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The Role of Language in Alexithymia: Moving Towards a Multiroute Model of Alexithymia

Abstract

Alexithymia is characterised by difficulty identifying and describing one’s own emotion. Identifying and describing one’s emotion involves several cognitive processes, so alexithymia may result from a number of impairments. Here we propose the alexithymia language hypothesis - the hypothesis that language impairment can give rise to alexithymia - and critically review relevant evidence from healthy populations, developmental disorders, adult-onset illness and acquired brain injury. We conclude that the available evidence is supportive of the alexithymia-language hypothesis, and therefore that language impairment may represent one of multiple routes to alexithymia. Where evidence is lacking, we outline which approaches will be useful in testing this hypothesis.
Article Type: Original article
Corresponding Author: Hannah M. Hobson, Department of Psychology, Social Work
& Counselling, University of Greenwich, Park Row, London SE10 9LS
Email: h.hobson@greenwich.ac.uk
Title: The role of language in alexithymia: moving towards a multi-route model of
alexithymia
Authors: Hannah Hobson1, Rebecca Brewer2, Caroline Catmur3, Geoffrey Bird4,5
1 Department of Psychology, Social Work & Counselling, University of Greenwich, Park
Row, London SE10 9LS. Email: h.hobson@greenwich.ac.uk
2 Department of Psychology, Royal Holloway University of London, Egham, Surrey,
TW20 0EX. Email: rebecca.brewer@rhul.ac.uk
3 Department of Psychology, Institute of Psychology, Psychiatry and Neuroscience,
King’s College London, De Crespigny Park, London, SE5 8AF. Email:
caroline.catmur@kcl.ac.uk
4 Department of Experimental Psychology, University of Oxford, 15 Parks Rd, Oxford,
OX1 3PH. Email: geoff.bird@psy.ox.ac.uk
5 Social, Genetic and Developmental Psychiatry Centre, Institute of Psychiatry,
Psychology and Neuroscience, King’s College London, De Crespigny Park Rd, London,
SE5 8AF.
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Abstract
Alexithymia is characterised by difficulty identifying and describing one’s own emotion.
Identifying and describing one’s emotion involves several cognitive processes, so
alexithymia may result from a number of impairments. Here we propose the alexithymia
language hypothesis - the hypothesis that language impairment can give rise to
alexithymia - and critically review relevant evidence from healthy populations,
developmental disorders, adult-onset illness and acquired brain injury. We conclude that
the available evidence is supportive of the alexithymia-language hypothesis, and
therefore that language impairment may represent one of multiple routes to alexithymia.
Where evidence is lacking, we outline which approaches will be useful in testing this
hypothesis.
Keywords: Alexithymia; Emotion development; Emotion recognition; Language.
LANGUAGE AND ALEXITHYMIA
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The role of language in alexithymia: moving towards a multi-route model of
alexithymia
Alexithymia is characterised by difficulties identifying and describing one’s emotions,
and a tendency towards externally oriented thinking (Nemiah, Freyberger, & Sifneos,
1976). Research has demonstrated the negative impact of alexithymia across a broad
range of cognitive domains, in both typical and clinical populations, including decision
making (Kano, Ito, & Fukudo, 2011), recognition of emotional facial expressions
(Brewer, Cook, Cardi, Treasure, & Bird, 2015; Cook, Brewer, Shah, & Bird, 2013;
Grynberg et al., 2012), empathy (Grynberg, Luminet, Corneille, Grèzes, & Berthoz,
2010), moral judgements (Patil, Melsbach, Hennig-fast, & Silani, 2016; Patil & Silani,
2014a, 2014b), reward processing (Foulkes, Bird, Gökçen, McCrory, & Viding, 2015)
and pro-social behavior (FeldmanHall, Dalgleish, & Mobbs, 2013). While alexithymia
severity varies in the general population, it is elevated in multiple psychiatric conditions,
including schizophrenia, autism spectrum disorder, substance and alcohol abuse, and
feeding and eating disorders, as well as in neurodegenerative disorders and populations
with traumatic brain injury (Berthoz & Hill, 2005; Henry, Phillips, Crawford, Theodorou,
& Summers, 2006; Pinard, Negrete, Annable, & Audet, 1996; Schmidt, Jiwany, &
Treasure, 1993; Sturm & Levenson, 2011; Thorberg, Young, Sullivan, & Lyvers, 2009;
van ’t Wout, Aleman, Bermond, & Kahn, 2007). Additionally, alexithymia is associated
with emotion regulation impairment, increased risk of self-harm, and poorer therapy
outcomes for some forms of psychological interventions (Norman & Borrill, 2015;
Ogrodniczuk, Piper, & Joyce, 2011; Pandey, Saxena, & Dubey, 2011).
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Understanding the causes of alexithymia therefore has clear implications for
theories of emotion, decision-making and social cognition, and practical applications for
mental health services. Work is beginning to address which cognitive processes are
necessary in order to identify and describe one’s own emotions, and therefore which
cognitive impairments may give rise to alexithymia. Much research has focused on
interoception (the perception and recognition of the internal state of one’s body; Craig,
2002, 2003, 2009). Nonetheless, the impairments associated with alexithymia are
complex and high-level skills that presumably rely on, and interact with, a number of
cognitive processes. The interoception hypothesis presents one account of how deficits in
one cognitive process - interoception - may impact on the ability to identify one's
emotions. However, there are likely multiple cognitive routes to alexithymia, which may
exist independently of each other, or interact with each other.
The current paper proposes that language impairment may contribute to
alexithymia. At first glance, the role of language in alexithymia seems obvious, and even
tautological. Alexithymia literally translates from Greek as “lack of words for emotion”,
and a core element of alexithymia is a difficulty expressing (including talking about)
emotions. However, there are deeper theoretical reasons to expect language to contribute
to alexithymia, beyond this superficial overlap. Most, if not all, theories of emotions posit
that language processes contribute to emotion processes, though the nature of this
contribution varies between nativist and constructivist theories. According to
constructionist theories, language processes may drive the categorization of emotional
experience, and emotion words act as key components in children’s development of
emotion concepts (see Lindquist, MacCormack, & Shablack, 2015). From a nativist
LANGUAGE AND ALEXITHYMIA
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viewpoint, while emotion categories are innately specified, language still plays an
influential role in the development of emotion schemas, emotional decision making and
regulation (Izard, 2007b; see section “A role for language in theories of emotion” below).
A recent review by Welding and Samur (2018) has highlighted the abnormalities
in emotion-related language in alexithymia. However, in order to examine whether
alexithymia arises due to broader language-related deficits, it is crucial to examine
performance on non-emotional language tasks. If alexithymia is unrelated to language,
other linguistic processes should be unaffected. In contrast, abnormalities in non-
emotional language would suggest a broader underlying linguistic deficit.
Despite the hypothesized link between language and emotion processing, there
has been very limited study of language abilities in alexithymia. This may be due to the
finding that those with alexithymia are impaired on emotion recognition tasks that are
non-verbal in design, suggesting that impairments are not limited to the language domain
(Lane et al., 1996). However, this argument ignores the potential role of language in the
initial development of emotional understanding. Furthermore, even tasks that do not
include verbal stimuli or require verbal responses can be affected by language abilities.
For example, acquired language impairment affects putatively “non-verbal” tasks: in a
large group of individuals with acquired aphasia, language impairment influenced
performance on picture-based reasoning tasks usually described as capturing “non-verbal
IQ” (Baldo, Paulraj, Curran, & Dronkers, 2015). Indeed, it has been argued that “There
is no such thing as ‘nonverbal’ ability—only abilities that are expressed nonverbally”
(McGrew and Flanagan, 1998, p. 25).
LANGUAGE AND ALEXITHYMIA
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Aims and scope
The aim of this review is to provide an overview of the existing evidence relevant
to the alexithymia-language hypothesis, which suggests that language deficits contribute
to increased alexithymia. While previous reviews have described emotion-related
language abnormalities in alexithymia (Welding & Samur, 2018), the current article
examines evidence for problems in language beyond simply emotion-related language,
with the aim of ascertaining whether language problems might provide a causative
explanation for alexithymia.
