Dave started going to counseling because his marriage was falling apart. He said that wife had enough of his lack of presence, no emotional response, and no intimacy. While he agreed with her analysis, he was unable to describe it for himself and minimized the impact these things played in their marriage. He reasoned that because he was a strong provider, he was already showing love and therefore did not need to do it any other way.

When recounting traumatic childhood abuse, he remained flat and unaffected at first but then experienced sudden flooding of emotion. He was unable to describe what he was feeling or even why he felt it. He only knew that he didnt like the feeling and quickly shut down his emotional reaction changing the subject quickly.

It was clear during the first several sessions that Dave had some post-traumatic stress from his childhood, strong obsessive-compulsive behaviors, anxiety from his increase in emotional flooding, and depression from his marriage falling apart. However, as Dave was being treated for these, he improved some but did not progress as expected.

During one of his sessions, he recounted flooding of emotions that occurred at his house. After ruling out any negative associations (it was not the result of a PTSD moment), Dave realized that the flooding might be the result of a positive feeling (happy, pleasure, excitement). He admitted that he was unable to distinguish between a sad or happy feeling, they both felt the same. It was then that another hidden factor became more obvious: alexithymia.

What is alexithymia? This is a personality trait in which a person had difficulty identifying and describing their feelings and is more focused on logic. The key symptoms include an inability to verbalize their emotions, inability to verbalize the emotions of others, a limited fantasy life, little to no pretend play with children, difficulty reacting to others emotions, difficulty showing empathy, and concrete ways of thinking.

What other symptoms exist? These symptoms may or may not be present depending on the severity of alexithymia. They include: difficulty distinguishing somatic feelings in the body, a show of less distress when others are in pain, confusion of their sensations or emotions, few dreams or dreams that are very logical and rational, chronic outbursts (flooding) of crying or rage with no apparent cause, and confusion when asked about their emotional response. Because they are highly logical, they can appear to be super adjusted to reality and unaffected by daily stress. However, when recounting events including traumatic ones, they can be monotoned with a flat affect.

Is this a mental disorder? No, it is not listed in the DSM-5 and therefore is not a mental disorder by itself. However, it can be seen on the Autism spectrum which now encompasses Aspergers Syndrome. It can also be a component of a personality disorder such as Anti-social, Schizoid, and Obsessive-compulsive Personalities. Some studies suggest that approximately 10% of the population has this personality trait in a variety of severities, although others say it is much smaller.

What causes it? It could be nature and/or nurture. Nature or biological component might be the result of a neurological problem such as a traumatic brain injury (TBI) or a limited release in serotonin. Serotonin is neurotransmitter which contributes to the feelings of happiness and well-being, reward, learning, and memory. Binding of serotonin can explain the symptoms of alexithymia. The nurture component could be the result of early childhood abuse and/or neglect especially if there is little to no emotional training, encouragement, or support.

What other disorders are seen with alexithymia? It is not unusual for a person to also present with OCD, panic disorders, anxiety, depression, PTSD, social anxiety, eating disorders, and/or substance abuse. At some level, a person with alexithymia knows they are different due to their lack of or inappropriate emotional response and therefore has poor coping mechanisms for dealing with their discomfort.

Does this impact relationships? Yes, it strongly impacts relationships because there is no emotional awareness of their own feelings let along the feelings of others resulting in an emotional detachment with others. Relationally they are dominant, dependent, passive-aggressive, and impersonal. There is also a lack of social attachment, increase in social anxiety, and a tendency towards shallow relationships. Because of this, there is an increase in loneliness even with marriage and children present. Because their perception of the world tends to be very black and white, their ability to relate to others is limited.

Are there different types? It is believed that there are two main types of alexithymia with a variety of severities for each: primary and secondary. Primary or trait alexithymia means that it is prevalent in multiple environments and even with therapy it does not change. Secondary or state alexithymia is symptomatic and can disappear after the stressful situation is removed. This is most often seen following the successful treatment of PTSD.

What is the difficulty? People with alexithymia tend to lack imagination which makes interacting with children more difficult. They have limited intuition and as they are unable to accurately pick up on the emotions of others. When they do perceive an emotion from someone else, they assume the worst even when that emotion might be positive. They are not relationally oriented and prefer objects or tasks instead. Others often describe them as robotic in nature.

What is the treatment? Traditional psychotherapy does not work. Rather, emotional retraining or rewiring in the brain is required. This might be done in a variety of ways such as using mindfulness techniques, emotional intelligence, group therapy, creative arts techniques, and journaling. Given awareness and time, a person can improve.

Once Daves therapist identified his alexithymia, they started to do psychoeducation for him and his family. This helped everyone to see it differently and not as an intentional desire to pull away and not engage. Dave improved over time and his marriage survived.