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How a Fear of Sadness Prevented My Friend from Saying Goodbye to Her Dying Brother

The interplay of affect phobia, alexithymia and somatic symptom disorder



Several years ago, I learned from my mother that the brother of one of my best friends was terminally ill. I didn’t know the brother very well, but my friend and I had always been very close, so I was a little surprised that I hadn’t received the news from her. I assumed that she must have been busy dealing with her brother’s difficult situation. When I mentioned that I hadn’t heard anything from my friend, my mother looked at me pensively, as if she were trying to find the right words, before disclosing that something seemed to be off about the way my friend had been behaving since learning about her brother’s illness. My mother also noted that although the health of my friend’s brother was declining rapidly, my friend had become virtually unapproachable by her own family members, including her dying brother. “Maybe give her a call,” my mother proposed.


When I got home later that day, I tried to contact my friend by phone, but she didn’t answer or return my call. After waiting a few days, I finally sent her an email in which I offered my support and cautiously asked her if it was true that she hadn’t visited her brother in quite a while. I also mentioned that I understood that he might not make it to the end of the month, and suggested that she might want to see him before it was too late. I offered to accompany her if she found it too difficult to go by herself.


About a week later, I received a reply from my friend. She stated that she understood the urgency, but that she was not planning on visiting her brother. Moreover, she wrote that she didn’t plan to attend his funeral. It struck me that her writing style was unusually formal, and she made it unmistakably clear that she fully understood the consequences of her actions.


I wondered what had happened between them that made her unwilling to visit her brother and support him during his final days. Strangely, according to my mother, there had been no falling out between my friend and her brother, at least as far as the brother was concerned. This puzzled me even more. I started to wonder whether my friend feared facing her own mortality, or perhaps didn’t know what to do or say if she saw him in his debilitated state.


Months later, after her brother had died, I finally got the opportunity to meet up with my friend. I asked her what had prevented her from spending time with her brother during the later stages of his illness, or from going to his funeral. With a defeated look on her face and sadness in her voice, she answered: “I just couldn’t. I am too afraid of the feelings that surround these kinds of situations. This fear is so strong that I suffer from severe panic attacks. I needed to go to intensive care five times during the period that my brother was sick and dying. Each time, I genuinely thought that I was having a heart attack. This fear is just too overwhelming, and I am sure I would not have been able to express my sadness in a normal way. After a moment of silence, she lowered her head and added, “Now, however, the thought of not having been there for my brother eats at me, but I just couldn’t face it.”


At that moment, I realized that for some people, the fear of experiencing certain feelings can be so strong that it even prevents them from bidding a final farewell to a loved one.


What can make somebody so afraid of experiencing and expressing affects (emotions, feelings and moods)?


The introduction of this article depicts a person who fears the affect of sadness. The severity of the fear correlates with the degree to which an individual reacts to it with avoidance. The fear of sadness that my friend experienced was apparently extremely high, as she opted to avoid the experience of sadness over visiting her brother before his death. Paradoxically, her fear of sadness had turned into an even more profound sadness for not having visited him.


Many of us find it difficult at times to deal with affects, especially negative ones. Most of us, however, don’t have anxiety attacks when we experience strong emotions. The excessive and overwhelming fear of the experience and expression of an affect is referred to as affect phobia, also known as animotophobia.


The fear of a particular negative affect does not automatically translate into a fear of all negative affects. Fears of different negative emotions are not correlated with one another. To illustrate, a fear of sadness tends to be linked to complicated grief, depression and borderline personality disorder. The fear of becoming anxious is linked to disorders such as agoraphobia (the fear and avoidance of places or situations that might cause panic due to a perceived inability to escape), feelings of helplessness, or feelings of embarrassment. A fear of anger is often linked to relative social power. For instance, certain people can react angrily toward their children, but fear the expression of anger toward their supervisor or colleagues.(1) Interestingly, there are people who fear positive affects such as happiness and compassion (for themselves and others).


What makes people fear positive affects when they are so important to counterbalance negative affects?


