Interestingly, a recent study suggests that specifically the cognitive, but not affective, component of alexithymia is associated with deficits in emotional attention and recognition[ 48 ]. Thus, while several studies suggest that alexithymia alters the way individuals perceive emotions, the specific effects on emotion regulation remain uncertain[ 44 , 48 ]. The association of alexithymia with sociodemographic and familial factors has been extensively studied. Of the sociodemographic factors, the relation of alexithymia with low educational level, low socio-economic status and living in a rural area have been firmly established[ 9 , 11 , 49 ].
Previous research also indicates that a lack of social support is associated with alexithymia, both in adults[ 50 , 51 ] and adolescents[ 52 ].
However, these studies are scarce, and the causality is difficult to establish. Low social support may promote the emergence of alexithymia; however, alexithymic features may also impede the ability to build supportive relationships or the ability to utilize them. Maternal alexithymia and general psychopathology in the family while growing up have been associated with the development of alexithymic features[ 54 ]. Inadequate parenting and childhood adversities have been repeatedly shown to impair the development of emotion regulation and are thus likely to have a significant impact on the development of alexithymic features[ 5 , 55 - 57 ].
However, it has been observed that even if one parent exhibits an optimal parenting style, this may very well prevent the development of alexithymia in the child[ 58 ]. In a recent study, the degree of alexithymia was significantly associated with early neglect[ 59 ]. In two other recent studies, previous traumatic experiences were significantly associated with alexithymia[ 60 , 61 ].
However, the cross-sectional design in all of these studies limits the generalization of the results. Overall, parental care during childhood, or rather, the lack of it, has also been associated with alexithymic features. In two separate studies, low experienced parental care has been associated with difficulties in the identification and verbalization of emotions[ 62 , 63 ].
However, some studies found no direct relation between reported parental care and the development of alexithymia[ 52 , 64 ]. In addition, there are studies that indicate that parental, in particular maternal, overprotection may have an effect on later alexithymia[ 52 , 65 ].
In both of these studies, maternal overprotection was associated with the dimensions of difficulties in identifying and describing feelings.
This finding leads to a hypothesis that an overprotective, and hence restrictive and intrusive, mother denies psychological autonomy, which may lead to difficulties in sharing feelings with others. However, the assessment of childhood experiences, such as traumatic experiences and parental attitudes, is difficult in cross-sectional settings because of the subjective nature and because the assessment often concerns experiences that date back several decades. As Kooiman et al[ 64 ] note, it is questionable whether the victims of parental neglect and abuse are suitable subjects for studies that use self-reporting instruments because they are prone to use primitive defense mechanisms.
Individual developmental factors associated with alexithymia have scarcely been studied. In one particular study, congenital cardiac malformations have been associated with a risk for alexithymic features[ 66 ]. This is due to the relationship between congenital cardiac malformations and neurodevelopmental morbidities that affect social cognition. In longitudinal studies, both Kokkonen et al[ 67 ] and Karukivi et al[ 68 ] reported the associations of alexithymia with lagging speech development in childhood.
Mixed emotions: the contribution of alexithymia to the emotional symptoms of autism
Kokkonen et al[ 67 ] demonstrated that the ability to speak at the age of one year was negatively associated with adult alexithymia, in particular, with the dimension of externally oriented thinking. Karukivi et al[ 68 ] studied the association between various developmental factors assessed at the age of five and alexithymia in late adolescence. They determined that in males, deficit in speech development at 5 years was associated with later alexithymia.
Previous research indicates that children with impaired speech development often have difficulties in various social situations and face problems in creating gratifying peer relationships, because of their lack of communication and regulation skills[ 69 - 71 ]. A central hypothesis is that these children struggle with interpreting both vocal and facial emotional cues[ 72 , 73 ], and thus, the association is similar to that of adults with alexithymia.
It has been suggested that alexithymic individuals have adequate vocabulary to depict their feelings, but because these feelings are poorly differentiated, it is difficult for these individuals to itemize and verbalize them[ 74 , 75 ]. The hypothesis that children lacking language skills would have a higher risk of developing alexithymia because of their struggles in social situations is suggestible, but the limited research does not enable firm conclusions. Nevertheless, this association would only explain alexithymia in adults to a small extent.
An interesting standpoint is the connection between alexithymia and ASD. Because impaired recognition and expression of feelings are intrinsic features of ASD, it is not surprising that an association between alexithymia and autistic syndromes has been hypothesized. Indeed, an overlap of some extent between alexithymia and Asperger syndrome[ 76 , 77 ] has been observed. It has also been reported that clinically significant alexithymic features in the parents of children with ASD are more common than on average[ 78 ]. One hypothesis for this overlap is similar deficits in the theory of mind in both ASD and alexithymia[ 79 ].
