Introduction
Alexithymia (from the greek αλϵξιθυμία: α-(a) = absence, λέξις (lexis) = word, θυμός
(thymos) = emotion) is a specific form of emotional dysregulation, characterized by
difficulty in identifying, describing, and communicating emotions as well as in discriminating
one’s own emotional experiences from the underlying ‘physiological activation’ (1).
Alexithymia also comprises a cognitive style oriented towards an external reality,
poor imaginative processes, and low levels of introspection and pragmatic thinking
(1). However, competing hyperarousal and hypoarousal models of alexithymia have been
proposed (2). Individuals with alexithymia may display poorly regulated emotions due
to a state of hyperarousal related to the deficits in identifying and/or describing
one’s own emotions, or in adequately reacting to or modulating them (3). According
to the hyperarousal model, alexithymic subjects also display a reduced activation
in brain regions related to mentalizing capabilities (i.e., the temporo-parietal junction
and dorsomedial pre-frontal cortex) (3). Some authors argue that a hypoarousal model
(e.g. characterized by a low autonomic arousal) may explain the increased risk of
substance abuse amongst alexithymic subjects (2, 4). In particular, according to the
hypoarousal model, alexithymic subjects are more prone to use substances in an attempt
to optimize these inherently low arousal levels (2, 4). Moreover, alexithymia has
been demonstrated to be closely related to the concept of emotional intelligence (5,
6) and an inverse relationship exists between alexithymia levels and the ability to
be resilient to negative life events (7). Furthermore, a potential role of dysfunctional
primary parental bonding experiences in childhood and subsequent insecure adult attachment
and alexithymia development has been proposed (8). The construct of alexithymia has
been largely defined, as shown in
Table 1
(7, 9).
Table 1
The construct of alexithymia: main features.
• Difficulty in identifying feelings and in distinguishing them from bodily sensations
that accompany emotional activation
• Difficulty in describing own feelings to others
• Limited imaginative processes, highlighted by the poverty of imagination and fantasy
thought
• Cognitive style related to the stimulus and externally oriented
• Strict adherence to the rules, as if the identity is defined only from the outside
and external reality
• Lack of introspective abilities and lacking mentalizing processes
• Inability to recognize and express emotions even at a non-verbal level
• Lack of emotional activation even in the face of emotionally meaningful events
• Lack of relational skills, poor tolerance to stress, lack of humor and excessive
self-control
The identification and evaluation of an impaired emotional regulation have been widely
linked to the etiology and treatment of substance use disorders (SUDs), alcohol use
disorders (AUDs), and behavioural addictions (10). The incapability to modulate emotions,
due to a cognitive elaboration, may explain the higher levels of impulsivity and compulsive
behaviors (i.e. binge eating, drug and/or alcohol addiction, sex addiction, internet
addiction, and gambling) which have been observed amongst alexithymic subjects. In
addition, individuals with alexithymia appear to have difficulties in addressing stressful
situations and are more prone to use ‘addictive’ modalities as a coping strategy for
managing potentially distressing situations (11). In fact, alexithymia has been widely
associated with increased cannabis use in adolescence, increased caffeine consumption,
and increased development of mobile phone addiction and/or pathological gambling (10–17).
Substance and Alcohol Use Disorder and Alexithymia
Alexithymia may be a risk factor for SUDs, particularly in the context of AUDs (13,
14). The relationship between alexithymia and addiction is supported by significant
findings describing a correlation between alexithymic traits and craving, severity
of SUD and/or AUD, and related complications (18, 19). Emotional dysregulation has
been widely associated with alexithymia in SUD and/or AUD (3). Individuals with illicit
drug use frequently (45% to 50%) exhibit alexithymia (20, 21). Research suggests a
correlation between alexithymia and craving for drugs and/or alcohol (22–24). Around
45% to 67% of subjects with AUD reported high alexithymia scores (23). Moreover, alexithymia
has been associated with a family history of alcoholism (24). In social drinkers,
alexithymia may predict alcohol consumption (25). Several mechanisms have been proposed
to explain the neurobiological basis of alexithymia in addiction, from an aberrant
hypothalamic-pituitary-adrenal axis functioning associated with chronic stress, to
the lack of interoceptive and emotional awareness which may prevent effective emotion
regulation and lead an individual to use a substance addiction as a coping strategy
to alleviate distress (26–29). Furthermore, some findings reported an anxious attachment
style, alcohol expectancy, and drinking motives as mediating factors in AUDs (18,
19). Moreover, inadequate parental bonding during infancy and childhood may result
in deficits of self-regulation, emotion recognition, and an insecure interpersonal
adult attachment, which may encourage reliance on substances and/or alcohol as emotional
disinhibiting and/or alleviating tools in response to negative effects in alexithymic
subjects (8).
