Alexithymia: When "How Do You Feel?" Has No Answer
- Melanie Du Preez
- Mar 14
- 13 min read
The therapist asks: "How does that make you feel?"
You sit there. Silent. Not because you're being difficult or resistant. Not because you don't want to answer.
Because you genuinely have no idea.
You know something is happening in your body. There's a sensation—tightness, heaviness, maybe heat. But you can't name it. You can't tell if it's anxiety or sadness or frustration or something else entirely.
Or someone asks, "Are you upset?" and you say, "I don't know," and they assume you're deflecting when you're giving the most honest answer you have.
Or you're in a conversation where everyone else is identifying and articulating their emotions fluently, and you're sitting there thinking, "How do they know that? How are they so sure?"
This is alexithymia. And if you're autistic, there's a 50-65% chance you experience it. Even if you have ADHD without autism, prevalence is elevated. In the general population, it's around 10%.
Alexithymia isn't about not having emotions. It's about not being able to identify, describe, or differentiate them—even though they're happening.
And here's what makes this clinically significant: many of the emotional processing difficulties historically attributed to autism are actually explained by alexithymia, not autism itself.
Including the damaging stereotype that autistic people lack empathy.
What alexithymia actually is
Alexithymia—from Greek a (without), lexis (words), thymos (emotion)—literally means "no words for feelings."
It was first described by psychiatrist Peter Sifneos in 1973, but the concept has gained substantial traction in autism research over the past decade.
Alexithymia has three core components:
1. Difficulty identifying feelings
You experience a physiological sensation but can't label it. Your chest is tight, your breathing is shallow, your muscles are tense—but you can't tell if that's anxiety, anger, sadness, or something else.
2. Difficulty describing feelings to others
Even if you have some sense of what you're feeling, you can't find the words to communicate it. Conversations about emotions feel impossibly vague. You might default to "good," "bad," "fine," or "I don't know" because nothing more specific is accessible.
3. Externally oriented thinking
Your cognitive style focuses on external facts and events rather than internal emotional experiences. You're more comfortable talking about what happened than how it made you feel. Introspection doesn't come naturally.
Not everyone with alexithymia experiences all three components equally. Some people can identify emotions but can't describe them. Others can describe emotions in general terms but can't identify their own in the moment.
The experience is also inconsistent. You might be able to recognize anger easily but struggle with sadness. Or you might identify emotions accurately when they're mild but lose the ability when they intensify.
The alexithymia hypothesis: reframing autism's "empathy problem"
For decades, autism was characterized by difficulties with empathy, emotional recognition, and social-emotional reciprocity. Autistic people were described—often clinically—as having reduced ability to understand or share others' emotions.
This was always contested by autistic people themselves, who consistently reported experiencing deep emotion, intense empathy, and emotional overwhelm.
The discrepancy led researchers to investigate whether the issue was truly empathy or something else.
Enter the alexithymia hypothesis, developed by neuroscientist Geoffrey Bird and colleagues.
The hypothesis proposes that many emotional processing differences attributed to autism are actually explained by co-occurring alexithymia—not by autism itself.
Multiple studies have now demonstrated this:
When you control for alexithymia, many of the emotional recognition deficits previously attributed to autism disappear
Autistic people without alexithymia don't show the same emotional processing difficulties
Non-autistic people with alexithymia show similar difficulties to autistic people with alexithymia
In other words: the issue isn't autism. The issue is alexithymia.
A 2016 study by Shah, Hall, Catmur, and Bird, published in Cortex, found that alexithymia—not autism—was associated with impaired interoception (the ability to sense internal body states). Autistic participants without alexithymia performed as well as neurotypical participants on interoceptive tasks.
A 2018 study by Murphy and colleagues reinforced this, showing that alexithymia, not autism, predicted difficulty recognizing one's own emotions.
The clinical implications are significant: if you're autistic and struggling with emotional awareness, the primary driver might not be your autism—it might be alexithymia. And alexithymia, unlike autism, is something that can potentially be addressed with specific interventions.
Why autistic people have high rates of alexithymia
If alexithymia is distinct from autism, why do 50-65% of autistic people experience it compared to 10% of the general population?
The answer isn't entirely clear, but several mechanisms are likely:
Interoceptive differences
Emotions are physical before they're cognitive labels.