First, we introduce the alexithymia-interoception hypothesis. Under this multiple
routes to alexithymia model, we predict that some populations may have alexithymia
due to interoceptive impairment, while other populations may have alexithymia due a
language problem. We then establish the theoretical basis for the role of language in
emotion in more depth, under both nativist and constructionist perspectives. This is not a
full review of theories of emotion, but is used to demonstrate that language impairment is
expected to affect emotion processing under most, if not all, theoretical perspectives. We
then address the challenges surrounding the contribution of language skills to the
measurement of alexithymia.
We then review the available evidence relevant to the alexithymia-language
hypothesis, from typical adults and patient populations with late-occurring or
neurodegenerative conditions, respectively. We also outline why the hypothesis of a link
between alexithymia and language impairment should be investigated with
developmental groups, particularly in developmental language disorder (DLD) and
LANGUAGE AND ALEXITHYMIA
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children with language difficulties acquired as a result of hearing loss. Where direct
evidence is currently lacking, we outline why a link would be expected in these
populations, and why gathering direct evidence of alexithymia in these groups is of
theoretical importance.
Given the growing evidence relating interoception to alexithymia, we outline a
theoretical model of how language impairment and/or interoceptive deficits may give rise
to alexithymia. We suggest that interoception and language may play distinct, but
potentially interacting, roles in the development of alexithymia, and that the contribution
of each may vary across clinical and developmental populations. Further challenges that
should be addressed and avenues for future research are then discussed.
For clarity, it is worth noting other constructs that are closely related to, or
overlap with, alexithymia. These include emotion differentiation/granularity, and
emotional awareness. Emotional granularity (often referred to interchangeably as
emotional differentiation; see Smidt & Suvak, 2015) describes the extent to which an
individual can distinguish between emotional states (Barrett, 2004). A simple definition
of emotional awareness is the conscious experience of emotions (Gu, Hof, Friston & Fan,
2013). One could consider alexithymia to represent a trait, while other constructs may be
thought of as more specific abilities, which are negatively associated with the broader
trait of alexithymia: i.e. in cases of high alexithymia, there is lower emotional granularity
and emotional awareness. This paper focuses on alexithymia, but many of the arguments
made for the role of language in alexithymia could be applied to the more narrowly-
defined constructs of emotional granularity and awareness.
LANGUAGE AND ALEXITHYMIA
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In addition, while the definition of alexithymia pertains to a difficulty processing
one’s own emotions, there have been several other sociocognitive difficulties and
demonstrated to be (moderately or strongly) associated with alexithymia (Grynberg,
Berthoz & Bird, 2018). These include interpersonal difficulties, particularly decreased
empathy (Grynberg, etal., 2010), poor emotion regulation (Pandey et al., 2011), poor
mental health, difficulties recognizing others’ emotions (Brewer et al., 2015; Cook, et al.,
2013; Grynberg et al., 2012), and increased somatization (De Gucht & Heiser, 2003;
Mattila et al., 2008). These problems in and of themselves are not definitive markers for
alexithymia. However, in the absence of direct investigation of alexithymia in a given
population, the presence of such problems make it plausible that levels of alexithymia are
increased. As a consequence, this work should be considered both as a review of the
available research, and as an opinion piece that advances a specific hypothesis and the
ways in which it might be tested.
Interoception and alexithymia
Contemporary theories suggest that alexithymia may be, at least in part, a
consequence of a primary deficit in interoception, the ability to perceive and recognize
internal body states, including signals of fatigue, hunger, thirst, heart rate, respiratory
effort, and pain (Brewer, Cook, & Bird, 2016; Herbert, Herbert, & Pollatos, 2011;
Murphy, Brewer, Catmur, & Bird, 2017; Murphy, Brewer, Hobson, Catmur, & Bird,
2018; Pollatos, Kirsch, & Schandry, 2005; Wiens, 2005). Thus, individuals who struggle
to identify their own emotions may also struggle to detect and distinguish non-emotional
interoceptive states, such as thirst, hunger and tiredness. Indeed, individuals with
alexithymia are objectively worse at perceiving their own heartbeat (Herbert et al., 2011;
LANGUAGE AND ALEXITHYMIA
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Shah, Hall, Catmur, & Bird, 2016), muscular effort and taste (Murphy, Catmur, & Bird,
2018), are less likely to rely on interoceptive cues to gauge respiratory effort (Murphy et
al., 2018). They also report difficulties recognising interoceptive cues associated with a
broad range of internal states (Brewer et al., 2016; Longarzo et al., 2015). Individuals
with alexithymia also report difficulties differentiating between emotion-related and non-
emotion-related interoceptive signals (Brewer et al., 2016). Relatedly, alexithymia is
associated with increased somatising and unexplained medical symptoms (e.g. De Gucht
& Heiser, 2003; Mattila et al., 2008), theorised to be due to misinterpretation of benign
interoceptive signals as troubling medical symptoms (Larsen, Brand, Bermond, &
Hijman, 2003; Taylor, Bagby, & Parker, 1991). Indeed, the links between somatisation
and alexithymia extend back to the very conception of alexithymia in the 1970s (Sifneos,
1973). In addition to behavioural work suggesting a link between interoception and
alexithymia, neuroimaging and lesion studies indicate that alexithymia is associated with
functional and structural abnormalities or damage to cortical areas involved in
interoception, in particular the anterior insula and anterior cingulate cortex (Bush, Luu, &
Posner, 2000; Goerlich-Dobre, Bruce, Martens, Aleman, & Hooker, 2014; Gu et al.,
2012; Hogeveen, Bird, Chau, Krueger, & Grafman, 2016; Ihme et al., 2013; Moriguchi et
al., 2007; Silani et al., 2008).
Furthermore, a number of the conditions that are characterised by an increased
prevalence of alexithymia also show abnormalities in interoception. Objective
impairments in interoception in clinical groups have been demonstrated using widely-
used cardiac measures of interoception, such as the heartbeat tracking and heartbeat
discrimination tasks (in anxiety and panic disorder; Ehlers & Breuer, 1992; Paulus &
LANGUAGE AND ALEXITHYMIA
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Stein, 2010; Yoris et al., 2015; in alcohol and substance abuse; Naqvi & Bechara, 2010;
Paulus & Stewart, 2014; Paulus, Tapert, & Schulteis, 2009; Verdejo-Garcia, Clark, &
Dunn, 2012; in depression; Dunn, Dalgleish, Ogilvie, & Lawrence, 2007; Harshaw, 2015;
Pollatos, Traut‐Mattausch, & Schandry, 2009; in somatoform disorders; Schaefer, Egloff,
& Witthöft, 2012; in autism; Garfinkel, Tiley, et al., 2016; Shah et al., 2016; in OCD;
Lazarov, Dar, Oded, & Liberman, 2010; Stern, 2014; in eating disorders; Klabunde,
Acheson, Boutelle, Matthews, & Kaye, 2013; and in schizophrenia; Ardizzi et al., 2016).
In addition, other evidence highlights unusual interoception in clinical conditions. For
example, patients with eating disorders atypical neural responses during the perception of
hunger and satiety signals (Santel, Baving, Krauel, Münte, & Rotte, 2006). According to
care-giver reports and free-feeding observations, patients with frontotemporal dementia
show a disturbance in their food preferences and satiety levels (Ikeda, Brown, Holland,
Fukuhara, & Hodges, 2002; Woolley et al., 2007). Substance and alcohol abuse is related
to reduced sensitivity to reward signals and poor awareness of intoxication levels (for a
review, see Volkow, Wang, Fowler, Tomasi, & Baler, 2010).
In sum, there is compelling evidence for the role on interoception in the
development of alexithymia. Nonetheless, it seems improbable that all cases of
alexithymia will be able to be reduced to an impairment in interoception, or that an
interoceptive difficulty can account for all clinical populations in which alexithymia is
elevated. Interoception has long been considered to be necessary for emotion (Darwin,
1965; Gendron & Barrett, 2009; James, 1894; Lange, 1885), but language is also
considered to underpin emotion processing (although the precise role of language is a
LANGUAGE AND ALEXITHYMIA
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matter of debate). In the following section, we outline why a language impairment may
be affect emotion processing, and ultimately result in alexithymia.
A role for language in theories of emotion
Over the decades, many different theories of emotion have been proposed (see
Brosch, Portois & Sander, 2010, and Moors, 2009, for comprehensive reviews of theories
of emotion). While there are numerous ways of categorizing this broad spectrum of
theories, one approach is to place these theories on a continuum anchored by nativist
theories at one extreme and constructionist theories at the other. Both types of theory
ascribe some role for language in the development of emotion processes, although they
differ in the extent to which language is considered “foundational” for emotion
categorization (see Sauter, 2018, for a recent discussion).
