day, the norm for her. My best diagnostic call was depressive disorder, not otherwise specified.
Kooiman CG (1998), The status of alexithymia as a risk factor in medically unexplained physical symptoms. Compr Psychiatry 39(3):152-159.
Lesser IM (1985), Current concepts in psychiatry. Alexithymia. N Engl J Med 312(11):690-692.
Lumley MA, Stettner L, Wehmer F (1996), How are alexithymia and physical illness linked? A review and critique of pathways. J Psychosom Res 41(6):505-518.
Nemiah JC (1977), Alexithymia. Theoretical considerations. Psychother Psychosom 28(1-4):199-206.
Sifneos PE (1972), Short-Term Psychotherapy and Emotional Crisis. Cambridge, Mass.: Harvard University Press.
Sifneos PE (1996), Alexithymia: past and present. Am J Psychiatry 153(7 suppl):137-142.
Taylor GJ, Bagby RM, Parker JD (1991), The alexithymia construct. A potential paradigm for psychosomatic medicine. Psychosomatics 32(2):153-164.
Zeitlin SB, McNally RJ, Cassiday KL (1993), Alexithymia in victims of sexual assault: an effect of repeated traumatization? Am J Psychiatry 150(4):661-663.