Anxiety is a racing heart, shallow breathing, tight chest.Sadness is heaviness, low energy, constricted throat.Anger is heat, muscle tension, surging energy.
If your interoceptive system—your ability to sense internal body signals—is disrupted (which it is in many autistic and ADHD individuals), you're missing the foundational data needed to identify emotions.
You might be experiencing a strong physiological response, but without clear interoceptive signals, you can't decode what emotion that response represents.
Developmental factors
Many autistic children aren't taught emotion vocabulary in the same way neurotypical children are. Caregivers, teachers, and peers make assumptions about what autistic children are feeling—and those assumptions are often wrong.
An autistic child might be experiencing sensory overload (a physical state) and be told they're "angry" or "defiant" when neither is accurate. Over time, this creates a disconnect between internal experience and emotion labels.
Alexithymia as protective mechanism
There's emerging evidence that alexithymia can develop as a response to trauma or chronic invalidation.
If your emotions were consistently misunderstood, dismissed, or punished in childhood, disconnecting from them becomes adaptive. You stop trying to identify feelings because doing so didn't lead to support—it led to more confusion or harm.
For autistic people who experienced significant childhood trauma (which is disproportionately high in autistic populations), alexithymia may be partially learned.
The interoception-alexithymia-autism connection
Interoception—the sense that tells you what's happening inside your body—is the foundation of emotional awareness.
Before you can label an emotion, you have to sense it physically.
Research consistently shows that autistic individuals have reduced interoceptive accuracy. A 2025 meta-analysis in Frontiers in Psychiatry synthesized 31 studies and found significant interoceptive deficits across autistic populations.
Here's how this creates alexithymia:
Your body generates an emotional response (physiological arousal)
Your interoceptive system is supposed to sense that response and send the information to your brain
Your brain is supposed to interpret those signals and assign an emotion label
In alexithymia, step 2 or step 3 fails
You might be receiving weak or inconsistent signals (interoceptive disruption), or you might be receiving signals but your brain can't interpret them accurately (alexithymia-specific processing difference).
Either way, the emotion label doesn't form.
This is why body-based interventions—somatic therapy, interoceptive awareness training, mindfulness practices focused on sensation rather than emotion—are often more effective than traditional talk therapy for alexithymia.
You can't talk about feelings you can't sense.
Why traditional talk therapy fails for alexithymia
Most therapeutic approaches assume a baseline level of emotional awareness.
Cognitive Behavioral Therapy (CBT) asks you to identify the thought that triggered the feeling. But if you can't identify the feeling, you can't work backward to the thought.
Psychodynamic therapy explores the emotional meaning of experiences. But if you can't access the emotional layer of experience, the exploration has no material to work with.
Even person-centered or emotion-focused therapies—designed to be gentle and client-led—rely on the client being able to articulate internal emotional states.
The therapist asks: "What came up for you when that happened?"
And the honest answer is: "I have no idea."
This creates a therapeutic impasse. The therapist might interpret the "I don't know" as resistance, avoidance, or intellectualization. They might push harder: "Just sit with it. What do you notice in your body?"
But if your interoceptive system isn't sending clear signals, sitting with it doesn't produce clarity. It produces more frustration.
For people with alexithymia, traditional talk therapy can feel like being asked to describe a color you've never seen. You understand that other people can do it. You can tell it matters. But you don't have access to the perceptual data required.
This is why so many neurodivergent people—particularly autistic people—report years of therapy that "didn't work." It's not that therapy is inherently ineffective. It's that the therapeutic approach wasn't matched to their neurological profile.
What actually helps: alexithymia-informed approaches
1. Start with interoceptive awareness, not emotion labels
If you can't reliably sense your body, you can't reliably identify emotions. Interoceptive training comes first.
This looks like:
Noticing body sensations without trying to label them emotionally (heart rate, temperature, muscle tension, breathing depth)
Tracking patterns: "When X happens, I notice Y in my body"
Using interoceptive scales: "On a scale of 1-10, how activated does my body feel right now?" (You don't have to know the emotion, just the intensity)
Kelly Mahler's Interoception Curriculum is specifically designed for this. It teaches you to notice body signals first, then connect them to contexts, and only later connect them to emotion labels.
2. Use emotion wheels and visual tools
When asked "How do you feel?" your brain might go blank. But when shown an emotion wheel with dozens of specific emotion words, you might be able to point to one that approximates the experience.
Visual tools provide external scaffolding for a process that doesn't happen automatically internally.