Pathological Gambling and Alexithymia
Pathological gambling and gambling disorder are two terms often used interchangeably,
characterized by financial, psychological, employment, and interpersonal difficulties
related to excessive wagering (30). Gambling disorders may lead to legal issues and
suicidal ideation and behaviours (31). Several risk factors have been hypothesized,
including socio-cultural background, personality factors (i.e. impulsivity, sensation
seeking, antisocial behaviours, etc.), cognitive distortions, and an impairment of
emotional processes (32, 33). Amongst the different personality traits thought to
be implicated in the development and maintenance of gambling disorders, the construct
of alexithymia and an affect dysregulation, i.e. the inability to tolerate negative
affect, have been further investigated (34). Alexithymia is commonly represented in
subjects with gambling-related problems by causing a worsening in symptom severity
and increasing the risk of pathological gambling (34). The difficulty in identifying
one’s own emotional state may impair the decision-making process, which is particularly
relevant in gambling disorders. Thus, the subject is unable to use the information
contained in an aversive (negative) emotional state related to a negative external
feedback due to impaired emotional regulation (35). Furthermore, alexithymia displays
a clinically significant interaction with maladaptive personality (e.g. impulsivity,
aggressiveness, and sensation-seeking personalities), cognitive factors (e.g. gambling-related
cognitive distortions, motivation, strategic and non-strategic games) as well as psychopathological
symptomatology, including depression and anxiety (34).
Internet Addiction and Alexithymia
Internet Addiction (IA) is characterized by staying on the Internet for longer than
planned and experiencing withdrawal symptoms such as nervousness, low mood, or restlessness
when the subject is deprived of the Internet (36, 37). The symptomatology is often
accompanied by diminished sleep quality and hygiene, relational maladjustment, and
progressive worsening of personal, family, social and occupational/school functioning
due to excessive Internet use and consequent cognitive and psychological impairment(s)
(36, 37). IA has been associated with several psycho-social determinants/risk factors,
including impaired emotional regulation and higher levels of alexithymia, particularly
amongst youngsters/adolescents (37–40). Overall, adolescents with IA appear to have
more difficulties in identifying and describing emotions, understanding emotional
reactions, and controlling their impulsive behaviours in response to negative emotional
experiences (mainly due to an inadequate prefrontal cognitive control). Moreover,
adolescents with an IA appear to be less able to use effective strategies in emotional
regulation compared to adolescents without an IA (41–43). Similarly, subjects with
higher levels of alexithymia are more likely to develop an IA compared to non-alexithymic
subjects (38, 39, 44).
Mobile Phone Addiction and Alexithymia
Mobile phone addiction is a behaviour characterized by an excessive indulgence to
activities related to mobile phones, accompanied by a constant dependence on mobile
phones, which results in a general loss of self-control and compromised psychological
and social functioning (44–46). Mobile phone addicts might possess emotional recognition
deficits, which may lead to more interpersonal issues as they usually attempt to cover/mask
their own emotional states by escaping from reality by means of mobile phones (9).
Alexithymic subjects may use online gaming as a coping strategy for their distressing
psychosocial issues in real life (9, 47).
Internet Gaming Disorder and Alexithymia
A failure of emotional regulation and control associated with high levels of alexithymia
have been demonstrated by several studies which investigated the features underlying
the development of a pathological gaming (12, 48, 49). Alexithymia might explain the
engagement in and the maintenance of video game use amongst those individuals with
poorly regulated emotions. In fact, these individuals often engage in maladaptive
behaviours, including internet gaming disorders, to escape from or downregulate their
own emotions (35, 49).
Discussion
Currently, alexithymia is mainly considered as a personality construct, characterized
by a marked dysfunction in emotional awareness, social attachment, and interpersonal
relating (50). However, some authors suggest that alexithymia might represent a state-dependent
mechanism (as in, something which is temporary and situation-dependent, i.e. secondary
alexithymia) which may develop as a reaction to psychological distress (50, 51). Taylor
et al. (51) demonstrated that alexithymic subjects generally attempt to regulate their
emotions through compulsive and/or impulsive behaviours (e.g., SUDs, AUDs, and behavioural
addictions) (3). Other studies suggest that alexithymia might be considered a state-dependent
mechanism in patients addicted to substances and/or behaviours (13), hence, secondary
to an immature/maladaptive defense style used by these patients, in an attempt to
relieve negative emotions, such as anxiety or depression (50). Further studies support
the hypothesis that alexithymia might represent a stable personality trait, greatly
influenced and caused by several factors, including life experiences, previous relationships,
early traumatic experiences (e.g. childhood maltreatment and/or abuse), and the type
of attachment system (e.g. insecure attachment), which may, in turn, cause increased
vulnerability to addictive disorders (9, 18, 52).
