Friday, May 22, 2009

Affective Deprivation Disorder: Does it Constitute a Relational Disorder?

Harriet F. Simons Ph.D
Jason R. Thompson

About the authors

Harriet Simons is Adjunct Associate Professor at Smith College School for Social Work and runs a private social work practice for individuals and couples specializing in infertility and Asperger’s relationships. Among her published works are Wanting Another Child: Coping with Secondary Infertility. Jossey-Bass, 1998; (Contributor), Infertility Counseling: A Handbook for Clinicians. Parthenon Press, 1997; and (Co-editor and Contributor) Infertility: Medical, Emotional and Social Considerations. Human Sciences Press, 1984.
Jason Thompson is Community Support Officer at SPARAL Disability Services specializing in rehabilitation and lifestyle support for individuals with intellectual and physical disabilities. He has completed certified studies in Applied Behaviour Analysis and Normative Male Alexithymia. He recently published an essay on the subject of alexithymia Alexithymia: An Imaginative Approach, Psychotherapy Australia Journal, vol 14, No 4, Aug. 2008

Having worked with individuals and couples involving one or both partners on the autism spectrum, the authors have undertaken the following independent assessment of Maxine Aston’s proposal that some of these couples may experience emotional dysregulation and concomitant relational dysfunction. Actually, Hans Asperger himself first asserted that relationships might well be problematic. The idea that Asperger's Syndrome or other conditions characterized by low emotional intelligence would impact others in a close relationship with the person on the spectrum has occasioned much opposition. While this fact seems apparent to many, especially those in these relationships, there has been a call for empirical rather than anecdotal evidence.
The following study explores Maxine Aston's concept Affective Deprivation Disorder, a pattern of relating that often develops when one or both partners in a relationship have low emotional intelligence. This article provides data supporting various relational disturbances which tend to arise from low emotional intelligence. We maintain that the concept AfDD as proposed by Maxine Aston satisfies the criteria for the new diagnostic category Relational Disorders (RD). We endorse the need for ongoing research into this disorder.

For the first time, the forthcoming DSM-V may include a category of Relational Disorder. According to Michael First M.D. of the DSM-V research committee, the locus of a relational disorder, in contrast to individual disorders, is on the relationship “juncture” between two or more people rather than on any one individual in the relationship (First, 2002). An additional and somewhat controversial criterion is that whilst aspects of relational disorders may be modulated by individual disorders, the relational disorder cannot be due solely to a problem in one member of the relationship, but requires maladaptive interaction from each individual involved in the relationship (First, 2002). This is not to say that one person may not be the primary contributor to the Relational Disorder; however, it is possible that both parties may have equally initiated the relational difficulties or that the ongoing reactivity of the partner has co-created the disjuncture.

Relational disorder is defined as persistent and painful patterns of feelings, behaviours, and perceptions among two or more people in an important personal relationship, such as a parent and children or a husband and wife. (First,, 2002). While the following discussion focuses primarily on Affective Deprivation Disorder (AfDD) a relational disturbance found in adult partner relationships as developed by U.K. couples specialist Maxine Aston (2007c), it should be remembered that the proposed diagnostic criteria may equally apply to the relationship between parents and children.

Unlike other Axis I diagnoses and corresponding to the proposed category of Relational Disorders, AfDD is not an enduring disorder of the self stemming from childhood deprivation, emotional trauma, or congenital defect, but rather is a relationship-dependent condition generated by the operation of low emotional-intelligence or alexithymia (lack of emotional awareness) in one or both partners of a relationship. Further, the symptoms of AfDD are more likely than individual disorders to be responsive to therapeutic intervention or a change in relationship status. In fact, the very knowledge of the primary condition underlying the relational imbalance can in and of itself be healing. Since AfDD is a consequence of individuals’ relational dynamics , it is possible to find ways to reduce the level of disorder by increasing awareness and interactional skills. Relationships “can work if both partners work together to understand their differences and develop a better way of communicating, showing emotional expression and loving that works for both of them” (Aston, 2007c).