Start broad: Is this feeling pleasant, unpleasant, or neutral?Then narrow: Is it high energy or low energy?Then choose from a short list: Frustrated, anxious, sad, tired?
This systematic approach bypasses the expectation that you'll spontaneously generate an emotion label.
3. Track physical sensations instead of emotions
If emotion identification isn't accessible, track body states:
Energy level (1-10)
Muscle tension (where in body, how intense)
Heart rate (fast, normal, slow)
Temperature (hot, cold, comfortable)
Breathing (shallow, deep, rapid, slow)
Over time, patterns emerge: "When my chest is tight and my breathing is shallow, that's usually anxiety. When my whole body feels heavy and moving is hard, that's usually sadness."
You're building an emotion vocabulary from the bottom up—sensation to label—rather than expecting the label to appear fully formed.
4. Externalize emotional processing
For people with externally oriented thinking, internal reflection doesn't produce results. External tools do.
Write it out. Talk it out. Draw it. Move it. Use metaphor. Use music.
Some people with alexithymia can't tell you how they feel but can show you a song that matches the internal state. Or they can describe it in terms of weather, color, or physical objects.
These aren't inferior forms of emotional expression. They're adaptive workarounds for a system that doesn't process emotion in the standard way.
5. Somatic and body-based therapies
Therapeutic approaches that don't rely on emotion labeling:
Somatic Experiencing (SE) - Focuses on completing physiological responses to stress/trauma without requiring cognitive processing or emotion labels
EMDR (Eye Movement Desensitization and Reprocessing) - Processes traumatic memories through bilateral stimulation while noticing body sensations, doesn't require articulating emotions
Sensorimotor Psychotherapy - Directly addresses how trauma lives in the body through movement and sensation rather than narrative
Hakomi - Mindfulness-based somatic therapy that works with body awareness and present-moment experience
These modalities meet you where your system actually is—in the body—rather than expecting you to translate body experience into emotion words before healing can happen.
6. Differentiate "I don't know what I feel" from "I don't want to talk about it"
Alexithymia is often misinterpreted as emotional avoidance.
If someone asks how you feel and you say "I don't know," they might hear:
"I don't want to tell you"
"I'm being difficult"
"I'm shutting you out"
When what you actually mean is: "I genuinely cannot identify what I'm feeling right now."
Teaching people in your life the difference matters. Alexithymia isn't withholding. It's a neurological difference in emotional processing.
You can say: "I have alexithymia, which means I often can't identify my emotions in the moment. It's not that I don't want to talk—I literally don't have the information yet. Can we revisit this in [timeframe] after I've had time to process?"
7. Accept that some emotional experiences won't have labels
Not every internal state maps neatly to an emotion word.
Sometimes you're experiencing something real, significant, and meaningful—and there's no single English word that captures it.
That doesn't mean the experience is invalid. It means language is limited.
You can communicate in approximations: "It's like sadness but also relief?" "It's closer to overwhelm than anxiety." "I don't have a word for it, but it feels important."
The trauma connection
Alexithymia rates are elevated not just in autism but also in populations with trauma histories—particularly complex trauma and childhood emotional neglect.
When your emotions were consistently invalidated, ignored, or punished, disconnecting from them becomes protective. If expressing sadness led to being told you were "too sensitive," and expressing anger led to punishment, and expressing fear led to dismissal, your system learns that identifying emotions is unsafe.
Over time, the skill atrophies. You stop being able to identify feelings because identifying them never led to anything helpful.
For autistic people who experienced significant invalidation (which is common—autistic children's emotions are often misread or pathologized), alexithymia may be partially developmental and partially protective.
This matters clinically because trauma-informed therapy that addresses the relational context of emotional disconnection can sometimes reduce alexithymia, whereas approaches that treat it as purely neurological may miss a treatable component.
Alexithymia in ADHD
While alexithymia research has focused primarily on autism, there's emerging recognition that ADHD populations also show elevated rates.
The mechanisms are somewhat different:
In ADHD, alexithymia may be related to:
Executive dysfunction affecting emotional processing (slower processing speed, difficulty with complex internal analysis)
Emotional dysregulation making it hard to identify emotions when they're intense
Impaired working memory making it difficult to hold an emotion steady long enough to examine and label it
Interoceptive disruption (ADHD brains don't reliably register body signals)
For AuDHD individuals, you get both sets of mechanisms simultaneously—autistic interoceptive and social-emotional processing differences plus ADHD executive function and regulation challenges.
