Navigating Emotional Awareness: Clinical Intersections, Divergences, and Therapeutic Implications of Alexithymia, Narcissism, and Related Mood and Emotional Conditions
A neurodiversity-affirming, trauma-informed guide for psychotherapists
Introduction
As clinicians, we often sit with clients navigating layers of emotional confusion, interpersonal distress, and unmet relational needs. Amidst this complexity, terms like alexithymia, narcissism, and emotional unavailability frequently arise, sometimes as clinical observations, other times as labels brought in by clients from the internet or their partners.
Earlier this week, I published a related article aimed at the general public and couples: Is My Partner a Narcissist – Or Could It Be Alexithymia? Understanding Emotional Disconnect in Relationships
This piece explores how mislabeling emotional processing difficulties as narcissism can harm neurodivergent individuals or those with trauma histories, and offers language to help navigate such situations with more clarity and care.
In the therapy room, it is essential to approach these constructs with nuance, humility, and non-pathologising curiosity. While diagnosis may not always be appropriate or necessary, emotional awareness and regulation sit at the core of psychological wellbeing and understanding their disruptions can powerfully inform formulation and intervention.
This article explores the intersections and divergences of alexithymia and narcissism in clinical settings, grounded in current research and psychological theory, with the goal of supporting emotionally attuned, trauma-informed care.
Key Concepts: What We’re Talking About
Alexithymia refers to difficulties in identifying and describing feelings, along with a tendency toward externally focused thinking. It is not a diagnosis, but a dimensional trait found across clinical and non-clinical populations, particularly in mood, personality, trauma-related, and neurodevelopmental conditions.
Narcissism exists on a spectrum, from healthy self-confidence to maladaptive traits. Clinical concerns generally emerge around Pathological Narcissism, which includes two core dimensions:
Grandiose narcissism (inflated self-importance, entitlement)
Vulnerable narcissism (hypersensitivity, shame, relational withdrawal)
These traits, when elevated, can impair empathy, intimacy, and emotional insight, but not always in the way stereotypes suggest.
Research Highlights: Clinical Intersections and Divergences
1. High Prevalence in Personality Disorder Populations
A recent multi-site study found that over 50% of patients in personality disorder services scored high on alexithymia measures (TAS-20).
Those with elevated alexithymia showed increased symptom severity, poorer psychosocial functioning, and higher rates of depression and anxiety.
2. Subtypes of Alexithymia and Their Relevance
The "Difficulties Identifying Feelings" (DIF) component is most associated with vulnerable narcissistic traits, including emotional fragility, interpersonal mistrust, and defensive withdrawal.
The "Externally Oriented Thinking" (EOT) subtype, thinking about events rather than emotions is less directly associated with narcissism, but often seen in neurodivergent or trauma-affected populations.
3. Emotion Regulation and Empathy: A Differentiating Lens
Narcissism (particularly vulnerable) is associated with emotion regulation difficulties, often involving expressive suppression or self-enhancement biases.
Alexithymia represents a more generalised unawareness of emotion, affecting both self-reflection and social-emotional responsiveness.
When co-occurring, these traits can exacerbate interpersonal difficulties, sometimes appearing as emotional coldness, but rooted in very different mechanisms.
4. Clinical Comorbidity and Misunderstanding
Alexithymia and narcissism frequently co-occur in clinical contexts. Without proper differentiation, clients may be mislabeled—e.g., neurodivergent individuals being called “narcissistic” or “emotionally manipulative” due to emotional expression differences.
This mislabeling can increase shame, disrupt identity development, and undermine therapeutic trust.
5. Developmental & Relational Origins
Unmet psychological needs in early life—such as emotional attunement, validation, and safety—are linked to later alexithymia and narcissistic traits.
In adolescents, higher alexithymia has been shown to predict narcissistic traits, highlighting its role in emotional development and the potential for early intervention.
Clinical Implications: Toward Attuned and Ethical Practice
1. Stay Curious, Not Diagnostic (Unless You're Trained To Be)
Not all therapists are licensed to diagnose, and not all clients benefit from labels. However, observing emotional patterns, such as restricted affect, misattuned empathy, or rigid self-image can inform how we show up therapeutically.
Curiosity + Compassion = Clarity
Rather than asking “Is this narcissism?”, ask:“What’s getting in the way of emotional connection here?”
“How does this client process, express, and experience emotion?”
“How does their self-image affect relational safety?”