Historical and Theoretical Antecedents of AfDD

Previous terms proposed for this dynamic were Cassandra Phenomenon (Rodman, 2003), Cassandra Affective Disorder (Aston, 2005) and more recently Cassandra Affective Deprivation Disorder (Aston, 2007b). These terms have referred to the experience of non- Asperger’s individuals in a relationship with someone with Asperger’s Syndrome (AS), many of whom showed disturbing physical and psychological reactions to the lack of emotional reciprocity in their relationships (priestess Cassandra was given the gift of knowing the truth and the curse of not being believed; this was seen as reflecting the reality of those in AS/non-AS relationships who knew that their relationships were atypical but found others, including therapists, unwilling to accept the truth of their relationships (Simons, 2008). These terms have become controversial since they have been mistakenly interpreted as putting all the blame for the relationship dysfunction on the previously diagnosed member of the dyad.

Unfortunately, Maxine Aston’s earlier development of the concept was misconstrued by AS/autism advocates to mean that AS-individuals caused individual psychiatric disorders in loved ones, independent of the loved one’s contribution to the relational interaction. Some AS/autism advocates have interpreted these earlier concepts as blaming the partner with the neuro-developmental difference for harming the non-AS partner who is perceived as being blameless. In their view, the term reflects a prejudice against those with such differences; however, this perspective does not acknowledge the very real deficits which exist and must be addressed. Aston later broadened the diagnostic scope and applicability from CADD which applied to AS to include all relational disorders in which low emotional intelligence (EI) or alexithymia contributed to the relational dysfunction, labelling these conditions Affective Deprivation Disorder (AfDD). Affective Deprivation Disorder results from a relationship in which emotional needs are chronically unmet creating a sense of emotional deprivation. This in no way should be taken to mean that either partner is actively or deliberately depriving the other. The deprivation is created by the fact that the partners are emotionally out of sync and it is overly simplistic to say that one partner causes the deprivation of the other. Instead, the reality is that each partner may contribute to the dysfunction in different degrees. While the relational difficulties may have originated from one partner’s emotional constraints, the other partner’s reaction may exacerbate the tension leading to defensiveness and creating a spiralling effect. For instance, the non-alexithymic partner’s reactivity can affect the alexithymic individual potentially creating anxiety attacks, anger, or distressing physical symptoms just as the alexithymic individual has been shown to impact the non-alexithymic partner.

A high level of alexithymia is thought to affect up to 10% of the overall population (Linden & Paulhaus, 1994), but has a striking prevalence of 85% in autistic spectrum disorders (Hill, Berthoz, & Frith, 2004). Since Affective Deprivation Disorder (AfDD) is employed (Aston, 2007c) for relationship dysfunction modulated by any individual disorder involving high levels of alexithymia, and not just in Asperger’s Syndrome, the following discussion of the emotional sequelae of low EI/alexithymia should be understood as applying to the many relationships affected by Asperger’s Syndrome and similar disorders as well. An understanding of the interpersonal relationships of those with low-EI or alexithymia underscores the applicability of the relational disorder diagnosis since these individuals are frequently hampered by poor emotional insight and communication. While these conditions are not dysfunctional in and of themselves, they become problematic when a person with low EI is in a relationship with someone with different emotional needs and expectations. According to Vanheule, Desmet and Meganck (2006), interpersonal problems are created when alexithymic individuals form relationships with others because they tend to position themselves as either dependent or impersonal, “such that the relationship remains superficial” ( p.110). Further research reports inadequate differentiation between self and other by alexithymic individuals (Blaustein & Tuber, 1998; Taylor et al., 1997), negative associations with mental and relational wellbeing plus impaired relationship closeness due to reduced ability to experience affectionate communication (Hesse & Floyd), and chaotic interpersonal relationships (Sifneos, 1996). In addition there is evidence that low-EI may be a contributing factor in situations of domestic abuse (Winters, Clift, & Dutton, 2004) and that both low-EI and alexithymia affect the quality and satisfaction of the relationship, producing negative psychological symptoms in one or both parties (Brackett et al, 2005; Yelsma, & Marrow, 2003).