Nativist theories of emotion, such as Differential Emotion Theory (DET), argue
that certain discrete emotion categories (“basic emotions”) are innate, having evolved for
their adaptive value (Ekman, 1992; Izard, 2007a, 2009). These categories cannot be
created, taught, or learned via cognitive processes. Even so, language is still afforded a
central role in emotion-related processes within nativist theories: while language may not
have a role in the ontogeny of basic emotions themselves, theories such as DET argue
that language is crucial in the development of emotion schemas, which involve emotion
interacting dynamically with perception and cognitive processes. Emotion schema
development is considered important, as dysfunctional connections between emotion,
cognition and action are thought to lead to psychopathology (Izard, Youngstrom, Fine,
Mostow, & Trentacosta, 2006). Furthermore, recent reviews that outline evidence against
LANGUAGE AND ALEXITHYMIA
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linguistic relativity of emotions still acknowledge a role for language in later-occurring
cognitive processes central to emotion. For example, Sauter (2018) suggests that verbal
processes may affect decision-making during emotion categorization, even if the
categories themselves are not the product of linguistic processes.
At the other end of the spectrum, constructionist accounts such as Conceptual Act
Theory (CAT) (Barrett, 2006), or the circumplex model of affect (Posner, Russell &
Peterson, 2005), suggest that the “natural kinds” of emotion proposed by nativist
accounts do not exist. Rather, discrete emotion categories are the result of conceptual
processes acting on underlying dimensional, non-specific affect. Emotion categories are
not considered to be pre-destined by evolution but rather to emerge, dependent upon
culture and development.
Accounts such as CAT do not argue that the structure of individuals’ emotional
experiences is wholly determined by linguistic factors. Rather, language is one of many
factors that contribute to emotional development. One proposed mechanism by which this
occurs is that emotion words support the acquisition of conceptual knowledge, just as
labels support category acquisition and the development of conceptual knowledge in
other domains (for instance, in learning abstract spatial relations between objects; see
Casasola, 2005. See also Althaus & Mareschal, 2014; Plunkett, Hu, & Cohen, 2008). For
example, a child may hear the word “angry” in several scenarios, which have little
perceptually in common: they may witness a friend get “angry” at the theft of a toy, they
may be told their caregiver is “angry” at them, or their own behavior may be labeled as
“angry” during a tantrum. The phonological form “angry” links together these perceptual
and behavioral experiences of a child’s own and other people’s anger, in a variety of
LANGUAGE AND ALEXITHYMIA
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scenarios (see Lindquist et al., 2015). Emotion words thus act as a catalyst in developing
acquired equivalence between category members. In support of this position, children’s
use of emotion words correlates with behavioral performance in categorising emotions;
children’s increased production of different emotion labels during free labeling
corresponds with increasingly differentiated and adult-like categorical perception of
emotional facial expressions (Widen & Russell, 2003, 2008), and the presence of emotion
labels facilitates the categorisation of emotions in childhood (a label superiority effect;
Russell & Widen, 2002).
In addition to this developmental evidence, it has been suggested that language
continues to contribute to emotion processes in adulthood (Lindquist, 2017). It is argued
that cues to another’s emotional state (e.g. a person’s facial expression) are variable and
ambiguous, and that verbal labels act to reduce this ambiguity and therefore assist in
efficient processing of emotion information (Barrett, Lindquist, & Gendron, 2007;
Lindquist, Barrett, Bliss-Moreau, & Russell, 2006; see also Lindquist, Satpute &
Gendron, 2015, for a review).
Clearly, under either account, language plays an important role in emotion
processes, and language difficulties would be predicted to disrupt emotional abilities.
According to constructionist accounts, a language deficit may prevent or delay the
development of conceptual categories for labeling one’s core affect, and negate the
advantageous contextual effects on emotion recognition provided by emotion language in
adulthood (Lindquist et al., 2006). Within nativist models, a language deficit would leave
the innately-endowed discrete basic emotions untouched, but could lead to abnormal
emotion schemas, leading to poor recognition of one’s own emotions, and emotion
LANGUAGE AND ALEXITHYMIA
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regulation difficulties. The notion that alexithymia could be a product of language
deficits is therefore in keeping with both nativist and constructionist approaches; the
alexithymia-language hypothesis does not depend on the adoption of any particular
theory of emotion.
The measurement of alexithymia
One requirement for research examining the relationship between language ability
and alexithymia is the careful consideration of how alexithymia should be measured.
Alexithymia is usually assessed via self-report questionnaires, which may be problematic
(Gaigg, Cornell & Bird, 2016). Potential issues with self-report measures are not limited
to those with language problems. Even for those without language difficulties, highly
alexithymic individuals may lack insight into their emotion-specific difficulties, causing
individuals with alexithymia to fail to identify and report their own deficits. Furthermore,
it is also possible that those with low alexithymia rate their levels of alexithymia as high,
due to low self-esteem or a positively-biased representation of others’ abilities.
In addition to these general concerns, the current self-report measures for
alexithymia may be particularly problematic for language-impaired samples. First, for
individuals with pronounced language difficulties, self-report data may be inaccurate
unless questionnaires have limited language demands. Second, there is conceptual
overlap between language and emotional problems in some questionnaire items. For
example, the Toronto Alexithymia Scale’s “Difficulty Describing Feelings” subscale
includes items such as “It is difficult for me to the find the right words for my feelings”,
and (the reverse-coded) “I am able to describe my feelings easily” (Taylor et al., 1988).
LANGUAGE AND ALEXITHYMIA
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Control items that assess how easily an individual finds it to describe other, non-
emotional things, or to find other classes of words, would reduce this issue, but are
currently not assessed by self-report alexithymia measures.
In some cases, measurement issues may be overcome by gathering multiple
sources of information about alexithymia, including parent- or observer-report, but these
approaches come with their own additional considerations. First, developmental language
impairments have been shown to run in families (Bishop, 2006). Thus it is possible that
parents of children with language impairment also have some language or literacy
difficulties. Second, self-report and observer-report measures of alexithymia do not
always agree (e.g. Griffin, Lombardo, & Auyeung, 2016). Discrepancies could arise for
multiple reasons; some individuals with alexithymia may lack the metacognitive ability
and insight into their own impairments to rate themselves as having alexithymia, while
these problems may be readily apparent to close relatives. Alternatively, given that
individuals with alexithymia produce fewer emotional facial expressions, find expressing
emotions harder and less beneficial, and have more interpersonal problems (Loiselle &
Dawson, 1988; Lumley, 2004; Spitzer, Siebel-Jürges, Barnow, Grabe, & Freyberger,
2005; Trevisan et al., 2016), parents or partners may lack insight into the emotional
abilities of the child or spouse.
Despite these concerns, self-report measures of alexithymia are highly predictive
of emotional abilities (Lumley, Neely, & Burger, 2007), suggesting that many individuals
with alexithymia do have good insight into their difficulties. It may be the case that self-
report measures are more appropriate for some individuals than others. Those with
particularly severe language or interoceptive difficulties, for example, may struggle to
LANGUAGE AND ALEXITHYMIA
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recognize and report alexithymic tendencies. The development of objective tests for
alexithymia is therefore a clear priority for such research with these populations. One
possibility is that explored by Gaigg et al. (2016); participants’ galvanic skin response
(GSR) was monitored while participants viewed emotion-inducing stimuli and rated their
emotional response along a simple scale. Correlations between participants’ GSR and
emotional ratings were strongly associated with self-reported alexithymia (r = -.57),
suggesting that the discrepancy between physiological responses and emotional ratings
might provide an alternative measure of alexithymia that is less demanding of verbal
skills than self-report questionnaires.
In summary, measurement of alexithymia in language-impaired samples currently
poses a challenge. Potential solutions include: routinely including control items in self-
report measures that capture broader linguistic difficulties; gathering observer-report
alexithymia measures as well as participants’ self-report; and the development and
validation of tests that do not rely on self-report.
