(Quartz) The man whose medical condition limits him to two emotions: fear and anger
WRITTEN BY Emma Young May 30, 2018
Stephen has been married twice. Two wedding days. Two I dos. Yet Stephen has no happy memories from either—or, in fact, from the marriages or any of his relationships.
He met his first wife on a pre-nursing course when he was just 16. Six years later, they were married. Three years after that, they got divorced; she was never really the right one for him, he says. Almost two decades on, in 2009, he met his second wife through a dating site. He threw himself into the relationship and, the following year, with his father and her two adult siblings present, they married at the registrar’s office in Sheffield, where they both live.
He put on smiles for the wedding photos because he recognized that they were expected but, as he explains: “From an inner feeling point of view, anything I do that requires an emotional response feels like a fake. Most of my responses are learned responses. In an environment where everyone is being jolly and happy, it feels like I’m lying. Acting. Which I am. So it is a lie.”
Happiness isn’t the only emotion that Stephen struggles with. Excitement, shame, disgust, anticipation, even love… he doesn’t feel these, either. “I feel something but I’m unable to distinguish in any real way what that feeling is.” The only emotions he is familiar with are fear and anger.
Such profound problems with emotion are sometimes associated with autism, which Stephen does not have, or with psychopathy, which he doesn’t have, either. Last year, at the age of 51, he finally learned what he does have: a little-known condition called alexithymia, a word made from Greek parts meaning, roughly, “no words for emotion”.
Despite the name, the real problem for people with alexithymia isn’t so much that they have no words for their emotions, but that they lack the emotions themselves. Still, not everyone with the condition has the same experiences. Some have gaps and distortions in the typical emotional repertoire. Some realize they’re feeling an emotion, but don’t know which, while others confuse signs of certain emotions for something else—perhaps interpreting butterflies in the stomach as hunger pangs.
Surprisingly, given how generally unrecognized it is, studies show that about one in 10 people fall on the alexithymia spectrum. New research is now revealing what’s going wrong—and this work holds the promise not only of novel treatments for disorders of emotion, but of revealing just how the rest of us feel anything at all.
* * *
After working as a nurse for ten years, Stephen decided he wanted to do something different. A two-year Access to University course led to a degree in astronomy and physics, and then to a job testing computer games. He built a successful career for himself, working for various companies in their computer testing departments, managing teams, and travelling around the world to speak at conferences. He had no problem conveying facts to colleagues. It was in the context of more personal relationships—or any other scenario that would typically involve expressions of emotion—that he felt things were “wrong”.
“It’s not real. It seems fake. Because it is fake. And you can only pretend for so long.” “At the beginning of a relationship, I’m totally into who that person is,” he explains. “I’ve been told I’m very good at maintaining a honeymoon period for ‘longer than expected’.But after a year it takes a massive turn. It all falls apart. I’ve put myself on a pedestal to be this person which I’m really not. I react mostly cognitively, rather than it being emotions making me react. Obviously, that is not valid. It’s not real. It seems fake. Because it is fake. And you can only pretend for so long.”
He and his current wife stopped living together in 2012. He saw a GP and was prescribed antidepressants. Though he was still in contact with his wife, it was clear that the relationship was no longer working. In June 2015, he attempted suicide. “I had actually been posting on Facebook and Twitter regarding killing myself, and someone—I’ve never found out who—contacted the police. I was taken to hospital and treated.”
A psychiatrist referred Stephen for a series of counselling sessions and then a course of psychodynamic psychotherapy, a type of Freudian-based therapy that, in trying to uncover unconscious drivers of thoughts and behavior, is similar to psychoanalysis.
It was in a book called Why Love Matters by Sue Gerhardt, which his therapist recommended, that he first came across the concept of alexithymia. “I brought it up in therapy, and that’s when we started talking about how I was very alexithymic. Obviously, I’ve got a vocabulary. I’ve got words for emotions. But whether they’re the right words for the right emotion is a different point altogether… I just thought that I wasn’t good at talking about how I feel and emotions and stuff like that. But after a year of therapy, it became apparent that when I talk about emotions I don’t actually know what I’m talking about.”
The term “alexithymic” dates from a book published in 1972 and has its origins in Freudian psychodynamic literature. Freudian ideas are now out of favor with most academic psychologists, as Geoff Bird, a professor of psychology at the University of Oxford explains. “Not to disrespect those traditions, but in the cognitive, neuro, experimental field, not so many people are really very interested in anything associated with Freud any more.”
But when Bird read about alexithymia, he found the descriptions intriguing. “Actually, it’s really quite amazing.” For most people, “at a low level of emotion, you might be a bit unsure about exactly what you’re feeling, but if you have a strong emotion, you know what it is”. And yet somehow, here were people who simply did not know.
