Alexithymia: When Emotions Cannot Find Words

Article written in collaboration with  @dott.ssamartinamarano

Introduction

Many people find themselves answering "I'm fine" or "I don't know" when asked how they feel — not out of unwillingness, but because accessing their own emotional world is genuinely difficult. This phenomenon has a precise name: alexithymia. A clinical and psychological construct that, since its first formal definition in the 1970s, has progressively gained attention in research and clinical practice, revealing how complex — and how often underestimated — the process is through which human beings recognize, name, and regulate their own emotions.

This article aims to provide a comprehensive overview of the alexithymia construct: its theoretical origins, its clinical manifestations, its relationship with the body and interpersonal relationships, and the intervention possibilities currently available.

Origins of the Construct: Sifneos and the Birth of a Term

The term alexithymia — from the Greek a- (lack), lexis (word) and thymos (emotion) — was coined by the Greek-American psychiatrist Peter Sifneos in 1973, during his work with patients suffering from psychosomatic disorders. Observing these patients, Sifneos noticed a recurring and peculiar characteristic: despite presenting significant physical symptoms, they showed a marked difficulty in describing their own internal emotional states, tended to use concrete and externally oriented thinking, and seemed almost devoid of imaginative life (Sifneos, 1973).

This observation was part of a line of research already initiated by Nemiah and colleagues, who had begun investigating the relationship between emotional life and psychosomatic illness. Nemiah, Freyberger, and Sifneos (1976) proposed a more systematic conceptualization of the construct, identifying four core characteristics that still today constitute the defining nucleus of alexithymia:

1. Difficulty identifying feelings and distinguishing them from the bodily sensations of emotional arousal

2. Difficulty describing feelings to other people

3. Impoverished imaginative processes (reduced fantasy and dream life)

4. An externally oriented cognitive style (externally oriented thinking)

These characteristics do not describe an absence of emotions, but rather a difficulty in consciously accessing one's own emotional world and translating it into symbolic language.

Measurement and Prevalence

From the 1980s onwards, research on alexithymia benefited from the development of standardized measurement tools. The most widely used and validated is the Toronto Alexithymia Scale (TAS-20), developed by Bagby, Parker, and Taylor (1994), a self-report instrument composed of 20 items organized into three subscales corresponding to the main dimensions of the construct: difficulty identifying feelings (DIF), difficulty describing feelings (DDF), and externally oriented thinking (EOT).

The TAS-20 has enabled large-scale epidemiological studies. Estimates of the prevalence of alexithymia in the general population range between 10% and 13%, with significant differences based on demographic variables such as sex, age, and level of education (Taylor, Bagby, & Parker, 1997). More recent studies suggest that prevalence may be higher in specific clinical populations, such as patients with personality disorders, eating disorders, addictions, and conditions on the autism spectrum (Luminet, Bagby, & Taylor, 2018).

Primary and Secondary Alexithymia

A fundamental distinction in the literature concerns the etiology of the construct. Taylor et al. (1997) proposed differentiating between:

• Primary alexithymia, neurobiological in nature, which manifests in a relatively stable manner over time independently of environmental experience. It would be associated with structural and functional differences in the central nervous system, particularly in the connections between the limbic system — responsible for emotional processing — and the prefrontal cortex, which governs mentalization and conscious emotional regulation.

• Secondary alexithymia, which instead emerges as an adaptive response to adverse life experiences, particularly trauma, chronic stress, or early relational environments in which emotional expression was not safe, welcomed, or encouraged. In these cases, the difficulty in accessing emotions functions as a defensive mechanism developed to protect oneself from internal states that are too painful or threatening (Frewen, Pain, Dozois, & Lanius, 2006).

This distinction has relevant clinical implications: while primary alexithymia requires more structured and long-term interventions aimed at developing new emotional-cognitive competencies, the secondary form can benefit significantly from psychotherapeutic pathways focused on trauma processing and the restoration of emotional safety.