People more easily understand the fear of negative emotions since they can imagine the experience of those affects as threats. The fear of positive emotions is more difficult to comprehend. Studies on the subject attribute a fear of happiness and passion to being stuck in a grieving process. In other words, someone who has suffered the loss of a loved one may feel guilty about experiencing positive affects when “they should be grieving.” It is also found with people who are struggling with letting go of an imagined future that is no longer possible, due to extenuating circumstances. These people appear to be frozen in negative affect to such an extent that positive affects feel uncomfortable. Additionally, certain beliefs can underlie a fear of positive affects, such as the belief that if you allow yourself to feel happy, something bad will always come along to rain on your parade. Other research links positive affect phobia to fear of success, preparing for rejection by those who might become envious.


Fearing positive affects, it turns out, is highly correlated with anxiety, depression and stress.(1) This fear prevents people from enjoying the benefits of positive emotions, which they try to avoid at any cost. Failing to address such fears can have dire consequences. For instance, they contribute heavily to unsuccessful therapy outcomes for people who suffer from depression, as most therapies focus on reducing negative affect and increasing positive affect.(2) Curiously, a fear of positive affects is often linked to a fear of negative emotions such as anger and sadness.


Attachment traumas are often the cause of affect phobia


Research that focuses on attachment relationships indicates that fundamental causes of affect phobias are often rooted in childhood experiences. Sometimes children are chastised, or even punished, by their caregivers when they exhibit negative or positive affects. During childhood we learn from our caregivers, who also serve as our role models, how we should behave emotionally. If, perhaps due to cultural norms, caregivers do not validate the appropriate expressions of emotions by children in their care, such children may learn that the way they feel and act is not OK. If this happens regularly, these children will learn to suppress certain affects and avoid situations that might evoke these emotions. As a consequence, they may become disconnected from the emotional world around them and alienated from their own embodied self.


Affect phobia correlates with alexithymia


The suppression and avoidance of experiencing affects is correlated with alexithymia. The term alexithymia is derived from the Greek words: a- (lack), lexis (word), thymos (emotions). It is not classified in the DSM-V as a mental disorder, but is conceptualized as a cluster of cognitive traits, which include difficulty identifying feelings, difficulty describing feelings to others, externally oriented thinking, and limited imaginative capacity.(3)


Suffering from alexithymia does not render a person incapable of feeling or describing emotions, feelings, or moods. Although a person with alexithymia might, for instance, mention anxiety or depression, they are unable to elaborate on these feelings, or differentiate between them. Alexithymia is highly prevalent among individuals with mental disorders such as autism spectrum disorder, narcissistic personality disorder, anorexia nervosa and depressive disorder.


Difficulty in identifying, processing and expressing affects can manifest at both clinical and subclinical levels. Clinical levels correlate with neurological deficiencies in medical conditions such as brain injury, stroke and epilepsy, and in certain psychological disorders. Alexithymia on this level is difficult to treat and tends to impact the full array of affective experiences in a person.


There is also a subclinical level of alexithymia, which can be viewed as an acquired form of the same affective deficiency. Subclinical alexithymia tends to come about through the active suppression of affects. As with affect phobia, it tends to impact a smaller set of affects, or one particular emotion. Moreover, it shares the same underlying causes with affect phobia. For instance, a subclinical level of alexithymia, according to social learning theory, can be caused by growing up in a cultural or familial environment where the social climate and conditions discourage the expression of emotions. In several cultures, for instance, affects are viewed as private and are not to be expressed, out of respect for others.


In other cases, the expression of emotions can be viewed as a sign of weakness. This perception has contributed to the emergence of subclinical alexithymia disproportionately in males, a phenomenon known as Male Normative Alexithymia (MNA). Studies have indicated that males who suffer from MNA tend to experience and express anger (culturally often viewed as a sign of strength, and therefore more socially accepted) when they are actually feeling distressed.(4) Alexithymia on this subclinical level can often be treated successfully.


What if we fail to address the fear of, and inability to experience, process and express, affective states?


People who suffer from affect phobia and/or alexithymia might potentially translate emotional distress into a somatic experience, which could lead to somatic symptom disorder (SSD), previously referred to in the DSM as somatoform disorder. The key feature of SSD is the disproportionate or excessive concern of people with physical symptoms, such as stomach aches, back pain, weakness and shortness of breath, which they attribute to nonpsychological causes.


