Panic Attacks And the Inability to Express Emotions: Are They Related?

by Mike Nichols – Posted in: Panic Attacks

unsmiley-face-smThe search for the causes of panic attacks and Panic Disorder continues to turn up new and surprising clues to the origins and contributors to the disorders.

A new vein of research has been trying to find out if panic attacks are related to personality traits that are not mental illnesses. Researchers in Italy and Denmark have published studies in the last few months that show a distinct relationship between alexithymia, the inability to talk about feelings, and Panic Disorder.

Alexithymia is a relatively new field of study. The personality trait was only named in 1972, and has received increasing attention in the past few years as a cause or contributor to a number of medical and psychological maladies.

This post discusses alexithymia and its relationship to panic attacks and Panic Disorder under these headings:

  • What is alexithymia?
  • How do I tell if I’m alexithymic?
  • What relationship do panic attacks and Panic Disorder have with alexithymia?
Check out the article What Panic Attacks Have Taught Me for more help on overcoming Panic Attacks.

What is alexithymia?

Inability to talk about feelings due to a lack of emotional awareness

Alexithymia is the inability to talk about feelings due to a lack of emotional awareness. Alexithymics are typically unable to identify, understand or describe their own emotions.{{1}} It is a personality trait that places people at risk for other medical and psychiatric disorders while reducing the likelihood that these people will respond to conventional treatments for other conditions. 

Alexithymia is not listed in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) as a mental disorder, since it is considered to be a personality trait at this time.{{2}} This Manual is the source used by most US psychiatrists and psychologists to make diagnoses. The new DSM-V, due to be released in 2012, may change this.

The term “alexithymia” was coined in 1972 by Peter Sifneos from the Greek a (prefix meaning “lack”), lexis (“word”), and thymos (“feelings”), and can be read literally as “a lack of words for feelings.”{{3}}The name actually is inaccurate, since the syndrome involves much more than a simple inability to express feelings.

Alexithymia is a relatively new diagnosis, so there have been no large-scale studies of the prevalence of the syndrome in the general population. Smaller-scale studies point to the prevalence as being from 5 to 9 percent.

The key features of alexithymia are:{{4}}

  • Difficulty identifying different types of feelings
  • Difficulty distinguishing between emotional feelings and bodily feelings
  • Limited understanding of what caused the feelings
  • Difficulty verbalising feelings
  • Limited emotional content in the imagination
  • Functional style of thinking
  • Lack of enjoyment and pleasure-seeking
  • Stiff, wooden posture

Genetics play a large role in alexithymia

A study by Michael Jørgensen and colleagues in Denmark shows that genetics play a large factor in all aspects of alexithymia, much greater than environmental influences. {{5}} They studied 8,785 twin pairs in Denmark and found that, while environmental factors do play a role in alexithymia, the genetic makeup of a person plays a greater part.{{6}} This points up that alexithymia is more of an inherited personality trait, rather than something that is learned, and therefore fully treatable.

Note that alexithymia should not be confused with:

  • Sociopathy – a lack of concern for others
  • Stoicism – a deliberate resistance of emotional impulses
  • Apathy – a lack of emotional reactivity or motivation
  • Emotional repression – subconscious but motivated denial of emotion

How do I tell if I’m alexithymic?

Deficiency in emotional understanding

If you have a marked deficiency in emotional understanding, there will be various clues evident in everyday life. For example, you might:{{7}}

  • Find it difficult to talk about your own emotions
  • Be perceived by others as excessively logical, or unsentimental without being unfriendly
  • Be perplexed by other people’s emotional reactions
  • Give pedantic and long-winded answers to practical questions
  • Rarely daydream or fantasize about personal prospects
  • Have a subdued reaction to art, literature or music
  • Make personal decisions according to principles rather than feelings
  • Suffer occasional inexplicable physiological disturbances such as palpitations, stomach ache, or hot flushes

What relationship do panic attacks and Panic Disorder have with alexithymia?

