Thursday, July 14, 2016

Autism and alexithymia

There is a persistent stereotype that people with autism are individuals who lack empathy and cannot understand emotion. It’s true that many people with autism don’t show emotion in ways that people without the condition would recognize1.

But the notion that people with autism generally lack empathy and cannot recognize feelings is wrong. Holding such a view can distort our perception of these individuals and possibly delay effective treatments.

We became skeptical of this notion several years ago. In the course of our studies of social and emotional skills, some of our research volunteers with autism and their families mentioned to us that people with autism do display empathy.

Many of these individuals said they experience typical, or even excessive, empathy at times. One of our volunteers, for example, described in detail his intense empathic reaction to his sister’s distress at a family funeral.

Yet some of our volunteers with autism agreed that emotions and empathy are difficult for them. We were not willing to brush off this discrepancy with the ever-ready explanation that people with autism differ from one another. We wanted to explain the difference, rather than just recognize it.

So we looked into the overlap between autism and alexithymia, a condition defined by a difficulty understanding and identifying one’s own emotions. People with high levels of alexithymia (which we assess with questionnaires) might suspect they are experiencing an emotion, but are unsure which emotion it is. They could be sad, angry, anxious or maybe just overheated. About 10 percent of the population at large — and about 50 percent of people with autism — has alexithymia.

…even though there are higher rates of alexithymia in people with autism, there are equally high rates in people with eating disorders, depression, substance abuse, schizophrenia and many other psychiatric and neurological conditions.

So can alexithymia explain why some individuals with autism have difficulties with emotions and some don’t? Perhaps it is alexithymia, not autism, that caused the emotional difficulties we heard about from some of our participants, the difficulties that people often assume happen in everybody with autism…

We found that individuals with autism but not alexithymia show typical levels of empathy, whereas people with alexithymia (regardless of whether they have autism) are less empathic. So autism is not associated with a lack of empathy, but alexithymia is….

People with alexithymia may still care about others’ feelings, however. The inability to recognize and understand anger might make it difficult to respond empathically to anger specifically. But alexithymic individuals know that anger is a negative state and are affected by others being in this state. In fact, in a separate test we conducted last year, people with alexithymia showed more distress in response to witnessing others’ pain than did individuals without alexithymia...

We found that people with autism, whether with or without alexithymia, spend less time looking at faces than do people without autism. But when individuals who have autism but not alexithymia look at faces, they scan the eyes and mouth in a pattern similar to those without autism.

By contrast, people with alexithymia, regardless of their autism status, look at faces for a typical amount of time, but show altered patterns of scanning the eyes and mouth. This altered pattern might underlie their difficulties with emotion recognition…

We think these results, and the others we have found since, disprove the theory that autism impairs emotion recognition. If people assume that someone with autism lacks empathy, they will be wrong about half the time (because only half of individuals with autism have alexithymia). Making this assumption is unfair and can be hurtful.

What’s more, our work demonstrates that we urgently need tools to help individuals who have both autism and alexithymia understand their own and other people’s emotions. Meanwhile, people with autism who don’t have alexithymia might focus on building on their emotional strengths to mitigate the social difficulties associated with the condition…

Although people who have alexithymia but not autism find it acceptable to say hurtful things to others, people who have both autism and alexithymia do not. We think people with autism use other information (such as social rules) to decide whether what they say will be hurtful, rather than relying on their understanding of emotions.

Courtesy of Doximity


  1. Brewer R, Biotti F, Catmur C, Press C, Happé F, Cook R, Bird G. Can
    Neurotypical Individuals Read Autistic Facial Expressions? Atypical Production of Emotional Facial Expressions in Autism Spectrum Disorders. Autism Res. 2016 Feb;9(2):262-71.

