What is Avoidant Personality Disorder?

Introduction

Avoidant personality disorder (AvPD) is a Cluster C personality disorder in which the main coping mechanism of those affected is avoidance of feared stimuli.

Those affected display a pattern of severe social anxiety, social inhibition, feelings of inadequacy and inferiority, extreme sensitivity to negative evaluation and rejection, and avoidance of social interaction despite a strong desire for intimacy.

People with AvPD often consider themselves to be socially inept or personally unappealing and avoid social interaction for fear of being ridiculed, humiliated, rejected, or disliked. They often avoid becoming involved with others unless they are certain they will be liked.

Childhood emotional neglect (in particular, the rejection of a child by one or both parents) and peer group rejection are associated with an increased risk for its development; however, it is possible for AvPD to occur without any notable history of abuse or neglect.

Brief History

The avoidant personality has been described in several sources as far back as the early 1900s, although it was not so named for some time. Swiss psychiatrist Eugen Bleuler described patients who exhibited signs of avoidant personality disorder in his 1911 work Dementia Praecox: Or the Group of Schizophrenias. Avoidant and schizoid patterns were frequently confused or referred to synonymously until Kretschmer (1921), in providing the first relatively complete description, developed a distinction.

Signs and Symptoms

Avoidant individuals are preoccupied with their own shortcomings and form relationships with others only if they believe they will not be rejected. They often view themselves with contempt, while showing a decreased ability to identify traits within themselves that are generally considered as positive within their societies. Loss and social rejection are so painful that these individuals will choose to be alone rather than risk trying to connect with others.

Some with this disorder fantasize about idealized, accepting and affectionate relationships because of their desire to belong. They often feel themselves unworthy of the relationships they desire, and shame themselves from ever attempting to begin them. If they do manage to form relationships, it is also common for them to pre-emptively abandon them out of fear of the relationship failing.

Individuals with the disorder tend to describe themselves as uneasy, anxious, lonely, unwanted and isolated from others. They often choose jobs of isolation in which they do not have to interact with others regularly. Avoidant individuals also avoid performing activities in public spaces for fear of embarrassing themselves in front of others.

Symptoms include:

  • Extreme shyness or anxiety in social situations, though the person feels a strong desire for close relationships;
  • Heightened attachment-related anxiety, which may include a fear of abandonment; and
  • Substance abuse and/or dependence.

Comorbidity

AvPD is reported to be especially prevalent in people with anxiety disorders, although estimates of comorbidity vary widely due to differences in (among others) diagnostic instruments. Research suggests that approximately 10-50% of people who have panic disorder with agoraphobia have avoidant personality disorder, as well as about 20-40% of people who have social anxiety disorder. In addition to this, AvPD is more prevalent in people who have comorbid social anxiety disorder and generalised anxiety disorder (GAD) than in those who have only one of the aforementioned conditions.

Some studies report prevalence rates of up to 45% among people with GAD and up to 56% of those with obsessive-compulsive disorder. Posttraumatic stress disorder is also commonly comorbid with AvPD.

Avoidants are prone to self-loathing and, in certain cases, self-harm. In particular, avoidants who have comorbid PTSD have the highest rates of engagement in self-harming behaviour, outweighing even those with borderline personality disorder (with or without PTSD). Substance use disorders are also common in individuals with AvPD – particularly in regard to alcohol, benzodiazepines and heroin – and may significantly affect a patient’s prognosis.

Earlier theorists proposed a personality disorder with a combination of features from borderline personality disorder and avoidant personality disorder, called “avoidant-borderline mixed personality” (AvPD/BPD).

Causes

Causes of AvPD are not clearly defined, but appear to be influenced by a combination of social, genetic and psychological factors. The disorder may be related to temperamental factors that are inherited.

Specifically, various anxiety disorders in childhood and adolescence have been associated with a temperament characterised by behavioural inhibition, including features of being shy, fearful and withdrawn in new situations. These inherited characteristics may give an individual a genetic predisposition towards AvPD.

Childhood emotional neglect and peer group rejection are both associated with an increased risk for the development of AvPD. Some researchers believe a combination of high-sensory-processing sensitivity coupled with adverse childhood experiences may heighten the risk of an individual developing AvPD.

Subtypes

Millon

Psychologist Theodore Millon notes that because most patients present a mixed picture of symptoms, their personality disorder tends to be a blend of a major personality disorder type with one or

more secondary personality disorder types. He identified four adult subtypes of AvPD as outlined below.

SubtypePersonality Traits/Features
Phobic Avoidant (including dependent features)General apprehensiveness displaced with avoidable tangible precipitant; qualms and disquietude symbolised by a repugnant and specific dreadful object or circumstances.
Conflicted Avoidant (including negativistic features)Internal discord and dissension; fears dependence; unsettled; unreconciled within self; hesitating, confused, tormented, paroxysmic, embittered; and unresolvable angst.
Hypersensitive Avoidant (including paranoid features)Intensely wary and suspicious; alternatively panicky, terrified, edgy, and timorous, then thin-skinned, high-strung, petulant, and prickly.
Self-Deserting Avoidant (including depressive features)Blocks or fragments self-awareness; discards painful images and memories; casts away untenable thoughts and impulses; ultimately jettisons self (suicidal).

Others

In 1993, Lynn E. Alden and Martha J. Capreol proposed two other subtypes of avoidant personality disorder, as outlined below.

