Why You Can't Always Tell What You're Feeling

In the early 1970s the Boston psychiatrist Peter Sifneos was working with patients whose illnesses were then classed as psychosomatic: peptic ulcers, ulcerative colitis, asthma, rheumatoid arthritis. Many of them, he found, had great difficulty saying what they felt. In 1973 he gave the pattern a name built from Greek: a, without, lexis, word, thymos, emotion. Alexithymia. No words for feelings.

The name has outlived the theory it came from. The peptic ulcer, the classic psychosomatic illness of that era, turned out in the 1980s to be largely the work of a bacterium. Alexithymia, meanwhile, became one of the most measured traits in clinical psychology, and the measuring has turned up as many questions as answers.

What is alexithymia?

Alexithymia is a personality trait made up of three linked difficulties: identifying your own feelings, describing them to other people, and a thinking style that stays on the external and practical rather than on inner experience. Those three parts come from the questionnaire that defined the field, the 20-item Toronto Alexithymia Scale published by Michael Bagby, James Parker and Graeme Taylor in 1994. Someone high on the first part might know something is wrong and be unable to say whether it is anger or fear. Someone high on the second might know and still be unable to put it into words for anyone else.

It is not a diagnosis, and it is not something a person either has or lacks. In a Finnish population sample of 1,285 people, scores were normally distributed, the shape of a personality dimension that everyone sits somewhere along. The cut-off used to call someone alexithymic is a line drawn across that continuum.

Where the line is drawn, about one adult in ten falls above it. Finland’s Health 2000 study, with more than 5,000 participants, put the figure at 9.9 per cent, higher in men than in women and rising with age. A representative German sample found ten per cent. The trait is also stable: Finnish adults retested eleven years later had essentially the same average score as before.

Alexithymia and interoception

The obvious explanation for alexithymia is that the signal never arrives. Emotions are partly bodily, a racing heart or a tight stomach, and the sense that reads the body’s internal state is interoception. If you cannot read the body, the argument goes, you cannot know what you feel.

In 2016 Rebecca Brewer, Richard Cook and Geoffrey Bird tested a version of this. They asked people about non-emotional body signals, such as hunger, tiredness and temperature, and about how similar emotional and non-emotional states felt to them. People higher in alexithymia reported more trouble with the non-emotional signals too, and found emotional and bodily states harder to tell apart. The authors proposed that alexithymia is best described as a general failure of interoception rather than a problem specific to emotion. On this account, the person who cannot tell anxiety from hunger is not missing a feeling. They are receiving a signal and cannot sort it.

The broader evidence is less tidy. A 2019 meta-analysis pooling 66 samples and more than 7,000 people found only a small overall correlation between alexithymia and interoceptive awareness. In samples with psychiatric or developmental conditions it was moderate. In healthy, typically developing samples it was not significant at all. Part of the trouble is measurement. The meta-analysis found that the size and even the direction of the link depended on which part of interoception was measured and whether it was measured objectively or by asking people, and the standard objective test, counting your own heartbeats, has well-documented problems of its own.

The body account is strongest where it started, among people who are unwell. In the general population, alexithymia does not reduce to a sensor that fails to report.

The measurement problem

The questionnaire has a dispute of its own. In 2009 Daniel Leising and colleagues gave the Toronto scale to 63 people, half of them psychiatric inpatients, and then interviewed them about their relationships. People with higher alexithymia scores described more emotions in the interviews, not fewer, especially negative ones. The authors concluded that the scale was picking up general psychological distress.

That is one small study, but the concern has persisted. In a Finnish population sample, 32 per cent of people with depressive symptoms scored above the cut-off, against 4.3 per cent of those without. David Preece and colleagues found in 2024 that the scale’s difficulty-identifying-feelings items loaded heavily on current distress in a sample of 508 American adults. In 2026 Bagby, one of the scale’s authors, and colleagues tested 681 people and found no such problem. The argument is unresolved.

The disagreement matters beyond the methods section. If part of what the scale captures is distress, then some of what gets called difficulty identifying feelings is the experience of having too much feeling to sort, not too little to find.

Alexithymia and autism

The same research group that proposed the interoception account made a second argument that has changed how emotion and autism are studied. In 2013 Geoffrey Bird and Richard Cook proposed that where autistic people show difficulties recognising emotions or with empathy, the cause is the alexithymia that frequently co-occurs with autism, not autism itself. Autistic people without high alexithymia, on this view, do not show those emotional difficulties. Bird and Cook called it the alexithymia hypothesis and noted elevated alexithymia in eating disorders, anxiety disorders, substance use and several neurological conditions as well, which is part of why the trait is now treated as something that cuts across diagnoses rather than belonging to any one of them.

What is settled, and what is not

Some of this is solid. Alexithymia, as the questionnaires define it, is a stable, continuously distributed trait. Around one adult in ten scores high. It is more common in men and in older people, and strongly associated with depression. Those findings rest on the same questionnaire whose meaning is argued over, but as descriptions of what it measures they hold across countries and decades.

What remains open is what the trait actually is. One account puts it in the body, a failure to read internal signals. The general-population evidence for that account is weak. Another puts it in attention and language, a failure to turn signals that do arrive into named, usable feelings. A third possibility, raised by the measurement dispute, is that the questionnaires partly capture something closer to being overwhelmed.

Sifneos named a gap between what happens in a person and what they can say about it. Fifty years on, the research can measure the gap. It still cannot say for certain which side of the gap the trouble lives on, whether the feeling is missing or only the word.

FAQ

What is alexithymia?

Alexithymia is a personality trait involving difficulty identifying your own feelings, difficulty describing them to other people, and a style of thinking that stays on external events rather than inner experience. The word was coined by the psychiatrist Peter Sifneos in 1973 from Greek roots meaning no words for emotion. It runs on a continuum across the population rather than being something a person either has or lacks.

Is alexithymia a mental illness?

No. Alexithymia is not a diagnosis in the DSM. It is treated in research as a personality dimension that everyone has to some degree. High levels are more common in depression, in some medical conditions and among autistic people, and it is studied as a risk factor that cuts across many conditions rather than as a condition of its own.

How common is alexithymia?

Large population studies in Finland and Germany found that around one adult in ten scores above the usual cut-off on the most widely used questionnaire, the 20-item Toronto Alexithymia Scale. Adult men score above it more often than women, and scores rise with age. A Finnish study found scores were very stable over eleven years.

Is alexithymia caused by poor interoception?

Not simply. Some studies find people high in alexithymia also report trouble reading non-emotional body signals such as hunger and tiredness. But a meta-analysis of 66 samples found only a small overall link between alexithymia and interoception, and no significant link in healthy, typically developing samples. The connection appears mainly in clinical and developmental groups.