Roughly half of autistic people also meet the threshold for alexithymia, a trait characterized by difficulty identifying and describing one’s own emotions. In the general population, that rate hovers around five percent. The overlap is so substantial that researchers have spent the past decade trying to untangle which emotional and social difficulties stem from autism itself and which are better explained by alexithymia riding alongside it. The answer has real consequences for how clinicians understand autistic experience and which interventions actually help.
How Common Is Alexithymia Among Autistic People?
A systematic review and meta-analysis pooling data across multiple studies found that about 50% of autistic participants scored above the clinical cutoff for alexithymia, compared to roughly 5% of non-autistic participants.1PubMed Central. Investigating alexithymia in autism: A systematic review and meta-analysis Individual studies in that analysis reported prevalence rates ranging from about 33% to 63% among autistic groups. The overall risk ratio was 6.5, meaning autistic people were roughly six and a half times more likely to meet criteria for alexithymia than non-autistic people.
That said, “roughly half” means roughly half do not have alexithymia. Autism and alexithymia are distinct constructs that happen to co-occur at high rates. They are not the same thing, and neither one inevitably leads to the other. This distinction matters because the emotional profile of an autistic person with alexithymia can look quite different from the profile of an autistic person without it.
The Alexithymia Hypothesis
For a long time, clinicians and researchers attributed a wide range of emotional difficulties directly to autism: trouble reading facial expressions, muted empathic responses, poor awareness of one’s own bodily states. A growing body of research now argues that many of these difficulties are better explained by alexithymia than by autism per se. This idea is sometimes called the “alexithymia hypothesis,” and it has gathered strong support from studies that carefully measure both traits and ask which one actually predicts the outcome in question.
The logic is straightforward. If you study a group of autistic people without controlling for alexithymia, and you find that the group struggles with emotion recognition, you might assume that’s an autism thing. But if you then separate the autistic people who have alexithymia from those who don’t, the picture often changes. The emotional difficulty tracks with alexithymia levels, not autism levels. The autism diagnosis, on its own, stops being a reliable predictor once alexithymia is accounted for.
Reading Faces and Recognizing Emotions
Facial emotion recognition is one area where the alexithymia hypothesis has been tested repeatedly. A study of autistic adult women found that higher levels of alexithymia, but not the severity of autism traits, predicted less accuracy in identifying emotions on faces.2PubMed Central. Facial emotion recognition in autistic adult females correlates with alexithymia, not autism Specifically, difficulty identifying one’s own feelings and a tendency toward externally oriented thinking were the facets of alexithymia most closely tied to poorer emotion recognition accuracy.
Neuroimaging work tells a complementary story. When researchers measured brain responses to emotional and neutral faces, alexithymic traits, rather than autistic traits, modulated how the brain processed the emotional content of those faces at a neural level.3PubMed Central. Autistic and alexithymic traits modulate distinct aspects of face perception People with higher alexithymia scores showed faster neural responses to neutral faces, suggesting their brains process social-emotional information differently in ways that are tied to the alexithymia component rather than to autism alone.
This doesn’t mean autism has zero relationship with social perception. Autistic traits can affect other aspects of face processing, like attention to faces or how gaze patterns unfold. But the specific ability to decode what emotion a face is expressing appears to be largely an alexithymia story.
The Role of Interoception
Interoception is your brain’s ability to sense what’s going on inside your body: a racing heartbeat, a churning stomach, the warmth of a blush. It’s the foundation for how most people come to recognize their own emotions, because emotions are partly built on these bodily signals. If you can’t easily feel your heart pounding, you may not register that you’re anxious.
A study that measured interoceptive accuracy in autistic and non-autistic adults found that alexithymia, not autism, was associated with impaired interoception.4PubMed Central. Alexithymia, not autism, is associated with impaired interoception Autistic traits on their own didn’t explain a significant portion of the variation in how well people could detect their own internal signals. Once alexithymia was accounted for, the connection between autism and poor interoception largely disappeared.
This finding is important because it helps explain why alexithymia makes emotions hard to identify. If the bodily signals that normally give emotions their felt quality are muted or harder to detect, the person is left trying to figure out their emotional state from context alone, which is a much harder task. It also suggests that interoception might be a useful target for intervention, a point we’ll return to later.
