Alexithymia, Cumulative Feedback, and Differential Response Patterns on the Iowa Gambling Task

The process of emotion identification: Considerations for psychiatric disorders

Emotional regulation is important for mental health and behavioral regulation. A relevant precursor to emotional regulation may involve identification of one's emotions. Here, we propose a model of seven components that may provide a foundation for emotion identification. These factors include baseline mood, monitoring, physiological responses, interoception, past personal experiences regarding emotions/metacognition, context, and labeling. We additionally examine how deficits in different components may contribute to the concept of alexithymia, which is defined by difficulty identifying and describing one's own emotions. Ultimately, we explore how the model may support a relationship between specific psychiatric disorders and alexithymia. The proposed model may help explain emotional identification impairment in multiple psychiatric disorders and guide future research and treatment development efforts.

Atypical interoception as a common risk factor for psychopathology: A review

The inadequacy of a categorial approach to mental health diagnosis is now well-recognised, with many authors, diagnostic manuals and funding bodies advocating a dimensional, trans-diagnostic approach to mental health research. Variance in interoception, the ability to perceive one's internal bodily state, is reported across diagnostic boundaries, and is associated with atypical functioning across symptom categories. Drawing on behavioural and neuroscientific evidence, we outline current research on the contribution of interoception to numerous cognitive and affective abilities (in both typical and clinical populations), and describe the interoceptive atypicalities seen in a range of psychiatric conditions. We discuss the role that interoception may play in the development and maintenance of psychopathology, as well as the ways in which interoception may differ across clinical presentations. A number of important areas for further research on the role of interoception in psychopathology are highlighted.

The Agony of Choice? Preserved Affective Decision Making in Early Multiple Sclerosis

Background: Cognitive impairment (CI) is an early and frequent symptom of multiple sclerosis (MS). Likewise, affective symptoms (e.g., depression and anxiety) and alterations in the processing of emotional stimuli have been frequently reported. Thus, abilities that integrate affective and cognitive processes such as decision making (DM) based on affective feedback are potentially valuable early diagnostic markers for MS. The available research on this topic, however, is still inconclusive and suffers from methodological issues. Methods: We compared DM ability in a clinically homogeneous cohort of 24 patients with early relapsing-remitting MS (RRMS) and 59 age-matched healthy controls (HCs). A modified version of the Iowa gambling task (IGT) allowed us to control for individual differences in search strategies during the risk exploration phase. Besides standard IGT measures (netscore, obtained play money, and learning index), we also examined reaction times and post-error slowing (PES) patterns as a proxy for abnormalities in the processing of affective feedback. Results: The performance of patients did not significantly deviate from HCs in any standard parameter of the modified IGT. Furthermore, although RRMS patients reacted significantly slower than HCs overall, we found similar patterns of PES in both groups, suggesting similarly efficient processing of affective feedback. Conclusion: We conclude that there is no specific deficit in affective feedback processing in early RRMS. Previous findings of IGT impairments in this patient group may thus not represent a genuine deficit in affective DM but rather be related to sample characteristics, general CI, and/or differences in individual search strategies. Future research should explore the potential influence of lesion volumes and locations on DM ability by employing brain imaging techniques.

Aberrant reward prediction error during Pavlovian appetitive learning in alexithymia

Extensive literature shows that alexithymia, a subclinical trait defined by difficulties in identifying and describing feelings, is characterized by multifaceted impairments in processing emotional stimuli. Nevertheless, its underlying mechanisms remain elusive. Here, we hypothesize that alexithymia may be characterized by an alteration in learning the emotional value of encountered stimuli and test this by assessing differences between individuals with low (LA) and high (HA) levels of alexithymia in the computation of reward prediction errors (RPEs) during Pavlovian appetitive conditioning. As a marker of RPE, the amplitude of the feedback-related negativity (FRN) event-related potential was assessed while participants were presented with two conditioned stimuli (CS) associated with expected or unexpected feedback, indicating delivery of reward or no-reward. No-reward (vs reward) feedback elicited the FRN both in LA and HA. However, unexpected (vs expected) feedback enhanced the FRN in LA but not in HA, indicating impaired computation of RPE in HA. Thus, although HA show preserved sensitivity to rewards, they cannot use this response to update the value of CS that predict them. This impairment may hinder the construction of internal representations of emotional stimuli, leaving individuals with alexithymia unable to effectively recognize, respond and regulate their response to emotional stimuli.