Existing Evidence for the alexithymia-language hypothesis: Language and
alexithymia in non-clinical adult samples
Although alexithymia is thought to be a dimensional trait, individuals who score
above a clinically-significant cut-off on measures such as the Toronto Alexithymia Scale
(Taylor et al., 1988) are considered to be alexithymic, and constitute approximately 8-
10% of the general population in Western samples (Franz et al., 2008; Linden, Wen, &
Paulhus, 1995; Salminen, Saarijärvi, Äärelä, Toikka, & Kauhanen, 1999). While few in
LANGUAGE AND ALEXITHYMIA
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number, studies on language abilities in relation to alexithymia in typical adults have
been conducted.
Several studies report that individuals with alexithymia produce fewer emotion-
related words than those without (Luminet, Rime, Bagby, & Taylor, 2004; Roedema &
Simons, 1999; Wotschack & Klann-Delius, 2013), although only one study has measured
the production of other word categories. This is important, as reduced expression of
emotion may reflect the fact that those with alexithymia are generally less verbally
expressive than those without, rather than specifically less expressive about emotion. The
available evidence supports a general reduction in expressivity; individuals with
alexithymia are also more likely to not respond to non-emotional stimuli. In two studies
the difference in the absolute number of emotion words produced by those with
alexithymia can be accounted for statistically by their total word production (Roedema &
Simons, 1999; Wotschack & Klann-Delius, 2013). Where differences in the proportion of
emotion words (rather than just absolute number of emotion words produced) have been
found (Luminet et al., 2004), there may nonetheless be other word categories with
reduced expressivity. Emotion words represent a class of abstract words, which are
typically acquired later and show evidence of slower processing than concrete words
(Schwanenflugel, 1991). Alexithymia may be associated with reduced use of abstract
words in general, rather than emotion words specifically, but differences in use of
abstract words would not be apparent from the coding of the data used in studies thus far.
Evidence for a relationship between verbal IQ and alexithymia also suggests that
verbal abilities may have a mediating role in the association between alexithymia and
poor performance on emotion-related tasks. Significantly lower verbal IQ scores have
LANGUAGE AND ALEXITHYMIA
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been reported in those with alexithymia, compared to control participants, and controlling
for verbal IQ reduced the effect of alexithymia on processing of emotional facial
expressions to non-significance in some cases (Hsing, Mohr, Stansfield, & Preston, 2013;
Montebarocci, Surcinelli, Rossi, & Baldaro, 2011; see review by Grynberg et al., 2012).
Weaker verbal IQ may reflect abnormalities in language skills, such as vocabulary,
syntactical skills, verbal reasoning, receptive or expressive abilities. However, as no
studies have examined the association between alexithymia and specific structural
language abilities in the general population, the exact nature of this verbal weakness in
alexithymia remains unclear.
Existing evidence for the alexithymia-language hypothesis: Acquired brain injury
and adult-onset neurodegenerative conditions
The alexithymia-language hypothesis would predict that emotion processes would
be detrimentally affected by acquired language disorders. Studying groups such as those
who have acquired brain injuries or neurodegenerative conditions may elucidate the
biological basis of alexithymia, specifically the potential role of brain regions thought to
support language. Furthermore, evidence from adult populations, with presumably typical
language and emotional development until the onset of illness or brain trauma, may
reveal the role of language processes “online” in emotion tasks. That is, if language only
plays a role in alexithymia during the acquisition of emotion concepts and knowledge
and language is no longer necessary to support emotion processing once this knowledge
has been acquired then an acquired language impairment may leave conceptual
knowledge or emotion schemas intact. If, however, language processes continue to
LANGUAGE AND ALEXITHYMIA
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contribute to emotion processing, then even late-acquired deficits in language should
disrupt emotional processes and lead to alexithymia.
A straightforward prediction of the alexithymia-language hypothesis would be
that aphasia following stroke, in which key language regions suffer damage leading to
lasting language impairment, would result in impaired emotion processes. Specifically,
there should be more severe alexithymia in aphasic compared to non-aphasic stroke
survivors. Although alexithymia has been examined in relation to stroke and suggested to
be an important factor in the development of post-stroke depression (Hung, Chou, & Su,
2015; Spalletta et al., 2001), no research has examined emotion processing abilities in
aphasia following stroke. Instead, patients with aphasic symptoms are commonly
excluded from such studies.
Despite the lack of study of alexithymia in aphasia following stroke, other
acquired or late-occurring conditions do provide evidence for an association between
language and alexithymia. This includes evidence from patients with Traumatic Brain
Injury (TBI). In such samples, verbal measures correlate significantly with alexithymia
traits, and verbal abilities differ significantly between groups of TBI patients with and
without alexithymia (Henry et al., 2006; Wood & Williams, 2007). Data from the large
Vietnam Head Injury Study has recently demonstrated that damage to the inferior frontal
gyrus, a key language region of the brain, is associated with alexithymia (Hobson et al.,
2018). Furthermore, this study demonstrated that patients with naming deficits suffered
more severe alexithymia than those with intact naming abilities. This extends findings in
the same TBI sample demonstrating a role for the anterior insula, a region considered
crucial to interoception, in alexithymia (Hogeveen et al., 2016). Together, these findings
LANGUAGE AND ALEXITHYMIA
20
suggest that damage to either interoception-related or language-related brain regions may
contribute to alexithymia. However, TBI samples commonly do not have focal lesions,
but damage to several areas. Indeed, the proximity of the inferior frontal gyrus to the
anterior insula makes it difficult to disentangle the role of language disruption (due to
inferior frontal gyrus damage) from interoceptive failure (caused by anterior insula
damage).
Where neurodegenerative conditions are concerned, current data from
frontotemporal dementia (FTD) suggest that either interoceptive or language impairments
may underpin alexithymia. FTD is usually split into behavioural and language subtypes.
In the behavioural variant of FTD (bv-FTD), the presenting difficulties at symptom onset
are changes in personality, usually including a loss of empathy and emotional blunting.
The language variants of FTD include progressive non-fluent aphasia and semantic
dementia. In progressive non-fluent aphasia, speech becomes non-fluent, containing
grammatical errors, and patients’ understanding of complex sentence structures is
compromised, although word-level comprehension is usually preserved. In semantic
dementia, speech is fluent but there is a loss of semantic knowledge, reflected in word-
finding difficulties and poor comprehension of previously known words (Bonner, Ash, &
Grossman, 2010). As well as elevated rates of alexithymia (Sturm & Levenson, 2011),
patients with FTD exhibit emotional difficulties associated with alexithymia, such as poor
recognition of others’ emotions from faces and voices (Keane, Calder, Hodges, & Young,
2002), and reduced carer-reported empathy (Eslinger, Moore, Anderson, & Grossman,
2011). These difficulties are considered particularly characteristic of bv-FTD, but
LANGUAGE AND ALEXITHYMIA
21
emotion processing problems have been observed in all three FTD subtypes (Kumfor &
Piguet, 2012).
While alexithymia in FTD has been reported to be elevated relative to controls
(Sturm & Levenson, 2011), there has been no direct comparison of alexithymia between
the different FTD subtypes. However, indirect evidence from emotional difficulties
associated with alexithymia supports the idea that different cognitive problems may
underpin emotional impairments in the different subtypes. Specifically, we propose that
emotion impairments are associated with interoceptive abnormalities in bv-FTD, but with
language difficutlies in semantic dementia. For example, although facial emotion
recognition is impaired in both semantic dementia and bv-FTD, controlling for verbal
ability specifically reduces deficits seen in semantic dementia (Miller et al., 2012).
Emotion word comprehension is impaired in semantic dementia, and correlates with
comprehension of non-emotional abstract words, suggesting poor emotion word
performance is driven by broader language disability in semantic dementia. These
emotion word deficits are absent in bv-FTD (Hsieh et al., 2012). Conversely, the profile
of impairments seen in bv-FTD is more in keeping with an underlying interoceptive
cause. Interoceptive atypicalities in bv-FTD have been reported, including reduced
responses to pain and temperature, feeding dysregulation and eating despite satiety, and
increased sugar cravings (Fletcher et al., 2015; Miller, Darby, Swartz, Yener, & Mena,
1995; Woolley et al., 2007). Furthermore, the anterior insula, a brain region considered
key to both interoceptive and emotional processes, has been found to be particularly
affected in bv-FTD compared to other FTD subtypes (Rosen et al., 2002; Seeley, 2010).
