A feature of posttraumatic stress disorder (PTSD) in many individuals is emotion numbing, or a limited capacity to feel. This can be a barrier to achieving optimal results from trauma-focussed treatments. Alexithymia, or a lack of emotion awareness, is a similar construct to emotion numbing, and a new study in the Journal of Affective Disorders has shed light on what differentiates the two in PTSD, and outlines implications for choosing an appropriate therapy to achieve optimal results.
Australian and international guidelines for treating PTSD recommend trauma-focussed treatments. However, while gold standard treatments such as Prolonged Exposure have been shown to be effective, not everyone responds to them. One possible reason for treatment resistance is that alexithymia is a common comorbidity with PTSD and may prevent the necessary emotional engagement in therapy to process the traumatic memories.
Alexithymia in PTSD
Alexithymia is described as an inability to identify, describe or tune into feelings. It occurs in ten per cent of the general population, but in combat veterans with PTSD the rate is a startling 43 percent. When levels of alexithymia are higher, PTSD is found to be more severe. There has been an ongoing debate amongst practitioners and researchers as to whether alexithymia is a symptom of PTSD, overlapping with emotion numbing, or if it is a unique condition. Given that alexithymia may help to explain treatment resistance in PTSD, it is important to gain a clearer understanding about its nature.
Dr Andrea Putica, a PhD candidate at Phoenix Australia, conducted a systematic review of brain imaging studies of alexithymia and emotion numbing in relation to PTSD. The aim was to identify via objective measurement whether alexithymia and emotional numbing are overlapping or different experiences.
“This was the first review to compare brain scans of both conditions. What we found was that alexithymia is indeed distinct from emotion numbing in terms of functional brain connectivity. And that means there are implications for how we treat PTSD.”
The review revealed that emotion numbing is a symptom of PTSD, while alexithymia exists in the background, regardless of PTSD. A person experiencing emotion numbing has access to their feelings, but those feelings have been numbed as a result of the traumatic experience. Conversely, a person with alexithymia is unable to engage with their emotions, independent of their trauma history.
Implications for treatment
While the conditions may present similarly in the clinic, the differing underlying mechanisms suggest that utilising different treatment approaches could have benefits.
Where emotion numbing is a feature of a PTSD presentation, the numbing is essentially an avoidance strategy. In order to help a person better tolerate trauma-focussed treatment, an adjunctive treatment may be beneficial. One such option is the Skills Training in Affective and Interpersonal Regulation (STAIR) protocol, which aims to build emotion regulation skills, thereby preparing the person to cope with difficult emotions.
In the case of a person presenting with PTSD and alexithymia, because of the inability to identify or engage with feelings, a transdiagnostic intervention may be more appropriate, such as the Unified Protocol for Transdiagnostic Treatment of Emotion Disorders (UP). UP gradually builds up emotional elements so that later in treatment the patient is more able to engage with intense emotions.
For practitioners who treat PTSD, particularly in military and emergency services veterans, alexithymia should be considered when planning treatment, and the Toronto Alexithymia scale is the recommended measure to assist diagnosis.
Dr Putica’s advice to practitioners is to “ask the patient what they were like before the traumatic event occurred – if they always struggled emotionally, then investigate alexithymia. If they had a significant change in their emotional responses after the trauma, then they are more likely experiencing emotional numbing.
“Understanding the nuanced differences between emotion numbing and alexithymia can really help a practitioner to target their treatment and potentially avoid PTSD treatment resistance.”