The Interplay between Interoceptive and Cognitive Components in Alexithymia

Alexithymia is a multidimensional psychiatric construct indicating impaired emotional awareness. Its main features are (i) difficulties in identifying feelings and distinguishing them from bodily sensations, (ii) difficulties describing feelings to others, (iii) an externally oriented style of thinking, and (iv) a poor imaginal capacity. Alexithymia attracts great attention among practitioners and researchers in the clinical field because it has the potential to unveil the emotional disturbances occurring in several mental and physical diseases. As has recently been shown, most of these diseases are not only characterized by an altered perception of emotional states but, more generally, by an altered perception of internal bodily states, namely an altered interoceptive awareness. Consequently, a large body of research has focused on the interplay between alexithymia and interoceptive deficits. Yet, the extent of their association is to date unclear. This question is coupled with a further one concerning whether all or just a few features of alexithymia have clinical relevance and/or an association with interoceptive deficits. Indeed, differences in interoceptive ability are not the only candidate to explain differences in emotional awareness. Rather, the sociocultural environment the individual is surrounded by might play a role at least in the way emotions are expressed, but also in the way emotions are felt. This thesis considers both the mentioned issues, thus addressing the relationship that alexithymia entertains with interoceptive abilities on the one hand and with sociocultural factors on the other. I call these, respectively, the embodied and the embedded aspects of alexithymia. This manuscript is articulated in four parts. Part I introduces alexithymia and shows how the operationalization of the construct through time has facilitated the broadening of its conceptual nucleus. Part II focuses on the embodied aspect of alexithymia, namely its relationship with interoceptive deficits. This section outlines results from two empirical studies testing the association between alexithymia and self-reported interoceptive awareness across three large nationality samples. Part III examines the embedded aspect of alexithymia, namely its relationship with sociocultural factors. Together these studies show that (1) interoceptive deficits are a core component of alexithymia, although the latter cannot be reduced to the former, and (2) differences in externally–oriented thinking are empirically predicted by sociocultural factors more than by self-reported interoceptive awareness, even within the same ethnocultural group. In the fourth and last part, a general discussion summarizes the contribution of this work, raising criticisms regarding the current operationalization of alexithymia and the misunderstandings it can cause, especially when combined with a fallacious interpretation of nosological categories. The thesis concludes with the suggestion that adopting a stricter conception of alexithymia and analyzing the interplay between its interoceptive and cognitive subcomponents is beneficial for both emotion theory and clinical practice.