The Body as an Alternative Language: Alexithymia and Somatization

One of the most clinically relevant aspects of alexithymia concerns its relationship with the body. When emotions are not recognized and integrated at a psychological level, they tend to manifest through somatic channels. This process — known as somatization — was at the center of Sifneos's (1973) original studies and has continued to represent a productive line of research.

Van der Kolk (2014) deepened this mechanism in the context of trauma, showing how the autonomic nervous system continues to respond to past threats through bodily responses — muscle tension, alterations in heart rhythm, gastrointestinal disturbances, states of hypervigilance — even in the absence of conscious emotional awareness. The body, in the absence of words, becomes the primary archive of unresolved emotional experiences.

Neuroscientific studies have supported this perspective, showing that in alexithymic subjects the activation of the insula — a brain region involved in interoception, that is, the ability to perceive the body's internal states — is reduced in response to emotional stimuli (Bird et al., 2010). This finding suggests that alexithymia is not simply a linguistic deficit, but reflects a deeper difficulty in the interoceptive processing of emotional experiences.

Emotions and Feelings: A Necessary Distinction

To understand alexithymia in depth, it is useful to refer to the distinction — theoretically and neurobiologically grounded — between emotions and feelings, proposed by Damasio (1994) in his pioneering work.

• Emotions are relatively automatic and universal biological responses, shared with other mammals, that activate in response to stimuli relevant to the survival and well-being of the organism. They are accompanied by measurable physiological modifications — variations in heart rate, perspiration, muscle tension — and do not necessarily require conscious awareness to activate.

• Feelings, on the other hand, are the subjective and conscious representation of these emotions. They arise when the brain maps and interprets the bodily modifications induced by the emotion, inserting them into a narrative and biographical context. They therefore require cortical activity and the capacity for mentalization.

People with alexithymia experience emotions — their nervous system responds to emotional stimuli — but have difficulty consciously accessing the feelings that arise from them (Damasio, 1994). The gap is not in the basic emotional experience, but in its symbolic and linguistic elaboration.

Alexithymia and Interpersonal Relationships

The impact of alexithymia does not end in the intrasubjective sphere but extends significantly to interpersonal relationships. The ability to recognize and name one's own emotions is, in fact, a fundamental prerequisite for empathy, emotional communication, and the construction of intimacy.

Several studies have documented that subjects with high levels of alexithymia show difficulties in cognitive empathy — the ability to understand the emotional perspective of others — as well as deficits in communicating their own internal states (Grynberg et al., 2010). This can generate in relationships a sense of emotional distance, misunderstanding, or apparent indifference, which may be experienced painfully by both partners.

It is important to emphasize that this difficulty does not equate to a lack of affection or relational desire. Rather, it reflects an emotional processing system that does not yet have the tools to translate internal experience into shared connection. The therapeutic relationship can represent, in this sense, a privileged context in which to gradually develop these competencies through a corrective relational experience (Taylor et al., 1997).

Alexithymia and Psychopathology

Alexithymia has been associated with a broad spectrum of psychopathological conditions. It is not considered a clinical diagnosis in itself, but rather a transdiagnostic risk factor that can contribute to the development and maintenance of various disorders (Luminet et al., 2018).

The most robust associations documented in the literature concern:

• Eating disorders: the difficulty in recognizing emotions may favor the use of food — or its restriction — as an alternative emotional regulation strategy (Corcos et al., 2000)

• Addictions: substance abuse and compulsive behaviors may represent attempts to manage emotional states that are neither identifiable nor tolerable (Taylor et al., 1997)

• Anxiety and depressive disorders: alexithymia is associated with greater vulnerability to anxious and depressive symptomatology, probably due to the reduced capacity to process and regulate negative emotional states (Luminet et al., 2018)

• Psychosomatic disorders: the original link identified by Sifneos (1973) remains one of the most robust in the literature

• Autism spectrum conditions: high levels of alexithymia are frequently found in this population, although the debate on the nature of this association remains open (Bird & Cook, 2013)

Intervention Possibilities

Although alexithymia has long been considered a relatively stable and difficult-to-treat characteristic, more recent research offers more optimistic perspectives, especially for secondary forms.