Indeed, insula degeneration has been linked to interoceptive deficits (Woolley et al.,
LANGUAGE AND ALEXITHYMIA
22
2007) and emotional deficits (Cerami et al., 2014) in FTD. Taken together, these findings
suggest that in semantic dementia, emotion processing impairments may be largely
accounted for by patients’ language difficulties, while in bv-FTD alexithymia may be
associated with a more ‘pure’ interoception deficit. Drawing together the evidence from
TBI patients and language-subtypes of FTD, acquired language disorders appear to affect
emotional processes in adulthood. This suggests that linguistic processes are not just
required for the development of emotional concepts, but that language continues to
contribute to the processing of emotions in adulthood. In addition, the behavioral profiles
of other adult populations, such as patients with bv-FTD, highlight the fact that
alexithymic difficulties can occur in the apparent absence of a language problem.
Collectively, these findings demonstrate that acquired interoceptive and linguistic deficits
may each be sufficient to cause increasing levels of alexithymia in adult populations.
Populations of Interest: Language-impairment, hearing-impairment and autism
The alexithymia-language hypothesis predicts that language impairment during
development will interfere with the acquisition of typical emotional knowledge and
emotional functioning, and thus predicts developmental associations between language
and alexithymia, with worse language resulting in more severe alexithymia. Here we
consider whether such predictions are borne out by the available developmental evidence,
including studies with autistic
1
, language-impaired and deaf populations. While there is
very little direct evidence relating to the contribution of language impairment to
1
To respect the wishes of autistic individuals and report the study in line with scientific parlance,
we use language preferred by clinical professionals (e.g., 'individuals with autism’), as well as the term
‘autistic’, a term endorsed by many individuals with ASD (see Kenny et al., 2016).
LANGUAGE AND ALEXITHYMIA
23
alexithymia in these populations, the indirect evidence is reviewed here, as these
populations are extremely interesting with respect to the alexithymia-language hypothesis
and should be important foci for future research. The alexithymia-language hypothesis
has clear predictions: if emotional development is dependent upon good language ability,
then alexithymic traits should characterize all children with developmental language
disorder (DLD) (previously known as Specific Language Impairment). In autistic and
deaf populations however, language ability is highly heterogeneous. Therefore, if
language impairment results in alexithymia, then one would expect language ability and
alexithymia to co-vary in autistic and deaf populations.
Alexithymia per se has not been studied directly in language-impaired children,
although cohort studies provide evidence for a link between speech and language delays
and alexithymia in later life (Karukivi et al., 2012; Kokkonen et al., 2003). Nonetheless,
many difficulties common to children with language impairment fit with the notion that
these children have alexithymia; children with language impairments show difficulties
recognizing facial emotion (Merkenschlager, Amorosa, Kiefl, & Martinius, 2012; Nelson,
Welsh, Trup, & Greenberg, 2011), difficulties with emotion regulation (Fujiki, Brinton,
& Clarke, 2002) and social difficulties (Mok, Pickles, Durkin, & Conti-Ramsden, 2014;
St Clair, Pickles, Durkin, & Conti-Ramsden, 2011), and are at an increased risk for poor
mental health outcomes (Beitchman et al., 2001). Thus, the constellation of emotional
difficulties reported in DLD is in keeping with higher rates of alexithymia than in the
typical population. Indeed, clinicians have suggested that speech and language
professionals ought to consider the impact that language deficits may have on children’s
emotional processing, with explicit reference to alexithymia as a potential explanation for
LANGUAGE AND ALEXITHYMIA
24
links between poor language and emotional problems (Way, Yelsma, Van Meter, &
Black-Pond, 2007).
Evidence for the role of language in emotion and alexithymia can also be drawn
from research with deaf children. Deaf or hearing-impaired populations present an
intriguing opportunity to study the relationships between language development and
emotion processes. First, while in DLD it is assumed there is some cognitive deficit that
underlies the language learning problems, this is not presumed to be the case in deafness.
Second, language difficulties are related to early linguistic experience, which varies in the
deaf population; there is reduced opportunity for linguistic experience if deaf children are
born to hearing families, whereas deaf children born to deaf parents experience rich
conversational input through sign language from the start of life. Language delay is a key
factor in impaired emotion recognition and empathy in hearing-impaired individuals, and
group differences in emotion recognition and empathy between hearing impaired and
control groups are removed when verbal ability is controlled for (Dyck, Farrugia,
Shochet, & Holmes-Brown, 2004; Netten et al., 2015). There is also evidence, albeit
limited, that linguistic input can ameliorate the emotion recognition impairment in this
population (see Dyck & Denver, 2003).
Reduced linguistic input for some hearing-impaired children thus leads to
language delay, reducing understanding of others’ emotions. However, language delay
may also affect deaf individuals’ ability to recognize and manage their own emotions.
Indeed, children and adolescents with hearing problems show limited emotion regulation
strategies (Rieffe, 2012). No studies have directly examined rates of alexithymia in deaf
populations, or the potential role of alexithymia in the emotional processing deficits seen
LANGUAGE AND ALEXITHYMIA
25
in this group. The profile of emotional difficulties in deaf individuals, however, make a
compelling case for investigating the role of alexithymia in emotional difficulties
experienced by some deaf individuals.
The population that has received the greatest research interest in terms of
alexithymia is that of individuals with autism spectrum disorder (henceforth autism). The
prevalence of alexithymia in autism is estimated to be around 50% (Berthoz, Lalanne,
Crane, & Hill, 2013; Hill, Berthoz, & Frith, 2004). Autism and alexithymia are thus
distinct but commonly co-occurring. Previous inconsistent findings regarding emotional
deficits in autism, including difficulties with emotion recognition and empathy, may be
related to the high but not universal co-occurrence of alexithymia and autism (Bird &
Cook, 2013; Bird et al., 2010; Brewer, Happe, Cook, & Bird, 2015; Cook et al., 2013;
Oakley, Brewer, Bird, & Catmur, 2016). Language functioning is very heterogeneous in
autism; some individuals acquire age-appropriate language skills, while a significant
proportion of autistic individuals remain essentially nonverbal (Howlin, Goode, Hutton,
& Rutter, 2004; Kjelgaard & Tager-Flusberg, 2001; Tager-Flusberg, Paul, & Lord, 2005).
A seemingly straightforward prediction is that alexithymia will be associated with
the language status of autistic children, but the wide variation of language skills in autism
has yet to be capitalized upon by researchers. Language heterogeneity could contribute to
the variability in terms of alexithymia seen in autism, but instead language or verbal IQ
more generally is usually considered an extraneous variable to be controlled. Existing
evidence also relies on less than ideal language measures. As in non-clinical alexithymic
samples, participants with autism who also have alexithymia have lower verbal IQ than
participants with autism but without alexithymia, and verbal IQ correlates with
LANGUAGE AND ALEXITHYMIA
26
alexithymia in the autistic population (although this may have been due to the inclusion
of individuals with intellectual disability; Milosavljevic et al., 2016). As discussed in
relation to alexithymia in the general population, verbal IQ measures alone do not allow
for alexithymia to be related to specific language abilities.
The pattern of emotional and social difficulties seen in children with disorders of
language and communication is consistent with alexithymia playing a mediating role
between poor language and emotional problems, and we predict that future investigation
will uncover elevated rates of alexithymia in these groups. There is a clear theoretical
case for examining alexithymia across these diverse developmental language-impaired
groups. This would allow researchers to tease apart the contribution of specific language
problems without known cognitive deficits (deaf children), specific language problems
arising from cognitive deficits (DLD), and language problems in the context of a
condition with broader social-communicative problems (autism) to emotion processes.
Incorporating language into the interoception hypothesis of alexithymia: A multiple
route model
Substantial evidence exists for a link between interoceptive impairment and
alexithymia (e.g. Murphy et al., 2017; Murphy et al., 2018; Shah et al., 2016; Brewer et
al., 2016; Herbert et al., 2011; Pollatos et al., 2005; Wiens, 2005). Although there has
been limited direct study of the role of language, this review suggests that linguistic
abilities are also likely to contribute to alexithymia. Given these two rather divergent
streams of evidence, determining how they may be combined is likely to contribute to our
understanding of alexithymia.