There are several benefits to employing the designation of Relational Disorder in these instances. Firstly, it shifts the focus away from the low-EI/alexithymic person’s condition and onto the larger nexus of relational dysfunction, meaning there will be less focus on blame and an invitation for the involved individuals to develop skills for recognizing and managing these difficulties together. Secondly, it steers away from the erroneous and damaging suggestion that alexithymic persons create personality disorder in their partners or children looking instead at the problematic relationship dynamic. However, it must be noted that while an individual with low EI might well have problems across relationships, for a partner with higher emotional intelligence the relational difficulty may be specific to that relationship.

AfDD Diagnostic Criteria

To qualify for a diagnosis of AfDD one or more of the following indicators in each category must be present:

At least one partner must meet diagnostic criteria for one or more of the following:
  • Low Emotional Intelligence
  • Alexithymia
  • Low Empathy Quotient

Relationship profile includes one or more of the following:
  • High relational conflict
  • Domestic abuse: emotional and/or physical
  • Reduced relationship satisfaction
  • Reduced relationship quality

Possible Psychological or Physical Symptoms:
  • Low self esteem
  • Feeling confused/bewildered
  • Feelings of anger, depression and anxiety
  • Feelings of guilt
  • Loss of self/depersonalization
  • Phobias – social/agoraphobia
  • Posttraumatic stress reactivity
  • Fatigue
  • Sleep loss
  • Migraines
  • Loss or gain in weight
  • PMT/female related problems

In summary, the construct of Affective Deprivation Disorder is comprised of the following factors; (a) at least one individual with low emotional/empathy quotient or alexithymia; (b) impaired relational interaction and experience; (c) negative psychological and/or physical symptoms.

The Emotional Sequelae of AfDDIt is unclear whether or not AfDD impacts both partners equally; while the partner with higher EI may be more cognizant of the effects of the imbalance, the resulting stress and dissatisfaction can be detrimental to both parties. For example, a husband might report that the relationship is fine while his wife is sitting next to him sobbing about it. However, some low EI individuals report that their partners’ response is the main problem stressing their need to be accepted as they are. As in Relational Disorders, AfDD does not result solely from alexithymia or low EI in one individual, but rather includes maladaptive patterns of responding by both individuals creating a dysfunctional juncture. There is the potential for partners to become polarized with one thinking the other either “selfish or cold” or “emotionally needy and self pitying.” The lack of empathy in these relationships is one key to their impacts. A lack of empathetic attunement disables the individual’s ability to recognise, interpret and to verify subtle emotional signals expressed by intimates and contributes to an impoverishment of emotional interaction. The interaction becomes further compounded when the unverified partner or family member reacts negatively to feelings of being misunderstood or neglected. In this sense the affective deprivation experienced in such relationships refers to the deprivation of emotional-attunement, emotional validation, and intelligent emotional responding. To the extent that people look to their significant other for validation, the lack of such validation can corrode their sense of self and lead to a discouragement of self expression whereby large portions of the individual’s emotional repertoire become deleted from the relationship (Goleman, 1996b). In Asperger’s relationships this tendency to eradicate emotionality and take on Asperger’s characteristics has been labelled becoming “Aspergated” (Stanford, 2003). The failure to understand and validate legitimate emotional experiences or behaviours of the other typically creates or exacerbates negative emotional arousal in the invalidated individual/s, potentially leaving each member of the relationship displaying some measure of dysregulated affect (Fruzzetti, A.E., & Iverson, 2006).

A second key issue involves the inability to identify and therewith modulate strong emotions such as sadness or anger, leaving the alexithymic/ low EI individual prone to “sudden affective outbursts such as crying or rage” (Nemiah, Freyberger & Sifneos, 1970; Taylor, Parker & Bagby, 1997) known as meltdowns which strongly negatively effect relationships. In some cases, this has been seen as increasing the risk of domestic abuse in couples (Winters, Clift & Dutton, 2004) because the lack of the ability to modulate emotions and reactive patterns can if unchecked lead to violence. Although it is possible for an understanding partner with higher emotional intelligence to compensate for a partner with low emotional intelligence, these developments can take a toll on the couples’ emotional-security, and ferment emotional dysregulation. Unfortunately, if left unchecked a reciprocal process of reactivity and dysregulation can develop that:
…is self-maintaining and contributes to increased negative interactions, decreased positive interactions, increased individual distress, and diminished relationship satisfaction. Over time, this pattern may further deteriorate into many of the problematic behaviours we see in distressed and reactive couples and families. From an intervention standpoint, targeting an increase in the use of emotion regulation skills, as well as a reduction of invalidating behaviours and increased validating behaviours, follows logically from this model. (Fruzzetti & Iverson, 2006 p.256)
While the conventional wisdom is that true empathy cannot be taught, such cognitive- behavioural skills can be learned and can greatly improve relationship satisfaction.