Same brain dysfunction in panic and alexithymia

A definite relationship has been found by Silvana Galderisi and her colleagues in Italy between dysfunction in certain parts of the brain (the fronto-temporo-limbic circuits) in both alexithymia and panic disorder.{{8}} These parts of the brain process emotional stimuli, among other things.{{9}} 

Galderisi found that alexithymia was more frequent in patients with Panic Disorder than in those without it. Those with Panic Disorder had lower verbal cognitive abilities and more difficulty in inhibiting interference from nonverbal stimuli and panic-related words. She notes that this reduction in verbal skills might suggest reduced abstraction and symbolization.{{10}}

Another study by Carlo Marchesi and colleagues showed that patients with Panic Disorder were more alexithymic than normal patients, even when their Panic Disorder was in complete remission.{{11}} Though the levels of alexithymia dropped after the remission of panic attacks, phobic avoidance and anticipatory anxiety, those with Panic Disorder were still more alexithymic and anxious than normal people.

What do you think?

I spent most of this post describing alexithymia, but it’s a syndrome that most people are unfamiliar with. We all know people that are not forthcoming with their emotions, particularly men, and particularly men in the southern and upper midwest US. But much of this is a learned cultural behavior. 

The unanswered question

The question unanswered by these studies is what kind of environment might foster alexithymic tendencies? There are many different kind of environmental influences that might come into play: cultural, religious, and family, to name but a few.

On reflection, I think that I have known several people who could be alexithymic. They were cold, unsentimental, and had no reaction to the arts. My wife even worked for one! 

  • Do you know someone who might be alexithymic? Why do you think so?
  • What part do you think cultural learning might have in alexithymia?
  • What do you think are some of the environmental influences that might bolster alexithymia?

As always, your comments are welcome!

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[[1]] Hal. (2003, July 28). The Alexithymia FAQ. Retrieved December 18, 2008 from http://www.alexithymia.supanet.com/faq.html “What is alexithymia? ¶1[[1]] 

[[2]]Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. Arlington, VA: American Psychiatric Association. 1994.[[2]]

[[3]]Hein, Steven. (2007, July 27). Alexithymia. Retrieved January 3, 2009 from http://eqi.org/alexi.htm “The History of the Term” ¶1[[3]]

[[4]] Hal. (2003, July 28). “What are the key features of the alexithymia syndrome?”[[4]]

[[5]]Jørgensen, Michael; Zachariae, Robert; Skytthe, Axel; Kyvik, Kirsten. (2007, October). Genetic and Environmental Factors in Alexithymia: A Population-Based Study of 8,785 Danish Twin Pairs. Retrieved January 3, 2009 from Psychotherapy and Psychosomatics: http://content.karger.com/ProdukteDB/produkte.asp?Aktion=ShowAbstract&ArtikelNr=107565&Ausgabe=233736&ProduktNr=223864 [[5]]

[[6]]Science Daily. (2007, November 19). Is the Inability to Express Emotions Hereditary?. Retrieved January 3, 2009 from http://www.sciencedaily.com/releases/2007/11/071117114401.htm ¶3 ¶6 [[6]]

[[7]] Hal. (2003, July 28). “How do I tell if I’m alexithymic?”[[7]]

[[8]]Galderisi, Silvana; Mancuso, Francesco; Mucci, Armida; Garramone, Stefania; Zamboli, Rosita; Maj, Mario. (2008). Alexithymia and Cognitive Dysfunctions in Patients with Panic Disorder. Retrieved December 12, 2008 from Psychotherapy and Psychosomatics: http://content.karger.com/ProdukteDB/produkte.asp?doi=10.1159/000119738 [[8]]

[[9]]Science Daily. (2008, June 5). Are Panic and Inability to Express Emotions Related?. Retrieved July 1, 2008 from http://www.sciencedaily.com/releases/2008/06/080602155657.htm ¶2[[9]]

[[10]]Galderisi. (2008).[[10]]

