I came across a study recently that piqued my interest. The study aimed to investigate the “double empathy problem” in autism, exploring how non-autistic individuals empathise with autistic people. The researchers examined empathic accuracy, cognitive empathy, and affective empathy in 81 non-autistic adults when viewing emotional narratives from both autistic and non-autistic individuals. Their main findings revealed that participants had lower empathic accuracy scores when viewing autistic narrators, especially for happy and sad emotions, while experiencing more intense bodily sensations for anger and fear. These results appeared to support the double empathy hypothesis, suggesting that non-autistic individuals struggle to accurately empathise with autistic people.
However, a critical consideration in interpreting these results is the role of alexithymia in autism research. Alexithymia, characterised by difficulty identifying, sourcing, and/or describing one’s own emotions, co-occurs in approximately 50% of autistic individuals (myself included). This high prevalence makes alexithymia a crucial factor to consider when studying emotional expression and perception in autism. Alexithymia can significantly impact how emotions are expressed and interpreted, potentially confounding results attributed to autism alone. By not controlling for alexithymia, the study may have inadvertently conflated autism-specific traits with alexithymia-related characteristics. This oversight highlights the importance of carefully considering co-occurring conditions in autism research to ensure more accurate and nuanced understanding of autistic experiences and interactions.
Background on Alexithymia
Alexithymia is a subclinical condition characterised by difficulties in identifying, sourcing, describing, and distinguishing between one’s own emotions. It is often described as a reduced ability to recognise and verbalise internal emotional states. Whilst not exclusive to autism, alexithymia has a notably high prevalence in the autistic population, with studies suggesting it affects approximately 50% of autistic individuals compared to about 10% of the general population. This significant co-occurrence has led some researchers to propose that alexithymia, rather than autism itself, may be responsible for many of the emotional processing differences observed in autism.
The effects of alexithymia on emotional expression and perception are profound and multifaceted. Alexithymic people often struggle to identify and describe their own emotional states, which can lead to difficulties in expressing emotions in ways that are easily interpretable by others. This can result in facial expressions, body language, and vocal intonations that may seem incongruent or atypical to observers, potentially contributing to the perception of reduced emotional expressivity in autism. Furthermore, alexithymia can impact the ability to recognise and interpret emotions in others, which may contribute to social interaction challenges often associated with autism.
Interestingly, in hyper-empathic autistic individuals like myself, alexithymia presents a unique challenge. We may experience intense emotional responses to others’ states but struggle to identify the source or nature of these emotions due to alexithymia. This mismatch between intense emotional experiences and difficulty in emotional identification can lead to significant confusion and distress. It also complicates behavioural interventions in schools and therapy approaches that rely on accurate emotional self-reporting and introspection. Traditional therapeutic techniques may be less effective for these individuals, as they may struggle to articulate their emotional experiences or connect them to specific triggers or situations. This underscores the importance of considering alexithymia in autism research and clinical practice, as it can significantly impact both the expression and internal processing of emotions, potentially leading to misinterpretations of autistic emotional experiences and responses.
Sidebar: The Complex Interplay of Alexithymia, Autism, and Identity
As an autistic individual navigating gender transition, I found myself in a unique position that highlighted the complex interplay between autism, alexithymia, and identity. During the initial stages of my transition, I was acutely aware of my tendency to absorb others’ emotions, a trait common in many autistic people. This, combined with the challenges of alexithymia in identifying my own feelings, led me to take a more measured and lengthy approach to my transition.
I felt it was crucial to ensure that the emotions driving my desire to transition were truly my own, not simply reflections of others’ expectations or experiences. This need for certainty meant that the early phases of my transition were necessarily longer than might be typical. I had to carefully sift through my emotional responses, distinguishing between internally generated feelings and those I might have unconsciously absorbed from my environment or the transgender community.
This experience underscored for me the importance of allowing autistic individuals, especially those dealing with alexithymia, the time and space to process complex emotional experiences. In the context of significant life changes like gender transition, the usual timelines or expectations may not always apply. My journey highlighted the need for personalised approaches in both personal development and clinical settings, accommodating the unique way many autistic people process and understand their emotions.