Treatment of AfDD

Maxine Aston (2007c ) has put forward valuable recommendations for treating those non-alexithymic individuals affected by AfDD focusing on rebuilding self-esteem which may have been affected by the lack of emotional reciprocity and validation and aimed at rebuilding their sense of self. Some techniques have proven beneficial when working with alexithymic individuals, focussing on increasing levels of emotional intelligence and improving relational skills (Bar-On , 2007; Thompson, 2008) However, since a relational disorder results from the juncture of both parties, Aston (2007c) recommends that interventions also be targeted at the couple as a unit.

The most important first step in working with couples is acknowledging the relational imbalance. This can occur through a self recognition of different cognitive neurological styles or as the result of neuro-psychological testing. Some individuals with low EI or alexithymia self-diagnose and even embrace the diagnosis; for them it represents the answer to why they may have felt different and why their partners may have accused them of coldness or selfishness. For the partners it can produce a radical reframing of past and present behaviours causing them to realize that their partners were not unwilling to meet their emotional needs or being punitive or withholding, but rather had difficulty with social interactions.. The goal of treatment then becomes negotiating a balance between the differing needs and expectations and promoting non-judgmental communication. However, sometimes it is necessary for one party to mourn for the idealized relationship in order to accept the reality and constraints of the existing relationship. Clarity in communication is vital taking into account the tendency toward literalness among alexithymic individuals. For example, instead of asking a partner if he or she would “like” to do something, it is recommended that one states the specific action required. While a person may not really want to do something, he or she might be willing to if the need were clearly articulated. Similarly, behavioural expectations need to be spelled out or often written out; understanding that partners can not intuit needs lessens the disappointment and may prevent the affective deprivation which stems from chronic loss. Another barrier to communication is the alexithymic individual’s tendency to respond in the negative (Thompson, 2009). A partner should be encouraged to persevere in spite of feelings of rejection since the initial negative response will often change upon reflection. Setting realistic expectations for one another can prevent much pain. A partner can understand that his or her significant other may be wired differently and therefore may appear to be either emotionally “needy” or emotionally “distant”. While understanding does not negate the longing for a closer connection or for more space in the relationship, it may remove the anger stemming from negative interpretations of these differences. And it also should minimize the cycling dynamic of withdrawal, pursuit, and greater withdrawal or reactive lashing out.

While such changes may seem somewhat simplistic, they are far from easy to implement. It is necessary for each member of the couple to practice mindfulness in their interactions and consciously process what is said and done and consider the impact on each other in order to provide the needed emotional regulation. This is extremely demanding and requires strong motivation on both sides. If one partner feels that the other’s needs are invalid and sees no need for change, the potential for AfDD and relational disorder is increased. However, a willingness to learn how to adapt to one another can prevent or to some degree even reverse long term damage. Once a couple is able to establish guidelines for acceptable compromise, it may be desirable to educate others as to the norms. There is no one right way for a relationship to be conducted and outside pressures to conform to idealized norms can be stressful and invalidating.


Our survey of the construct Affective Deprivation Disorder and associated findings about the impact of low-EI/alexithymia on relationships suggests that it does satisfy the criteria for Relational Disorder as delineated by the American Psychiatric Association’s current conceptualisation [see Table 1]. Further research into the validity and clinical utility of the construct and of the development of uniform assessment methods are required.