SubtypePersonality Traits/Features
Cold-AvoidantCharacterised by an inability to experience and express positive emotion towards others.
Exploitable-AvoidantCharacterised by an inability to express anger towards others or to resist coercion from others. May be at risk for abuse by others.

Diagnosis

ICD

The World Health Organisation’s ICD-10 lists avoidant personality disorder as anxious (avoidant) personality disorder (F60.6).

It is characterised by the presence of at least four of the following:

  1. Persistent and pervasive feelings of tension and apprehension.
  2. Belief that one is socially inept, personally unappealing, or inferior to others.
  3. Excessive preoccupation with being criticised or rejected in social situations.
  4. Unwillingness to become involved with people unless certain of being liked.
  5. Restrictions in lifestyle because of need to have physical security.
  6. Avoidance of social or occupational activities that involve significant interpersonal contact because of fear of criticism, disapproval, or rejection.

Associated features may include hypersensitivity to rejection and criticism.

It is a requirement of ICD-10 that all personality disorder diagnoses also satisfy a set of general personality disorder criteria.

DSM

The Diagnostic and Statistical Manual of Mental Disorders (DSM) of the APA also has an avoidant personality disorder diagnosis (301.82). It refers to a widespread pattern of inhibition around people, feeling inadequate and being very sensitive to negative evaluation. Symptoms begin by early adulthood and occur in a range of situations.

Four of the following seven specific symptoms should be present:

  1. Avoids occupational activities that involve significant interpersonal contact, because of fears of criticism, disapproval, or rejection.
  2. Is unwilling to get involved with people unless certain of being liked.
  3. Shows restraint within intimate relationships because of the fear of being shamed or ridiculed.
  4. Is preoccupied with being criticised or rejected in social situations.
  5. Is inhibited in new interpersonal situations because of feelings of inadequacy.
  6. Views self as socially inept, personally unappealing, or inferior to others.
  7. Is unusually reluctant to take personal risk or to engage in any new activities because they may prove embarrassing.

Differential Diagnosis

In contrast to social anxiety disorder, a diagnosis of AvPD also requires that the general criteria for a personality disorder are met.

According to the DSM-5, avoidant personality disorder must be differentiated from similar personality disorders such as dependent, paranoid, schizoid, and schizotypal. But these can also occur together; this is particularly likely for AvPD and dependent personality disorder. Thus, if criteria for more than one personality disorder are met, all can be diagnosed.

There is also an overlap between avoidant and schizoid personality traits and AvPD may have a relationship to the schizophrenia spectrum.

Epidemiology

Data from the 2001-2002 National Epidemiologic Survey on Alcohol and Related Conditions indicates a prevalence of 2.36% in the US general population. It appears to occur with equal frequency in males and females. In one study, it was seen in 14.7% of psychiatric outpatients.

Criticism

There is controversy as to whether avoidant personality disorder (AvPD) is distinct from generalised social anxiety disorder. Both have similar diagnostic criteria and may share a similar causation, subjective experience, course, treatment and identical underlying personality features, such as shyness.

It is contended by some that they are merely different conceptualisations of the same disorder, where avoidant personality disorder may represent the more severe form. In particular, those with AvPD experience not only more severe social phobia symptoms, but are also more depressed and more functionally impaired than patients with generalised social phobia alone. But they show no differences in social skills or performance on an impromptu speech. Another difference is that social phobia is the fear of social circumstances whereas AvPD is better described as an aversion to intimacy in relationships.

Treatment

Treatment of avoidant personality disorder can employ various techniques, such as social skills training, psychotherapy, cognitive therapy, and exposure treatment to gradually increase social contacts, group therapy for practicing social skills, and sometimes drug therapy.

A key issue in treatment is gaining and keeping the patient’s trust since people with an avoidant personality disorder will often start to avoid treatment sessions if they distrust the therapist or fear rejection. The primary purpose of both individual therapy and social skills group training is for individuals with an avoidant personality disorder to begin challenging their exaggerated negative beliefs about themselves.

Significant improvement in the symptoms of personality disorders is possible, with the help of treatment and individual effort.

Prognosis

Being a personality disorder, which is usually chronic and has long-lasting mental conditions, an avoidant personality disorder is not expected to improve with time without treatment. Given that it is a poorly studied personality disorder and in light of prevalence rates, societal costs, and the current state of research, AvPD qualifies as a neglected disorder.

Can We Link Personality Pathology with Smoking & Traits?

Research Paper Title

Predicting smoking and nicotine dependence from the DSM-5 alternative model for personality pathology.

Background

Individuals with personality disorders (PDs) have higher morbidity and mortality than the general population, which may be due to maladaptive health behaviours such as smoking.

Previous studies have examined the links between categorical PD diagnoses/personality traits and smoking/nicotine dependence, but little is known about how the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition alternative model for personality disorders relates to smoking and nicotine dependence.

Methods

The current study examined this question in a sample of 500 participants using the Levels of Personality Functioning Scale to assess general personality pathology, the Personality Inventory for the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition to measure specific traits, the Fagerström test for Nicotine Dependence to assess nicotine dependence, and questions about current and past smoking to assess smoking status (i.e. current, former, never).