    The difficulties encountered by individuals with autism spectrum disorder (ASD) when interacting with neurotypical (NT, i.e. nonautistic) individuals are usually attributed to failure to recognize the emotions and mental states of their NT interaction partner. It is also possible, however, that at least some of the difficulty is due to a failure of NT individuals to read the mental and emotional states of ASD interaction partners. Previous research has frequently observed deficits of typical facial emotion recognition in individuals with ASD, suggesting atypical representations of emotional expressions. Relatively little research, however, has investigated the ability of individuals with ASD to produce recognizable emotional expressions, and thus, whether NT individuals can recognize autistic emotional expressions. The few studies which have investigated this have used only NT observers, making it impossible to determine whether atypical representations are shared among individuals with ASD, or idiosyncratic. This study investigated NT and ASD participants' ability to recognize emotional expressions produced by NT and ASD posers. Three posing conditions were included, to determine whether potential group differences are due to atypical cognitive representations of emotion, impaired understanding of the communicative value of expressions, or poor proprioceptive feedback. Results indicated that ASD expressions were recognized less well than NT expressions, and that this is likely due to a genuine deficit in the representation of typical emotional expressions in this population. Further, ASD expressions were equally poorly recognized by NT individuals and those with ASD, implicating idiosyncratic, rather than common, atypical representations of emotional expressions in ASD.

  2. Brewer R, Marsh AA, Catmur C, Cardinale EM, Stoycos S, Cook R, Bird G. The impact of autism spectrum disorder and alexithymia on judgments of moral acceptability. J Abnorm Psychol. 2015 Aug;124(3):589-95.

    One's own emotional response toward a hypothetical action can influence judgments of its moral acceptability. Some individuals with autism spectrum disorder (ASD) exhibit atypical emotional processing, and moral judgments. Research suggests, however, that emotional deficits in ASD are due to co-occurring alexithymia, meaning atypical moral judgments in ASD may be due to alexithymia also. Individuals with and without ASD (matched for alexithymia) judged the moral acceptability of emotion-evoking statements and identified the emotion evoked. Moral acceptability judgments were predicted by alexithymia. Crucially, however, this relationship held only for individuals without ASD. While ASD diagnostic status did not directly predict either judgment, those with ASD did not base their moral acceptability judgments on emotional information. Findings are consistent with evidence demonstrating that decision-making is less subject to emotional biases in those with ASD.

  3. Cook R, Brewer R, Shah P, Bird G. Alexithymia, not autism, predicts poor recognition of emotional facial expressions. Psychol Sci. 2013 May;24(5):723-32

    Despite considerable research into whether face perception is impaired in autistic individuals, clear answers have proved elusive. In the present study, we sought to determine whether co-occurring alexithymia (characterized by difficulties interpreting emotional states) may be responsible for face-perception deficits previously attributed to autism. Two experiments were conducted using psychophysical procedures to determine the relative contributions of alexithymia and autism to identity and expression recognition. 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. Neither alexithymia nor autism was associated with biased or imprecise identity attributions. 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.

  4. Brewer R, Collins F, Cook R, Bird G. Atypical trait inferences from facial cues in alexithymia. Emotion. 2015 Oct;15(5):637-43.

    It is often difficult to distinguish strangers' permanent facial shapes from their transient facial expressions, for example, whether they are scowling or have narrow-set eyes. Overinterpretation of ambiguous cues may contribute to the rapid character judgments we make about others. Someone with narrow eyes might be judged untrustworthy, because of strong associations between facial anger and threat. To test this hypothesis, we investigated the trait judgments made by individuals with severe alexithymia, associated with impaired recognition of facial emotion. Consistent with the hypothesis, alexithymic participants demonstrated reduced interrater consistency when judging the character traits of unfamiliar faces, and the presence of subtle emotions. Nevertheless, where alexithymics perceived, or misperceived, emotion cues, the character traits inferred thereafter were broadly typical. The finding that individuals with developmental deficits of emotion recognition exhibit atypical attribution of character traits, confirms the hypothesis that emotion-recognition mechanisms play a causal role in character judgments.