TABLE 1. Correspondence of Relational
Disorder and AfDD criteria
Relational disorder (First, 2002)

Affective Deprivation Disorder (Aston, 2007c)

#. Embedded disorders are relational problems that are implanted in already defined syndromes of individual psychopathology." (p.160)

At least one partner must meet the diagnostic criteria for one or more of the following:
Low Emotional Intelligence
Low Empathy Quotient
¬[i.e. correlates with embedded RD]
#. It is the juncture or bond between or among the members of a relationship that is disordered. The disorder cannot be reduced to an individual diagnosis of any member and its consequent impact on others."(p.157)

“Affective Deprivation Disorder (AfDD) is a relational disorder”
“AfDD is a consequence of the relational situation a sufferer is in…”
# "relational disorders are serious behavioral disturbances that can lead to major impairments in physical health and psychological adjustment." (p.159)

# "there is clear evidence of a major impact of these patterns on psychological functioning, physical health, social adaption, and/or occupational effectiveness in one or both partners." (p.162)

Relationship profile includes one or more of the following: High relational conflict. Domestic abuse: emotional and/or physical. Reduced relationship satisfaction. Reduced relationship quality.

Possible Psychological or Physical Symptoms:
Low self esteem. Feeling confused/ bewildered. Feelings of anger, depression and anxiety. Feelings of guilt. Loss of self, depersonal-isation. Phobias social/agoraphobia. Post-traumatic stress reactivity. Fatigue. Sleep loss. Migraines. Loss or gain in weight. PMT, female related problems.
# "clear, repeated, fixed patterns of feelings, behavior, and perceptions can clearly be recognized..... the patterns are of long standing and are not a response to a recent stressful event." (p.161)

-Nil mention.-


Aston, Maxine., The other half of Asperger Syndrome. (2001) published by National Autistic Society

Aston, Maxine., Cassandra Affective Deprivation Disorder, retrieved online Dec2005 at

Aston, Maxine., (b) Cassandra Affective Deprivation Disorder, retrieved online 15 October 2007 at

Aston, Maxine., (c) Affective Deprivation Disorder, retrieved online 15 October 2007 at

Bar-On, R., Maree, K., Maree, J. G., Elias, M.J., (2007) Educating People to be Emotionally Intelligent Praeger

Geoffrey Bird, Giorgia Silani, Rachel Brindley, Tania Singer, Uta Frith. Alexithymia in Autism Spectrum Disorders: an fMRI Investigation (2006). Retrieved online 28- July 2008 at

Blaustein, J. P., & Tuber, S. B., (1998) Knowing the Unspeakable. Bulletin of the Menninger Clinic, 62, 351-365

Brackett et al - ‘Emotional Intelligence and Relationship Quality Among Couples’ in P Yelsma, P., Marrow, Personal Relationships, 12 (2005), 197-212.

First, M.B., Bell, C.C., Cuthbert, B., Krystal, J.H., Malison, R., Offord, D.R., Riess, D., Shea, T., Widiger, T., Wisner, K.L., Personality Disorders and Relational Disorders, p.163, Chapter 4 of Kupfer, D.J., First, M.B., & Regier, D.A. A Research Agenda For DSM-V. Published by American Psychiatric Association (2002)

Fruzzetti, A.E., and Iverson, M.I., Intervening with couples and families to treat emotion dysregulation and psychopathology, p.252 in Snyder, K.D., Simpson, A., and Hughes, J.N., (eds) Emotion Regulation in Couples and Families (2006) American Psychological Association.

Goleman, Daniel., ‘The Roots of Empathy’ in Emotional Intelligence; Why it Can Matter More Than IQ. (1996a) Bloomsbury

Goleman, Daniel., ‘The costs of misattunement’ in Emotional Intelligence; Why it Can Matter More Than IQ. (1996b) Bloomsbury

Hesse, C & Floyd, K. (2008) Affectionate experience mediates the effects of alexithymia on mental health and interpersonal relationships. Journal of Social and Personal Relationships 25 (5), 793-810

Hill, E., Berthoz, S., & Frith, U (2004) ‘Brief report: cognitive processing of own emotions in individuals with autistic spectrum disorder and in their relatives.’ Journal of Autism and Developmental Disorders 34, 2, 229-235

Linden, W., Wen, F., Paulhaus, D. L. (1994) Measuring alexithymia: reliability, validity, and prevalence. In: J. Butcher, C. Spielberger, (Eds.). Advances in Personality Assessment. Hillsdale, NJ: Lawrence Erlbaum Associates.).