Failures in emotional regulation, observed in alexithymic subjects, makes it difficult
for them to discern, assess, and express their feelings and to understand others’
feelings/emotions in face-to-face communication (11). These core features of alexithymia
may cause an inadequate emotional response and a perceived lack of empathy, which,
in turn, may cause a failure to establish and maintain ‘face-to-face’ relationships
in the real world (11). Therefore, the feeling of not being accepted and the lack
of a sense of belonging might lead alexithymic subjects to use alternative modalities
to communicate and interact with others (e.g. online platforms, Internet, and mobile
phones) which may result in the early development of a technological addiction (46).
Overall, one could argue that alexithymia might be both a stable personality trait
that may constitute a vulnerability/risk factor for the development and/or maintenance
of an addiction disorder, and a defensive mechanism (i.e., a variable state) secondary
to a psychological distress which may arise or worsen an SUD/AUD or a behavioural
addiction already present (3, 53).
Moreover, the early identification and assessment of the presence of an alexithymic
dimension (trait or state) may help clinicians to adequately assign patients to specific
treatments associated with better outcomes, such as computerized cognitive behavioural
therapy (3, 54). In this regard, clinicians working in addiction services should be
aware of the current validated instruments and scales designed to assess alexithymic
traits and/or states in medical and psychiatric research (55–57), especially amongst
addictive subjects (58–62). Presently, the Toronto Alexithymia Scale-20 items (TAS-20)
and the Bermond-Vorst Alexithymia Questionnaire (BVAQ) are the most known, reliable,
and validated alexithymia self-report tools, also commonly used in the addiction field
(58, 59, 61, 63, 64). However, several studies have specifically investigated the
psychometric properties of further alexithymic self-reports or observer-rated tools
in clinical samples with addiction disorders (60, 62). Amongst these rating scales,
researchers suggest also using the Observer Alexithymia Scale (OAS, 33-item, observer-rated
scale) (62, 65).
Alexithymia may interfere with treatment and prognosis outcomes in the addiction context
(62). In fact, those individuals for whom it is difficult to recognize and describe
emotional states may not be able to adequately regulate their emotional states or
recognize their relationship to the initiation and/or the maintenance of a substance/alcohol
and/or a behavioral addiction, especially in a state of heightened distress (66–69).
Alexithymia may also predict treatment engagement and adherence, in terms of session
attendance and working alliance (58) and may cause higher rates of relapse and premature
treatment discontinuation (70). However, the evidence so far generated is limited
and non-univocal. In fact, de Haan et al. (71) did not report any differences in mean
time in treatment or dropout rates amongst SUD subjects with high-scoring vs low-scoring
alexithymia, both measures being continuous and categorical variables. Similarly,
alexithymia was not strongly associated with treatment adherence or retention in an
8-week randomized clinical trial (54, 72).
Overall, clinicians should be aware of the possible interdependent relationship between
the presence of alexithymic dimensions (trait or state) and the development, maintenance,
and/or worsening of an addictive disorder, in order to better assemble and perform
personalized treatment protocols, which also take into account the dimension of alexithymia.
Furthermore, although the “chicken or the egg causality dilemma” remains unresolved
(i.e. if alexithymic dimension is a trait or state), clinicians should always investigate
the presence of alexithymic traits of personality or alexithymic state which could
cause different outcomes and prognoses in the context of an addiction. Moreover, in
the context of the recent growth and dissemination of digital platforms and the subsequent
development of intriguing, potentially addictive and appealing online modalities amongst
youngsters, clinicians should consider the possibility of a relationship between the
presence of an alexithymic trait/state and the subsequent occurrence of IA, mobile
phone dependence, and/or online gaming disorder amongst adolescents. Finally, one
could argue that an alexithymic dimension is likely becoming a ‘quasi-pandemic’/’quasi-physiologic’
trait of modern adolescence, in the light of the increasing incidence of several co-occurring
changes which may affect individual, social, and family contexts. Therefore, clinicians
should consider the preventive strategies (if any) and therapeutic approaches needed
in the concurrent presence of alexithymic traits/states in the context of an addiction.
Further research should address and further develop this issue in the context of addiction.
Author Contributions
The author confirms being the sole contributor of this work and has approved it for
publication.
Conflict of Interest
The author declares that the research was conducted in the absence of any commercial
or financial relationships that could be construed as a potential conflict of interest.