Results

Multinomial logistic regression results demonstrated that general personality pathology (Criterion A) was not related to smoking status, and there were no reliable associations between traits (Criterion B) and smoking status. However, correlations showed that higher negative affectivity and disinhibition were related to higher levels of nicotine dependence within smokers.

Conclusions

Findings are discussed in regard to previous findings linking personality pathology to smoking/nicotine dependence as well as the general validity of this new personality disorder diagnostic system.

Reference

Halberstadt, A.L., Skrzynski, C.J., Wright, A.G.C. & Creswell, K.G. (2021) Predicting smoking and nicotine dependence from the DSM-5 alternative model for personality pathology. Personality Disorders. doi: 10.1037/per0000487. Online ahead of print.

What is the Taylor Manifest Anxiety Scale?

Introduction

The Taylor Manifest Anxiety Scale, often shortened to TMAS, is a test of anxiety as a personality trait, and was created by Janet Taylor in 1953 to identify subjects who would be useful in the study of anxiety disorders. The TMAS originally consisted of 50 true or false questions a person answers by reflecting on themselves, in order to determine their anxiety level. Janet Taylor spent her career in the field of psychology studying anxiety and gender development.

Her scale has often been used to separate normal participants from those who would be considered to have pathological anxiety levels. The TMAS has been shown to have high test-retest reliability. The test is for adults but in 1956 a children’s form was developed. The test was very popular for many years after its development but is now used infrequently.

Refer to Zung Self-Rating Anxiety Scale.

Development and Validation

The TMAS has been proven reliable using test-retest reliability. O’Connor, Lorr, and Stafford found there were five general factors in the scale: chronic anxiety or worry, increased physiological reactivity, sleep disturbances associated with inner strain, sense of personal inadequacy, and motor tension. This study showed that persons administered the test could be display different anxiety levels across these areas. O’Connor, Lorr, and Stafford’s realisation allows patients and their doctors to better understand which dimension of anxiety needs to be addressed.

Childhood and Adolescence

The Children’s Manifest Anxiety Scale, sometimes shortened to the CMAS, was created in 1956.

This scale was closely modelled after the Taylor Manifest Anxiety Scale. It was developed so that the TMAS could be applied to a broader range of people, specifically children.

Kitano tested the validity of the CMAS by comparing students who were placed in special education classes versus those placed in regular classrooms. Kitano proposed the idea that children who were in special education classes were more likely to have higher anxiety than those in regular classrooms. Using the CMAS, Kitano found boys tested in the special education classes had higher anxiety scores than their regular classroom counterparts.

Hafner tested the reliability of the CMAS with the knowledge that the TMAS had a feminine bias. Hafner found that the CMAS did not have a female bias. He only found two questions that females always scored higher on than their male counterparts.

As the test stands now, the suggestion is to compare the female and male participants separately. Castaneda found significant differences across different grade levels, indicating that as students develop they are affected differentially by various stressors.

Gender Differences

Although the CMAS proved to not have a feminine bias, Quarter and Laxer found that females tend to score higher on the TMAS than their male counterparts. An example of these questions endorsed more frequently by females is, “I cry easily”. Similarly, Goodstein and Goldberger found that 17 of the 38 questions were more likely to be endorsed by females than males. Gall found that when she tested the femininity versus masculinity qualities of men and women, then compared them to the TMAS score, the people that were more feminine, either male or female, were more likely to have a positive correlation with their anxiety level score. Based on this, Gall agreed with previous research that stated the TMAS is more strongly female based. Hafner, however, found that the CMAS does not reflect the gender difference as the girls that took the children’s test only scored higher than the boys consistently on two of the questions.

Cultural Differences

Since the TMAS was introduced in 1953, comprehensive research has been done regarding the validity of the scale. across different cultures. In 1967, a study of cross-cultural differences in the scale was done between 9 year-old Japanese, French, and American students. The data concluded that Japanese and French students tested significantly lower on anxiety scores compared to the American students. Thus, there are strong cross-cultural differences related to the scores on the TMAS. Additional studies of the validity of the TMAS include a study between South African Natives and South African Europeans in 1979. Both groups included individuals with varying levels of education. This study found that the TMAS is sensitive to certain cross-cultural differences, but precautions should be taken when interpreting scores from the scale in non-Western cultures, regardless of the individual’s education level.

The Adult Manifest Anxiety Scale

In 2003, the Adult Manifest Anxiety Scale (AMAS) was introduced. It was made for three different age groups. The AMAS takes into account age-related situations that affect an individual’s anxiety. The divisions include:

  • One scale for adults (AMA-A);
  • One scale for college students (AMAS-C), and
  • The other for the elderly population (AMAS-E).

Each scale is geared towards examining situations specific to that age group. For example, the AMAS-C has items pertaining specifically to college students, such as questions about anxiety of the future.

The AMAS-A is geared more toward mid-life issues, and the AMAS-E has specific anxieties the older population deals with, such as fear of aging and dying. The AMAS-A contains 36 items. It has 14 questions relating to worry/oversensitivity, nine questions about physiological anxiety, seven questions about social concerns/stress, and six questions about lies. An example of an age appropriate item for this scale is, “I am worried about my job performance”. The AMAS-C contains 49 items about the same topics, but incorporates 15 items related specifically to test anxiety. Questions relating to the items on this scale include, “I worry too much about tests and exams”. This scale is similar in structure to the CMAS discussed above. The AMAS-E contains 44 items related to worry/oversensitivity, physiological anxiety, lying, and the fear of aging. Twenty-three of the questions on the AMAS-E are related to worry/oversensitivity, but The Fear of Aging category of this scale includes items such as, “I worry about becoming senile”. Similar to the TMAS, the AMAS can be given in a group or individual setting, and the person responds either yes or no to each item listed according to if it pertains to themselves or not. The more items that are answered yes, suggest a higher level of anxiety. The scale has been said to be easy to complete and practical, because it takes only about 10 minutes to complete and just a few minutes to score.

