Feelings, Sensations, Emotions, oh my!

The Intersection of Alexithymia and Interoceptive Awareness in Neurodivergence

David Rich Sol

Oct 24, 2023

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Imagine feeling angry and not knowing why, or having someone ask you to name the physical sensations in your body, but you don’t have the words to describe them. Well, I don’t have to imagine these experiences too hard because I’ve personally experienced them and so have many others.

What I’m exploring today are two separate and interconnected traits called Alexithymia and interoceptive awareness. Two very fancy medical terms which I’ll unpack and discuss here.

Alexithymia

So, let’s first start with Alexithymia which is sometimes referred to as emotional blindness and comes from the Greek term that means “no words for emotions.” According to a 2018 study, entitled “Alexithymia and Autism Spectrum Disorder: A Complex Relationship,” the authors state:

“Over the last two decades, the relationship between alexithymia and autism spectrum disorder (ASD) has gained significant attention – there has been a surge in the number of studies aimed at investigating the relationship between these conditions, including from a conceptual and etiological point of view, as well as with regards to the implications of this relationship for clinical and therapeutic practices. Alexithymia is highly prevalent and plays an important and complex role in ASD, with approximately half of [autistic] individuals…estimated as having alexithymia, but the nature of its role remains elusive.”¹

So, from this and other studies, we know that alexithymia is very common, especially among autistic individuals. But, why is it something worth talking about? Well, a 2019 systematic review and meta-analysis gave more insight into the inter-relationship between autism and alexithymia. The authors write that:

“An increasing body of empirical research supports the hypothesis that emotion processing difficulties in ASD are in fact driven by alexithymia. Studies controlling for both alexithymia and autism have found that alexithymia, rather than autism, predicts difficulties in facial, vocal, and musical emotion recognition. Furthermore, imaging research suggests that empathetic brain activity in response to the pain of others is predicted by alexithymia, not autism.”²

Let’s summarize what we covered so far. Alexithymia also known as emotional blindness is very common in autistics and has been found to be the main reason for all the various emotional processing challenges including problematic interpersonal relationships that have been associated with autism. In other words, it’s alexithymia that’s at the core of the issue, not autism per se.

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The researchers further suggest that those with co-occurring autism and alexithymia are more likely to experience anxiety, depression, and other mental health and interpersonal challenges. More specifically, various studies and personal experiences note that the difficulties people face with understanding, processing, and interpreting emotional cues and feelings are at the heart of communication and interpersonal connection challenges including emotional intimacy issues. Many people with high alexithymic traits may feel like an outsider, a loner, someone who just can’t relate, or they feel like they don’t fit in. We’ll get back to this thought in a bit.

Now, autism is not the only neurotype that has a high likely rate of alexithymia. In addition to autism, the prevalence rates among ADHDers vary from study to study, but it is estimated that anywhere from 20% to 44% also experience alexithymia.³

In an article entitled, “Alexithymia and ADHD: the Most Common Overlappings,” Dr. Megan Ann Neff, a late-in-life diagnosed Autistic-ADHD Psychologist, writes:

“Both ADHD and Alexithymia are associated with difficulty regulating emotions. For ADHD, this is due to executive functioning difficulties and impulsivity, which impacts the brain’s ability to regulate emotions. For alexithymia, this is due to difficulty registering emotions until they are too overwhelming to manage.
Both ADHD and Alexithymia have higher rates of disordered eating, substance abuse, and negative emotional coping. Negative emotional coping is a broad term that refers to strategies for coping with emotions that lead to emotional avoidance and unhealthy ways of managing emotion.”⁴

So, for both autistic and ADHDers alike, alexithymia can be present at high rates and pose a challenge in understanding, interpreting, and processing emotions. The specific ways that this can create challenges for individuals vary based on different factors on how a person expresses their traits of alexithymia.

Alexithymia Test & My Experience

Anyone can take a free, online 37-question alexithymia screening test. This test⁵ shows both overall alexithymia results as well as seven detailed categories that can vary in severity from person to person including: 1) difficulty identifying feelings, 2) difficulty describing feelings, 3) externally oriented thinking, that is, focused outward outside one’s self rather than inward, 4) restricted imaginative processes, 5) problematic interpersonal relationships, 6) sexual difficulties and disinterest, and 7) vicarious interpretation of feelings, or needing someone else to help interpret and understand one’s own emotions or those of others.

