2 The body as a (muffled) sound box for emotion 65 On the ‘dysfunctional’ extreme end of the spectrum of emotional awareness, one can imagine and situate the different types of emotional impairment. Starting on the outer end with (1) agnosia (one cannot represent the affect but has a certain physical emotional response), transcending to (2) anomia (there is a basic understanding or concept of emotions but there is no conscious access) then entering the area of (3) basic emotional awareness (one can only express himself in terms of basic unidimensional emotions). General adoption of this representation could resolve the disagreement regarding use of the term ‘agnosia’ alongside, or even instead of, alexithymia. Whether anomia and basic emotional awareness is to be considered as (a degree/subtype of) alexithymia is not yet decided. With regard to the diagnostic assessment of alexithymia, clinicians can make use of various questionnaires, observation scales and semi-structured interviews, several of which we have discussed. It is recommended to always apply a multi-test/multimethod strategy in diagnostic testing. Currently available diagnostic instruments can inform the clinician on the presence of alexithymia, several of its characteristics, and the level of emotional awareness. The main challenge in diagnostics is to develop instruments that are capable of distinguishing between and capturing the several underlying processes or mechanisms as sources of dysfunction in emotional processing. Such instruments, that most likely will include psychophysiological and neuropsychological data, are yet to be developed but are expected to be available in the future. Both academic psychology and clinical practice could benefit from the ability to study and assess low-level emotional awareness on a continuum of interconnected but staged underlying processes. Moreover, such information could be used to perform more differentiated diagnostics that distinguish multiple forms of disturbed processing, leading to deficiencies in emotional awareness [5]. As a result, treatment planning and choice of interventions would not rely on the outer clinical presentation. More refined assessment is expected to significantly improve treatment effects. In treatment of alexithymia and adjacent deficits in emotion processing, it is essential for the clinician to accurately tailor his interventions to the level of emotional awareness of the patient. With low emotional awareness, as is the case with alexithymia (agnosia), this is at the level of the bodily experiences. Although the development of therapies and skills trainings aimed at improving emotional awareness have emerged in recent years, a best practice, evidence-based treatment is yet to be developed for this transdiagnostic, common impairment. Important work remains to be pursued by healthcare professionals and experts of other disciplines who specialize in the field of body-oriented therapy and diagnostics [144].
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