Dissociating the Impact of Alexithymia and Impaired Self-Awareness on Emotional Distress and Aggression After Traumatic Brain Injury

Objective: Alexithymia, a deficit in identifying and describing feelings, is prevalent in traumatic brain injury (TBI). Sometimes referred to as "emotional unawareness," we sought to investigate whether alexithymia after TBI was related to, or distinct from, impaired self-awareness (ISA) and whether the two predicted differentiable emotional and aggression profiles. Further, the mediating role of frontal system behaviors (disinhibition, dysexecutive function, apathy) was explored. Method: Participants with TBI (N = 40) from diverse backgrounds completed self-report measures of alexithymia, emotional distress, aggression, and frontal system behaviors. For the assessment of ISA, significant other ratings were obtained to identify discrepancies from self-ratings. Data were analyzed quantitatively using independent samples t tests, correlations, partial correlations, and simple mediation. Results: There was a negative correlation between alexithymia and ISA. Alexithymia, but not ISA, was associated with higher expressions of emotional distress and aggression even after controlling for the effects of ISA via partial correlations. Exploratory analyses found that frontal system behaviors mediated the relationships between alexithymia and aggression and alexithymia and emotional distress. Conclusions: Alexithymia is more accurately conceptualized as an emotional processing deficit than an awareness deficit. Indeed, self-awareness may be a prerequisite for the ability to identify alexithymic tendencies. Negative psychological effects of alexithymia are compounded by poorer executive function and disinhibition and call for the development of TBI-specific alexithymia screening tools and interventions. Alexithymia interventions are best delivered in conjunction with rehabilitation of emotion regulation and executive function. Key Points Question: This article examines the relationship between alexithymia and impaired self-awareness (ISA) after traumatic brain injury (TBI), and their associations to emotional difficulties, aggression, and frontal system behaviors. Findings: We present a novel finding that alexithymia does not equal a deficit in emotional insight and that emotional and behavioral difficulties in TBI are compounded by alexithymia, dysexecutive function, and impulse disinhibition. Importance: This article is the first sufficiently powered TBI study, demonstrating (a) a conceptual finding that alexithymia is not merely a manifestation of ISA and (b) a prac