[[11]]Marchesi, Carlo; Fontó, Stefania; Balista, Chiara; Cimmino, Carmen; Maggini, Carlo. (2005). Relationship between Alexithymia and Panic Disorder: A Longitudinal Study to Answer an Open Question. Retrieved December 18, 2008 from Psychotherapy and Psychosomatics: http://content.karger.com/ProdukteDB/produkte.asp?typ=pdf&doi=82028  [[11]]

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18 comments… add one
Olive January 7, 2009, 4:39 am

I believe everyone’s anxiety is very different and stems from very different causes. Although I wouldn’t rule out this idea, I personally experience the opposite- I express too many emotions and am too in touch with my emotions. In some ways I feel like this leads to a lot of anxiety.

Tracy January 7, 2009, 10:39 am

That’s very interesting. I wonder if that’s why a lot of people on the autism spectrum also have problems with anxiety and panic attacks?

Tracy’s last blog post..Why I Love My Message Board

Mike January 8, 2009, 7:50 am

Olive, thank you for visiting and commenting!

I agree, everybody has a different mix of reasons for their Anxiety: genetic, environmental, personality, and so on. Your experience — being very much aware of your emotions — is much more in the mainstream than alexithymia.

In fact, I was very surprised at the conclusions of the research in this post. I still am trying to find out more about how not being able to express one’s feelings can lead to panic attacks. I hope to be able to post a follow-up on this subject soon.

Mike January 8, 2009, 7:57 am

Tracy,
I wondered the same thing as I was researching and writing the post. I’d be interested in finding out whether any research has been done regarding alexithymia and autism.

Researchers have only recently been able to connect different personality traits and mental illnesses to each other. It’s my opinion that there are many more connections that will be discovered in the near future, and that mental illnesses such as Anxiety Disorders are not discrete diagnoses, but are bundles of symptoms and syndromes from across a wide spectrum of human behavior.

Doug January 10, 2009, 5:04 am

Mike, this is certainly an interesting post! I’m interested in learning more, as I really don’t understand some of the pathology here (Maybe some people just don’t like art?).

Doug’s last blog post..Ending the worrying about worrying

Mike January 10, 2009, 6:23 pm

Hi, Doug – thanks for the comment!

The research reported in this post is the first of its kind, and only established that there is a link between the brain functions of alexithymics and those with Panic Disorder. I’m sure that research is continuing to fill in the blanks now that the relationship has been proven.

While writing the post I had all sorts of questions pop up in my mind, like “What kind of behaviors do alexithymics and Panic Disorder sufferers have in common?” and “What exactly would characterize alexithymic thinking among the Panic Disorder symptoms?” There are many more.

Like many groundbreaking research studies, this one raises more questions than it answers. I will be following developments closely and report them as they appear.

Dave April 25, 2009, 10:58 pm

Hadn’t noticed this posting back in January, so just now commenting.

For me, I don’t find this study surprising at all. As I’ve mentioned before in other posts, I believe that panic attacks are a physiological reaction that some people have when their “emotional bucket” is full and overflowing. Some people react in others ways; some have panic attacks.

So, if you are unable to “emote” what’s going on inside, then your “bucket” will eventually get full, leading you down the PD path.

[Editor’s note: Dave is the author of the post, Conquering Your Panic: Dave’s Success Story where he explains the “emotional bucket.” In addition, he has contributed many insightful comments, particularly on the post I’m Dying: What a Panic Attack Feels Like.]

Mike April 26, 2009, 5:53 pm

Thank you again, Dave, for another great comment!

I hadn’t thought of Alexithymia in terms of the “emotional bucket,” but it makes perfect sense. You know first-hand how that bucket can overflow into panic attacks that disrupt the lives of the sufferer and everyone around them.

I’m keeping an eye on this subject and will report as more research is released. To me, there seems to be a lot of interconnectedness among Alexithymia and symptoms of other Anxiety Disorders, but I won’t express them here because they are just hunches rather than facts.

