When it comes to alexithymia, there is a lot of ambiguity, confusion, and questions. From: “what is alexithymia” to “am I born with it” to “do I have alexithymia?” to “how do I pronounce alexithymia”! In this guide to alexithymia, I will answer all of these questions and more. So let’s dive in!

What is Alexithymia?

Alexithymia is a broad term that means difficulty identifying and describing emotions. The concept of alexithymia is relatively new in all things mental health history. The term was coined by the psychoanalytic psychiatrist Peter Sifneos in 1972.

He used this term to describe his patients who struggled to perceive and describe their emotions. Sifneos, born on the Greek island of Lesbos borrowed from his native language to coin this term. In Sifneos' native Greek, the word means "without words for emotion."

Alexithymia Defined

When a person has alexithymia, it means they struggle with distinguishing between emotions and bodily sensations. Alexithymia occurs on a spectrum, and a person can have mild to severe alexithymic traits. Alexithymia is broadly considered a personality trait. While it is not a medical diagnosis, alexithymia is associated with several medical and mental health conditions.

How Common is Alexithymia?

Studies vary regarding the prevalence of alexithymia. Roughly 1 in 10 people experience alexithymia (Goerlich, 2018). However, this rate is higher among neurodivergent people (including ADHD and Autism) and those experiencing mental health conditions (such as depression, anxiety, etc.), chronic pain, and other health conditions.

What are the Core Features of Alexithymia

Different online alexithymia tests and alexithymia measures define alexithymia slightly differently. For example, the Online Alexithymia Test includes 7 different dimensions, while the Toronto Alexithymia Scale includes fewer.

Within the alexithymia literature, the following dimensions are broadly considered as core features of alexithymia. It is important to note that a person may have high alexithymia traits in one area but low alexithymia traits in other areas.

• Difficulties identifying and describing feelings

• Difficulty differentiating between typical bodily processes (hunger cues, exhaustion) and emotions (anxiety, sadness)

• An externally oriented cognitive style (paying more attention to external things happening around you than to internal experiences

• Challenges generating mental images and fantasies

Alexithymia Occurs on a Spectrum

Similar to how Autistic and ADHD traits exist on a spectrum. Alexithymia also occurs on a spectrum. A person can have low to severe alexithymic traits. There are also several different factors of alexithymia. The Online Alexithymia Measure captures seven areas where a person may experience alexithymic traits. A person may have alexithymia in some areas but not in others. The most common areas of alexithymia for Autistic and ADHD people are difficulties in identifying and describing feelings. The following pages provide an overview of the seven different areas a person may experience alexithymic traits.

For more of a deep dive into alexithymia you can check out the ADHD, Autism, and Alexithymia workbook.

Primary Vs. Secondary Alexithymia

A person can have primary (trait) alexithymia, secondary (state situational, temporary) alexithymia, or both.

Primary alexithymia (also referred to as trait alexithymia) is an innate, stable personality trait that is present from birth and consistent across time and situations. It is considered a part of a person's baseline personality. Trait alexithymia likely has environmental and genetic components.

Secondary alexithymia (also referred to as state alexithymia) is temporary and/or situational alexithymia. State alexithymia often results from life circumstances or a recent medical diagnosis (for example, in the case of PTSD, a person may have a season of alexithymia).

What Causes Alexithymia?

Alexithymia is primarily considered a personality trait, which likely results from the complex interplay of nature (family environment, early attachments) and nature (genetics).

Genetics: genetic factors such as neurodevelopmental differences, interoception and proprioception issues, sensory processing disorders, and more can make it more difficult for a person to perceive and identify subtle shifts in the body (emotions). Interoception difficulties play a significant role in alexithymia. In fact, some researchers have suggested alexithymia is ultimately an issue of interoception (Brewer, Cook, and Bird, 2016).

Nurture: Early environment can also play a role in the development of alexithymia. How available early attachment figures were, how much emotions and emotional labeling were modeled in the home, and the general emotional tone of the home can all impact a person’s ability to perceive and register emotions.

The Alexithymia Wheel

In the same way that the Autistic and ADHD wheel has become helpful metaphors for understanding the diverse ways autism and ADHD can present, I find that thinking about alexithymia as a “wheel” is a helpful framework.

Alexithymia Occurs on a Spectrum

Similar to how Autistic and ADHD traits exist on a spectrum. Alexithymia also occurs on a spectrum. A person can have low to severe alexithymic traits. There are also several different factors of alexithymia. The Online Alexithymia Measure captures seven areas where a person may experience alexithymic traits. A person may have alexithymia in some areas but not in others. The most common areas of alexithymia for Autistic and ADHD people are difficulties in identifying and describing feelings. The following is an overview of the seven different areas a person may experience alexithymic traits.

