Chapter 3 82 Besides the importance of emotional awareness in BPP clinical theories and therapies, the lack of emotional awareness has also been studied extensively in research on alexithymia. Alexithymia (roughly translated from the Greek means “no words for feelings”) was first described by Sifneos in 1973 as a deficit in identifying and describing feelings [29, 30]. Results of epidemiological studies on the presence of alexithymia found that approximately 10 to 19% percent of the general population is (highly) alexithymic [31-33]. Elevated levels of alexithymia are common in several forms of psychopathology, for instance, psychosomatic disorders [34], posttraumatic stress disorder (PTSD), eating disorders [35-37], and several somatic diseases [38]. Alexithymia is viewed as a unidimensional construct [39-42] that nevertheless encompasses several related but distinguishable facets [43]. Originally defined by Nemiah and colleagues [29], these include: (1) difficulty identifying and describing subjective feelings; (2) difficulty distinguishing between feelings and the bodily sensations of emotional arousal; (3) constricted imaginal capacities, as evidenced by a paucity of fantasies; and (4) an externally oriented cognitive style [34, 44-46]. Although alexithymia has more facets than just a lack of emotional awareness, that lack is considered the hallmark criterion of alexithymia [30, 41, 42, 47-54]. For example, in a study using confirmatory factor analysis of the Toronto Structured Interview for Alexithymia (TSIA), an interview-based instrument for the assessment of alexithymia, Bagby and colleagues [41] found that the facets “difficulty identifying feelings” and “difficulty describing feelings” belonged to one of two higher order factors they labeled “Affect Awareness.” Treatises on alexithymia from fields of science other than clinical psychology are in keeping with Bagby and colleagues’ assumption. Seen from a developmental psychological perspective, alexithymia can be placed at the lower end of an emotional awareness continuum [12, 44, 55]. From a neuroscientific perspective, alexithymia has been proposed to be the emotional equivalent to the neurological phenomenon of blindsight and has been described as “blindfeel” [42], and more recently as “affective agnosia” [56]. There are different psychometric instruments to measure emotional awareness or alexithymia. Emotional awareness is usually represented in instruments with a broader scope on emotion regulation. Examples are the “awareness of emotions” and “clarity of emotions” scales in the Difficulties in Emotion Regulation Scale (DERS) [7]; or the “perceiving emotions” scale from the Schutte Emotional Intelligence Scales (SEIS) [57]. Other instruments focus on alexithymia, such as the Toronto Alexithymia Scale (TAS-20) [39, 40] and the Bermond–Vorst Alexithymia Questionnaire (BVAQ) [58]. These instruments include subscales that represent different aspects of alexithymia, such as difficulty in identifying emotions, difficulty
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