In 2019 the World Health Organisation launched the 40 Seconds of Action campaign for suicide prevention, in recognition of the 800,000 lives lost to suicide each year across the world.

Among their suggested actions, the first proposed:

If you are struggling, take 40 seconds to kickstart a conversation with someone you trust about how you are feeling
– WHO, 2019

Good advice, and in many instances, potentially life-saving. But talking about your feelings is not always easy. I know from working on a suicide prevention helpline that some people struggle more than others to describe how they feel. I wonder how often we take this into account when we encourage others to reach out and seek help.

Difficulty describing feelings is a feature of the trait alexithymia. In fact, the word ‘alexithymia’ translates from Greek as “no words for emotion” (Sifneos, 1973). Other characteristics of alexithymia are difficulties identifying feelings, and a thinking style that’s focused on external events, rather than internal introspection and imagination (Taylor et al., 1997).

People who have attempted to end their lives, or who have self-harmed for other reasons, tend to have comparatively high alexithymia scores (e.g. Borrill et al., 2009; Ghorbani et al., 2017). This may be due to the increased risk of depression among people with high alexithymia (Honkalampi et al., 2000), or due to difficulties in regulating emotions that are poorly understood (Venta et al., 2013).

Alexithymia is not a mental health condition, but a transdiagnostic trait. If you’re new to this term, read When You Don’t Have The Words on the excellent NetECR website.

A recent review by Hemming et al. (2019) synthesised the evidence relating to the relationship between alexithymia and suicide ideation and behaviour. Suicide ideation was defined as thoughts, plans and wishes to end life (Beck et al., 1972), while suicide behaviour was limited to suicide attempts. The authors acknowledged evidence suggesting that suicide ideation and behaviour may have different clinical correlates (May & Klonsky, 2016). One aim of the review, therefore, was to assess whether alexithymia was differentially related to suicide ideation and behaviour.

Methods

The review followed PRISMA guidelines and was preregistered with the Prospero database. Nine databases were searched using the term “alexithymi*” together with a broad range of synonyms for suicidal behaviour and ideation. No date restriction was applied.

Studies had to use a validated measure of alexithymia and report on the relationship between alexithymia and suicide ideation and/or behaviour. A minimum age of 16 was set because the measurement of alexithymia in younger age groups has not been validated, and may not be appropriate at such an early stage of emotional development (Parker et al., 2010).

Risk of bias was assessed using the AXIS tool (Downes et al., 2016), which facilitates a qualitative assessment of common areas of bias. A random effects meta-analysis was conducted, using the correlation coefficient (r) as the effect size.

Results

Of the 894 studies identified through the searches, a total of 34 studies met the inclusion criteria, involving 10,104 participants in total.

All studies used a version of the Toronto Alexithymia Scale (Bagby et al., 1994). In contrast there was considerable variation in the measurement of suicide ideation and behaviour.

• The review found a large effect size for the relationship between alexithymia and suicide ideation (r=0.54, 95% CI=0.40 to 0.65)
• The effect size for the relationship between alexithymia and suicide behaviour was smaller, but still significant (r=0.25, 95% CI=0.16 to 0.34)
• Both relationships were driven principally by the alexithymia sub-scales:
  • difficulty identifying feelings
  • difficulty describing feelings.

Demographic factors such as age, gender or location were not found to affect the relationship between alexithymia and either suicide ideation or behaviour. However, there was some indication that depression might mediate between alexithymia and suicide behaviour.

The quality of the included studies was judged to be good. However, heterogeneity between the studies was high, and funnel plots revealed the possibility of publication bias.

Conclusions

This systematic review provides evidence of a strong association between alexithymia and suicide ideation. This means that people who are having suicidal thoughts are likely to have higher alexithymia scores. The authors interpret this as consistent with evidence that suicide ideation in particular is related to difficulties with emotion regulation (Anestis et al., 2011).