2. Assess Alexithymia When Relevant
Use validated self-report tools such as the TAS-20 to understand emotional awareness levels, particularly when:
Clients struggle to name feelings
Sessions feel cognitively “stuck”
Affective resonance is low
3. Use Non-Pathologising Language
Avoid pathologising terms like “emotionally unavailable,” “toxic,” or “manipulative” unless used within a clear clinical framework. Instead, reframe:
“Emotionally disconnected” → “May be experiencing difficulties identifying or expressing feelings”
“Doesn’t care” → “Might not be aware of how their actions affect others”
4. Work with the System, Not Just the Symptoms
Support clients in building emotional granularity (naming nuances of feelings)
Integrate body-based awareness (somatic anchors, interoception mapping)
Use interpersonal feedback loops: notice and reflect in real-time on emotional ruptures, avoidant behaviors, or shutdowns
Free Tool for Therapists:
Reflective Clinical Assessment Worksheet: Alexithymia & Narcissistic Traits in Emotional Formulation
This downloadable worksheet helps therapists:
Reflect on emotional processing patterns without diagnosing
Map key indicators of alexithymia vs. narcissistic traits
Consider developmental, cultural, and neurodivergent influences
Identify possible clinical goals (e.g., increasing affective insight, relational repair, enhancing empathy)
Final Thoughts
In this era of viral diagnoses and quick labels, clinicians carry a unique responsibility: to hold space for emotional complexity, developmental nuance, and the dignity of every client. When we approach traits like alexithymia and narcissism not as fixed categories, but as intersecting experiences shaped by neurodiversity, trauma, and relational history, we deepen our clinical presence, not just diagnostically, but relationally.
By cultivating curiosity and compassion, we support clients in developing emotional language, building self-awareness, and fostering more meaningful connections with themselves and others.
Curious about how to explore this topic further with clients or colleagues?
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Keep an eye out for upcoming case-based trainings on relational ruptures, alexithymia, and empathy development in therapy.
Interested in supervision or training? I welcome enquiries from fellow clinicians, whether you're looking for reflective supervision or want to know where I’ll next be presenting on this subject. Visit JKL Therapy Centre for more information.
Let’s continue to do work that resists oversimplification and centers the emotional humanity of every person who enters the therapy room.
References & Recommended Reading
Raskin, R., & Terry, H. (1988). A principal-components analysis of the Narcissistic Personality Inventory and further evidence of its construct validity. Journal of Personality and Social Psychology, 54, 890–902.
Ames, D. R., Rose, P., & Anderson, C. P. (2006). The NPI-16 as a short measure of narcissism. Journal of Research in Personality, 40, 440–450.
Aaron, J., et al. (2023). Alexithymia, emotion dysregulation and maladaptive narcissism: Clinical implications in PD services. Clinical Psychology Review.
Heinzer, S., et al. (2022). Understanding emotional processing difficulties in narcissism: A systematic review. Personality Disorders: Theory, Research, and Treatment.
Bagby, R. M., Taylor, G. J., & Parker, J. D. A. (1994). The twenty-item Toronto Alexithymia Scale: I. Item selection and cross-validation of the factor structure. Journal of Psychosomatic Research, 38, 23–32.
Bird, G., & Cook, R. (2013). Mixed emotions: The contribution of alexithymia to the emotional symptoms of autism. Translational Psychiatry, 3(7), e285. https://doi.org/10.1038/tp.2013.61
Kinnaird, E., Stewart, C., & Tchanturia, K. (2019). Investigating alexithymia in autism: A systematic review and meta-analysis. European Psychiatry, 55, 80–89. https://doi.org/10.1016/j.eurpsy.2018.09.004
Poquérusse, J., Pastore, L., Dellantonio, S., & Esposito, G. (2018). Alexithymia and autism spectrum disorder: A complex relationship. Frontiers in Psychology, 9, 1196. https://doi.org/10.3389/fpsyg.2018.01196
Edey, R., Cook, J. L., Brewer, R., Turner, T., & Bird, G. (2016). Alexithymia is associated with a multidomain, multilevel failure of empathy in autism. Journal of Autism and Developmental Disorders, 46, 3291–3305. https://doi.org/10.1007/s10803-016-2871-5
Ramos, F., &Tracey, K. (2021). Alexithymia, emotion regulation, and ADHD symptoms in adults: A mediation analysis. Journal of Attention Disorders, 25(2), 178–187. https://doi.org/10.1177/1087054718770012