Applications and Limitations of AMAS

The AMAS has a broad range of applications, but also a number of limitations. The AMAS can be used in clinical settings, career counselling centres on campuses, hospices, nursing homes, and to monitor the progress and effectiveness of psychotherapy and drug treatment. Effective psychotherapy is indicated by a decrease in AMAS. Almost all college students will experience some type of stress in their academic career. Examples of their stress range from text anxiety to worry of the future after graduation. The AMAS-C items can provide psychologists with a statistical reference point to judge the student’s level of anxiety compared to other college students. A limitation of the AMAS-C is that it does not lend insight into the factors that are influencing the students anxiety, such as lack of studying and social factors. A more formal and extensive level of testing is necessary to resolve this limitation.

Utility

The utility of the TMAS is that it is a way to relate anxiety directly to performance in a certain area. The scale is able to measure anxiety levels and use the scores to determine performance on certain tasks. In some studies, researchers found that high anxiety (high drive) participants would make a greater number of mistakes, therefore taking longer for the participants to reach the learned criterion, whereas participants with low anxiety (low drive) would reach the learned criterion quicker. The TMAS was able to measure that anxiety, so the researchers could make inclusions or exclusions of the participants for their specific studies. This would allow them to achieve the results they want. The TMAS was also a way to relate intelligence to anxiety. Studies have shown there is a possible correlation between anxiety and academic achievement, but they do not recommend it be the sole predictor of achievement. It should be paired with other tests in order to make an accurate prediction.

Decline

The TMAS scale was frequently used in the past, however, its use has declined over the years due to problems with the validity of this self-report measure. Participants use their own judgement when answering questions, which causes internal and construct validity issues, which makes the interpretation of results difficult. Another possible reason this scale has declined in its use over the years is that researchers seemed to only get results of anxiety from participants under threat conditions and not under non-threat conditions, which again questioned the scale’s validity.

Awards

The Association for Psychological Science established an award in honour of Janet Taylor Spence for her contributions to psychology. Receiving this award means that the psychologist made honourable, new, creative, and cutting edge contributions to research and impact in the early years of their career, as Janet Taylor did during her career. The award is named the Janet Taylor Spence Award for Transformative Early Career Contributions.

Reference

Taylor, J. (1953). A Personality Scale of Manifest Anxiety. The Journal of Abnormal and Social Psychology. 48(2), pp.285-290. doi:10.1037/h0056264.

Can We Link Alexithymia, Stress, and the Nervous System?

Research Paper Title

Alexithymia Formation as an Adaptation to Everyday Stress is Determined by the Properties of the Nervous System.

Background

The aim of the study was to determine the psychological nature and mechanisms of alexithymia formation by way of the analysis of its relation to the properties of the nervous system, mental states, and characteristics of the emotional sphere of the personality.

Methods

In the process of the study, for the diagnostics of alexithymia, the researchers used the 26-item Toronto Alexithymia Scale (TAS-26) developed by G.J. Taylor and a block of psycho-diagnostic methods aimed at the diagnostics of properties of the nervous systems, the emotional sphere and mental states of respondents. The relationships were evaluated using Spearman’s rank correlation coefficient and Pearson’s correlation coefficient.

Results

The main factors related to alexithymia were weak nervous system, low stress resistance and such characteristics of the emotional sphere as marked extraversion, high level of trait anxiety, neuroticism, indirect verbal aggression, low levels of aggressiveness. The emotional exhaustion and reduction of personal achievements, the Resistance Phase, chronic fatigue and depression were the most pronounced within the alexithymia group. The alexithymic personality type demonstrated less developed spatial anticipation.

Conclusions

In accordance with the results, the weakness of the nervous system and high trait anxiety facilitate the adaption to stressful situations by avoiding and crowding out negative emotions, lead to the inability of verbal description and expression of emotions. A low level of stress resistance conduces to neurotisation, chronic fatigue, and emotional burnout. The predominance of refractory and dysphoric reactions causes a negative vision of the situation and can provoke the development of psychosomatic disorders.

Reference

Tukaiev, S.V., Vasheka, T.V., Dolgova, O.M., Fedorchuk, S.V. & Palamar, B.I. (2020) Alexithymia Formation as an Adaptation to Everyday Stress is Determined by the Properties of the Nervous System. Wiadomosci Lekarskie (Warsaw, Poland: 1960). 73(11), pp.2461-2467.

What is Alexithymia?

Introduction

Alexithymia is a personality trait characterised by the subclinical inability to identify and describe emotions experienced by one’s self or others. The core characteristic of alexithymia is marked dysfunction in emotional awareness, social attachment, and interpersonal relation. Furthermore, people with alexithymia have difficulty distinguishing and appreciating the emotions of others, which is thought to lead to nonempathic and ineffective emotional responses.