An experimental investigation of the role of delay discounting and craving in gambling chasing behavior

Chasing is a central feature of gambling disorder and refers to the attempt by individuals to recover financial losses by continuing to gamble. Although several efforts have been made to individuate the factors involved in the complex phenomenon of chasing, little is known regarding its association with delay discounting and craving, both considered important in the development and maintenance of gambling disorder. In the present study, the interplay between chasing, delay discounting, and craving (while controlling for gambling severity) was investigated. The sample comprised 128 adult gamblers aged between 18 and 67 years and consisted of non-problem gamblers (n = 58), problem gamblers (n = 18), and pathological gamblers (n = 52) based on the South Oaks Gambling Screen (SOGS) scores. Participants were administered the Monetary Choice Questionnaire (MCQ) and the Gambling Craving Scale (GACS), as well as completing the ChasIT, a computerized task assessing chasing behavior. Participants were randomly assigned to the control and the loss condition of the ChasIT. Results showed that pathological gamblers were more likely to chase and reported more severe chasing persistence. Regression analyses indicated that heightened levels of craving and the inability to tolerate delay in gratification, along with gambling severity, predicted both the decision to chase and chasing persistence. The present study contributes important findings to the gambling literature, highlighting the role of craving and delay discounting in facilitating the inability to stop within-sessions gambling. These findings may provide evidence that chasers and non-chasers represent two different types of gamblers, and that the difference may be useful for targeting more effective therapies.

Does emotion matter? The role of alexithymia in violent recidivism: A systematic literature review

BACKGROUND

Several variables have been evidenced for their association with violent reoffending. Resultant interventions have been suggested, yet the rate of recidivism remains high. Alexithymia, characterised by deficits in emotion processing and verbal expression, might interact with these other risk factors to affect outcomes.

AIM

Our goal was to examine the role of alexithymia as a possible moderator of risk factors for violent offender recidivism. Our hypothesis was that, albeit with other risk factors, alexithymia increases the risk of violent reoffending.

METHOD

We conducted a systematic literature review, using terms for alexithymia and violent offending and their intersection.

RESULTS

(a) No study that directly tests the role of alexithymia in conjunction with other potential risk factors for recidivism and actual violent recidivism was uncovered. (b) Primarily alexithymia researchers and primarily researchers into violence have separately found several clinical features in common between aspects of alexithymia and violence, such as impulsivity (total n = 24 studies). (c) Other researchers have established a relationship between alexithymia and both dynamic and static risk factors for violent recidivism (n = 16 studies).

CONCLUSION

Alexithymia may be a possible moderator of risk of violent offence recidivism. Supplementing offenders' rehabilitation efforts with assessments of alexithymia may assist in designing individually tailored interventions to promote desistance among violent offenders.

Alexithymia and the Reduced Ability to Represent the Value of Aversively Motivated Actions

Alexithymia is a subclinical trait defined by difficulties in identifying and describing feelings and a cognitive style avoidant of introspection. Extensive literature shows that alexithymia is characterized by multifaceted impairments in processing emotional stimuli. Nevertheless, the mechanisms that may account for such impairments remain elusive. Here, we hypothesize that alexithymia may be understood as impairment in learning the emotional value of one’s own actions and test this comparing performance of participants with high (HA) and low (LA) levels of alexithymia on a probabilistic selection task. Results show that, compared to LA, HA need more time to learn the value of individual stimuli and associated actions as difference in reinforcement rate between stimuli decreases. In addition, HA appear less able to generalize the value of previously learned actions that lead to a negative outcome, to make adaptive choices in a new context, requiring more time to avoid the most negative stimulus between two negative stimuli. Together, the results indicate that individuals with alexithymia show impaired learning of the value of aversively motivated actions. We argue that this impairment may hinder the construction of internal representations of emotional stimuli and actions and represent a mechanism that may account for the difficulties of alexithymia in processing emotional stimuli.

