Defining alexithymia: The clinical relevance of cognitive behavioral vs psychoanalytic conceptualizations

Alexithymia is widely seen as a risk factor for psychopathology, and is thus of high clinical interest. However, there is ongoing debate about the definition of alexithymia, much of which focuses on its externally oriented thinking (EOT) facet. Cognitive behavioral conceptualizations (i.e., the attention-appraisal model) define EOT in a manner specific to emotion processing, as difficulties focusing attention on emotions. Psychoanalytic conceptualizations define EOT more broadly, including difficulties attending to emotions, but also a tendency towards utilitarian thinking focused on the concrete details of the external world, which is closely linked with a reduced capacity for daydreaming. In this paper, across two studies (Ns = 508; 595), we examine the clinical relevance of both EOT conceptualizations via the strength of their associations with a range of clinical symptoms: depression, anxiety, stress, somatic symptoms, alcohol use problems, post-traumatic stress disorder, eating disorder symptoms, dissociation, and obsessive-compulsive disorder. Cognitive behavioral EOT was operationalised using the Perth Alexithymia Questionnaire and psychoanalytic EOT with the Toronto Alexithymia Scale-20. Across both studies, the cognitive behavioral conceptualization consistently demonstrated stronger relationships with clinical symptoms and explained more variance in regression models. Overall, our findings support the cognitive behavioral conceptualization of EOT, which shows higher clinical relevance.