Study Design and Methodology
The study involved 81 non-autistic adults from the general population, divided into three groups based on their Autism-Spectrum Quotient (AQ) scores: Low-AQ, Medium-AQ, and High-AQ. Participants completed an empathic accuracy task where they viewed video clips of autistic and non-autistic narrators recounting emotional experiences. They were asked to continuously rate the narrator’s emotional intensity, identify the emotion being expressed, and report their own emotional response. Additionally, participants used a body mapping tool to indicate where and how intensely they felt emotions in their bodies while watching the clips. The researchers analysed empathic accuracy, cognitive empathy, affective empathy, and interoceptive intensity across the different groups and narrator types.
Notably absent from the study design were any measures or controls for alexithymia. Despite acknowledging the high prevalence of alexithymia in autism and its potential impact on emotional expression and perception, the researchers did not include any assessments of alexithymia in their participants or narrators. This omission represents a significant limitation in the study methodology. Without controlling for alexithymia, it becomes difficult to distinguish whether the observed differences in empathic responses are due to autism-specific traits or alexithymia-related characteristics. This lack of control potentially confounds the interpretation of the results and limits the study’s ability to draw conclusive insights about autism-specific empathic processes.
Potential Confounds Due to Uncontrolled Alexithymia
The lack of control for alexithymia in this study potentially introduces several significant confounds that could affect the interpretation of the results. The finding of lower Empathic Accuracy (EmpAcc) scores for autistic narrators is particularly vulnerable to alexithymia-related confounds. Alexithymia, again characterised by difficulties in identifying, sourcing, and describing emotions, could lead to atypical emotional expressions that are harder for others to interpret accurately. If a substantial portion of the autistic narrators had co-occurring alexithymia, their emotional expressions might have been less clear or conventional, making it more challenging for participants to accurately track their emotional intensity. This could result in lower EmpAcc scores that are more reflective of alexithymia than autism-specific traits.
The higher Participant Interoceptive Intensity (ParInt) reported when viewing autistic narrators, especially for anger and fear, could also be influenced by uncontrolled alexithymia. Individuals with alexithymia often have difficulty distinguishing between emotional and physical sensations, which can lead to more intense or ambiguous bodily experiences of emotions. If autistic narrators with alexithymia were expressing emotions in ways that seemed more intense or ambiguous due to their difficulty in emotional identification, this could elicit stronger interoceptive responses in participants. The higher ParInt scores might thus reflect reactions to alexithymia-influenced expressions rather than autism-specific emotional communication.
The lack of significant differences in Cognitive Empathy (CogEmp) and Affective Empathy (AffEmp) based on narrator type is also subject to potential confounding by alexithymia. Alexithymia can affect both the expression and recognition of emotions, potentially masking or altering any autism-specific differences in these areas. For instance, if autistic narrators with alexithymia were expressing emotions in atypical ways, participants might have struggled to accurately identify these emotions (affecting CogEmp) or to share in the emotional experience (affecting AffEmp). Conversely, if non-autistic participants had varying levels of alexithymia themselves, this could have influenced their ability to identify and share emotions regardless of the narrator type, potentially flattening out any group differences.
Moreover, the complex interaction between autism and alexithymia could create unexpected patterns in the data. Some autistic individuals might be highly empathetic but struggle with emotional expression due to alexithymia, while others might have lower empathy but clearer emotional expression. Without controlling for alexithymia, these nuanced differences are conflated, potentially leading to misleading conclusions about autism-specific empathic abilities.
The study’s finding of no significant differences in CogEmp and AffEmp based on narrator type could be particularly affected by this conflation. If alexithymia were more prevalent in the autistic narrator group, it might have created a scenario where participants struggled equally with interpreting emotions from autistic narrators (due to alexithymia-related expression difficulties) and from non-autistic narrators (due to the absence of such difficulties), resulting in seemingly equivalent empathy scores that mask underlying differences in emotional processing and expression.
As such, the uncontrolled presence of alexithymia introduces a layer of complexity to the interpretation of all main findings in this study. It potentially confounds the lower EmpAcc scores, higher ParInt responses, and lack of differences in CogEmp and AffEmp for autistic narrators. Without distinguishing between autism-specific traits and alexithymia-related characteristics, it becomes challenging to draw clear conclusions about the nature of empathic processes in autism based on these results.