On the Processes Underlying the Relationship Between Alexithymia and Gambling Severity

A great number of individuals with persistent problematic gambling behavior exhibit alexithymic tendencies, greater impulsivity, impaired working memory and poor mood. However, the relationship between these cognitive, affective and personality factors in problem gambling remains poorly understood. Our aim was to investigate multiple pathways of the alexithymia and problem gambling relationship. One hundred and six male subjects with different levels of gambling problem severity were recruited. Alexithymia, impulsivity and verbal working memory were evaluated, and their relationships to disordered gambling was examined by means of a path analysis. Results indicate that alexithymia is related to an increase in the severity of gambling indirectly, i.e., through distress severity. In addition, a rise of alexithymic tendencies was also associated with problem gambling severity through enhanced impulsivity that directly increased distress. Working memory capacity failed to significantly impact our path model. Overall, our findings contribute a new finding to the literature by highlighting the importance of alexithymia, in addition to impulsivity, in the understanding of gambling problem severity and its clinical course.

Language and alexithymia: Evidence for the role of the inferior frontal gyrus in acquired alexithymia

The clinical relevance of alexithymia, a condition associated with difficulties identifying and describing one's own emotion, is becoming ever more apparent. Increased rates of alexithymia are observed in multiple psychiatric conditions, and also in neurological conditions resulting from both organic and traumatic brain injury. The presence of alexithymia in these conditions predicts poorer regulation of one's emotions, decreased treatment response, and increased burden on carers. While clinically important, the aetiology of alexithymia is still a matter of debate, with several authors arguing for multiple 'routes' to impaired understanding of one's own emotions, which may or may not result in distinct subtypes of alexithymia. While previous studies support the role of impaired interoception (perceiving bodily states) in the development of alexithymia, the current study assessed whether acquired language impairment following traumatic brain injury, and damage to language regions, may also be associated with an increased risk of alexithymia. Within a sample of 129 participants with penetrating brain injury and 33 healthy controls, neuropsychological testing revealed that deficits in a non-emotional language task, object naming, were associated with alexithymia, specifically with difficulty identifying one's own emotions. Both region-of-interest and whole-brain lesion analyses revealed that damage to language regions in the inferior frontal gyrus was associated with the presence of both this language impairment and alexithymia. These results are consistent with a framework for acquired alexithymia that incorporates both interoceptive and language processes, and support the idea that brain injury may result in alexithymia via impairment in any one of a number of more basic processes.

Alexithymia predicts loss chasing for people at risk for problem gambling

Background and aims The aim of this research was to investigate the relationship between alexithymia and loss-chasing behavior in people at risk and not at risk for problem gambling. Methods An opportunity sample of 58 (50 males and 8 females) participants completed the Problem Gambling Severity Index and the Toronto Alexithymia Scale (TAS-20). They then completed the Cambridge Gambling Task from which a measure of loss-chasing behavior was derived. Results Alexithymia and problem gambling risk were significantly positively correlated. Subgroups of non-alexithymic and at or near caseness for alexithymia by low risk and at risk for problem gambling were identified. The results show a clear difference for loss-chasing behavior for the two alexithymia conditions, but there was no evidence that low and at-risk problem gamblers were more likely to loss chase. The emotion-processing components of the TAS-20 were shown to correlate with loss chasing. Discussion and conclusion These findings suggest that loss-chasing behavior may be particularly prevalent in a subgroup of problem gamblers those who are high in alexithymia.