Alexithymia - Wikipedia
Therefore, although the theory of mind deficit is an attractive hypothesis, it only explains alexithymia to a limited extent. Indeed, alexithymia and ASD are considered to be different constructs, but alexithymic features appear to be an idiosyncratic trait in many individuals with ASD[ 81 ].
Alexithymia has also been associated with certain irregularities in the autonomic nervous and immune systems. For example, aberrant immune responses have led Guilbaud et al[ 82 ] to suggest that individuals with significant alexithymic features may suffer from unnoticed chronic stress. Furthermore, dysregulation of the autonomic nervous system has been hypothesized to be related to alexithymia[ 83 , 84 ]. Particularly, the affective component of alexithymia has been suggested to be of importance in the regulation of sympathetic responses[ 85 ].
However, the overall results regarding the associations with the autonomic nervous system are discordant[ 86 , 87 ]. Taking into account that, for example, depression has been associated with aberrations in the immune system[ 88 ], this is one possibility how alexithymia is connected to mental disturbances. Additionally, it has been suggested that alexithymia may be linked to somatic illnesses through an over-activation of the hypothalamic-pituitary-adrenal axis[ 89 ]. Although an interesting issue to debate, the current evidence for the causality between these aberrations and the development of alexithymia is practically non-existent.
From a developmental standpoint, the most interesting questions concern the age at which the prevalence settles at this level.
In studies conducted in adolescent populations, the prevalence of alexithymia has varied from 7. On average, the prevalence is approximately the same as in adults[ 91 - 93 ]. One interesting finding is that to date, in contrast to adults, no gender difference regarding the prevalence has been identified in adolescents. In two studies, different age groups of adolescents were compared, and the prevalence of alexithymia was significantly higher in younger adolescents[ 90 , 93 ].
However, Parker et al[ 94 ] have questioned the measurement of alexithymia using the TAS scale in adolescents, particularly in younger age groups, because of readability issues.
Previous research has shown that owing to their lack of cognitive capacity and adequate emotion regulation skills, children typically present psychosomatic symptoms when they face anxiety-provoking circumstances[ 95 ]. Therefore, it can be hypothesized that alexithymic characteristics are normal in childhood, at least to some extent. This would explain the finding that younger adolescents appear to be somewhat more alexithymic than older adolescents.
The later development of emotion regulation skills facilitates the proper identification and verbalization of emotions. Thus, it is likely that developmental stages have a significant impact on the prevalence of alexithymic features. The major question is whether alexithymia simply persists in alexithymic individuals from childhood or if it actually develops de novo in later phases.
Soon after the concept of alexithymia was introduced, Freyberger[ 96 ] introduced the concepts of primary and secondary alexithymia, of which the first was defined as a disposition factor, and the latter as a defense mechanism. Several subsequent studies suggested that alexithymia might develop in response to overwhelming stress to avoid experiencing agonizing and unbearable emotions[ 97 , 98 ].
Overall, the contemporary view is that alexithymia is a multifaceted construct that often includes trait and state components alike. To comprehensively assess the current scientific evidence for the stability of alexithymia as a personality trait, a systematic review of the literature was conducted.
A systematic search was conducted using the PubMed database. The period ranged from September 1, , to September 1, The studies were inspected manually, and 34 papers met the inclusion criteria. The studies are presented in Table 1. In terms of stability, it is vital to differentiate the absolute and relative stabilities of alexithymia. Absolute stability refers to potential changes in individual alexithymia scores over time, whereas relative stability refers to potential relative differences among individuals.
Overall, a vast majority of the studies have been conducted in patient populations, and only a few studies have assessed the stability of alexithymia in non-clinical populations. Regardless of the studied sample, most studies indicate a rather high relative stability for alexithymia, which is typical for a personality-like feature. However, as some authors have noted, there are unanswered questions regarding the relative stability of alexithymia in patient populations[ , ].
Marchesi et al[ ] , for example, state that because alexithymic features decrease simultaneously with mental disorder symptoms, we do not know if they return to the level that preceded the mental disorder. The few studies conducted with non-clinical populations also indicate high absolute stability, whereas in clinical samples, significant sample-wise changes in the scores over time weaken the absolute stability.
It is plausible that this effect is related to an association between the alexithymic features and mental disorder symptoms. Factors beyond mental disorders can weaken the absolute stability of alexithymia: the studies conducted in populations with, for example, previous myocardial infarction[ ], breast cancer[ ] or service as peacekeepers[ ] indicate that other stressful events may cause significant changes in absolute stability over time. Overall, understanding the stability of personality features over time is difficult. For example, personality disorders have typically been perceived as chronic and treatment-resistant; however, recent longitudinal studies indicate that they remit more often and faster than typically assumed[ ].
Thus, personality features may be more flexible than we originally assumed.
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Although other methods of alexithymia assessment exist, the studies that assess the stability of alexithymia have been conducted almost invariably with the TAS scale. Regarding the TAS scale, the stability of alexithymia appears to vary depending on the studied dimension.