Alexithymia occurs in approximately 10% of the population and can occur with a number of psychiatric conditions as well as any neurodevelopmental disorder. When the difficulty with recognising and talking about their emotions appears at subclinical levels in men who conform to western cultural notions of masculinity (such as thinking that sadness is a feminine emotion), it may be called normative male alexithymia.

Classification

Alexithymia is considered to be a personality trait that places affected individuals at risk for other medical and psychiatric disorders while reducing the likelihood that these individuals will respond to conventional treatments for the other conditions. Alexithymia is not classified as a mental disorder in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). It is a dimensional personality trait that varies in intensity from person to person. A person’s alexithymia score can be measured with questionnaires such as the:

  • Toronto Alexithymia Scale, 20 or 26 items (TAS-20 or TAS-26);
  • The Bermond-Vorst Alexithymia Questionnaire (BVAQ);
  • Online Alexithymia Questionnaire (OAQ-G2); or
  • Observer Alexithymia Scale (OAS).

It is distinct from the psychiatric personality disorders, such as antisocial personality disorder.

Alexithymia is defined by:

  • Difficulty identifying feelings and distinguishing between feelings and the bodily sensations of emotional arousal.
  • Difficulty describing feelings to other people.
  • Constricted imaginal processes, as evidenced by a scarcity of fantasies.
  • A stimulus-bound, externally orientated cognitive style.

Studies have reported that the prevalence rate of alexithymia is less than 10% of the population. A less common finding suggests that there may be a higher prevalence of alexithymia amongst males than females, which may be accounted for by difficulties some males have with “describing feelings”, but not by difficulties in “identifying feelings” in which males and females show similar abilities.

Psychologist R. Michael Bagby and psychiatrist Graeme J. Taylor have argued that the alexithymia construct is inversely related to the concepts of psychological mindedness and emotional intelligence and there is “strong empirical support for alexithymia being a stable personality trait rather than just a consequence of psychological distress”.

Signs and Symptoms

Typical deficiencies may include problems identifying, processing, describing, and working with one’s own feelings, often marked by a lack of understanding of the feelings of others; difficulty distinguishing between feelings and the bodily sensations of emotional arousal; confusion of physical sensations often associated with emotions; few dreams or fantasies due to restricted imagination; and concrete, realistic, logical thinking, often to the exclusion of emotional responses to problems. Those who have alexithymia also report very logical and realistic dreams, such as going to the store or eating a meal. Clinical experience suggests it is the structural features of dreams more than the ability to recall them that best characterises alexithymia.

Some alexithymic individuals may appear to contradict the above-mentioned characteristics because they can experience chronic dysphoria or manifest outbursts of crying or rage. However, questioning usually reveals that they are quite incapable of describing their feelings or appear confused by questions inquiring about specifics of feelings.

According to Henry Krystal, individuals suffering from alexithymia think in an operative way and may appear to be superadjusted to reality. In psychotherapy, however, a cognitive disturbance becomes apparent as patients tend to recount trivial, chronologically ordered actions, reactions, and events of daily life with monotonous detail. In general, these individuals can, but not always, seem oriented toward things and even treat themselves as robots. These problems seriously limit their responsiveness to psychoanalytic psychotherapy; psychosomatic illness or substance abuse is frequently exacerbated should these individuals enter psychotherapy.

A common misconception about alexithymia is that affected individuals are totally unable to express emotions verbally and that they may even fail to acknowledge that they experience emotions. Even before coining the term, Sifneos (1967) noted patients often mentioned things like anxiety or depression. The distinguishing factor was their inability to elaborate beyond a few limited adjectives such as “happy” or “unhappy” when describing these feelings. The core issue is that people with alexithymia have poorly differentiated emotions limiting their ability to distinguish and describe them to others. This contributes to the sense of emotional detachment from themselves and difficulty connecting with others, making alexithymia negatively associated with life satisfaction even when depression and other confounding factors are controlled for.

Associated Conditions

Alexithymia frequently co-occurs with other disorders. Research indicates that alexithymia overlaps with autism spectrum disorders (ASD). In a 2004 study using the TAS-20, 85% of the adults with ASD fell into the impaired category; almost half of adults with ASD fell into the severely impaired category. Among the adult control, only 17% was impaired; none of them severely. Fitzgerald & Bellgrove pointed out that, “Like alexithymia, Asperger’s syndrome is also characterised by core disturbances in speech and language and social relationships”. Hill & Berthoz agreed with Fitzgerald & Bellgrove (2006) and in response stated that “there is some form of overlap between alexithymia and ASDs”. They also pointed to studies that revealed impaired theory of mind skill in alexithymia, neuroanatomical evidence pointing to a shared aetiology and similar social skills deficits. The exact nature of the overlap is uncertain. Alexithymic traits in AS may be linked to clinical depression or anxiety; the mediating factors are unknown and it is possible that alexithymia predisposes to anxiety. On the other hand, while the total alexithymia score as well as the difficulty in identifying feelings and externally oriented thinking factors are found to be significantly associated with ADHD, and while the total alexithymia score, the difficulty in identifying feelings, and the difficulty in describing feelings factors are also significantly associated with symptoms of hyperactivity/impulsivity, there’s no significant relationship between alexithymia and inattentiveness symptom.

