How accurate is medicine in medical dramas and literary fiction? As you can assume, probably not too accurate since medical details can often be added for drama in literary fiction, but sometimes they do exist. In Won-Pyung Sohn’s novel, Almond, the main character has a medical condition called “alexithymia”, and upon further research, it turns out this is a real medical condition!

Alexithymia is a psychological condition where a person cannot identify and describe their feelings and emotions [1].  People with this condition have dysfunctional emotional processing, limited imagery, and problems communicating with others. Aside from their feelings, they cannot understand the emotional states of other people [1]. 

To better understand the mechanism of alexithymia, Yoshiya Moriguchi and Gen Komaki conducted a systematic study that attempts to make a connection between alexithymia and brain regions by analyzing neuroimaging done on alexithymia patients. They found that patients have increased activity in the anterior cingulate cortex (ACC) and the pain matrix of the brain, but have decreased activity in the medial prefrontal cortex (mPFC), anterior insula (AI), posterior cingulate cortex, and the left insula. The different levels of activity are consistent with brain regions that have to do with emotional processing and physical processing. This means that alexithymia patients are particularly sensitive to physical stimuli but are insensitive to emotional stimuli.

Before diving into the studies analyzed, it is important to get a quick overview of some of the different imaging techniques and tests conducted. Due to the high level of details provided, positron emission tomography (PET) scans and functional magnetic resonance imaging (fMRI) are commonly used in psychiatric studies. Both of these imaging techniques measure brain activity, but the method is slightly different. PET scans use an intravenous (IV) radioactive tracer [2], while fMRIs use the changes of the blood flow in the brain [3]. The Levels of Emotional Awareness (LEAS) is a common test done on patients suspected with alexithymia, which assesses a person’s ability of awareness of their own emotion [4]. In general, those who scored high on the LEAS have high emotional awareness. The International Affective Picture System (IAPS) provides ratings of emotion for photographs meant to elicit emotional stimuli for experiments [5]. 

A 1998 study on patients without alexithymia showed high neural responses in the anterior cingulate cortex (ACC) that positively correlated with their scores on the LEAS [6, 7]. Participants watched emotional films while researchers collected brain imaging via PET scans. The ACC is involved in attention and response selection, and this study suggests that it plays a role in emotional awareness, which is something that is not seen in patients with alexithymia [1]. 

Other studies using the IAPS found decreased brain activation in the medial prefrontal cortex (mPFC) and the anterior insula (AI) [8, 9]. It is known that the ACC, mPFC, and AI form a network that works cooperatively in tasks related to self-recognition (Figure 1) [10, 11]. Thus, it can be assumed that the dysfunction in these three brain regions causes the impaired recognition of emotional states among alexithymia patients. 

Figure 1. Cross-section of the brain showing the ACC, mPFC, and AI [12].

Alexithymia patients have a limited ability to fantasize. One study that tried to focus on their ability to fantasize found reduced activation in the posterior cingulate cortex when patients were asked to picture a happy emotion (Figure 2) [13]. It showed they have a reduced self-originating brain function. In other words, their brains cannot come up with fantasized situations relating to emotions. But, when patients were put under physical stimuli, as opposed to emotional stimuli in the previous study, their brains showed increased activity in areas associated with somatosensory and sensorimotor areas. These brain regions are associated with sensory and motor functions. This means that alexithymia patients are more sensitive to physical stimuli. A 2007 study found increased activation in areas of physical processing when the researchers inserted a balloon inflator into alexithymia patients’ colons and conducted PET scans [14]. Also, when shown pictures depicting painful stimulation, there was increased activation in the somatosensory cortex, insula, and ACC, which is known as the “pain matrix” of the brain [15]. It was as if the patients themselves were receiving the painful stimulation.

Alexithymia patients also have difficulty communicating with others. A 1987 study had alexithymia patients guess the mental states of triangles that were animated like human beings [16]. The fMRI showed low activation in the mPFC, which, as mentioned earlier, is involved with self-recognition as well as recognizing the mental states of others. In another study in 2010, when patients were told that someone close to them is in pain, researchers found decreased activity in the left insula, which is involved in empathy [17]. Their decreased activation of the mPFC and the left insula suggests that they have an impaired ability to understand and empathize with other people, leading to difficulty in communication. 