Personally, I’ve taken this screening test multiple times over the past year and have found the results to be very similar and consistent regardless of when I’ve taken it. Overall, I scored 139 out of 185 (or, 75% alexithymic traits) which is considered high. More specifically, of the seven sub-categories, I show high traits in six out of seven areas. The only area in which I have low alexithymic traits is in restricted imaginative processes. I am very imaginative and have been known to be a daydreamer as a child. Even as an adult, I have gotten lost in imagination and fantasy. So, this is one area that I have no challenge in. However, my highest areas on the alexithymia test include problematic interpersonal relationships where I scored 29 out of 30 (or, 97%), and externally-oriented thinking where I scored 30 out of 35 (or, 86%). Both of these are not surprising to me.

For starters, as with most things related to human health and well-being, it’s complicated. My externally oriented thinking may be related to my innate personality trait, or it could be related to my acquired complex trauma experiences. A 2023 study exploring the relationship between adverse childhood experiences (i.e., complex traumas) and alexithymia found that the most common trait among participants with high ACEs (adverse childhood experiences) was externally oriented thinking.⁶

In terms of living in survival mode, having an externally oriented focus makes absolute sense as a natural response being a complex trauma survivor. Forget thinking about or considering one’s own feelings or inner states when you are always hyper-vigilant and on the lookout to stay safe. That certainly resonates with me. As a child, I got really good at observing other people and my surroundings. In a way, my innate skill at noticing patterns (which is a typical characteristic of autism) helped me survive. There were many occasions when I was able to predict abusive situations and their outcomes based on previous patterns that I observed in my environment and the people around me. This skill helped me better prepare and get out of the way of the abusers in many situations growing up. Or, at least this is how I see it today. If nothing more, it helped me feel like I had some locus of control in the unpredictable environment I grew up in.

When it comes to the Adverse Childhood Experiences (ACEs) test,⁷ I scored an 8 out of 10 which is considered very high. Anything past a score of 3 is high and the greater the number the more likely a person will have a higher risk of developing both physical and mental health adverse consequences.

According to ACESTooHigh, a nonpartisan traditional online news site that reports on research about positive and adverse childhood experiences⁸:

“When children are overloaded with stress hormones, they’re in flight, fright or freeze mode. They can’t learn in school. They often have difficulty trusting adults or developing healthy relationships with peers (i.e., they become loners). To relieve their anxiety, depression, guilt, shame, and/or inability to focus, they turn to easily available biochemical solutions — nicotine, alcohol, marijuana, methamphetamine — or activities in which they can escape their problems — high-risk sports, [the] proliferation of sex partners, and work/over-achievement. (e.g. Nicotine reduces anger, increases focus, and relieves depression. Alcohol relieves stress.)”⁹

As a child, I developed several unhealthy coping strategies to deal with all the trauma and chaos in my life including using food to cope which turned into an eating disorder and over-achievement. Oh, yeah, collecting certificates and degrees became a special interest and sport for me. Currently, I have earned a bachelor’s degree, three master’s degrees including an MBA, and a doctorate degree. Talk about escapism! Well, I’ll share about that in another post. For now, let’s get back to the topic at hand.

When the fact of my high ACEs score is combined with my neurodivergence differences, social anxiety, and other sensitivities that I’ve had throughout my life, I can clearly see how all of this has contributed to the development of my high alexithymia traits.

Interoceptive Awareness, Alexithymia, & Neurodivergence

Closely related to having a high externally oriented focus is what’s called poor interoceptive awareness. That is, “Interoception is a [body] sense that allows us to feel our feelings and notice the internal sensations inside our bodies.”¹⁰

Nearly a decade ago, researchers discovered and have consistently confirmed that the sense of interoception is the main underlying neurobiological basis for alexithymia. Specifically, the landmark 2016 study entitled, “Alexithymia: A General Deficit of Interoception,” stated that:

“The current study extends evidence that alexithymia is associated with affective interoception deficits and suggests that the condition should be thought of as a general impairment of interoception (including non-affective internal states). Those with alexithymia are likely to confuse non-affective internal states with emotional experiences and may find it difficult to identify cues relating to states such as hunger, satiety, and arousal in themselves. Importantly, the relationship between alexithymia and interoceptive confusion appears to be present across typical and clinical populations.”¹¹

In other words, people with poor interoception have a difficult time recognizing and distinguishing their physical sensations and emotional states. In many cases, those two varied experiences are confused and attributed to the other. That is, one is physiological and the other one is emotional, but both are experienced physically in the body. For example, feeling hungry and experiencing it as anger, or confusing anxiety as sexual arousal and vice versa. In these cases, there is a poor body-felt sense of where the feeling state is coming from, what it means, and how to address it.