Mike December 13, 2009, 2:55 am

I really don’t know how to start this but I believe i have Alexithymia. I have been trying to research why i don’t feel things like other people do. And that research led me to Alexithymia and eventually to you. You have the most detailed article i could find so far. Especially with linking it to panic disorders.

I find it interesting as I was diagnosed with Conversion Disorder. Although i do not believe that is a panic disorder but i do not believe i was accurately diagnosed.

I was hoping that you could point me in the right direction to get this fixed or at least towards getting it fixed. I greatly appreciate anything you could do or give to help me.

Celly March 23, 2010, 2:14 am

I very much, identify with this article.

I have trouble expressing my emotions. I do not know how I feel the majority of the time. I know when I feel positively about something and negatively about something. I don’t think that I have ever felt sad. I tend to make guesses at what emotion would best fit how I feel at any given time, when asked, but when I really take the time to reflect I find I have no name for how I feel at any time. It’s difficult to describe >.< I do however like various music and artwork. A wide spectrum in fact. I can not tell you what my favorite genre would be, out of those that I find pleasant. I can however, quickly recognize something that I do not like. In addition I do have some sense of humor, though there are many jokes that I do not get. Some types of humor/jokes I have simply learned the "correct" response to. I did not have much of a sense of humor when I was younger. I did not get most jokes, and had to have them explained to me. My recent discovery, with help from my husband, is situational humor.

I have spent a lot of time over the last year, learning to recognize facial cues for various feelings. I can recognize happy, and sad and anger. I cannot tell, very well, the differences between anger and disgust. I find myself asking how the other person in the conversation feels, and did not always recognize in school when someone was upset. I learned to be "empathetic" through questions about the other persons feelings, and simply by listening. My interest in how another person is feeling, despite not picking up on it, seems to have taken me a long way.

Growing up I had just assumed I was empathetic. How wrong I was.

I have been told on many occasions, that I look intimidating and angry all the time, or sad, though I am quite sure that I am not. I attempted to visit with a counselor to help me with these issues, but we weren't really getting anywhere. I'm not really certain who I can talk to to help. Even if just for intellectual pursuit, I'd like to understand more about emotion, and perhaps someday, be able to identify how I feel, myself.

For the sake of relating to this article, I have had quite a few panic attacks in the past, but did not know what was happening to me until quite recently. In addition, I have tested 176 on the mensa I.Q. pretest. (I never followed through with official entry due to lack of activities in my area). I also scored high in testing when I was in grade school, after my unusual behavior was noted.

Milkmann October 8, 2010, 12:23 pm

For many years I have struggled with this and I’m glad to have found a name for what it is.

Ravi Uppal December 28, 2011, 12:47 pm

I think i suffer from Alexithymia , is their a way to cure it ,,,, if yes it would be a blessing in disguise for me

eija July 21, 2012, 3:03 am

now i understand why i do not react normally.i always thought im normal n other people who r weird.no wonder people would look at me n find me so mysterious.they always tell dat theydont know what im thinking when actually im not thinking of anything.whwnever i talk i could not spill wat in my mind.i tend 2 end up conversation quickly.prefer more 2 listen than talk.i could not identify why people feel this n that.i cant even talk 2 myself verbally.its much more easier 2 talk in my mind than using word.i hurt lots oof people bcoz of dis.i really love 2 be alone n i doont even use my phone or soocial websites.my dad the one who bought it n i have social websites so dat i can know wats going on recently.n i do have prob 2 find job dat fits my personality.coz i tend 2 hurt others

Eric September 12, 2017, 1:16 pm

Hey I suffer with anxiety and depression, and I still have some emotions that I can never explain to people even if they are close to me, however even going through life I feel emotionaless to alot of things including the loss of loved ones on the day of finding out about it, and even when I’m saposte to be happy at something I’ve done. It’s the fact of I’m sick to death of asking out emotions I don’t really feel to make other people happy. Do you have any advice?

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