Alexithymia & autism

The prevalence of alexithymia among autistic people was found to be 40–65%^[1]The validity of using self-reports to assess emotion regulation abilities in adults with autism spectrum disorder (Berthoz & Hill, 2005)^[2]Brief report: cognitive processing of own emotions in individuals with autistic spectrum disorder an20d in their relatives (Hill & Berthoz, 2004) with some studies indicating a prevalence as high as 70%.^[3]Measuring the effects of alexithymia on perception of emotional vocalizations in autistic spectrum disorder and typical development (Heaton et al., 2012)

So alexithymia is very common among autistic people, and in fact, some symptoms generally attributed to autism actually stem from alexithymia instead! More about that later in this post.

Alexithymia in autism

Autistic people were found to have a particular form of alexithymia that results in differences or challenges in the cognitive domain, rather than in the affective domain.^[4]The validity of using self-reports to assess emotion regulation abilities in adults with autism spectrum disorder (Berthoz & Hill, 2005) In other words, autistic individuals may experience:

1. 1. Difficulty identifying feelings.
   2. Difficulty distinguishing between feelings and the bodily sensations of emotional arousal.
   3. Difficulty describing feelings to other people.
   4. Difficulty identifying facial expressions.
   5. Difficulty identifying/remembering faces.

They do not, however, tend to have constricted imaginal processes as evidenced by a scarcity of fantasies, nor a stimulus-bound, externally oriented cognitive style—which are two aspects of affective alexithymia. For more information on the differences between cognitive and affective alexithymia, read the previous post:

Alexithymia

Face-perception differences

It is often stated that autistic people have difficulty identifying emotional facial expressions, but research from 2013 by Richard Cook et al. indicated that the face-perception differences attributed to autism are actually the cause of frequently co-occurring alexithymia.^[5]Alexithymia, Not Autism, Predicts Poor Recognition of Emotional Facial Expressions (Cook et al., 2013)

Experiment 1 showed that alexithymia correlates strongly with the precision of expression attributions, whereas autism severity was unrelated to expression–recognition ability.

Experiment 2 confirmed that alexithymia is not associated with impaired ability to detect expression variation; instead, results suggested that alexithymia is associated with difficulties interpreting intact sensory descriptions.

The research even indicates that existing diagnostic criteria of autism may need to be revised. I quote:^[6]Alexithymia, Not Autism, Predicts Poor Recognition of Emotional Facial Expressions (Cook et al., 2013)

These findings accord with the hypothesis that the emotional symptoms of autism are in fact due to co-occurring alexithymia and that existing diagnostic criteria may need to be revised.

Reduced(?) empathy

Situational or context-dependent difficulties with empathy (i.e. sometimes showing an apparent lack of empathy) are also often attributed to autism. However, research indicates that autistic individuals without alexithymia show typical levels of empathy, whereas people with alexithymia—regardless of whether they are autistic—are less empathetic.^[7]People with Autism Can Read Emotions, Feel Empathy | Scientific American

In other words, it isn’t autism, but (cognitive) alexithymia, that is associated with diminished empathy. Based on a study from 2013 by Geoff Bird and Richard Cook, the so-called alexithymia hypothesis was proposed, which argues that emotional symptoms of autism are due to the high co-occurrence of alexithymia among autistic people, and not due to autism per se.^[8]Mixed emotions: the contribution of alexithymia to the emotional symptoms of autism (Bird & Cook, 2013)

Neither autistic people nor those with alexithymia inherently lack empathy, however; people with alexithymia may still care about others’ feelings, but experience difficulties in assessing certain situations correctly. For example, the inability to recognize and understand that a person is upset in a given situation will make it difficult to respond with empathy, simply because it’s overlooked (not ignored). As such, people with alexithymia—as well as a substantial portion of autistic people—can show a situational lack of empathy. This is probably due to diminished awareness of other people’s emotions.

When a given situation and the emotions involved are understood—or are otherwise made salient to us—we usually will respond with empathy. In fact, we tend to be a lot more empathetic than people suspect. Read more about how empathy presents in autistic people here:

Autism & empathy

Social isolation

Lastly, it seems that social isolation is probably an aspect of alexithymia more so than autism. At least, research from 2019 by Matthew D. Lerner et al. suggests this might be the case. The research shows that:^[9]Alexithymia – not autism – is associated with frequency of social interactions in adults (Lerner et al., 2019)

• Autistic adults demonstrated a similar amount and pattern of social interactions compared to non-autistic adults.
• Difficulties with identifying emotions in both the self and others were associated with fewer social interactions.
• The severity of alexithymia symptoms predicts fewer social interactions regardless of autism status.

This seems to suggest that when you have a lower awareness of emotions in the self and others, you are less likely to be socially motivated, or maybe more likely to be put off by the social challenges.

So if you isolate yourself a lot, it may be due to your (co-occurring) alexithymia rather than your autism.

Aspects of alexithymia

So to recap, there are three aspects of alexithymia that we thought were part of autism:

• Difficulty identifying emotional facial expressions, as alexithymia undermined the precision of expression attributions.
• Reduced empathy, which is probably due to a diminished awareness of other people’s emotions.
• Fewer social interactions, which were associated with difficulty identifying emotions in the self and others.