What Happens in the Brain
The anterior insula, a region deep inside the brain, consistently shows up in research on both empathy and interoception. It acts as a kind of hub where bodily signals get integrated with emotional meaning. In a study examining empathic brain responses, activity in the left anterior insula when watching another person in pain was negatively correlated with alexithymia scores in both autistic and non-autistic groups. The higher a person’s alexithymia, the less their insula activated during empathic processing, and this held regardless of whether the person was autistic.5Brain. Empathic brain responses in insula are modulated by levels of alexithymia but not autism
Further neuroimaging work has found that autistic individuals show different patterns of connectivity between the anterior insula and other brain regions when viewing facial expressions, and that alexithymia specifically alters the way the insula communicates with areas involved in self-referential thought and attention.6PubMed Central. The relationship between alexithymia, interoception, and neural functional connectivity during facial expression processing in autism spectrum disorder In other words, autism may shape the broader architecture of social brain networks, but alexithymia fine-tunes the emotional processing within those networks.
Depression and Mental Health
Autistic adults experience depression at elevated rates, and for years the assumption was that the social difficulties inherent to autism drove much of that risk. Recent evidence complicates this picture considerably. A study that measured both autistic traits and alexithymia traits in autistic adults found that difficulty identifying feelings was the single strongest predictor of depression severity, accounting for half of the explained variance.7Scientific Reports. Alexithymia traits outweigh autism traits in the explanation of depression in adults with autism Difficulty describing feelings also contributed. Autistic traits themselves did not meaningfully add to the prediction of depression once alexithymia was in the model.
This has practical implications. If alexithymia is a stronger driver of depression in autistic people than autism traits per se, then therapeutic approaches aimed at helping someone identify and describe their emotions may do more to reduce depression than approaches focused solely on social skills or autism-related support. It also means that depression screening in autistic populations might benefit from including alexithymia measures, so clinicians can identify who is at highest risk.
Gender Differences in the Overlap
The connection between alexithymia and autism is not experienced identically across genders. A large study found that 47% of autistic women met the clinical cutoff for alexithymia, compared to 21% of autistic men.8PubMed Central. Alexithymia in autism: cross-sectional and longitudinal associations with social-communication difficulties, anxiety and depression symptoms Both rates are far above the general population average, but the gap between autistic women and autistic men is striking.
Several explanations have been proposed for this disparity. Autistic women are more likely to camouflage, meaning they consciously mask their autistic traits to fit social expectations. The sustained effort of monitoring and suppressing one’s natural responses may contribute to a kind of emotional disconnection over time. There’s also the possibility that women who reach an autism diagnosis tend to have more complex presentations overall, including higher rates of co-occurring conditions like anxiety and depression, both of which are linked to alexithymia independently.
Whatever the cause, the gender difference is relevant for clinicians. An autistic woman presenting with emotional difficulties, social withdrawal, or chronic stress may look different from the textbook autistic profile if her presentation is shaped more by alexithymia than by the social-communication features typically associated with autism.
How Alexithymia and Autistic Traits Interact With Empathy
A common misconception about autistic people is that they lack empathy. Research increasingly suggests the picture is more nuanced, and that alexithymia is the variable that matters most when parsing empathic abilities. A network analysis examining the interplay between autistic traits, alexithymia, and empathy found that difficulties identifying and describing feelings served as the key bridging nodes connecting the two conditions.9Personality and Individual Differences. Exploring the interactions between autistic traits, alexithymia and empathy: A network analysis In plain terms, the specific alexithymia features of not being able to name or articulate what you’re feeling act as the channel through which autistic traits and emotional processing difficulties feed into each other.
The same analysis found that self-oriented and other-oriented forms of empathy behaved differently. Personal distress, a form of self-oriented empathy where you feel overwhelmed by another person’s suffering, showed positive connections with difficulty identifying emotions and with communication difficulties. But cognitive empathy, the ability to intellectually understand what someone else is feeling, and empathic concern, actually caring about their wellbeing, showed negative links with externally oriented thinking, a facet of alexithymia characterized by focusing outward on facts and events rather than inward on feelings. In other words, autistic people who don’t have that outward-facing cognitive style tend to maintain their cognitive empathy and compassion.
This matters because it pushes back against the flat stereotype. Many autistic people feel deeply and care intensely about others. The ones who struggle most with empathic engagement tend to be those who also have high alexithymia. When clinicians or family members attribute a perceived empathy gap to autism itself, they may miss the actual driver and therefore miss the intervention that could help.
Measurement Problems
Almost all of the research on alexithymia in autism relies on the Toronto Alexithymia Scale (TAS-20), a 20-item self-report questionnaire. There’s a fundamental tension here: the TAS-20 asks people to report on their own emotional awareness, but alexithymia by definition means impaired awareness of emotions. Asking someone who can’t identify their feelings to rate how well they identify their feelings introduces obvious circularity.
A study comparing self-report scores on the TAS-20 with observer-rated assessments of alexithymia found that both measures detected higher alexithymia in autistic adults, but the two measures did not correlate with each other.10PubMed. Objective and Subjective Measurement of Alexithymia in Adults with Autism In other words, what a clinician observes and what the person self-reports may be capturing different facets of the same trait, or possibly related but distinct phenomena.