Now or not-now? The influence of alexithymia on intertemporal decision-making

Optimal intertemporal decisions arise from the balance between an emotional-visceral component, signaling the need for immediate gratification, and a rational, long-term oriented component. Alexithymia, a personality construct characterized by amplified sensitivity to internal bodily signals of arousal, may result in enhanced activation of the emotional-visceral component over the cognitive-rational one. To test this hypothesis, participants with high- and low-alexithymia level were compared at an intertemporal decision-making task, and their choice behavior correlated with their interoceptive sensitivity. We show that high-alexithymic tend to behave more impatiently than low-alexithymic in intertemporal decisions, particularly when the sooner reward is immediately available. Moreover, the greater their sensitivity to their own visceral sensations, the greater the impatience. Together, these results suggest a disproportionate valuation of reward available immediately in high alexithymia, possibly reflecting heightened perception of bodily physiological signals, which ultimately would bias their intertemporal decision-making.

Associations between sheep farmer attitudes, beliefs, emotions and personality, and their barriers to uptake of best practice: The example of footrot

There is interest in understanding how farmers' behaviour influences their management of livestock. We extend the theory of planned behaviour with farmers attitudes, beliefs, emotions and personality to investigate how these are associated with management of livestock disease using the example of footrot (FR) in sheep. In May 2013 a one-year retrospective questionnaire was sent to 4000 sheep farmers in England, requesting data on lameness prevalence, management of footrot, farm/flock descriptors, and farmer-orientated themes: barriers to treating footrot, opinions and knowledge of footrot, relating to other people and personality. Principal component analysis (PCA) was used to make composite variables from explanatory variables and latent class (LC) analysis was used to subgroup farmers, based on nine managements of FR. Associations between LC and composite variables were investigated using multinomial logistic regression. Negative binomial regression was used to investigate associations between the proportion of lame sheep and composite and personality variables. The useable response rate was 32% and 97% of farmers reported having lame sheep; the geometric mean prevalence of lameness (GMPL) was 3.7% (95% CI 3.51%-3.86%). Participants grouped into three latent classes; LC1 (best practice-treat FR within 3days of sheep becoming lame; use injectable and topical antibiotics; avoid foot trimming), 11% farmers), LC2 (slow to act, 57%) and LC3 (slow to act, delayed culling, 32%), with GMPL 2.95%, 3.60% and 4.10% respectively. Farmers who reported the production cycle as a barrier to treating sheep with FR were more likely to be in LC2 (RRR 1.36) than LC1. Negative emotions towards FR were associated with higher risk of being in LC2 (RRR 1.39) than LC1. Knowledge of preventing FR spread was associated with a lower risk of being in LC2 (RRR 0.46) or LC3 (RRR 0.34) than LC1. Knowledge about FR transmission was associated with a lower risk of being in LC3 (RRR 0.64) than LC1. An increased risk of lameness was associated with the production cycle being a barrier to treating sheep with FR (IRR 1.13), negative emotions towards FR (IRR 1.13) and feelings of hopelessness towards FR (IRR 1.20). Conscientiousness (IRR 0.95) and understanding the importance of active control of lameness (IRR 0.76) were associated with reduced risk of lameness. We conclude that emotions and personality are associated with differences in farmer management of FR and prevalence of lameness. Further understanding how personality and emotions influence change in behaviour is key to increasing uptake of new information.

Loss-Chasing, Alexithymia, and Impulsivity in a Gambling Task: Alexithymia as a Precursor to Loss-Chasing Behavior When Gambling

Objective: To examine the relationship between loss-chasing, the propensity to continue gambling to recover from losses, alexithymia, a personality trait associated poor emotional processing and impulsivity, the tendency to act quickly without reflection or consideration of the consequences.

Method: Two experiments are reported (E1: N = 60, Males, 11; Age, 21.6 years. E2: N = 49, Males, 22; Age, 21.1 years). In experiment 1, two groups (low alexithymia, high alexithymia) completed the Cambridge Gambling Task (CGT). Loss-chasing behavior was investigated. In experiment 2, both alexithymia (low, high) and impulsivity (low, high) were examined also using the CGT. A further change was the order of bet proportion from ascending to descending.