Several psychotherapeutic approaches have shown effectiveness in working with alexithymic patients:

Emotion-focused therapy (EFT) and experiential approaches in general promote gradual contact with one's own emotional experiences in a safe and supportive context (Greenberg, 2002). Cognitive-behavioral therapy (CBT) can be useful in working on emotional awareness and psychoeducation. Body-based approaches such as Somatic Experiencing (Levine, 2010) work directly on bodily experience, bypassing the linguistic difficulty and fostering integration from within. Mindfulness has shown promising results in improving interoceptive awareness and the ability to identify emotional states (Luminet et al., 2018).

Practical tools such as the emotion wheel — developed by Robert Plutchik and subsequently reworked in various versions — can support the process of emotional identification by providing an accessible visual vocabulary.

Conclusions

Alexithymia represents a complex and nuanced psychological dimension, one that calls into play the neurobiology of emotions, individual relational history, defensive mechanisms, and the human capacity to make sense of one's inner life. It is not indifference, it is not an absence of feelings — it is the difficulty of finding words for what one feels, often because no one taught them, or because learning to feel was too risky.

Recognizing this difficulty is already a first step. Naming it, even more so.

References

Bagby, R. M., Parker, J. D. A., & Taylor, G. J. (1994). The twenty-item Toronto Alexithymia Scale—I. Item selection and cross-validation of the factor structure. Journal of Psychosomatic Research, 38(1), 23–32. https://doi.org/10.1016/0022-3999(94)90005-1

Bird, G., & Cook, R. (2013). Mixed emotions: The contribution of alexithymia to the emotional symptoms of autism. Translational Psychiatry, 3(7), e285. https://doi.org/10.1038/tp.2013.61

Bird, G., Silani, G., Brindley, R., White, S., Frith, U., & Singer, T. (2010). Empathic brain responses in insula are modulated by levels of alexithymia but not autism. Brain, 133(5), 1515–1525. https://doi.org/10.1093/brain/awq060

Corcos, M., Guilbaud, O., Speranza, M., Paterniti, S., Loas, G., Stephan, P., & Jeammet, P. (2000). Alexithymia and depression in eating disorders. Psychiatry Research, 93(3), 263–266. https://doi.org/10.1016/S0165-1781(00)00109-8

Damasio, A. R. (1994). Descartes' error: Emotion, reason, and the human brain. Putnam.

Frewen, P. A., Pain, C., Dozois, D. J. A., & Lanius, R. A. (2006). Alexithymia in PTSD: Psychometric and FMRI studies. Annals of the New York Academy of Sciences, 1071(1), 397–400. https://doi.org/10.1196/annals.1364.029

Greenberg, L. S. (2002). Emotion-focused therapy: Coaching clients to work through their feelings. American Psychological Association.

Grynberg, D., Luminet, O., Corneille, O., Grèzes, J., & Berthoz, S. (2010). Alexithymia in the interpersonal domain: A general deficit of empathy? Personality and Individual Differences, 49(8), 845–850. https://doi.org/10.1016/j.paid.2010.07.013

Levine, P. A. (2010). In an unspoken voice: How the body releases trauma and restores goodness. North Atlantic Books.

Luminet, O., Bagby, R. M., & Taylor, G. J. (Eds.). (2018). Alexithymia: Advances in research, theory, and clinical practice. Cambridge University Press.

Nemiah, J. C., Freyberger, H., & Sifneos, P. E. (1976). Alexithymia: A view of the psychosomatic process. In O. W. Hill (Ed.), Modern trends in psychosomatic medicine (Vol. 3, pp. 430–439). Butterworths.

Sifneos, P. E. (1973). The prevalence of 'alexithymic' characteristics in psychosomatic patients. Psychotherapy and Psychosomatics, 22(2), 255–262. https://doi.org/10.1159/000286529

Taylor, G. J., Bagby, R. M., & Parker, J. D. A. (1997). Disorders of affect regulation: Alexithymia in medical and psychiatric illness. Cambridge University Press.

Van der Kolk, B. A. (2014). The body keeps the score: Brain, mind, and body in the healing of trauma. Viking.