Nemiah, C.J., Freyberger, H., & Sifneos, P.E., ‘Alexithymia: A View of the Psychosomatic Process’ in O.W.Hill (1970) (ed), Modern Trends in Psychosomatic Medicine, Vol-2, p.432-33; Taylor, G.J, Parker, J.D.A., & Bagby, R.M. Disorders of Affect Regulation- Alexithymia in Medical and Psychiatric Illness (1997), p.246-47

Parker, J.D.A., Taylor, G.J. & Bagby, R.M (2001) The relationship between emotional intelligence and alexithymia. Journal of Personality and Individual Differences 30, 107-115

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Thompson, J., Alexithymia: An imaginative approach, Psychotherapy Australia Journal, vol 14, No 4, Aug. 2008.

Thompson, J. Emotionally dumb: An introduction to alexithymia, Jessica Kingsley, (2009).

Vanheule, S., Desmet, M., &Meganck, R. (2006) Alexithymia and interpersonal problems, Journal of Clinical Psychology 63(1):109-117.

Winters, J., Clift, R.., & Dutton, D. Emotional intelligence and domestic abuse. Journal of Family Violence 19[2] (2004) pp. 255-267.

Yelsma, P., Marrow, S. An examination of couples’ difficulties with emotional expressiveness and their marital satisfaction. Journal of Family Communication 3 (2003) pp..41-62.


Harriet F. Simons Ph.D
Jason Thompson

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  1. "At least one partner must meet the diagnostic criteria for one or more of the following:

    Low Emotional Intelligence
    Low Empathy Quotient"

    It seems to me this wouldn't be a problem in a relationship if the other party of the relationship didn't have an underlying need for the specific kinds of demonstrative emotiveness the low EI party has. It also seems to me a person could also have AfDD even if the other party has normal, or even relatively high abilities in EI, was non-alexithymic, and had a high empathy quotient, if said abilities were still below the thresholds needed by the deprived party. Some people just need more (or different kinds), and some people may need (hypothetically) a monstrous amount more of demonstrative empathy, at least in this specific kind of relationship.

    To even be further considered as a DSM-class disorder, this criteria should be modified such that the specific amount and kinds of affection needed by the first party must contrast with the other parties ability to demonstrate such kinds and amounts of affection. Taking into account something such as love languages (, should probably be part of the extended diagnostic criteria. (I am unfamilar with whether the "love languages" idea is vaildated enough to be part of a DSM diagnostic critieria, but if a new category of relational disorders is going to be made, something like it should be in there, or the category is almost useless).

    I also think the following criteria should be removed from the diagnosis, or given explicit caveats (for what seems to me obvious reasons): "Reduced relationship satisfaction. Reduced relationship quality."

    Reduced compared to what baseline of judgment?

  2. Pulnimar,

    Thanks for your post. Your questions are all answered in the studies provided in the 'References' section at the bottom of the essay, including what is being referred to by "Reduced relationship satisfaction. Reduced relationship quality". I recommend you take a look at them.

    You may find these (listed above) helpful in answering your questions:

    Brackett et al - ‘Emotional Intelligence and Relationship Quality Among Couples’ in P Yelsma, P., Marrow, Personal Relationships, 12 (2005), 197-212.

    Hesse, C & Floyd, K. (2008) Affectionate experience mediates the effects of alexithymia on mental health and interpersonal relationships. Journal of Social and Personal Relationships 25 (5), 793-810

    Vanheule, S., Desmet, M., &Meganck, R. (2006) Alexithymia and interpersonal problems, Journal of Clinical Psychology 63(1):109-117.

    Winters, J., Clift, R.., & Dutton, D. Emotional intelligence and domestic abuse. Journal of Family Violence 19[2] (2004) pp. 255-267.

    Yelsma, P., Marrow, S. An examination of couples’ difficulties with emotional expressiveness and their marital satisfaction. Journal of Family Communication 3 (2003) pp..41-62.

    Kind Regards