Now, Almond’s depiction of alexithymia is not the same. For the sake of minimizing spoilers for the curious, the main character’s alexithymia is due to a small amygdala. It does match with a study that used a “backward-masking technique,” finding low amygdala activation in alexithymia patients [18].  Almond isn’t completely off the mark about alexithymia, but the actual condition is a lot more complex than what the book presents.

References

1. Moriguchi M. & Komaki G. (2013). Neuroimaging studies of alexithymia: physical, affective, and social perspectives. BioPsychoSocial Medicine, 7, 8. 
2. Positron emission tomography scan. Mayo Clinic. Last edited August 10, 2021.
3. Magnetic Resonance, Functional  (fMRI) – Brain. Radiology Info. 
4. The Levels of Emotional Awareness Scale. eLEAS, The University of Arizona.
5. Bradley MM & Lang PJ. IAPS Message. The Center for the Study of Emotion and Attention, University of Florida.
6. Lane, RD, Reiman, EM, Axelrod, B., et. al. (1998). Neural correlates of levels of emotional awareness. Evidence of an interaction between emotion and attention in the anterior cingulate cortex. Journal of Cognitive Neuroscience, 10(4), 525–535. 
7. Lane, RD, Quinlan, DM, Schwartz, GE, et. al. (1990). The Levels of Emotional Awareness Scale: a cognitive-developmental measure of emotion. Journal of Personality Assessment, 55(1-2), 124–134.
8. Berthoz, S., Artiges, E., Van De Moortele, P.F, et. al. (2002). Effect of impaired recognition and expression of emotions on frontocingulate cortices: an fMRI study of men with alexithymia. The American Journal of Psychiatry, 159(6), 961–967. 
9. Kano, M., Fukudo, S., Gyoba, J., et. al. (2003). Specific brain processing of facial expressions in people with alexithymia: an H2 15O-PET study. Brain: A Journal of Neurology, 126(Pt 6), 1474–1484.
10. Craig AD. (2009). Emotional moments across time: a possible neural basis for time perception in the anterior insula. Philosophical Transactions of the Royal Society of London. Series B, Biological Sciences, 364(1525), 1933–1942. 
11. Craig AD. (2009). How do you feel — now? The anterior insula and human awareness. Nature Reviews Neuroscience, 10, 59-70.
12. Henshilwood, CS. (2011). The Still Bay and Howiesons Poort, 77-59 ka: Symbolic Material Culture and the Evolution of the Mind During the African Middle Stone Age. Current Anthropology, 52(3), 361-400.
13. Mantani, T., Okamoto, Y., Shirao, N., et. al. (2005). Reduced activation of posterior cingulate cortex during imagery in subjects with high degrees of alexithymia: a functional magnetic resonance imaging study. Biological Psychiatry, 57(9), 982–990. 
14. Kano, M., Hamaguchi, T., Itoh, M., et. al. (2007). Correlation between alexithymia and hypersensitivity to visceral stimulation in human. Pain, 132(3), 252–263. 
15. Moriguchi, Y., Decety, J., Ohnishi, T., et. al. (2007). Empathy and judging other’s pain: an fMRI study of alexithymia. Cerebral Cortex (New York, N.Y.: 1991), 17(9), 2223–2234. 
16. Lane, RD & Schwartz, GE. (1987). Levels of emotional awareness: a cognitive-developmental theory and its application to psychopathology. The American Journal of Psychiatry, 144(2), 133–143. 
17. Bird G., Silani G., Brindley R., et. al. (2010) Empathic brain responses in insula are modulated by levels of alexithymia but not autism. Brain, 133(5), 1515-1525.
18. Kugel, H., Eichmann, M., Dannlowski, U., et. al. (2008). Alexithymic features and automatic amygdala reactivity to facial emotion. Neuroscience Letters, 435(1), 40–44.