Implications for Study Conclusions
The uncontrolled influence of alexithymia in this study has significant implications for its conclusions, particularly regarding the ‘double empathy problem in autism.’ Whilst the results appear to support the notion that non-autistic individuals struggle to empathise accurately with autistic people, the absence of alexithymia measures complicates this interpretation. The observed differences in empathic accuracy and interoceptive intensity may be partially or largely attributable to alexithymia rather than autism-specific traits, potentially overstating the extent of the double empathy problem. This limitation raises serious concerns about the generalisability of the study’s findings to the broader autistic population. Given the high co-occurrence of alexithymia in autism, but its variable presence, it’s unclear whether these results would hold true for autistic individuals without alexithymia or how they might differ across various levels of alexithymic traits.
Furthermore, there’s a significant risk of misattributing alexithymia effects to autism itself. The study’s conclusions about autism-specific differences in emotional expression and perception may be conflating two distinct phenomena. This conflation could lead to inaccurate characterisations of autistic emotional experiences and capabilities, potentially reinforcing misconceptions about autism and empathy. It also complicates the practical applications of these findings in therapeutic or social contexts, as interventions designed based on these results might not adequately address the true nature of empathic differences in autism. Ultimately, whilst the study provides valuable insights into empathic processes, the lack of control for alexithymia limits the strength and specificity of its conclusions about autism-specific empathic abilities.
Suggestions for Future Research
Future research in this area should prioritise incorporating alexithymia measures to address the limitations of the current study. By including validated assessments of alexithymia, such as the Toronto Alexithymia Scale, researchers can better differentiate between autism-specific traits and alexithymia-related characteristics. This would allow for a more nuanced analysis of empathic processes in autism. Studies should aim to separate the effects of autism and alexithymia by including groups of autistic individuals with and without alexithymia, as well as non-autistic individuals with and without alexithymia. This four-group design would enable researchers to tease apart the unique contributions of autism and alexithymia to empathic abilities and emotional expression. Additionally, longitudinal studies tracking the development of empathic skills in autistic individuals with varying levels of alexithymia could provide insights into the interplay between these factors over time. Employing mixed-methods approaches, combining quantitative measures with qualitative interviews, could offer a more comprehensive understanding of the subjective experiences of empathy and emotion processing in autism. These refined study designs would significantly enhance our understanding of the double empathy problem and contribute to more targeted interventions and support strategies for autistic individuals.
Broader Implications for Autism Research
The limitations identified in this study underscore broader implications for autism research as a whole. The oversight of alexithymia highlights the critical importance of considering co-occurring conditions in autism studies. Autism rarely occurs in isolation, and conditions like alexithymia, anxiety, depression, and ADHD frequently co-exist with autism, potentially influencing research outcomes. Failing to account for these co-occurring conditions can lead to misattributions of observed effects to autism itself, resulting in an incomplete or inaccurate understanding of autistic experiences and behaviours. This complexity presents significant challenges in isolating autism-specific traits. The high heterogeneity within ‘the autism spectrum,’ combined with the variable presence of co-occurring conditions, makes it difficult to determine which characteristics are truly unique to autism. Researchers must strive for more comprehensive study designs that systematically control for and analyze the effects of co-occurring conditions. This approach, while more complex, is essential for advancing our understanding of autism and developing more effective, personalized interventions. It also highlights the need for a more nuanced, individualised approach in both research and clinical practice, recognising the diverse presentations and experiences within the autism spectrum.
Final thoughts …
To wrap up, the uncontrolled presence of alexithymia in this study potentially confounds its results, complicating the interpretation of empathic differences attributed to autism. The observed variations in empathic accuracy and interoceptive intensity may reflect alexithymia-related characteristics rather than autism-specific traits. Despite this limitation, the study provides valuable insights into the complexities of empathic processes and highlights the need for more nuanced research approaches in autism studies. It serves as a crucial stepping stone, emphasising the importance of considering co-occurring conditions in autism research. Moving forward, it is imperative that future studies incorporate measures to differentiate between autism and alexithymia effects. This refined approach will not only enhance our understanding of autism-specific empathic experiences but also contribute to the development of more inclusive and supportive environments that respect and accommodate the diverse ways autistic individuals process and express emotions.
Thanks again for this thorough analysis of how alexythimia needs to be addressed as a separate, co-occurring condition of both autistic and non-autistic persons. I can relate to your experience of easily absorbing other people’s emotions while not being able able to accurately identify my own emotions. And I like the guideline mentioned in the article of “giving autistic persons time and space to process complex emotions.”