Image: (amazingbelgium.be) “The small statue is called ‘La Mer, ce grand sculpteur’ or ‘The Sea, the Great Sculptor’. It proposes a man with a hat, sitting on the beach. The use of a hat is typical for Folon’s work. Folon was inspired by the work of ‘René Magritte’. ‘The man with the hat’. However, the character also look a lot like ‘Inspector Maigret’ from the books of writer ‘Georges Simenon’.”
René J. Muller, PhD, wrote in the Psychiatric Times of July 1, 2000:
“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…
…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.