1. Difficulty Identifying Feelings: People who experience difficulty identifying emotions experience confusion about their internal experiences, including emotions. Their bodily sensations often cause confusion, and they struggle to distinguish between emotions and bodily sensations (for example, the difference between hunger and anxiety). The ability to identify emotions plays a key role in our ability to regulate emotions. Difficulty in this area has been linked with depression, non-suicidal self-harm, and suicidal behavior (Cerutti et al., 2018).

2. Difficulty Describing Feelings: While difficulty describing feelings sounds similar to identifying feelings, it is slightly different. Difficulty describing feelings refers to difficulty with:

   • finding words for your feelings and

   • being able to express these feelings to others

   People who struggle with this often experience difficulty labeling emotions and finding the right words to describe their feelings. Descriptors of emotions may be vague, general, and diffuse. Difficulty describing emotions is associated with more relationship difficulty.

3. Externally oriented thinking: Externally oriented thinking occurs when a person's thought process is focused externally (vs. internally). An externally oriented thinker focuses their energy on external events and tends to avoid focusing on internal experiences. When a person has high alexithymic traits in this area, it means they experience difficulty attending to their own emotions and inner states. Externally oriented thinking has been linked with a reduced ability to experience positive emotions, which can contribute to depression and other mood concerns.

4. Vicarious Interpretation of Feeling: Vicarious emotions refers to the experience of feeling other people's feelings alongside them. An example of vicarious emotions is when you experience a strong emotion when you learn something has happened to someone else (an emotion that mirrors what they felt). These experiences are often referred to as affective empathy (the experience of feeling alongside the other). This ability to understand what others are experiencing is a key role in developing relationships and creating strong interpersonal connections. (Note: Vicarious interpretation of feelings is not always considered a core component of alexithymia, although it is often correlated or linked with the core dimensions of alexithymia).

5. Restricted Imaginative Processes: Many people with alexithymia (but not all) have a diminished fantasy life with limited imaginative capacities. Such people tend to be oriented toward the concrete world of facts and pragmatics with little interest in fantasy and imaginative processes. They may have little interest in fantasy, creative efforts, and art. They also are unlikely to spend time daydreaming. (Note: This is not always considered a core feature of alexithymia).

6. Interpersonal Relationship Difficulties: (Note: These last two subscales, problematic interpersonal relationships, and sexual difficulties/disinterest, aren’t specifically part of the formal definition of alexithymia but often correlate with alexithymia). Alexithymia has been linked to difficulties with empathy (difficulty perceiving other people's perspectives and understanding their feelings and intentions) (Goerlich, 2018), which negatively influences relationships (the ability to make and deepen relationships). One study found that it was alexithymia rather than autism that led to difficulties in cognitive and affective empathy. Autistic people who did not also have alexithymia did not have the same struggles with empathy as Autistic people with alexithymia. This has led some researchers to believe it is alexithymia and not autism that results in difficulty with empathy (Bird and Viding, 2014).

7. Sexual Difficulties and Disinterest: While not a primary feature of alexithymia, alexithymia is often connected to reduced sexual satisfaction and greater detachment from potential sexual partners. It is also associated with sexual shyness and nervousness. This may be related to several factors: 1) alexithymia is associated with more negative emotion, which appears to impact sexual attitudes, and 2) alexithymia often results in a greater and more avoidant/detached attachment structure, which lends to a more avoidant sexual style (Scimeca et al., 2013). People with alexithymia are also more likely to identify as asexual (source). This may be one reason there is a higher rate of asexual people within the Autistic population.

How Do I know if I Have alexithymia?

Two online measures widely used include the Alexithymia Online Test and Toronto Alexithymia Scale. The online alexithymia test mirrors the traits mentioned above and will show you your range (from no alexithymia traits to severe).

Alexithymia Online Test

Pros: Will provide you with visual results (show your results on bars and provides your scores in 7 different areas

Cons: Is not widely used in medical research

Link: https://www.alexithymia.us/test-alexithymia

Toronto Alexithymia Scale (TAS-20)

Pros: The Toronto (TAS-20) is more widely accepted and used in medical research and has been normed in clinical trials.

Cons: The feedback does not provide the same level of detailed results as the Online Alexithymia Test.

Link: https://embrace-autism.com/toronto-alexithymia-scale/

Summary

Alexithymia is broadly considered a personality trait. It develops from a complex intersection of nature (genetics) and nurture (environment). Core features of alexithymia includes: difficulty identifying emotions, difficulty describing emotions, external oriented thinking, difficulty with imagination, a reduced vicarious interpretation of emotion. Additionally, relationship difficulty and sexual disinterest/difficulty is associated with alexithymia.

About 10% of people have alexithymia, however, the prevalence is higher among ADHDers, and Autistic people, and people with depression and other mental health conditions. To learn more about the relationship between ADHD, Autism, and Alexthymia you can check out the full workbook over here.