The internal structure of the TAS-20 also shows cracks when used with autistic populations. A psychometric investigation using a large autistic sample found that the full 20-item scale didn’t fit well as a measurement model, and that the “externally oriented thinking” subscale in particular had very poor reliability.11PubMed Central. Improving the measurement of alexithymia in autistic adults: a psychometric investigation and refinement of the twenty-item Toronto Alexithymia Scale The two subscales capturing difficulty identifying feelings and difficulty describing feelings performed much better. This suggests that when researchers report alexithymia rates in autistic people, the numbers are most trustworthy for those emotional identification and description components, and less reliable for the externally oriented thinking component.
These measurement limitations don’t invalidate the research linking alexithymia to autism. The convergence across self-report, observer-rated, neuroimaging, and behavioral studies is strong enough that the core overlap is not in serious doubt. But the exact prevalence rates should be understood as estimates shaped by imperfect tools, and future research using improved instruments may revise the numbers.
Interoception Training as an Intervention
If alexithymia is partly rooted in poor interoceptive awareness, then training people to better sense their internal bodily states could, in theory, improve emotional clarity and reduce alexithymia. This idea has gained traction in autism research. A study of autistic adults found results consistent with the notion that interoceptive training may enhance emotional clarity and reduce alexithymia, with the authors arguing for significant implications in treatment planning.12PubMed Central. Emotional Dysfunction and Interoceptive Challenges in Adults with Autism Spectrum Disorders
That said, the evidence base is still thin. A pilot study testing an online interoception program for autistic adults found improvements in interoceptive awareness, alexithymia, anxiety, and quality of life, but the changes were not statistically significant, though effect sizes ranged from small to large across the different outcomes.13PubMed Central. Autistic Adult Online Interoception Feasibility Pilot Program The study was primarily a feasibility test, designed to show that such a program is workable rather than to definitively prove it helps. That’s typical for an area of research this young: the direction looks promising, but the robust evidence hasn’t arrived yet.
Interoception-based approaches represent a departure from older therapeutic models in autism. Rather than training social skills or behavioral compliance, they aim to help autistic people understand their own emotional landscape from the inside out. For someone whose primary struggle is “I know something is happening in my body, but I don’t know what it means,” this kind of approach is a much better match than social skills classes.
Why the Distinction Matters Beyond Research
For autistic people navigating everyday life, knowing whether you have co-occurring alexithymia can change how you understand yourself. An autistic person without alexithymia may feel emotions vividly and have no trouble naming them, but struggle with the social mechanics of expressing them in ways others expect. An autistic person with alexithymia faces a different challenge: the internal emotional signal itself is unclear, murky, or absent. These are fundamentally different experiences even though both people share an autism diagnosis.
The distinction also matters for relationships. Partners, family members, and friends of autistic people sometimes interpret a lack of emotional expression as a lack of emotional experience. When alexithymia is part of the picture, the reality may be closer to “I’m feeling something but I literally can’t tell what it is,” which is a very different situation from not caring. Being able to name alexithymia as a separate factor can help people close to an autistic person understand what’s actually happening and avoid misattributing emotional absence to autism as a whole.
In clinical settings, the overlap affects diagnosis in both directions. Some people with high alexithymia and no autism get misidentified as autistic because their flat emotional presentation and social difficulties mimic autistic features. Conversely, autistic people whose alexithymia drives their emotional struggles may not receive targeted help because clinicians assume the difficulties are simply “part of autism” and therefore not separately addressable. Neither outcome serves the person well.
Alexithymia as a Transdiagnostic Trait
Alexithymia is not unique to autism. It shows up at elevated rates in depression, anxiety disorders, eating disorders, substance use disorders, PTSD, and several other conditions. It is better understood as a transdiagnostic trait, one that cuts across many diagnostic categories and may serve as a vulnerability factor for emotional difficulties regardless of the primary diagnosis.
In autism, though, the co-occurrence rate is unusually high compared to most other conditions. Why this is the case remains an open question. One possibility is that early developmental differences in sensory processing or social learning, both of which are features of autism, create conditions under which alexithymia is more likely to develop. Another is that shared genetic or neurobiological factors predispose a person to both. A third possibility is that the chronic stress and social exclusion many autistic people experience throughout life contributes to emotional numbing and reduced emotional awareness over time. These explanations are not mutually exclusive, and the answer likely involves some combination of all three.
Understanding alexithymia as transdiagnostic helps explain why it bridges autism and conditions like eating disorders, where body awareness and emotional regulation are also disrupted. A person diagnosed with both autism and an eating disorder may find that alexithymia is a common thread running through both, and addressing it could have ripple effects across multiple areas of difficulty.