A smaller, but still significant, relationship was also identified between alexithymia and suicide attempts. The effect size (r = .25) was very similar to the size of the association between alexithymia and self-harm (excluding suicidal intent) identified in two other recent meta-analyses (Greene et al., 2020; Norman et al., 2020). In my view, this may indicate that, to some extent, studies of suicide and self-harm are drawing on similar populations, given the high prevalence of suicide attempts among people who self-harm (O’Connor et al., 2018).

Strengths and limitations

This is a clearly presented and thoroughly conducted systematic review of the current evidence base.

The authors acknowledged the limitations of the available evidence, including the reliance on cross-sectional studies. This means that we can’t be sure that alexithymia is a cause of suicide ideation and behaviour. In addition, the measures of suicide ideation all capture current state of mind, in contrast to the questions about lifetime suicide attempt. This may partly explain the lower effect size between alexithymia and suicide behaviour compared with ideation. Although alexithymia is generally thought to be a relatively stable trait (Porcelli et al., 2011), it can change as a result of treatment (Norman et al., 2019) or trauma (Messina et al., 2014). Perhaps participants would have scored more highly on alexithymia at the time they attempted suicide.

A further limitation of the available evidence, noted by the authors, is that 85% of the studies used clinical samples, limiting the extent to which the conclusions can be extrapolated to the general population. The literature on self-harm (as opposed to suicide attempts) includes a greater range of populations, including adolescents and students. Meta-analyses suggest that the relationship between alexithymia and self-harm is higher still among young people (Greene et al., 2020; Norman et al., 2020),

This review did not set out to investigate the mechanisms underlying the relationship between alexithymia and suicide, although the authors noted the need for further investigation into the mediating role of depression. Interestingly, other reviewers have proposed different hypotheses. Davey et al. (2018) suggested that the relationship between alexithymia and suicidality might be explained by a broader inability to perceive and interpret bodily sensations accurately, termed ‘interoception’. Alternatively, Iskric et al. (2020) pointed to evidence linking alexithymia with interpersonal problems (Vanheule et al., 2010), which may heighten the feelings of loneliness and social isolation associated with suicidality.

Implications for practice

Hemming and colleagues (2019) point out that screening is needed in order for clinicians to be able to address alexithymic symptoms. Targeted skills-based training to improve emotional clarity might enable patients with high alexithymia to engage more successfully with traditional therapies.

However, screening for alexithymia is not yet routine. An alternative use of the results of this review may be to inform knowledge about suicide more generally. There is a high prevalence of alexithymia in clinical samples (McGillivray et al., 2017) and it is likely that many people who engage in self-harm may struggle to identify and describe their feelings. The results of this review highlight how such difficulties may arise not only from a fear of the consequences of disclosure but also or instead from a cognitive deficit in the processing of emotions. It reminds us that the barriers to help-seeking may not be limited to fear of stigma (Nearchou et al., 2018), or unhelpful responses (Wadman et al., 2018), but may also include an inability to find the right words.

In my view, this study is a reminder to everyone involved in suicide prevention of the need to be aware of how hard it can be to talk about feelings. Sometimes we may need to take 40 seconds to reach out and start the conversation ourselves.

Statement of interests

My own PhD at Middlesex University is focused on the relationship between alexithymia and self-harm and I have published reviews on this subject (Norman et al., 2020; Norman & Borrill, 2015), as well as on the effect of mindfulness-based therapies on alexithymia (Norman et al., 2019).

Links

Primary paper

Hemming L, Taylor P, Haddock G, Shaw J, Pratt D. (2019) A systematic review and meta-analysis of the association between alexithymia and suicide ideation and behaviour. J Affect Disord. 2019 Jul 1;254:34-48. doi: 10.1016/j.jad.2019.05.013. Epub 2019 May 8. [PubMed full text]

Other references

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World Health Organisation (WHO) (2019) World Mental Health Day 2019: Working Together to Prevent Suicide.  Last Accessed: 15.9.2020

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