Primary care physicians often encounter individuals with physical complaints for which they cannot find any biological cause. This results in people who suffer from somatic symptom disorder being subjected to unnecessary diagnostic testing and medical procedures, aggravating the already existing feelings of distress. Therefore, appropriate diagnosis on both a physical level (to exclude an underlying disease), and psychological level (to diagnose affect phobia and alexithymia), are two critical initial steps in addressing SSD.


What are common symptoms of affect phobia, alexithymia, or somatic symptom disorder?


Please note that symptoms may vary from one individual to the next.


Affect phobia symptoms can include:

  • Becoming angry, anxious, or upset when confronted with a situation that might elicit the feared affect

  • Sensing an impending loss of control

  • Tightness in the chest

  • Feelings of heat in the body

  • Palpitations

  • Feelings of imminent fainting

  • A sudden fear of dying, or of behavior that results from loss of control (hurting oneself or others, suicide)

  • Symptoms resembling a panic attack, especially in people suffering from a panic disorder

  • Angry outbursts, to the extent of throwing and breaking things

  • Avoiding any situation that might elicit the feared affect


Alexithymia symptoms include a combination of the following:

  • Conspicuous difficulty in identifying and naming one’s own emotions, feelings and moods, and those of others

  • Difficulties in distinguishing between emotions, feelings and moods

  • Subdued responsiveness to the emotions of others

  • Difficulty discriminating between affects and bodily sensations

  • Marked constriction in imaginative processes

  • Concrete thinking style, for instance, basing explanations for affective states on what is seen, heard, felt and experienced in the present (disinclination to look for causes that require reasoning beyond the immediate physical surroundings, or that need introspection)

  • Tendency to conform to social norms, showing little contact with one’s own embodied state

  • Low tolerance for stress, and high levels of irritability or anger

  • Discomfort in connecting with affective states of others

  • Apathetic response to people, objects, or situations, which is often perceived by others as coldness


Somatic symptom disorder can be recognized by:

  • Disproportionate focus on physical symptoms such as pain, weakness, headache, fatigue, etc.

  • Digestive problems such as nausea, diarrhea, constipation, vomiting and abdominal pain

  • Dysfunctional sexual symptoms (loss of pleasure and sexual desire, feeling pain during sexual activity, excruciatingly painful menstrual symptoms)

  • Excessive thoughts, feelings and behaviors in relation to physical symptoms

  • Honest, albeit misplaced, belief in being ill (symptoms are not faked)

  • Emotional distress and functional impairment due to the foregoing symptoms


How can affect phobia, alexithymia and somatic symptom disorder be treated?


Affect phobia can be treated by “systematic desensitization” - helping the person to experience progressively higher levels of the feared emotion. Affect Phobia Therapy integrates techniques from psychodynamic, cognitive-behavioral and experiential therapies, which together can increase the effectiveness of this therapy, developed by Harvard Medical School psychologist and researcher, Leigh McCullough Vallaint.(5)


Another treatment approach is Acceptance and Commitment Therapy (ACT), which is a type of mindful psychotherapy. It helps clients to stay focused on the present moment and accept thoughts and feelings without judgment. ACT was developed in the 1980s by psychologist Steven C. Hayes, a professor at the University of Nevada.


Additionally, Dialectical Behavior Therapy (DBT), developed by Marsha M. Linehan, can be an option. DBT is a type of talk therapy based on cognitive behavioral therapy (CBT), but it is specially adapted for people who experience emotions very intensely.


The treatment of clinical alexithymic clients is most difficult. Moreover, stronger degrees of alexithymia predict less favorable therapy outcomes. The prognosis for people with a subclinical form of alexithymia is, therefore, potentially brighter. A prominent study recognizes that “there exists no treatment specifically designed to overcome the problems associated with alexithymia.”(7) The same study proposes that alexithymic individuals might benefit from training to enhance emotional recognition skills, for instance, in facial expressions and speech, and training in processing and recalling emotions. Additionally, training such individuals to use more vivid descriptive language and meaning sharing through metaphors can yield promising results.


In his book, Mentalizing the Body, Ulrich Schultz-Venrath refers to the “speechless mind,” which is an apparent reference to alexithymia. Treatment should include explicit mentalization of bodily states to help clients distinguish affects, broaden their affective palette and help them put words to affects so they can be explored, expressed and shared with others.(6)


Schultz-Venrath describes SSD as “the body’s attempt to do the work that should be located in the mind ‘the speaking body.’”(6) In the case of SSD, treatment should focus on mentalizing bodily states on a nonverbal and verbal level, to help clients reconnect with their affective selves, discover the psychological distress or illness that might be underlying physical symptoms, and address the psychological distress or illness.


