Other Research

HRV Linking Alexithymia, Emotional Dysregulation & Emotional Exhaustion?

January 10, 2025

Alexithymia, emotional regulation, and emotional exhaustion, they are not separate entities – each comes with a set of associated symptoms, connected via disruptions in both the central and autonomic nervous systems.

Alexithymia

Often described as emotional blindness, alexithymia is experienced as a sense of flatness or numbing, characterised by difficulties in perceiving, identifying, and describing emotions1. Specifically, difficulties in identifying emotions has been demonstrated to be correlated with aspects of psychological illness (depression (0.545), anxiety (0.328) and general distress (0.553)1, highlighting the extent to which alexithymia can impact upon an individuals’ wider mental wellbeing. Alexithymia additionally integrates itself into other aspects of daily life, in particular, contributing to poorer emotional regulation (ER)2,3, and the development of emotional exhaustion (EE) (a subdomain of burnout)4.

While being normally distributed in the general population, an increase in prevalence and severity of alexithymia is present in psychiatric and neurodevelopmental conditions5. As a result, individuals often use maladaptive ER strategies, such as avoidance, rumination, and suppression, which leads to further worsening of symptoms6.

In terms of neurobiology, alexithymic individuals demonstrate alterations, often lower reactivity in neural networks associated with emotion processing and regulation7. Such disruptions occur predominantly in limbic regions (anterior cingulate cortex (ACC), anterior insula, and amygdala) and prefrontal cortices (PFC). This functional connectivity is further altered in many neurological disorders7.

Alexithymia & Emotional Exhaustion

As identified in Maslach’s Burnout Inventory (MBI), MBI is strongly correlated (0.637) with a difficulty in identifying emotions4. It has been shown that burnout severity can be explained by reduced empathy-related brain activity4, and that EE is negatively correlated with activation in the anterior insula (-0.590), having connections with the ACC4. This hypoactivation of the ACC in alexithymia may be attributed to the presence of von Economo neurons, known to have a role in empathic behaviours and phenomenology8, and hence play a role in EE and alexithymia.

EE is also correlated with anxiety (r = 0.460)9, with approximately 60% of individuals diagnosed with burnout, to also be diagnosed with an anxiety disorder10. This anxiety often integrates itself into added relationship stress, as well as a lower perceived quality of relationships11, alongside an inability to focus, coinciding with reduced productivity12. Such factors themselves impact upon an individuals’ ability to regulate their emotions, and hence one may enter this vicious cycle of alexithymia, emotional dysregulation and EE.

Heart Rate Variability

As an accessible marker of general wellbeing, heart rate variability (HRV) provides rapid, real-time measurements, which can be used as a vital tool to enhance both patient monitoring and treatment.

HRV refers to the fluctuation in time between consecutive heartbeats, influenced by both the sympathetic and parasympathetic nervous systems13, particularly the predominance of the parasympathetic branch at rest14. A higher HRV reflects the capability of the autonomic nervous system to adapt to stressors, indicative of a flexible and resilient heart15. HRV differs based on sex, age, BMI, and health16, but, in general, HRV time parameters largely reduce with both age and declining health, often signalling stress and fatigue17.

With respect to neurobiology, similar prefrontal, and limbic regions (ACC, insular and amygdala), are involved in the stimulation and interpretation of mental and emotional states, as during the regulation of cardiac activity18. Individuals with higher vagally mediated HRV (vmHRV) are more efficient in recruiting these brain regions18, displaying stronger HRV to be associated with better health outcome19,20.

As mentioned above, such networks are disrupted within neural conditions, and hence lower HRV is often observed in alexithymia18, PTSD21, ADHD22,23, and anxiety disorders16 for example.

HRV & Emotional Wellbeing

Emotion Regulation

With changes in cardiac regulation and HRV accompanying changes in PFC functional connectivity during emotional and cognitive processing24, research has sought to investigate the extent of this relationship. For instance, a link between physiological (autonomic) and psychological (self-reported) ER has been shown in various treatments for PTSD. Mathersul & colleagues21 demonstrated coinciding improvements in HRV and emotional clarity in veterans undergoing cognitive processing therapies21.

Generally, higher HRV is associated with increased PFC and amygdala functional connectivity25, areas responsible for ER. In further support of this, whole-brain fMRI studies have revealed associations between resting state vmHRV and neural activity during explicit ER tasks26. When regulating unpleasant emotions, individuals with higher vmHRV displayed increased dorsomedial PFC connectivity when using reappraisal techniques (t(11) = 2.38, p = .037) 26. Conversely, individuals with lower vmHRV were more likely to have difficulties in recruiting prefrontal areas for amygdala modulation – this weakened connectivity resulted in poorer ER26. In turn, poorer ER is linked to worsened decision making and executive functioning27,20.

Alexithymia & Resilience

Additionally, with alexithymia significantly predicting emotional dysregulation (0.55) and resilience (-0.46)3, scientists are researching into a relationship between HRV, alexithymia18 and resilience15. Individuals with increased high frequency-HRV (HF-HRV) displayed lower alexithymia levels (F(1, 83) = 3.99, p = .049), and increased empathy (F(1, 73) = 6.51, p =.01315. Compared to individuals with lower HF-HRV, they reported fewer difficulties in identifying and describing their emotional states, demonstrating increased mutual understanding in relationships15.

Regarding resilience, in a longitudinal study, higher resting HRV at time point 0, was predictive of enhanced engagement in positive ER strategies at time point 1, suggestive of HRV acting as a precursor of resilience levels15.

Emotional Exhaustion

Given the strong associations between HRV and psychological stress, research has sought to investigate whether HRV can be used as a predictive marker of EE. As predicted, the research has indicated decreased RMSSD (HRV time parameter) to be in line with increased EE severity28. More recently, Wekenborg & colleagues29, have aided in assessing the directionality of this relationship, conducted in a cohort of 387 individuals, who self-reported EE using the MBI29. They demonstrated vmHRV to significantly predict symptoms of EE, and not vice versa. Similarly, higher RMSSD and higher HF-HRV recordings were associated with lower exhaustive symptoms – again, these relationships were uni-directional29.

There are additional networks, connecting HRV & EE with increased rumination24 and disengagement (a further subdomain of burnout)30, both of which are known to contribute to symptoms of anxiety31, 32 and alexithymia33. This again emphasises the danger of individuals’ entering this vicious cycle of alexithymia, emotional dysregulation and EE – highlighting the need to target these areas in mental health interventions.Encouragingly, research investigating smartphone-based biofeedback techniques has been shown to increase HRV, and in turn reduce depression & anxiety severity, rumination, and perceived stress also 24.

Managing Alexithymia & Emotional Exhaustion

It is well established that alexithymia severity can be improved by reducing avoidance behaviours and improving ER through emotional reappraisal and implicit affect labelling34. These techniques specifically increase neuronal activation and connectivity in limbic and prefrontal brains regions and, hence target issues of EE and alexithymia34.

Alongside such techniques, with physiological processes preceding psychological symptoms, this indicates the potential use of HRV as a predictive, diagnostic marker of worsening mental health. Through tracking one’s HRV, this will indicate times when perhaps your mental wellbeing may be suffering – one can then use reappraisal techniques to improve upon this. Thus, this will largely aid in preventing individuals from entering the negative cycle of alexithymia, emotional dysregulation and emotional exhaustion.

References

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