Affective agnosia: Expansion of the alexithymia construct and a new opportunity to integrate and extend Freud's legacy

Highlights

• Affective agnosia: an impairment in mentally representing emotional states.

• Addresses current limitations in the theory and measurement of alexithymia.

• Neural models of emotional awareness and affective agnosia are presented.

• Has important implications for basic science research and clinical treatment.

Abstract

We describe a new type of agnosia consisting of an impairment in the ability to mentally represent or know what one is feeling. Freud the neurologist coined the term “agnosia” in 1891 before creating psychoanalysis in 1895 but the term has not been previously applied to the domain of affective processing. We propose that the concept of “affective agnosia” advances the theory, measurement and treatment of what is now called “alexithymia,” meaning “lack of words for emotion.” We trace the origin of the alexithymia construct and discuss the strengths and limitations of extant research. We review evidence that the ability to represent and put emotions into words is a developmental achievement that strongly influences one's ability to experience, recognize, understand and use one's own emotional responses. We describe the neural substrates of emotional awareness and affective agnosia and compare and contrast these with related conditions. We then describe how this expansion of the conceptualization and measurement of affective processing deficits has important implications for basic emotion research and clinical practice.

Introduction

In 1891 Sigmund Freud coined the term “agnosia” (from the Greek meaning “absence of knowledge”) referring to patients with brain lesions who had lost their ability to recognize objects despite intact perception (Freud, 1953). He proposed that this recognition failure resulted from an inability to connect the stimulus information to the mental representation of the object. In 1895 Freud turned away from the study of neurological patients to the psychological investigation of patients with conversion disorder (Breuer and Freud, 1955), in so doing creating the field of psychoanalysis. Although the concept of agnosia was not invoked in subsequent psychoanalytic writings by Freud or his followers, within neurological circles the concept has thrived, referring to failures of recognition due to brain lesions that are specific to one sensory modality (e.g. the inability to recognize a person by viewing their face [prosopagnosia] but a retained ability to recognize a person by their voice) (Frederiks, 1969). The thesis of this paper is that the mental representation of emotion, including its conscious and unconscious vicissitudes, became a central concern of psychoanalysis, although not specifically described as such, and that severe impairments in this function can and should be linked to the agnosia concept. Parallel to the inability to map visual perceptual experience on to mental representations of conceptual meaning in visual agnosias (Crick and Koch, 2000, Jackendoff, 1987, Koch and Braun, 1996, Koch, 2004, Marr, 1982, Prinz, 2012), we here describe a new type of agnosia, called “affective agnosia,” that involves a deficit in the ability to mentally represent the meaning of emotional responses, which typically requires the integration of information from multiple interoceptive and somatic sensory modalities, as well as information regarding conscious/unconscious appraisals of one's situation.

The current concept most closely related to affective agnosia is alexithymia, a term coined in 1972 from the Greek meaning “lack of words for emotion” (Sifneos, 1972). Taken literally this term refers to a type of anomia. Although alexithymia has often been assumed to be something more than a simple lack of words, it has been challenging to find a more suitable term and conceptual framework to describe and measure it. In fact, although marked by notable successes, the empirical study of alexithymia has focused on milder versions of the originally observed lack of awareness of, or inability to experience, emotion (Nemiah and Sifneos, 1970), and has failed to support the original observation by the creators of the construct that alexithymia was associated with adverse physical health outcomes (Nemiah et al., 1976).

Based on a review of recent developments in the neuroscientific and psychological study of emotion, and the burgeoning literature on “theory of mind” or mentalization (Frith and Frith, 2012, Frith and Frith, 2006, Frith and Frith, 1999, Frith, 2001), we argue that such impairments in the mental representation of emotion, at the most severe end of the continuum, are more accurately conceptualized as an expression of affective agnosia. Lesser degrees of impairment are of course much more common, may be transitory and are likely grounded in related brain-based processes. By anchoring a continuum in this new way and describing a continuum of complexity of mental representation of emotion, however, the method for measuring and studying the phenomenon of “knowing one's own emotions” may be advanced. Clinically, this new perspective creates new opportunities for the psychotherapeutic treatment of impairments in emotional experience and emotional processing that are in fact quite common clinically but have previously been difficult to recognize and understand, and thus to identify and treat.