The combination often creates profound alexithymia that's particularly treatment-resistant with standard approaches.
If you're just figuring this out
If you're reading this and thinking, "I thought everyone struggled to identify their feelings the way I do," you're not alone.
Alexithymia is under-recognized, under-diagnosed, and rarely discussed outside academic circles—despite affecting a significant portion of the neurodivergent population.
You've probably spent years being told:
"You're emotionally unavailable"
"You need to open up more"
"You're intellectualizing your feelings"
"Just tell me how you feel"
And none of those statements acknowledged that you literally couldn't do what was being asked.
Now you have language for it.
Alexithymia isn't emotional unavailability. It's not resistance. It's not a character flaw.
It's a difference in how your brain processes internal emotional information.
And while it creates real challenges—in relationships, therapy, self-regulation—it's also something you can work with once you understand what you're working with.
You're not broken. Your emotional processing system just works differently. And there are approaches designed for exactly that difference.
If you're neurodivergent and struggling with alexithymia, difficulty identifying emotions, or feeling like traditional therapy isn't working because you can't access your feelings, I offer free 60-minute Clarity Sessions. We'll look at what's happening in your system and what body-based or alternative approaches might help. You can book at https://drmel1.podia.com/1-1-life-transformation-coaching .
For ongoing support, single Life Transformation Coaching sessions are available on my platform using somatic and subconscious techniques that don't require emotion labeling before change can happen. International, online, flexible. https://drmel1.podia.com/life-transformation-coaching-session
Download the free guide: https://drmel1.podia.com/alexithymia-toolkit
REFERENCES AND FURTHER READING
Academic & Clinical Sources:
Bird, G., & Cook, R. (2013). Mixed emotions: The contribution of alexithymia to the emotional symptoms of autism. Translational Psychiatry, 3(7), e285.Landmark paper on the alexithymia hypothesis
Kinnaird, E., Stewart, C., & Tchanturia, K. (2019). Investigating alexithymia in autism: A systematic review and meta-analysis. European Psychiatry, 55, 80-89.
Murphy, J., Brewer, R., Hobson, H., Catmur, C., & Bird, G. (2018). Is alexithymia characterised by impaired interoception? Further evidence, the importance of control variables, and the problems with the Toronto Alexithymia Scale. Journal of Psychosomatic Research, 107, 31-40.
Shah, P., Hall, R., Catmur, C., & Bird, G. (2016). Alexithymia, not autism, is associated with impaired interoception. Cortex, 81, 215-220.Critical study separating alexithymia from autism
Sifneos, P. E. (1973). The prevalence of 'alexithymic' characteristics in psychosomatic patients. Psychotherapy and Psychosomatics, 22(2-6), 255-262.Original alexithymia research
Taylor, G. J., Bagby, R. M., & Parker, J. D. A. (1997). Disorders of Affect Regulation: Alexithymia in Medical and Psychiatric Illness. Cambridge University Press.