You can also take a free online interoceptive awareness assessment to discover your own areas of interoceptive strength and challenge.¹² ¹³ For me, I scored lowest in three of the eight categories. My lowest score is in the “Not-Worrying” category which is the “Tendency not to worry or experience emotional distress with sensations of pain or discomfort.”¹⁴ A low score on this is counter-intuitive, it actually means the opposite of this statement. In other words, I scored lowest in this category because I do worry and experience emotional distress when I sense pain or discomfort in my body.

The second lowest score is in the “Not-Distracting” category which is the “Tendency not to ignore or distract oneself from sensations of pain or discomfort.”¹⁵ Again, as in the first category, I DO tend to ignore or distract myself when I sense pain or discomfort in my body.

Finally, the third lowest score on interoceptive awareness is in the “Attention Regulation” category which is the “Ability to sustain and control attention to body sensations.”¹⁶ This makes total sense to me. No, I generally am not good at sustaining and controlling my attention on my body sensations. Perhaps it has something to do with my ADHD traits, or maybe it’s a combination of things.

Even though this last category sounds opposite to my two other lowest scores, it’s not. For me, I generally have routinely avoided sensations in my body unless there is pain or major discomfort. This is a common occurrence that I’ve noticed with many of my various patients as well. These days, I’m working on being more mindful of my body sensations and staying aware of these sensations before I experience any pain or discomfort so that I can prevent unnecessary pain and discomfort in the future. However, making this change is a process for me.

As with everything else I’ve discussed, this too gets complicated when considering neurodivergence. In a 2023 study entitled, “Emotional Dysfunction and Interoceptive Challenges in Adults with Autism Spectrum Disorders,” the authors state that:

“People with autism spectrum disorder (ASD) frequently show impaired sensory processing in different senses, including the interoceptive system. Recent findings suggest that interoception is a fundamental component of emotional experience and that impaired interoception is associated with alexithymia.”¹⁷

Interestingly, the researchers of this study also reported the following:

“Scientific evidence showed that the interoceptive difficulties found among individuals with ASD are usually classified into three patterns. Interoceptive hyposensitivity is where the person is incapable of noting the internal bodily signals or emotional state unless they are very intense; interoceptive hypersensitivity is where the person perceives internal sensations quickly and intensely, or feels various sensations at the same time, causing difficulties in determining which signals are the most important. However, there is a third pattern of interoceptive impairment that includes poor discrimination (sometimes accompanied by a lack of verbal accuracy), where the person is unable to identify the exact internal feeling because the experience is a vague or generalized sensation, with a limited ability to identity the meaning of this feeling.”¹⁸

So let’s summarize what I’ve covered here thus far.

Research has found that poor inner body felt sensing (interoceptive awareness) which can be worsened through externally oriented thinking and focus is the foundation of emotional blindness and poor emotional processing including problems in interpersonal relationships, difficulty with identifying and describing feelings, having restricted imagination, having sexual difficulties, and showing poor empathy (alexithymia) which is highly associated with complex trauma (high ACEs) and very common among the neurodivergent community (both autistics and ADHDers among others).

Finding Solutions

What I hear when I go through that summary is hope and the possibility for positive change.

Let me explain.

If poor inner body felt sensing and externally oriented thinking and focus is the root of poor emotional processing, the answer is fairly simple. Work on improving inner body felt sensing and shifting the focus from the outside inward.

How do we do that?

There are multiple ways including mindfulness practice, body scan exercises, recreational and occupational therapy, and others. Additionally, one of the simplest ways is to cultivate a full yoga practice including physical yoga postures (or yoga asana), breathing exercises (or pranayama), meditation, and loving-kindness practices.

Multiple research studies support yoga as a way to increase both interoceptive and emotional awareness and self-regulation.¹⁹ ²⁰ ²¹ For example, mindfully practicing restorative yoga has been found greatly beneficial for autistics, ADHDers, and trauma survivors. The practice has multiple benefits including retraining the nervous system to better process tension and stress and allowing the body to more fully relax.²² Through the practice, a person can become more in tune with their body sensations, their breath, and even their feelings and emotions. Because restorative yoga practice is gentle and focused on deep relaxation, it can also be accessible to most.

If you were to ask me about my personal favorite restorative yoga shapes (or postures), I would tell you that I love supported legs up the wall and supported savasana.

In future posts, I will share more of my experiences with yoga and the benefits that I’ve experienced and introduced here.

What about you? Have you done anything to help increase your interoceptive awareness? Have you tried restorative yoga? Or, any other type of yoga practice? What’s been your experience?

I’d love to hear from you, so please leave a comment.