Alexithymia
Imagine a room in a house, with sounds coming from behind the door.
You can hear that something is happening in there. You can hear the sound is big. You press your ear to the door and you know it matters, whatever it is. But the door is locked, and the label that usually hangs on the front of it has fallen off, and you genuinely cannot tell if what you're hearing is music or crying or an argument or a party.
That is a little like what alexithymia feels like.
Alexithymia (say it: alex-ih-THEEM-ee-ah) is difficulty identifying and naming your own emotions. It doesn't mean you don't have feelings. It means the path between having a feeling and knowing what the feeling is called can be very unclear.
You might know that something is happening. Your chest is tight. Your stomach has gone strange. Something is different from usual, and it is not comfortable. But when someone asks "how are you feeling?", the most accurate answer you have is: "I'm not sure."
That is a valid answer.
The word was coined in 1972 by the psychiatrist Peter Sifneos, working with his colleague John Nemiah. He built it from Greek: a (without), lexis (words), thymos (emotion or feeling). Without words for feeling. The name describes the experience with unusual precision.
It is worth separating alexithymia carefully from two things it is often confused with. The first is not caring about others. Many autistic people with alexithymia care a great deal about the people around them; they simply have difficulty identifying, in the moment, what they themselves are feeling, and this can make it harder to express. The second is not having feelings. The feelings are present. The difficulty is the naming.
Alexithymia occurs in roughly half of autistic people, compared to around ten percent of the general population. An important finding, emerging from research in recent years, is that many of the emotional processing difficulties that have historically been attributed to autism specifically, including difficulties with empathy and emotional reciprocity, are better explained by co-occurring alexithymia than by autism itself. This is a significant reframe: autism and alexithymia are distinct, frequently overlapping, and the conflation of the two has led to inaccurate portraits of autistic emotional life for decades.
The connection to interoception, covered in the previous chapter, is close. Emotions are partly physical events: the racing heart, the cold in the stomach, the constriction in the throat. If interoceptive signals are harder to read in the first place, naming the emotions they signal becomes harder too. Alexithymia can be thought of, in part, as a downstream effect of the body not speaking quite the right language.
What this means practically is that "how are you feeling?" can be a genuinely difficult question, and the answer "I don't know" can be genuinely honest rather than evasive. Tools that give a different entry point into emotion, colour scales, body maps (where do you feel something? point to it), simplified emotion wheels, numbered intensity scales, can sometimes help bridge the gap between experience and expression when words alone don't reach.
- Accepting "I don't know" as a genuine and complete answer, rather than a deflection.
- Offering alternatives to the question "how do you feel?" (try: "where do you feel it in your body?" or "is it closer to a 2 or a 7 today?").
- Using visual tools (colour scales, emotion faces, body maps) as bridges into emotional communication.
- Asking specific, concrete questions rather than open-ended ones: "does something feel wrong?" rather than "are you okay?".
- Insisting the child must know how they feel and just won't say.
- Reading blankness or flatness as indifference.
- Pressing for emotional articulation in the moment of distress, when words are least available.
- Treating the difficulty as something to be overcome through willpower.