LANGUAGE AND ALEXITHYMIA
27
The ability to identify and express emotion is a high-level skill that presumably
relies on many cognitive processes. The constructionist theory of emotion CAT argues
that “core affect” (as it is termed in these theories) is categorized, and that the
categorization processes involve language. While interoceptive failure is not explicitly
discussed in CAT, core affect incorporates interoceptive information, and therefore
arguably a failure of interoception is as likely to cause alexithymia as a failure in
categorization processes. It thus seems likely that alexithymia may arise through
impairment in any one of a number of processes, including interoception and language.
While the interoception and language hypotheses of alexithymia are not mutually
exclusive, a ‘multiple routes model of alexithymia’ would need to consider how these
two abilities work together to influence the development of alexithymia. First,
interoception and language problems may have additive and independent effects on
alexithymia, and deficits in either domain may lead to an alexithymic profile at the
behavioral level. This would suggest that aetiological subtypes of alexithymia may exist,
in which either interoception or language is functioning typically. For example,
alexithymia is elevated in eating disorder populations (Berthoz, Perdereau, Godart,
Corcos, & Haviland, 2007; Lopez, Stahl, & Tchanturia, 2010), but individuals with
anorexia nervosa are thought to have generally higher IQ and better scholastic
achievement than typical individuals, factors highly related to verbal abilities. A language
impairment therefore seems relatively unlikely to explain alexithymia in anorexia.
Alternatively, interoception and language impairment may interact, and thus these
two processes may not be entirely independent. For example, verbal labelling of
children’s states by caregivers during development (e.g. “You must be hungry”, and
LANGUAGE AND ALEXITHYMIA
28
“You are so tired today”) may refine and tune categorization of interoceptive signals, as
well as emotional states (Heyes & Bird, 2007). Poor performance on interoception tasks
may thus arise as a downstream consequence of language problems that interfere with the
processing and acquisition of these labels, and the ability to associate them with internal
stimuli. Indeed, even in adulthood, language processes could continue to contribute to
online interoceptive abilities. The ability to recognize a state could depend, to some
extent, on one’s ability to rapidly verbally label the internal, and contextual, cues
associated with that state. Beyond interoception itself, there may be an online role for
language in tasks assessing interoception; for example, verbal working memory may be
involved in the commonly used heartbeat detection task, while verbally labelling
respiratory or muscular effort may aid performance on tasks assessing interoception in
these domains (e.g. Murphy, Catmur et al., 2018; Garfinkel et al., 2016).
Alternatively, interactive effects between interoception and language may arise if
poor interoception impacts on a child’s language development. Certainly, an
interoceptive impairment may mean that a child’s own internal states are poorly
distinguished and therefore an unreliable target for the ascription of verbal labels. Thus,
impoverished emotion vocabulary may be a secondary consequence of poor
interoception. It is more difficult, however, to explain how poor interoception could lead
to a general language impairment beyond specifically emotion or interoception-related
language. Arguably, from a developmental perspective, interoceptive failure could lead to
social abnormalities that reduce or interfere with key language learning experiences (i.e.
interoceptive failure may reduce social engagement, and could lead to an individual being
more excluded and thus reduce the opportunities for language learning experiences; see
LANGUAGE AND ALEXITHYMIA
29
Quattrocki & Friston, 2014, and corresponding commentary by Brewer et al., 2015).
While acknowledging the possibility that an interoceptive impairment may result in
social impairments that limit the opportunity for general language learning, it seems more
likely that any interaction effect between interoceptive and language impairment is due to
a general language problem impacting the development of accurate interoception, rather
than an interoceptive impairment affecting solely emotion and interoceptive-related
language.
Challenges to the study of language and alexithymia and outstanding questions for
future research
The theories and evidence reviewed here identify a number of opportunities for
future study. In addition, however, reviewing the available literature on linguistic ability
and alexithymia revealed several challenges to this line of enquiry, including the
measurement issues outlined previously. Further challenges are outlined here.
The finding that alexithymia is elevated in language-impaired groups, or can be
accounted for in other groups by considering language deficits, leads us to consider how
“pure” alexithymia should be defined. If a child with language impairment has difficulty
expressing themselves generally, a difficulty expressing their emotions is to be expected,
especially given that emotions are abstract concepts, which may be particularly reliant on
language during their acquisition. The same is true of a patient with a neurodegenerative
illness whose language abilities have deteriorated. These individuals may technically
score highly on an alexithymia measure, but should they be considered to have a different
type of alexithymia to that which arises due to pure interoceptive failure? Is alexithymia
LANGUAGE AND ALEXITHYMIA
30
only “pure” if basic language (and other cognitive) deficits have been accounted for? The
implication is that an alexithymia-like behavioral profile may, in some cases, be a
secondary consequence of other non-emotion related cognitive decline, and not
comparable to alexithymia in the absence of these broader deficits.
This issue of what is “pure” alexithymia may be further illustrated by considering
children who undergo schooling in their non-native language. These children may have a
genuine difficulty with language in a certain context, which likely includes difficulty
communicating their emotions (in a sense, a context-specific alexithymia). However, they
would have a different cognitive profile to those with generalized language impairment or
interoceptive deficits, and under the alexithymia language hypothesis would still be
expected to have appropriate emotion concepts, and typical emotion recognition and
empathy. Under our current conception of alexithymia, we would not regard these
children as being alexithymic, but, as above, agreement needs to be reached with regard
to what constitutes “pure” alexithymia.
There are also significant methodological challenges when investigating
alexithymia and its associated cognitive deficits in multiple developmental and clinical
populations. Not least is the fact that, in several clinical conditions, language impairment
is only part of a constellation of cognitive deficits. Research aiming to isolate the specific
contribution of language to alexithymia should therefore control for other cognitive
deficits that could feasibly contribute to alexithymia. Successfully isolating the
contribution of language to alexithymia also requires consideration of the analytical
approach. Several studies of alexithymia have claimed (e.g. Montebarrocci et al., 2011,
Miller et al., 2012, Netten et al., 2015), on the basis of Analysis of Covariance
LANGUAGE AND ALEXITHYMIA
31
(ANCOVA) analyses in which verbal ability or performance on a language task has been
the covariate, that differences between groups in terms of alexithymia or associated
emotional abilities can be accounted for by verbal abilities. However, despite such
approaches being widespread, the use of ANCOVA to address such questions is
inappropriate (see Miller & Chapman, 2001). Better approaches include having multiple
comparison groups that are matched versus unmatched on verbal abilities and also
matched versus unmatched on other cognitive abilities (indeed it is very common in DLD
research to have both a chronological age matched control group and a language age
matched control group to control for cognitive and language abilities respectively), or to
have a clinical group that can be dissociated on the basis of their language abilities (e.g.
individuals with autism with and without accompanying language impairment) in the
hope that the groups will be otherwise equivalent with respect to cognitive factors other
than language.
Of course, it must be recognized that much of the research on alexithymia to date
has been performed in a limited set of cultural contexts. This feature of the existing
research is important, as alexithymia prevalence has been shown to vary across cultures
(e.g. Zhu et al., 2007; Ryder et al., 2008). While there has been debate about the extent to
which alexithymia can be readily translated into different cultural contexts (see Dere,
Falk & Ryder, 2012; Fukunishi, Nakagwa, Nakamura, Kikuchi & Takubo, 1997), it has
been argued that alexithymia is present in a comparable form in a variety of cultures
(Parker, Shaughnessy, Wood, Majeski, Eastabrook, 2005), but that culture-specific tools
may be required to assess it. Differences in the prevalence of alexithymia may be
expected given cultural variations in the importance placed on emotions or parental
LANGUAGE AND ALEXITHYMIA
32
socialization of emotional expression, both of which may contribute to cultural variations
in alexithymia (Dere et al., 2012; Le, Berenbaum & Raghavan, 2002). As yet, cross-
cultural research into alexithymia has not considered variations in emotion labels as a
potential explanation for differences in alexithymia. Variation in emotion terms across
cultures, and how this does, or does not, impact on emotion perception, has been a central
issue in the debate between nativist and constructivist theories of emotion (as discussed
in Section 2.0). One prediction would be that rates of alexithymia over cultures would
pattern with the number of words for emotion in that culture’s language(s). However, any
investigation looking to isolate the effect of emotion lexicon size on alexithymia will also
need to control for other cultural factors that may affect alexithymia. Indeed, such
cultural factors and linguistic factors may not be independent; cultures that place less
importance on the sharing of emotion may have fewer words for emotions. Nonetheless,
research into the inter-relationships between culture, language and alexithymia could
represent a way to study the relationship between emotion language and alexithymia, in
those for whom typical brain development is assumed. Such research would be
significant for understanding alexithymia, but also has clear relevance to the competing
theories of emotion described in this article.