2023-2025 Research:
Smith, R., Osborn, J., Wharton, A., & Allen, R. (2023). Alexithymia in adult autism clinic service-users: Relationships with sensory processing differences and mental health. Healthcare, 11(24), 3114.Found 66.3% prevalence in clinic population, links to sensory processing and depression/anxiety
DuBois, D., Lyons-Ruth, K., Mackin, M. L., Schechter, J. C., & Elias Yacoub, S. (2025). Interoception in individuals with autism spectrum disorder: A systematic literature review and meta-analysis. Frontiers in Psychiatry, 16, 1573263.Meta-analysis connecting interoception deficits to emotional processing
Kinnaird, E., Norton, C., Pimblett, C., Stewart, C., & Tchanturia, K. (2019). Eating as an autistic adult: An exploratory qualitative study. PLOS ONE, 14(8), e0221937.Explores alexithymia's role in eating difficulties
Books for General Readers:
Levine, P. (2010). In an Unspoken Voice: How the Body Releases Trauma and Restores Goodness. North Atlantic Books.Somatic Experiencing approach to trauma, useful for body-based emotional work
Mahler, K. (2022). Interoception: The Eighth Sensory System. AAPC Publishing.Foundational interoceptive awareness training, critical for alexithymia
Ogden, P., Minton, K., & Pain, C. (2006). Trauma and the Body: A Sensorimotor Approach to Psychotherapy. W.W. Norton & Company.Sensorimotor psychotherapy framework for body-based healing
Price, D. (2022). Unmasking Autism: Discovering the New Faces of Neurodiversity. Harmony.Includes discussion of emotional processing differences in autism
Van der Kolk, B. (2014). The Body Keeps the Score: Brain, Mind, and Body in the Healing of Trauma. Penguin Books.Essential reading on how trauma affects body awareness and emotional processing
Online Resources:
Embrace Autism (embrace-autism.com)Comprehensive alexithymia resources, assessment tools, and the Alexithymia & Autism Guide
Neurodivergent Insights (neurodivergentinsights.com/autism-and-alexithymia/)Dr. Megan Anna Neff's accessible explanation of alexithymia in autism, includes Alexithymia Workbook
Kelly Mahler (kelly-mahler.com)Interoception resources essential for building emotional awareness foundation
The Alexithymia Subreddit (r/Alexithymia)Peer community discussing lived experience and coping strategies
Feeling Wheel / Emotion Wheel resourcesSearch "Plutchik emotion wheel" or "feelings wheel" for visual emotion identification tools
Assessment Tools:
Toronto Alexithymia Scale (TAS-20) - Most widely used alexithymia assessment20 items, self-report, freely available onlineNote: Some researchers question its validity for autistic populations
Bermond-Vorst Alexithymia Questionnaire (BVAQ) - Alternative assessment tool
Online Alexithymia Questionnaire (OAQ-G2) - Available through Embrace Autism
Note: These are screening tools, not diagnostic instruments. Consider working with a clinician familiar with alexithymia for interpretation.
Therapeutic Approaches:
Somatic Experiencing (SE) - Peter Levine's trauma therapy focusing on body sensationDirectory: traumahealing.org
EMDR - Processes trauma through bilateral stimulation without requiring emotion labelingDirectory: emdria.org
Sensorimotor Psychotherapy - Body-centered trauma therapyDirectory: sensorimotorpsychotherapy.org
Hakomi - Mindfulness-based somatic therapyDirectory: hakomiinstitute.com
Interoceptive Awareness Training - Occupational therapy focusing on body sense development
Dialectical Behavior Therapy (DBT) - Includes emotion regulation skills with specific labeling practice
Find a Therapist:
Psychology Today - Filter for somatic therapy, trauma, autism, alexithymia
Therapy Den - Search neurodivergent-affirming, somatic practitioners
STAR Institute Provider Directory - Sensory and interoception specialists
Research & Academic Resources:
Geoffrey Bird's lab publications - Leading alexithymia-autism researcher
Cortex journal - Regularly publishes alexithymia research
Autism Research - Journal covering emotional processing in autism
Books on Emotion & Body Awareness:
Barrett, L. F. (2017). How Emotions Are Made: The Secret Life of the Brain. Houghton Mifflin Harcourt.Constructionist theory of emotion—emotions are constructed, not discovered
Damasio, A. (1994). Descartes' Error: Emotion, Reason, and the Human Brain. Putnam.Classic neuroscience text on emotion and body connection
Payne, P., Levine, P. A., & Crane-Godreau, M. A. (2015). Somatic experiencing: Using interoception and proprioception as core elements of trauma therapy. Frontiers in Psychology, 6, 93.
Crisis Resources:
If alexithymia is contributing to difficulty identifying distress, suicidal thoughts, or crisis:
SADAG (South Africa): 0800 567 567 (24-hour)International: findahelpline.comCrisis Text Line (USA): Text HOME to 741741
NOTE TO READERS:
This blog post discusses alexithymia as a dimensional trait that exists on a spectrum. Alexithymia is not a formal psychiatric diagnosis but a well-researched construct with validated assessment tools. Prevalence estimates in autism range from 40-65% depending on the study and assessment method used.
The alexithymia hypothesis—that many emotional processing difficulties in autism are explained by alexithymia rather than autism itself—is supported by multiple studies but remains an active area of research. This doesn't mean alexithymia is "the answer" to all autism-related emotional challenges, but it is a significant contributing factor for many individuals.
If you suspect you have alexithymia, consider working with a therapist who understands alexithymia specifically and can adapt their approach. Traditional talk therapy that relies on emotion identification and articulation may not be effective without modification.
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