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      More Than Words Can Say: A Multi-Disciplinary Consideration of the Psychotherapeutic Evaluation and Treatment of Alexithymia

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          Alexithymia is a disorder that stands at the border of mind and body, with psychological/affective and physiological/experiential disturbances. The purpose of this article is to propose a new clinical access point for the evaluation and treatment of the deficits in emotional awareness demonstrated in alexithymia. This will be based on insights from recent neuroscientific research, which is adding to the psychodynamic understanding of alexithymia, regarding clinical presentation and etiology. Following a brief review of definitions, forms of measurement, and potential etiologic elements of alexithymia, current neuroscientific theory and research into “predictive processing” approaches to brain function will be outlined, including how “interoception” and “interoceptive inference” underpins emotion and emotional awareness. From this synergistic perspective, I will outline how interoceptive inference provides a key to the link between: problems in early life relational experiences and the patient’s long held, but suboptimal models of their inner and outer world. This is reflected in the deficits in affective experiencing and emotional awareness described in alexithymia. Three clinical cases will be presented to illustrate this nuanced consideration of alexithymic etiology and treatment. The implications of the historical, psychological, and somatic aspects of experience will be considered, regarding the patients’ diminished ability to: experience and represent emotional experience as distinct feeling states; signify the relevant meaning of affective experience; and incorporate such with cognitions to adaptively guide behavior. These will be addressed using psychometric, psychological, neuro-cognitive, and neurocomputational approaches. Elements from current theory, research, and treatment of alexithymia, will be highlighted that are salient to the clinician, in order to support their understanding of patients against the backdrop of current psychodynamic and neuroscientific research, which will thereby increase treatment options and benefits. The focus, and conclusion, of this article is the role that attention to interoception can play (within the safety of the therapeutic relationship and within any therapeutic process) in allowing updating of the patient’s strongly held but dysfunctional beliefs.

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          How do you feel--now? The anterior insula and human awareness.

          The anterior insular cortex (AIC) is implicated in a wide range of conditions and behaviours, from bowel distension and orgasm, to cigarette craving and maternal love, to decision making and sudden insight. Its function in the re-representation of interoception offers one possible basis for its involvement in all subjective feelings. New findings suggest a fundamental role for the AIC (and the von Economo neurons it contains) in awareness, and thus it needs to be considered as a potential neural correlate of consciousness.
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            The free-energy principle: a unified brain theory?

             Karl Friston (2010)
            A free-energy principle has been proposed recently that accounts for action, perception and learning. This Review looks at some key brain theories in the biological (for example, neural Darwinism) and physical (for example, information theory and optimal control theory) sciences from the free-energy perspective. Crucially, one key theme runs through each of these theories - optimization. Furthermore, if we look closely at what is optimized, the same quantity keeps emerging, namely value (expected reward, expected utility) or its complement, surprise (prediction error, expected cost). This is the quantity that is optimized under the free-energy principle, which suggests that several global brain theories might be unified within a free-energy framework.
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              Neural systems supporting interoceptive awareness.

              Influential theories of human emotion argue that subjective feeling states involve representation of bodily responses elicited by emotional events. Within this framework, individual differences in intensity of emotional experience reflect variation in sensitivity to internal bodily responses. We measured regional brain activity by functional magnetic resonance imaging (fMRI) during an interoceptive task wherein subjects judged the timing of their own heartbeats. We observed enhanced activity in insula, somatomotor and cingulate cortices. In right anterior insular/opercular cortex, neural activity predicted subjects' accuracy in the heartbeat detection task. Furthermore, local gray matter volume in the same region correlated with both interoceptive accuracy and subjective ratings of visceral awareness. Indices of negative emotional experience correlated with interoceptive accuracy across subjects. These findings indicate that right anterior insula supports a representation of visceral responses accessible to awareness, providing a substrate for subjective feeling states.

                Author and article information

                Front Psychiatry
                Front Psychiatry
                Front. Psychiatry
                Frontiers in Psychiatry
                Frontiers Media S.A.
                25 May 2020
                : 11
                Private Practice , Birmingham, MI, United States
                Author notes

                Edited by: Laura Orsolini, University of Hertfordshire, United Kingdom

                Reviewed by: Roberta Vecchiotti, Hermanas Hospitalarias, Italy; Federica Vellante, Università degli Studi G. d’Annunzio Chieti e Pescara, Italy

                *Correspondence: Patrice Duquette, patrice@

                This article was submitted to Psychosomatic Medicine, a section of the journal Frontiers in Psychiatry

                Copyright © 2020 Duquette

                This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

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                Figures: 0, Tables: 0, Equations: 0, References: 86, Pages: 19, Words: 16781
                Hypothesis and Theory


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