Although these issues will need consideration, there are currently several
intriguing lines of enquiry for future research to consider. First, this review has
highlighted a number of populations in which the alexithymia-language hypothesis could
be tested. In particular, alexithymia has yet to be directly studied in children with DLD,
or adults with aphasia following stroke. Work with these populations represents a means
to examine the role of developmental or late-acquired language disruption on alexithymia
LANGUAGE AND ALEXITHYMIA
33
and emotion processing more broadly. In addition, in exploring the literature on
neurodegenerative conditions for this review, we noted the increased rates of alexithymia
in HIV (Bogdanova, Diaz-Santos, & Cronin-Golomb, 2010), multiple sclerosis
(Prochnow et al., 2011), and Parkinson’s Disease (Costa, Peppe, Carlesimo, Salamone, &
Caltagirone, 2010). While language has received little study in these conditions, there is
evidence that language processes are disrupted in multiple sclerosis (Friend et al., 1999;
Lethlean & Murdoch, 1997; Prakash, Snook, Lewis, Motl, & Kramer, 2008) and in HIV
(Chan, Kandiah, & Chua, 2012; McCabe, Sheard, & Code, 2007; Woods et al., 2006;
Woods, Moore, Weber, & Grant, 2009). In Parkinson’s Disease, the majority of patients
have speech problems, particularly affecting voice and articulation (Ho, Iansek,
Marigliani, Bradshaw, & Gates, 1999), but these motoric speech-related problems are
arguably quite distinct from the language processes that would be predicted to affect
emotional functioning. Thus, Parkinson’s Disease may present a useful population to
which those with multiple sclerosis and HIV-related dementia can be contrasted.
Variation in language functioning, both in the aspects of language that are affected and in
the severity of the deterioration, in these conditions represents promising avenues for
future research, offering the potential to test different models of how language and
alexithymia may be affected in different neurodegenerative diseases.
Second, it will be crucial to understand which distinct aspects of language are
related to alexithymia. Clearly, deficits in emotion-related language must be considered
in the context of broader language ability, and if alexithymia is associated with some
form of non-emotional language impairment, then investigation is required into whether
LANGUAGE AND ALEXITHYMIA
34
these difficulties extend to all language processes, or only to particular sub-skills, such as
vocabulary, syntactic skills, pragmatic ability, or abstract language skills.
Third, the relationship between language and interoception is as yet unclear, and
the role language plays in the development of interoception and vice versa remains to be
determined. Indeed, the factors required for the development of interoceptive skill are
largely unknown at present. If language is found to shape interoceptive processes, this
would contribute to the debate concerning constructivist and nativist accounts of emotion,
as some nativist accounts argue that interoceptive experiences are innately given (e.g.
Eckman & Cordaro, 2011; Tooby & Cosmides, 2008). Thus, understanding the inter-
relationships between alexithymia, interoception and language has implications not just
for research on alexithymia and clinical populations, but also emotion theory.
Summary
Alexithymia is a construct that may not be reducible to one basic cognitive deficit
across the wide array of populations in which it is observed. It seems not only possible,
but probable, that there are multiple routes to the alexithymia phenotype. This review has
put forward the case for language problems being one potential route to alexithymia,
drawing upon competing emotion theories, and evidence from acquired and
developmental clinical conditions in both children and adults. Alexithymia may be more
likely to arise due to interoceptive difficulties in some clinical or developmental groups,
and due to language difficulties in others. This model clearly requires explicit
investigation, using identical methodologies across a range of populations. The current
review highlights key issues around the measurement and conceptual nature of
LANGUAGE AND ALEXITHYMIA
35
alexithymia, but the proposals outlined here generate many testable questions for future
research, including the separate and potentially interacting influences of interoceptive and
language abilities on the development of alexithymia.
Funding Statement/Declaration of Conflicting Interests
GB is supported by a grant from the Baily Thomas Charitable Fund. The authors
report no conflicts of interests.
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... Second, even if language does not play a role in the development of emotion concepts, language impairment would result in difficulties describing one's own emotions, again resulting in alexithymia. It should be noted, however, that the language hypothesis of alexithymia posits that language disorder plays a role in exacerbating and/or contributing to high alexithymia in a subgroup of individuals, i.e., just for those with language impairments (Hobson et al., 2019). Thus, while one would not expect every alexithymic individual to have language problems, one would expect language difficulties to lead to alexithymia (dependent upon the nature of those language deficits -see below). ...
... Although in general studies do demonstrate a link between alexithymia and poorer language ability, it should be noted that empirical evidence for the link between alexithymia and language abilities is mixed. Since alexithymia is associated with a wide range of psychiatric conditions, considerable heterogeneity in the demographic and clinical characteristics of participants across individual studies may account for some of the variance observed in the relationships between alexithymia and language abilities (Hobson et al., 2019). Moreover, language is a multifaceted construct. ...
... The current work critically evaluated the empirical literature on language abilities in alexithymia. Our systematic review and meta-analysis provides initial support for the 29 language hypothesis of alexithymia (Hobson et al., 2019), that alexithymia is associated with cross-domain language difficulties. These alexithymia-language associations are modest, consistent with the idea that alexithymia may be a product of language difficulties in a subgroup of individuals, rather than a feature of all alexithymic individuals. ...
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Alexithymia, the inability to identify and express one's own feelings, is a subclinical condition responsible for some of the socioemotional symptoms seen across a range of psychopathological and neurodevelopmental conditions. The language hypothesis of alexithymia posits a language-mediated disruption in the development of discrete and categorical emotion concepts from ambiguous and noisy affective states, exacerbating the risk of developing alexithymia in language-impaired individuals. To provide a critical evaluation of the hypothesis, a systematic review and meta-analysis of 29 empirical studies of language functioning in alexithymia was performed. A modest negative association was found between alexithymia and multi-domain language deficits (r =-.14), including structural language, pragmatics, and propensity to use emotional language. Crucially, a more theoretically-relevant subsample analysis comparing alexithymia levels in language-impaired and typical individuals revealed larger effects, but a limited number of studies adopted this approach. A synthesis of 11 emotional granularity studies also found an association between alexithymia and reduced granularity of emotion concepts (r =-.10). Language impairments and language disorders, therefore, seem to increase the risk of alexithymia. Initial evidence aside, heterogeneous samples and methodological variation suggest the need for more rigorous studies with improved alexithymia assessments.
... Many researchers have argued that alexithymia research would benefit from techniques that move beyond self-report, to incorporate the ratings of others and the analysis of alternative data sources (Kooiman et al., 2002;Leising et al., 2009;Ricciardi et al., 2015). Additionally, the hypothesised link between language and emotion processing abilities has been widely discussed in the alexithymia literature (Hobson et al., 2019;Welding & Samur, 2018) however few studies have empirically investigated this connection. ...
... This is calculated as the proportion of unique emotion words as a percentage of total word count (after the removal of stop words). Fourthly, given the risk that EV may represent a more general verbal ability, a point made by various previous researchers (Hobson et al., 2019;Luminet et al., 2004), the type/token ratio can be calculated for each participant as a measure of general linguistic ability. This is the number of unique words divided by the total number of words used. ...
... As a number of authors have pointed out, if alexithymia is unrelated to general language use, non-emotional language use should be unaffected, whereas if abnormalities are observed in non-emotional word use, this would suggest that alexithymia is, to at least some degree, mediated by a more general language impairment (Hobson et al., 2019;Luminet, et al., 2004). To test this hypothesis, we calculated the number and variety of both emotional and non-emotional words used by each participant in the study, after removing stopwords. ...
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This study examined alternative methods for detecting alexithymia to the Toronto Alexithymia Scale—20 (TAS-20) by comparing the emotional linguistic performance of ASD and NT samples (n = 32 in each) on the Alexithymia Provoked Responses Questionnaire (APRQ). We utilised both the LIWC and tidytext approaches to linguistic analysis. The results indicate the ASD sample used significantly fewer affective words in response to emotionally stimulating scenarios and had less emotional granularity. Affective word use was correlated with ASD symptomatology but not with TAS-20 scores, suggesting that some elements of alexithymia are not well detected by the TAS-20 alone. The APRQ, in combination with the tidytext package, offers significant potential for sophisticated exploration of emotional expression in ASD.