Results: Experiment 1 shows loss-chasing behavior in participants high in alexithymia but not those low in alexithymia (ηp2=0.09). Experiment 2 shows loss-chasing behavior in participants both low and high in alexithymia but it was greater for participants high in alexithymia (ηp2 = 0.09). The effect of impulsivity was not statistically significant (ηp2 = 0.01). Loss-chasing behavior was correlated with the emotional facets of alexithymia but not the cognitive facet.

Conclusions: Alexithymia is a precursor to loss-chasing when gambling and loss-chasing reflects the cognitive and emotional aspects of gambling. Specifically, the tendency to loss-chase depends on the need to recoup previous losses and failure to process the emotional consequences of those losses.

Interactions among attention-deficit hyperactivity disorder (ADHD) and problem gambling in a probabilistic reward-learning task

Problem gambling is thought to be highly comorbid with attention-deficit hyperactivity disorder (ADHD). We propose that the neurobiological pathologies underlying problem gambling overlap with those in ADHD. In this study, we used a simplified computerized version of the Iowa Gambling Task (IGT) to assess differences in reinforcement-driven choice adaptation among participants with pathological gambling and/or ADHD. The task contained two choice options with different net payouts over the session; a good bet that resulted in a win of +50 points on 60% of trials (and -50 points on 40%), and a bad bet that resulted in +100 points on 40% of the trials (and -100 points on 60%). We quantified participants' preference for the good bet over the session and their sensitivity to reinforcement. Both the control subjects and medicated ADHD nongamblers significantly increased the proportion of good bets over the 400-trial session. Subjects with problem gambling performed worse than controls and ADHD nongamblers, but better than our limited sample of unmedicated ADHD gamblers. Control subjects, medicated ADHD nongamblers, and unmedicated ADHD nongamblers tended to tolerate losses following good bets, whereas unmedicated ADHD gamblers tended to tolerate losses following bad bets. These data reveal that ADHD, particularly when treated with medication, is not associated with poor choices on the IGT, but may exacerbate pathological choices in problem gamblers. It seems that stabilization of dopamine signaling that occurs when ADHD is treated is itself also a treatment for certain forms of problem gambling.

Staying and shifting patterns across IGT trials distinguish children with externalizing disorders from controls

The Iowa Gambling Task (IGT) is the most widely instrument used in the assessment of affective decision-making in several populations with frontal impairment. The standard performance measure on the IGT is obtained by calculating the difference between the advantageous and the disadvantageous choices. This standard score does not allows the assessment of the use of different strategies to deal with contingencies of gain and losses across the task. This study aims to compare the standard score method used in IGT with a method that analyses the patterns of staying and shifting among different decks across the 100 choices, considering contingencies of choices with and without losses. We compared the IGT performance of 24 children with externalizing disorders (Attention Deficit Hyperactivity Disorder and Oppositional Defiant Disorder) and 24 healthy age-matched children. The analyses of the standard score across all blocks failed to show differences among children with externalizing disorders and control children. However, healthy children showed a pattern of shifting more from disadvantageous decks to advantageous decks and choosing more consecutive cards from the advantageous decks across all blocks, independently of the contingency of losses. On the other hand, children with externalizing disorders presented a pattern of shifting more from advantageous decks to disadvantageous ones in comparison to healthy children and repeatedly chose cards from the B deck across all blocks. This findings show that even though differences among groups might not be found when using the standard analyses, a different type of analysis might be able to show distinct strategies on the execution of the test.