There are many more psychiatric disorders that overlap with alexithymia. One study found that 41% of US veterans of the Vietnam War with post-traumatic stress disorder (PTSD) were alexithymic. Another study found higher levels of alexithymia among Holocaust survivors with PTSD compared to those without. Higher levels of alexithymia among mothers with interpersonal violence-related PTSD were found in one study to have proportionally less caregiving sensitivity. This latter study suggested that when treating adult PTSD patients who are parents, alexithymia should be assessed and addressed also with attention to the parent-child relationship and the child’s social-emotional development.

Single study prevalence findings for other disorders include 63% in anorexia nervosa, 56% in bulimia, 45% to 50% in major depressive disorder, 34% in panic disorder, 28% in social phobia, and 50% in substance abusers. Alexithymia is also exhibited by a large proportion of individuals with acquired brain injuries such as stroke or traumatic brain injury.

Alexithymia is correlated with certain personality disorders, particularly schizoid, avoidant, dependent and schizotypal, substance use disorders, some anxiety disorders and sexual disorders as well as certain physical illnesses, such as hypertension, inflammatory bowel disease and functional dyspepsia. Alexithymia is further linked with disorders such as migraine headaches, lower back pain, irritable bowel syndrome, asthma, nausea, allergies and fibromyalgia.

An inability to modulate emotions is a possibility in explaining why some people with alexithymia are prone to discharge tension arising from unpleasant emotional states through impulsive acts or compulsive behaviours such as binge eating, substance abuse, perverse sexual behaviour or anorexia nervosa. The failure to regulate emotions cognitively might result in prolonged elevations of the autonomic nervous system (ANS) and neuroendocrine systems, which can lead to somatic diseases. People with alexithymia also show a limited ability to experience positive emotions leading Krystal (1988) and Sifneos (1987) to describe many of these individuals as anhedonic.

Causes

It is unclear what causes alexithymia, though several theories have been proposed.

Early studies showed evidence that there may be an interhemispheric transfer deficit among people with alexithymia; that is, the emotional information from the right hemisphere of the brain is not being properly transferred to the language regions in the left hemisphere, as can be caused by a decreased corpus callosum, often present in psychiatric patients who have suffered severe childhood abuse. A neuropsychological study in 1997 indicated that alexithymia may be due to a disturbance to the right hemisphere of the brain, which is largely responsible for processing emotions. In addition, another neuropsychological model suggests that alexithymia may be related to a dysfunction of the anterior cingulate cortex. These studies have some shortcomings, however, and the empirical evidence about the neural mechanisms behind alexithymia remains inconclusive.

French psychoanalyst Joyce McDougall objected to the strong focus by clinicians on neurophysiological explanations at the expense of psychological ones for the genesis and operation of alexithymia, and introduced the alternative term “disaffectation” to stand for psychogenic alexithymia. For McDougall, the disaffected individual had at some point “experienced overwhelming emotion that threatened to attack their sense of integrity and identity”, to which they applied psychological defences to pulverise and eject all emotional representations from consciousness. A similar line of interpretation has been taken up using the methods of phenomenology. McDougall has also noted that all infants are born unable to identify, organize, and speak about their emotional experiences (the word infans is from the Latin “not speaking”), and are “by reason of their immaturity inevitably alexithymic”. Based on this fact McDougall proposed in 1985 that the alexithymic part of an adult personality could be “an extremely arrested and infantile psychic structure”. The first language of an infant is nonverbal facial expressions. The parent’s emotional state is important for determining how any child might develop. Neglect or indifference to varying changes in a child’s facial expressions without proper feedback can promote an invalidation of the facial expressions manifested by the child. The parent’s ability to reflect self-awareness to the child is another important factor. If the adult is incapable of recognizing and distinguishing emotional expressions in the child, it can influence the child’s capacity to understand emotional expressions.

Molecular genetic research into alexithymia remains minimal, but promising candidates have been identified from studies examining connections between certain genes and alexithymia among those with psychiatric conditions as well as the general population. A study recruiting a test population of Japanese males found higher scores on the Toronto Alexithymia Scale among those with the 5-HTTLPR homozygous long (L) allele. The 5-HTTLPR region on the serotonin transporter gene influences the transcription of the serotonin transporter that removes serotonin from the synaptic cleft, and is well studied for its association with numerous psychiatric disorders. Another study examining the 5-HT1A receptor, a receptor that binds serotonin, found higher levels of alexithymia among those with the G allele of the Rs6295 polymorphism within the HTR1A gene. Also, a study examining alexithymia in subjects with obsessive-compulsive disorder found higher alexithymia levels associated with the Val/Val allele of the Rs4680 polymorphism in the gene that encodes Catechol-O-methyltransferase (COMT), an enzyme which degrades catecholamine neurotransmitters such as dopamine. These links are tentative, and further research will be needed to clarify how these genes relate to the neurological anomalies found in the brains of people with alexithymia.

Although there is evidence for the role of environmental and neurological factors, the role and influence of genetic factors for developing alexithymia is still unclear. A single large scale Danish study suggested that genetic factors contributed noticeably to the development of alexithymia. However, such twin studies are controversial, as they suffer from the “equal environments assumption” and the “heritability” estimates in no way correspond to actual DNA structures. Traumatic brain injury is also implicated in the development of alexithymia, and those with traumatic brain injury are six times more likely to exhibit alexithymia.

