Intuiting Alexithymia

“Tell me about the day you passed out,” I asked the middle-aged woman in Room 4 the other morning. “How did you feel?”

“We were up early, my husband and I, because Debbie – that’s our daughter – was coming home for Easter break. She’s on the dean’s list at Swartham College. She wants to be a civil engineer with a double in business administration. She’s so talented…”

“Were you feeling okay when you woke up?” I tried to redirect her.

“Well, Gordon looked at me kind of funny and asked if I was feeling all right…”

“Were you?”

“He didn’t think I looked well. Pasty, he said my face was… Pasty-looking!” She sighed. “I didn’t finish my toast or my bran flakes, and I usually gulp my breakfast before Gordon even gets back in the house with the morning paper.”

“Did you feel nauseous?”

“I didn’t throw up, if that’s what you mean. Gordon asked me the same thing. He felt my forehead and said I was clammy.”

“Then, what happened?”

“We got ready to go to the airport to pick Debbie up. On the way, I asked Gordon to stop at Dunkin’ Donuts and get me some Munchkins, but he was worried we’d be too late, so he talked me out of it.”

I started to be increasingly aware of the time.

“Do you remember the moments before you passed out? What did you feel?” I asked.

“I remember thinking it was hot in the luggage hall, and I remember Debbie talking about her new roommate. Then Gordon said he should have stopped for Munchkins after all, because we had had plenty of time and I was probably getting a low blood sugar…”

I changed my strategy and asked several more directed, yes-or-no questions. I formulated a plan for what kind of workup to do.

The rest of the day I kept thinking about that encounter. Over the years I have seen so many patients who don’t seem to be able to describe or even recognize their own feelings, but instead tell me what other people notice about how they appear to them. I have often wondered if there was a name and a psychological profile for people like that. They are a challenge to take a medical history from, but they must also be challenged themselves by never really knowing how or what they feel.

Last night after supper, my brother-in-law called from the west coast. While my wife talked with him, I Googled my question.

“Inability to describe own feelings, relying on other people’s description” I typed.

The third link on my search gave me the word I needed: “What is alexithymia?” The literal meaning of a-lexi-thymia is “lack of words (for) emotion”. I searched for “alexithymia” and a half-dozen articles completely captured my attention while my wife and her brother continued their telephone conversation.

What I read resonated with my own observations. Curiously, the first website I looked at had been posted or updated the day before my search and the original article by P.E. Sifneos, introducing the word and describing the phenomenon, was published in 1973 – the year before I started medical school. It took me this long to “discover” it myself!

Alexithymia is not classified as a disease in DSM-IV, the psychiatric book of diagnostic definitions. It is rather more like a personality type. What I found fascinating as I read along is the link between alexithymia and psychosomatic illness.

People with alexithymia can’t tell if their bodily sensations represent physical or emotional phenomena, because they have trouble registering their emotions. They are likely to look for physical illness as an explanation for sensations others may easily recognize as related to strong emotions. An extreme example from one of the websites I read was that a crying alexithymic might worry about having a blocked tear duct instead of registering their sadness. A person with little insight into how upset, sad or anxious he or she might be would not have any ability to judge whether they might feel bad, be it headache, chest pain or belly cramps, for emotional reasons.

One article suggested up to 10% of people have some degree of alexithymia.

Those impromptu few minutes on the computer made me a wiser clinician. I will be more tenderhearted with patients who have trouble describing their feelings in a fifteen-minute visit, and I will look harder for that trait in patients whose symptoms baffle me.

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Osler said “Listen to your patient, he is telling you the diagnosis”. Duvefelt says “Listen to your patient, he is telling you what kind of doctor he needs you to be”.



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