Alexithymia associated with nightmare distress in idiopathic REM sleep behavior disorder

STUDY OBJECTIVES

Idiopathic REM sleep behavior disorder (iRBD) is characterized by atypical REM sleep motor activity, vivid dreams and nightmares, and dream-enacting behaviors that can result in injuries to the patient and bed partner. It is also a known predictor of Parkinson disease (PD). Alexithymia has been associated with disturbances in sleep and dreaming (e.g., nightmares) and is a non-motor symptom of PD. We assessed alexithymia and disturbed dreaming in iRBD patients with the aim of determining if these two factors are elevated and interrelated among this population.

DESIGN

Questionnaire study of clinically diagnosed patients.

SETTING

Clinical sleep disorders center.

PATIENTS OR PARTICIPANTS

Thirty-two iRBD patients and 30 healthy age- and sex-matched control participants.

MEASUREMENTS AND RESULTS

Participants completed the 20-item Toronto Alexithymia Scale (TAS-20), the Dream Questionnaire, and the Beck Depression Inventory. iRBD patients obtained higher TAS-20 total scores (62.16 ± 13.90) than did controls (52.84 ± 7.62; F 1,59 = 10.44, P < 0.01), even when controlling for depressive symptoms, and more frequently attained the suggested cutoff for alexithymia than did controls (P < 0.01). iRBD patients obtained higher scores on the Difficulty Identifying Feelings alexithymia subscale. For both iRBD and control groups, the Difficulty Indentifying Feelings subscale correlated positively with the Nightmare Distress scale of the Dream Questionnaire.

CONCLUSIONS

Elevated alexithymia scores among idiopathic rapid eye movement sleep behavior disorder patients, and especially a difficulty in identifying feelings, parallels evidence of dysautonomia in this population. The higher incidence of distressing nightmares and the association of nightmares with alexithymia further extend similar findings for both clinical and non-clinical samples and suggest that an affect regulation disturbance may be common to the two sets of symptoms.

Insula's functional connectivity with ventromedial prefrontal cortex mediates the impact of trait alexithymia on state tobacco craving

RATIONALE

Alexithymia is a personality trait characterized by difficulty indentifying and describing subjective emotional experiences. Decreased aptitude in the perception, evaluation, and communication of affectively laden mental states has been associated with reduced emotion regulation, more severe drug craving in addicts, and structural/functional alterations in insula and anterior cingulate cortex (ACC). The insula and ACC represent sites of convergence between the putative neural substrates of alexithymia and those perpetuating cigarette smoking.

OBJECTIVES

We examined the interrelations between alexithymia, tobacco craving, and insula/ACC neurocircuitry using resting-state functional connectivity (rsFC).

METHODS

Overnight-deprived smokers (n = 24) and nonsmokers (n = 20) completed six neuroimaging assessments on different days both in the absence of, and following, varenicline and/or nicotine administration. In this secondary analysis of data from a larger study, we assessed trait alexithymia and state tobacco craving using self-reports and examined the rsFC of bilateral insular subregions (anterior, middle, posterior) and dorsal ACC.

RESULTS

Higher alexithymia in smokers predicted reduced rsFC strength between the right anterior insula (aI) and ventromedial prefrontal cortex (vmPFC). Higher alexithymia also predicted more severe tobacco craving during nicotine withdrawal. Critically, the identified aI-vmPFC circuit fully mediated this alexithymia-craving relation. That is, elevated alexithymia predicted decreased aI-vmPFC rsFC and, in turn, decreased aI-vmPFC rsFC predicted increased craving during withdrawal. A moderated mediation analysis indicated that this aI-vmPFC mediational effect was not observed following drug administration.

CONCLUSIONS

These results suggest that a weakened right aI-vmPFC functional circuit confers increased liability for tobacco craving during smoking abstinence. Individual differences in alexithymia and/or aI-vmPFC functional coupling may be relevant factors for smoking cessation success.