In Relationships

Alexithymia can create interpersonal problems because these individuals tend to avoid emotionally close relationships, or if they do form relationships with others they usually position themselves as either dependent, dominant, or impersonal, “such that the relationship remains superficial”. Inadequate “differentiation” between self and others by alexithymic individuals has also been observed. Their difficulty in processing interpersonal connections often develops where the person lacks a romantic partner.

In a study, a large group of alexithymic individuals completed the 64-item Inventory of Interpersonal Problems (IIP-64) which found that “two interpersonal problems are significantly and stably related to alexithymia: cold/distant and non-assertive social functioning. All other IIP-64 subscales were not significantly related to alexithymia.”

Chaotic interpersonal relations have also been observed by Sifneos. Due to the inherent difficulties identifying and describing emotional states in self and others, alexithymia also negatively affects relationship satisfaction between couples.

In a 2008 study alexithymia was found to be correlated with impaired understanding and demonstration of relational affection, and that this impairment contributes to poorer mental health, poorer relational well-being, and lowered relationship quality. Individuals high on the alexithymia spectrum also report less distress at seeing others in pain and behave less altruistically toward others.

Some individuals working for organisations in which control of emotions is the norm might show alexithymic-like behaviour but not be alexithymic. However, over time the lack of self-expressions can become routine and they may find it harder to identify with others.

Treatment

Because alexithymia is still a fairly newly classified disorder without much research as of 2020, there are not many proven treatment options available.

In 2002, Kennedy and Franklin found that a skills-based intervention is an effective method for treating alexithymia. Kennedy and Franklin’s treatment plan involved giving the participants a series of questionnaires, psychodynamic therapies, cognitive behavioural and skills-based therapies, and experiential therapies. After treatment, they found that participants were generally less ambivalent about expressing their emotion feelings and more attentive to their emotional states.

In 2018, Löf, Clinton, Kaldo, and Rydén found that mentalisation-based treatment is also an effective method for treating alexithymia. Mentalisation is the ability to understand the mental state of oneself or others that underlies overt behaviour, and mentalisation-based treatment helps patients separate their own thoughts and feelings from those around them. This treatment is relational, and it focuses on gaining a better understanding and use of mentalising skills. The researchers found that all of the patients’ symptoms including alexithymia significantly improved, and the treatment promoted affect tolerance and the ability to think flexibly while expressing intense affect rather than impulsive behaviour.

A significant issue impacting alexithymia treatment is that alexithymia has comorbidity with other disorders. Mendelson’s 1982 study showed that alexithymia frequently presented in people with undiagnosed chronic pain. Participants in Kennedy and Franklin’s study all had anxiety disorders in conjunction with alexithymia, while those in Löf et al. were diagnosed with both alexithymia and borderline personality disorder. All these comorbidity issues complicate treatment because it is difficult to examine people who exclusively have alexithymia.

Lexicology

The term alexithymia was coined by psychotherapists John Case Nemiah and Peter Sifneos in 1973. The word comes from Greek: ἀ- (a-, ‘not’) + λέξις (léxis, ‘words’) + θῡμός (thȳmós, ‘heart’ or ’emotions’ or ‘seat of speech’) (cf. dyslexia), literally meaning “no words for emotions”.

Another etymology: Greek: Αλεξ(ι)θυμία άλεξ (διώχνω, απομακρίνω) to push away + θυμός emotion, feelings. Means to push away emotions, feelings

Nonmedical terms describing similar conditions include emotionless and impassive. People with the condition are called alexithymics or alexithymiacs.

Personality Core of Mental Illness

Research Paper Title

Does it exist a personality core of mental illness? A systematic review on core psychobiological personality traits in mental disorders,

Background

Research investigating the relationship between mental disorders and personality traits leads to interesting results. Individuals affected by several mental disorders have been worldwide assessed according to the psychobiological model of personality. This review aims to explore which temperament and character traits are recurrent in mental disorders and to highlight what traits may be shared determinants or consequences of the expression of a mental disorder.

Methods

Systematic search of Medline database between 1998 and 2011 has been conducted to select the studies exploring the Temperament and Character Inventory (TCI) dimensions in the most relevant axis I psychiatric disorders. Of the 110 studies that were retrieved, 88 met the inclusion/exclusion criteria and were analysed.

Results

High HA (HA) and low self-directedness are recurrent and can be considered as a “personality core” regardless of the diagnosis. They may be risk factors and relapse-related, they can indicate incomplete remission or chronic course of mental disorders, and consistently influence patients’ functioning. Furthermore, they can be modified by medications or psychotherapy and represent outcome predictors of treatments.

Conclusion

This “core” may represent a personality diathesis to psychopathology. Relational environment can influence the development of both temperament and character, thus prevention of mental disorders should promote a positive development of these traits. Although further research is needed, psychotherapeutic interventions should be performed also considering that mental disorders could benefit from HA desensitisation and SD reinforcement. Finally, these traits may be used to provide diagnostic, prognostic, quality of life and efficacy inferences on psychiatric treatments.

Reference

Fassino, S., Amianto, F., Sobrero, C. & Daga, G.A. (2020) Does it exist a personality core of mental illness? A systematic review on core psychobiological personality traits in mental disorders. Panminerva Medica. 55(4), pp.397-413.

Book: Working Effectively with ‘Personality Disorder’

Book Title:

Working Effectively with ‘Personality Disorder’: Contemporary and Critical Approaches to Clinical and Organisational Practice.