A recently developed therapy that looks promising for both alexithymia and SSD, and perhaps also for affect phobia, is Mentalization Enhancement Therapy, a therapeutic treatment based on mentalization-based therapy (MBT), developed by Peter Fonagy and Anthony Bateman. MBT was initially developed to treat adults with disorders that encompass, among other things, difficulties in inferring mental states accurately, especially emotions, feelings and moods (e.g., borderline personality disorder and narcissistic personality disorder).


A central focus of this therapy lies in detecting and describing bodily sensations and inferring the mental states that might underlie these bodily sensations. These skills are developed in interpersonal settings, with particular emphasis on the recognition of the sensations and mental states of the patient and others. Although there is indirect evidence that this treatment can be successful, additional research needs to be done to garner more conclusive evidence.


Body-Centered Psychotherapy, also referred to as Somatic Psychotherapy, is another available treatment. This therapeutic approach integrates a patient’s physical body into the therapy process. It recognizes the intimate relationship between the human body and the psychological well-being of a person.


Other evidence-based treatments for SSD include Cognitive Behavior Therapy (CBT), Mindfulness-Based Cognitive Therapy (MBCT) and pharmacotherapy.



 


In conclusion, affect phobia, alexithymia and SSD can significantly impact the ability of a person to accurately detect, process and effectively deal with emotions, feelings and moods. Most of us occasionally experience problems with certain aspects of dealing with affect. For instance, many of us find it difficult to explain the differences between emotions, feelings and moods. In more severe cases, however, affective impairment can significantly impact a person’s sense of well-being and functioning. The treatment of these conditions will vary, as they entail different deficiencies: Affect phobia entails a fear of specific affects, alexithymia entails an affective and cognitive inability to (accurately) recognize and describe affective experiences, and SSD encompasses the attribution of psychological distress and illness to physical ailments.



 


References:

  1. Gilbert, Paul. (2014). Fears of Negative Emotions in Relation to Fears of Happiness, Compassion,Alexithymia and Psychopathology in a Depressed Population: A Preliminary Study. Journal of Depression and Anxiety, S2(1), –. doi:10.4172/2167–1044.S2–004

  2. Gilbert, Paul; McEwan, Kirsten; Catarino, Francisca; Baião, Rita; Palmeira, Lara . (2014). Fears of happiness and compassion in relationship with depression, alexithymia, and attachment security in a depressed sample. British Journal of Clinical Psychology, 53(2), 228–244. doi:10.1111/bjc.12037

  3. Ricciardi, Lucia; Demartini, Benedetta; Fotopoulou, Aikaterini; Edwards, Mark J. . (2015). Alexithymia in Neurological Disease: A Review. The Journal of Neuropsychiatry and Clinical Neurosciences, 27(3), 179–187. doi:10.1176/appi.neuropsych.14

  4. Seidler, Z. E., Rice, S. M., Kealy, D., Wilson, M. J., Oliffe, J. L., & Ogrodniczuk, J. S. (2021). Men’s Shame and Anger: Examining the Roles of Alexithymia and Psychological Distress. The Journal of Psychology, 156(1), 1–11. https://doi.org/10.1080/00223980.2021.1977598

  5. Najavits, L. (1998). Changing Character: Short-Term Anxiety-Regulating Psychotherapy for Restructuring Defenses, Affects, and Attachments. Leigh McCullough Vaillant. New York: Basic (1997). Psychotherapy Research, 8(2), 240–241. https://doi.org/10.1080/10503309812331332347

  6. Schultz-Venrath, U ( ​​2024). Mentalizing the Body: Integrating Body and Mind in Psychotherapy. Routledge.

  7. Samur D, Tops M, Schlinkert C, Quirin M, Cuijpers P, Koole SL. Four decades of research on alexithymia: moving toward clinical applications. Front Psychol. 2013 Nov 19;4:861. doi: 10.3389/fpsyg.2013.00861. PMID: 24312069; PMCID: PMC3832802.

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