Health specific traits beyond the Five Factor Model, cognitive processes and trait expression: replies to Watson (2012), Matthews (2012) and Haslam, Jetten, Reynolds, and Reicher (2012)

In this article we reply to the issues raised by the three commentaries on Ferguson's (2012) article. Watson argues that the four traits identified by Ferguson (2012) – health anxiety, alexithymia, empathy and Type D – do not lie outside the Five Factor Model (FFM). We present factor analytic data showing that health anxiety forms a separate factor from positive and negative affectivity, alexithymia forms a factor outside the FFM and while emotional empathy loads with agreeableness, cognitive empathy forms a separate factor outside the FFM. Across these analyses there was no evidence for a general factor of personality. We also show that health anxiety, empathic facets and alexithymia show incremental validity over FFM traits. However, the evidence that Type D lies outside the FFM is less clear. Matthews (2012) argues that traits have a more distributed influence on cognitions and that attention is not part of Ferguson's framework. We agree; but Ferguson's original statement concerned where traits have their maximal effect. Finally, Haslam et al. suggest that traits should be viewed from a dynamic interactionist perspective. This is in fact what Ferguson (2012) suggested and we go on to highlight that traits can also influence group processes.

Personality is of central concern to understand health: towards a theoretical model for health psychology

This paper sets out the case that personality traits are central to health psychology. To achieve this, three aims need to be addressed. First, it is necessary to show that personality influences a broad range of health outcomes and mechanisms. Second, the simple descriptive account of Aim 1 is not sufficient, and a theoretical specification needs to be developed to explain the personality-health link and allow for future hypothesis generation. Third, once Aims 1 and 2 are met, it is necessary to demonstrate the clinical utility of personality. In this review I make the case that all three Aims are met. I develop a theoretical framework to understand the links between personality and health drawing on current theorising in the biology, evolution, and neuroscience of personality. I identify traits (i.e., alexithymia, Type D, hypochondriasis, and empathy) that are of particular concern to health psychology and set these within evolutionary cost-benefit analysis. The literature is reviewed within a three-level hierarchical model (individual, group, and organisational) and it is argued that health psychology needs to move from its traditional focus on the individual level to engage group and organisational levels.

The alexithymic brain: the neural pathways linking alexithymia to physical disorders

Alexithymia is a personality trait characterized by difficulties in identifying and describing feelings and is associated with psychiatric and psychosomatic disorders. The mechanisms underlying the link between emotional dysregulation and psychosomatic disorders are unclear. Recent progress in neuroimaging has provided important information regarding emotional experience in alexithymia. We have conducted three brain imaging studies on alexithymia, which we describe herein. This article considers the role of emotion in the development of physical symptoms and discusses a possible pathway that we have identified in our neuroimaging studies linking alexithymia with psychosomatic disorders. In terms of socio-affective processing, alexithymics demonstrate lower reactivity in brain regions associated with emotion. Many studies have reported reduced activation in limbic areas (e.g., cingulate cortex, anterior insula, amygdala) and the prefrontal cortex when alexithymics attempt to feel other people's feelings or retrieve their own emotional episodes, compared to nonalexithymics. With respect to primitive emotional reactions such as the response to pain, alexithymics show amplified activity in areas considered to be involved in physical sensation. In addition to greater hormonal arousal responses in alexithymics during visceral pain, increased activity has been reported in the insula, anterior cingulate cortex, and midbrain. Moreover, in complex social situations, alexithymics may not be able to use feelings to guide their behavior appropriately. The Iowa gambling task (IGT) was developed to assess decision-making processes based on emotion-guided evaluation. When alexithymics perform the IGT, they fail to learn an advantageous decision-making strategy and show reduced activity in the medial prefrontal cortex, a key area for successful performance of the IGT, and increased activity in the caudate, a region associated with impulsive choice. The neural machinery in alexithymia is therefore activated more on the physiologic, motor-expressive level and less in the cognitive-experiential domains of the emotional response system. Affects may play an important role in alleviating intrinsic physiologic reactions and adapting to the environment. Deficient development of emotional neural structures may lead to hypersensitivity to bodily sensations and unhealthy behaviors, a possible mechanism linking alexithymia to psychosomatic disorders.