Author(s): Jo Ramsden, Sharon Prince, and Julia Blazdell (Editors).

Year: 2020.

Edition: First (1st).

Publisher: Luminate.

Type(s): Paperback and Kindle.

Synopsis:

The history of personality disorder services is problematic to say the least. The very concept is under heavy fire, services are often expensive and ineffective, and many service users report feeling that they have been deceived, stigmatised or excluded. Yet while there are inevitably serious (and often destructive) relational challenges involved in the work, creative networks of learning do exist – professionals who are striving to provide progressive, compassionate services for and with this client group.

Working Effectively with Personality Disorder shares this knowledge, articulating an alternative way of working that acknowledges the contemporary debate around diagnosis, reveals flawed assumptions underlying current approaches, and argues for services that work more positively, more holistically and with a wider and more socially focused agenda.

Mental Disorders, Personality Traits & Impaired Work Functioning: Is There an Association?

Research Paper Title

Mental disorders and personality traits as determinants of impaired work functioning.

Background

Both mental disorders and personality characteristics are associated with impaired work functioning, but these determinants have not yet been studied together. The aim of this paper is to examine the impairing effects that mental disorders and personality characteristics (i.e. neuroticism, locus of control and self-esteem) have on work functioning.

Methods

Data for a representative sample of 3570 working people were derived from the first two waves of the Netherlands Mental Health Survey and Incidence Study (NEMESIS), a prospective cohort study in the Dutch adult population.

Results

Higher neuroticism, more external locus of control and lower self-esteem were each significantly associated with subsequent impairment in work functioning, independently of any effects from mental disorders. Associations between mental disorders and subsequent work impairment disappeared once personality traits were taken into account. Personality traits did not moderate the relationships between mental disorders and work functioning.

Conclusions

Working people with vulnerable personalities have a greater risk of impaired work functioning, independent of the risk from any mental disorder they may have.

Reference

Michon, H.W.C., Have, M.T., Kroon, H., van Weeghel, J., de Graaf, R. & Schene, A.H. (2020) Mental disorders and personality traits as determinants of impaired work functioning. Psychological Medicine. 38(11), pp.1627-1637. doi: 10.1017/S0033291707002449. Epub 2008 Jan 21.

Book: Psychiatry and Mental Health

Book Title:

Psychiatry and Mental Health: A guide for counsellors and psychotherapists.

Author(s): Rachel Freeth.

Year: 2020.

Edition: First (1st).

Publisher: PCCS Books.

Type(s): Paperback and Kindle.

Synopsis:

Increasingly, counsellors and psychotherapists are working with people who have been diagnosed with a mental disorder and are required to understand and navigate the mental health system. Counselling training rarely covers the fields of psychiatry and mental disorder in detail and there are few reliable resources on which they can draw.

This comprehensive guide to psychiatry and the mental health system, written by a psychiatrist and counsellor, aims to fill that gap.

The book is intended for counsellors and psychotherapists but will be helpful to others in the mental health field. It explains the organisation and delivery of mental health services in the UK, the theories and concepts underpinning the practice of psychiatry, the medical model of psychiatric diagnosis and treatment, the main forms of mental disorder, how to work therapeutically with people with a diagnosed mental disorder and how to work with risk of suicide and self-harm.

The text is designed to support continuing professional development and training and includes activities, points for learning/discussion and comprehensive references.

Book: Mental Health: Personalities

Book Title:

Mental Health: Personalities: Personality Disorders, Mental Disorders & Psychotic Disorders (Bipolar, Mood Disorders, Mental Illness, Mental Disorders, Narcissist, Histrionic, Borderline Personality).

Author(s): Carol Franklin.

Year: 2015.

Edition: Third (3rd).

Publisher: CreateSpace Independent Publishing Platform.

Type(s): Paperback and Kindle.

Synopsis:

At some point in your life you will probably start to think you are losing your mind, or that someone you know is in danger of losing theirs. The truth is that modern life is extremely stressful; there are many demands on your time and never enough hours in the day.

However, being at the end of your tether, worn out and overwhelmed is not the same as having a mental disorder. In fact mental health covers a wide range of illnesses including those which most people are aware of, such as Schizophrenia (which is classed as a psychotic disorder). What you may not be aware of is the number of people who have personality disorders and the reasons for these disorders. Most people are not diagnosed until into their twenties and symptoms will naturally reduce in their forties or fifties.

Knowing the difference between the various mental illnesses is essential to ensure you know when a friend or loved one needs professional help as opposed to just your care and attention. This book will guide you through the differences between personality disorders, mental disorders and psychotic disorders.

It will help you to understand the different elements of a personality and how you can test your friends to find out which personality type they are. It will even enlighten you as to the basic traits of each of the sixteen personality types, according to the Myers Briggs Personality test.

Reading this book will enlighten you as to the names and details of the nine main personality disorders, how to recognize the symptoms of each of these disorders and the best way to treat them. It is important to use this book as a guide to understanding these illnesses and to learn the best way to help and support anyone you know who is suffering from a personality disorder. However, a diagnosis must always be confirmed by a medical professional who will ensure treatment is available.

Many people who have a mental health issue will not recognise the issue in themselves; this book will ensure you understand each condition and can help your loved one to get the appropriate treatment.

Everyone deserves the chance to have a happy, fulfilling and balanced life. Read this and help those around you have that chance!