Dissociating the impact of alexithymia and impaired self-awareness after traumatic brain injury.

I previously did a post on impaired metacognition after TBI that included Dockree (Fitzgerald et al. 2022). In addition, two more recent posts (Adamowitcz et al. , 2022, and Ditzer et al., 2023) examined child maltreatment and alexithymia. Here, Dockree et al. look at alexithymia after TBI. Dockree, Ffrench, O'Hara, Carroll, Dockree & McGuire (2023) published “Dissociating the Impact of Alexithymia and Impaired Self-Awareness on Emotional Distress and Aggression after Traumatic Brain Injury” in Neuropsychology. Here are the edited abstract and impact statements:

Alexithymia, a deficit in identifying and describing feelings, is prevalent in traumatic brain injury (TBI). Sometimes referred to as “emotional unawareness,” we sought to investigate whether alexithymia after TBI was related to, or distinct from, impaired self-awareness (ISA) and whether the two predicted differentiable emotional and aggression profiles. Further, the mediating role of frontal system behaviors (disinhibition, dysexecutive function, apathy) was explored. Participants with TBI (N = 40) from diverse backgrounds completed self-report measures of alexithymia, emotional distress, aggression, and frontal system behaviors. For the assessment of ISA, significant other ratings were obtained to identify discrepancies from self-ratings. Data were analyzed quantitatively using independent samples t tests, correlations, partial correlations, and simple mediation. There was a negative correlation between alexithymia and ISA. Alexithymia, but not ISA, was associated with higher expressions of emotional distress and aggression even after controlling for the effects of ISA via partial correlations. Exploratory analyses found that frontal system behaviors mediated the relationships between alexithymia and aggression and alexithymia and emotional distress. Alexithymia is more accurately conceptualized as an emotional processing deficit than an awareness deficit. Indeed, self-awareness may be a prerequisite for the ability to identify alexithymic tendencies. Negative psychological effects of alexithymia are compounded by poorer executive function and disinhibition and call for the development of TBI-specific alexithymia screening tools and interventions. Alexithymia interventions are best delivered in conjunction with rehabilitation of emotion regulation and executive function. We present a novel finding that alexithymia does not equal a deficit in emotional insight and that emotional and behavioral difficulties in TBI are compounded by alexithymia, dysexecutive function, and impulse disinhibition. This article is the first sufficiently powered TBI study, demonstrating (a) a conceptual finding that alexithymia is not merely a manifestation of ISA and (b) a practical implication that treatment of alexithymia is best provided in conjunction with neuropsychological rehabilitation of frontal system behavior changes. Future research is encouraged to invest in the development of TBI-specific alexithymia screening tools and large-scale intervention studies to build the evidence base for effective assessment and treatment. 

What I find most fascinating here is the negative correlation between alexithymia and impaired self-awareness. In the blog titled “Child Maltreatment and Alexithymia,” I summarized the Ditzer et al. article. First, they found that emotional abuse, emotional neglect and physical neglect were predictors of alexithymia in adults. They also suggest that people with alexithymia have more difficulty describing emotions. It makes sense to me that impaired frontal system behaviors may be responsible for alexithymia. Since loved ones judge impaired self-awareness as lower when self-reported alexithymia is high, the inclusion of those ratings by loved ones may be important. Although the research sample is not large, the results of this study seem helpful to both diagnosticians and clinicians.