* * *
Bird started his academic career studying autism spectrum disorder, empathy and emotional awareness, which led to his interest in alexithymia. In one of his first studies in this field, he linked alexithymia, as measured with a 20-item checklist developed at the University of Toronto, with a lack of empathy. If you can’t feel your own emotions in the typical way, it makes sense that you can’t identify with those of others, either.
But what really drew Bird into alexithymia research were his interactions with people with autism. “There has been this perception that people with autism don’t have empathy. And that’s rubbish. And you can see that immediately as soon as you meet some autistic people.”
In a series of studies, Bird has found that about half of people with autism have alexithymia—it’s these people who struggle with emotion and empathy, while the rest do not. In other words, emotion-related difficulties are intrinsic to the alexithymia, not to the autism.
Bird is passionate about spreading this message. He talks with feeling about one particular autistic study volunteer who did not have alexithymia: “A lovely guy with an IQ we couldn’t measure, it’s that good. He couldn’t hold down a job. But he volunteered to work at a care home because he wanted to do something productive with his time. They said, ‘Oh because you’ve got a diagnosis of autism you can’t do empathy, therefore you can’t look after our elderly people.’ Which is just ridiculous.”
Bird has since run a series of studies exploring alexithymia outside the context of autism. He has found, for example, that people with the condition have no trouble recognizing faces, or distinguishing pictures of people smiling and frowning. “But for a few of our really alexithymic people, while they can tell a smile and a frown apart, they have no idea what they are. That is really quite strange.”
Many of the people with the condition who Bird has met talk about being told by other people that they’re different, though some do recognize it in themselves early on. “I guess it’s a bit like not being able to see color, and everybody’s always banging on about how red this is or how blue, and you come to realize there’s an aspect of human experience that you’re just not participating in.”
As well as better characterizing alexithymia, Bird and his colleagues have also dug into what explains it, taking what could seem to be a circular argument—Stephen has problems with emotion because he has alexithymia, which is characterized by problems with emotion—and blowing it right apart.
* * *
In situations that Stephen recognizes as being in theory highly emotional—like telling someone “I love you”—he experiences changes inside his body. “I feel my heart race and this rush of adrenaline, but to me that feeling is always scary. I don’t know how to react. It makes me want to either run away or react verbally aggressively.”
Fear and anger—and confusion—he understands. “Everything else just feels all the same… it’s this feeling of, ‘Errrr, I’m not quite comfortable with this—it’s not quite right.’”
For Rebecca Brewer, a former student of Bird’s and now a lecturer at Royal Holloway, University of London, this makes sense. “With alexithymia, people often know that they are experiencing an emotion but don’t know which emotion it is,” she explains. “This means they could still experience depression, possibly because they struggle to differentiate between different negative emotions, and struggle to identify [positive] emotions. Similarly with anxiety, it might be that someone experiences an emotional response associated with a fast heartbeat—which might be excitement—but they don’t know how to interpret that, and they could panic about what’s happening in their body.”
The ability to detect changes inside the body—everything from a racing heart to a diversion of blood flow, from a full bladder to a distension of the lungs—is known as interoception. It’s your perception of your own internal state.
Different emotions are associated with different physical changes. In anger, for example, the heart rate rises, blood rushes to the face, and fists clench. In fear, the heart rate also rises but blood drains from the face. It’s generally thought that these changes are not entirely specific to individual emotions, and so context is also important: if you feel your heart racing and you’re looking at a spider, you know it’s fear that you’re feeling, not sexual arousal.
What Bird, Brewer and others have found in people with alexithymia is a reduced ability, sometimes a complete inability, to produce, detect or interpret these internal bodily changes. People with the condition have normal-range IQs. They can understand as well as anyone else that they’re seeing a spider, rather than an attractive potential partner. But either their brains aren’t triggering the physical changes that it seems are needed for the experience of an emotion, or other regions of their brains aren’t reading these signals properly.
In 2016, Bird and Brewer, along with Richard Cook at City University in London, published a research paper that characterized alexithymia as a “generalized deficit of interoception”. Here, then, was an explanation for these people’s problems with emotion—but also, in effect, a manifesto stating that the perception of a range of bodily signals is important for the experience of emotion in the rest of us.
It’s an idea that we already express in everyday language: in English, for an apology to mean anything, it has to be “heartfelt”. If you truly love someone, it’s with “all your heart”. When you’re really angry, your “blood boils”. Instead of saying that you’re anxious, you might talk about having “butterflies in your stomach” (thought to be caused by a diversion of blood flow away from the digestive system).
While most people may not be familiar with alexithymia, there is a different disorder involving flat emotions and poor empathy that seems to fascinate us, even more than it repels us: psychopathy. Can we learn more about how we feel by understanding psychopaths?