... In fact, the TSIA represents a validated method to evaluate the level of alexithymia ("no words for emotion"), a personality construct characterized by marked difficulties in identifying emotions, finding appropriate words to describe them, and distinguishing feelings from bodily sensations [8]. Importantly, alexithymia can result from a failure of emotional categorization [9,10] or from a lack of relocation from the embodied internal state to the symbolic representation of emotional signals [3,11]. ...
... Surprisingly, however, the relation between alexithymia and language has been understudied. While most studies have counted the occurrence of emotional words, only a few studies have examined verbal encodings of emotion as a means of direct access to the symbolization of emotion [7,9,10]. ...
Article
Full-text available
The analysis of sequences of words and prosody, meter, and rhythm provided in an interview addressing the capacity to identify and describe emotions represents a powerful tool to reveal emotional processing. The ability to express and identify emotions was analyzed by means of the Toronto Structured Interview for Alexithymia (TSIA), and TSIA transcripts were analyzed by Natural Language Processing to shed light on verbal features. The brain correlates of the capacity to translate emotional experience into words were determined through cortical thickness measures. A machine learning methodology proved that individuals with deficits in identifying and describing emotions (n = 7) produced language distortions, frequently used the present tense of auxiliary verbs, and few possessive determiners, as well as scarcely connected the speech, in comparison to individuals without deficits (n = 7). Interestingly, they showed high cortical thickness at left temporal pole and low at isthmus of the right cingulate cortex. Overall, we identified the neuro-linguistic pattern of the expression of emotional experience.
... For example, if when a child is crying, parents or caregivers are biased towards emotional interpretations for female children ('she is feeling upset or frustrated') and biased towards more physiological interpretations for male children ('he is feeling tired or unwell'), these differences may have consequences for children's emotional processing in later life. Indeed, if as has been proposed, parental language plays a role in refining and tuning the categorisation of emotional and interoceptive states (Hobson et al., 2019), it likely that children who are exposed to more emotional or physiological labelling of their internal states by caregivers will, in turn, make more emotional and physiological interpretations of their own internal states, respectively, as they will have a greater differentiation of these concepts. ...
... However, if, as has been proposed, the availability of such language concepts contributes towards the ability to recognise such internal states (Hobson et al., 2019), it may be that differences in socialisation contribute to gender differences in recognition (interoceptive accuracy) and interpretation of one's internal states. Specifically, if boys are socialised to use greater and more complex interoceptive language these concepts may be more accessible and well-defined to them. ...
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Full-text available
Most theories of emotion describe a crucial role for interoceptive accuracy, the perception of the body’s internal physiological signals, in emotional experience. Despite support for interoceptive accuracy’s role in emotion, findings of gender differences in emotional and interoceptive processing are incompatible with theory; women typically show poorer interoceptive accuracy, but women often outperform men on measures of emotional processing and recognition. This suggests a need to re-evaluate the relationship between interoceptive accuracy and emotion considering sex and gender. Here we extend Pennebaker and Roberts’ (1992) theory of gender differences in the use of interoceptive signals for emotional experience, proposing that language socialisation may result in gender differences in the propensity to label internal state changes as physiological or emotional, respectively. Despite outstanding questions concerning the fractionation of interoceptive and emotional domains, this theory provides a plausible explanation for seemingly incompatible findings of gender differences in interoceptive and emotional abilities.
... Of course, given the small sample size, it is difficult to fully resolve the question of whether SAT performance results from poorer awareness and understanding of others' mental states or from poorer vocabulary. Nevertheless, these findings add further support to Vissen and Koolen's (2016) second causal model explaining the relation between language and ToM and to the wider literature, such as the alexithymia language hypothesis which implicates language difficulties as casual in difficulties identifying emotions (Hobson et al., 2019). ...
Article
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Social cognition impairments may explain social, emotional and behavioural difficulties (SEBD) in individuals with Developmental Language Disorder (DLD). In a novel approach, the Social Attribution Task (SAT) was used to examine this association. SAT narratives were coded from 53 participants [n = 26 DLD; n = 27 typical language development (TLD)] matched on age (Mage = 13;6) and gender (35.9% female). Parents reported SEBD. Adolescents with DLD performed worse than their TLD peers on the majority of SAT indices and had higher peer (d = 1.09) and emotional problems (d = .75). There was no association between social cognition abilities and SEBD. These exploratory findings suggest social cognition should be further examined in this population.
... Un second domaine du défi cit d'élaboration concerne la mise en relation des sentiments avec des mots pour les décrire, et la production d'images et de fantasmes exprimant les sentiments. Une grande partie des théories des émotions discutent du langage en tant que facteur contribuant au traitement des émotions ( Hobson et al., 2019 ), y compris dans le développement et l'adaptation des représentations schématiques des émotions et dans leur régulation ( Hoemann & Barrett, 2019 ). ...
Chapter
Dans ce chapitre, nous allons tout d'abord présenter plusieurs modèles qui rendent compte du développement normal des émotions. Ils permettront d'offrir un contraste intéressant avec les déficits d'élaboration émotionnelle et cognitive observés dans l'alexithymie , un construct apparu dans les années 70 afin de rendre compte d'un lien entre capacités cognitives et émotionnelles et troubles mentaux et somatiques. Même si la majorité des études soutiennent l'idée d'un déficit dans la réponse émotionnelle, il est intéressant de noter qu'une partie de la littérature suggère au contraire une réponse émotionnelle plus intense chez des personnes hautement alexithymiques. Nous verrons même que, dans certains cas, ces réponses peuvent être fonctionnelles, au moins sur le court terme. Ce chapitre a également pour objectif d'offrir une perspective clinique à la question de l'élaboration psychique dans l'alexithymie ; plusieurs cas seront présentés qui illustrent notre propos.
... These results bring a supplementary argument to the limited emotional language processing in alexithymia (for a review, see Welding & Samur, 2018). According to the alexithymia language hypothesis, verbal limitations in childhood could be considered as a potential mechanism of the development of emotional difficulties in adulthood, such as alexithymia (Hobson et al., 2019). ...
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This study investigated whether the visual recognition of neutral words might be influenced by the emotional dimensions (i.e., valence and arousal) of orthographically similar lexical representations, and whether this might also depend on emotional-related traits of participants (i.e., alexithymia). To this end, 108 participants performed a lexical decision task with 80 neutral words with a higher frequency orthographic neighbor that varied in valence (from neutral to negative) and arousal (from low to high). The main finding was the expected interaction effect between the valence and arousal of the neighbor on the lexical decision times of neutral stimulus words. Longer reaction times were found when the valence score of the neighbor decreased from neutral to negative for words with a low-arousal orthographic neighbor while this emotional neighbor effect was reversed for words with a high-arousal negative neighbor. This combined influence of the valence and arousal of the neighbor was interpreted in terms of increased lexical competition processes and direct influence of the affective system on the participant’s response. Moreover, this interaction effect was smaller when the level of alexithymia of the participants increased, suggesting that people with a higher level of alexithymia are less sensitive to the emotional content of the neighbor. The results are discussed within an interactive activation model of visual word recognition incorporating an affective system with valence and arousal dimensions, with regard to the role of the alexithymia level of participants.
... However, if RMET performance is solely determined by emotion recognition ability these results are at odds with previous studies reporting a negative relationship between emotion recognition and alexithymia even when various other traits are controlled for (e.g., gender, age, autistic traits and IQ; Cook et al., 2013). An alternative possibility is that RMET performance is determined both by emotion recognition capabilities and additional factors such as language skill or general problem-solving ability (e.g., IQ is related to performance on the RMET; see Baker, Peterson, Pulos, & Kirkland, 2014), that are either not predicted by alexithymia or share common variance with alexithymia (e.g., more recent evidence suggests a possible link between language ability and alexithymia; Hobson, Brewer, Catmur, & Bird, 2019;Hobson et al., 2018). If the RMET is to be used as a measure of ToM, it is important for future research to uncover the exact psychological processes it measures, and the contribution of ToM to successful task performance. ...
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