When Your Instruments Lie: Understanding Alexithymia and Interoceptionin Neurodivergent Adults

Image credit: Midjourney

A few years ago, I bought my wife and kids tickets to a Christmas Day San Francisco 49ers game. Late season, high stakes, incredible seats. I’ve been a 49ers fan for over 40 years and had never been to a game in person. The whole trip cost me a small fortune.

On game day, two of my sons had to walk me to my seat holding my arms, because the crowd was so overwhelming for me. It took until midway through the second quarter before I could pay attention at all — even with earplugs in. (The boys found this “pretty cringe.” I wore them anyway.) There was so much to look at, so much sound, so much unpredictable movement in my peripheral vision that I spent most of the game largely dissociated. Whenever the crowd erupted, I had to cover my ears even through the earplugs. I have a vague memory that my team lost. Other than that, the game is a blur.

The kids had fun. I did not.

I am a licensed clinical therapist. I specialize in neurodivergence and complex trauma. I help people understand their nervous systems for a living. And I spent an extremely expensive evening completely unable to access or regulate my own.

That’s not irony. That’s alexithymia and interoceptive differences, doing exactly what they do.

I’m also autistic, and possibly AuDHD, although at the time of this game I hadn’t yet been diagnosed. My experience in Levi’s Stadium that Christmas Day was one of the reasons I finally, after years of denial, went to get assessed for autism. It was, ultimately, both a shock and no surprise at all to hear the psychologist say, “Yep, you’re autistic.”

You’re Not Broken. Your Instruments Are Unreliable.

If you’ve ever been in therapy — or just in a conversation where someone asked “how does that make you feel?” — and you’ve found yourself genuinely unable to answer, this is for you.

If you’re anything like me, you aren’t deflecting or avoiding. You actually have no idea.

Maybe you’ve described your emotional state in physical terms for so long that you didn’t realize everyone else wasn’t doing that. I feel heavy. My chest is tight. I’m just really tired. 

Maybe you’ve had the experience of bursting into tears when someone was kind to you, and not knowing why, because you hadn’t known you were sad. 

Maybe you’ve looked down and noticed your hands are shaking and your jaw is clenched and had to work backwards — oh, I must be angry — rather than simply knowing it.

Maybe you’ve spent years in therapy trying to do the thing you were supposed to do, and feeling quietly ashamed that you couldn’t get it to work the way the books said it should.

There’s a name for this experience. Two of them, actually.

Alexithymia is difficulty identifying, labeling, and communicating emotional experience. It’s not an absence of feeling — people with high alexithymia often feel things intensely, sometimes more intensely than average. The difficulty is upstream: recognizing that a feeling is happening, being able to name it, being able to describe it to another person.

Interoception is the body’s ability to sense its own internal state — hunger, heartrate, muscle tension, temperature, the thousand small signals that tell you what’s happening inside. 

Emotions are partly interoceptive events. Fear has a physical signature. So does grief, excitement, overwhelm. 

If those signals are muffled, scrambled, absent, or so overwhelming they’re unreadable, identifying what you’re feeling becomes genuinely harder. Not because you don’t have feelings, but because the channel through which feelings would register for a “normal” person is, for you, highly unreliable.

You’re driving a car and the dashboard gauges don’t work. The fuel gauge says full when you’re running on fumes. The temperature gauge stays steady right up until the engine seizes. 

You’re not a bad driver. Your instruments are lying to you.

That’s what alexithymia and interoceptive differences feel like from the inside.

How Common Is This, Exactly?

More common than most people realize — especially among neurodivergent people and trauma survivors, who are exactly the populations most likely to be sitting across from a therapist who keeps asking them to identify their feelings.

In the general population, roughly 5% of people meet criteria for alexithymia. In autistic adults, a 2019 systematic review and meta-analysis found it in approximately 50% — about ten times the general rate.

The ADHD research is less developed, but clinical consensus strongly points to elevated rates, particularly in high-demand situations. 

In people with PTSD, estimates range from 16% to 43% (admittedly a very, very wide range), and alexithymia is associated with worse PTSD severity and poorer treatment outcomes.

The interoception picture is similar. A 2025 systematic review in Frontiers in Psychiatry confirmed significantly lower interoceptive accuracy in autistic people. 

Research on ADHD points to related disruptions through a different mechanism — state regulation difficulties that affect how arousal signals are processed — but the result is often the same: unreliable instruments.

And then there’s trauma. Approximately 60% of autistic adults report probable PTSD in their lifetime, compared to about 4.5% of the general population. ADHD has been identified as a predecessor risk factor for PTSD — meaning it tends to come first, and when both are present, PTSD tends to be more severe. 

This isn’t coincidental. Neurodivergent people face higher rates of bullying, abuse, medical trauma, and social rejection, plus the cumulative harm of years of not understanding why the world feels so hard — often without language or support to process any of it.

Stack complex trauma on top of already-unreliable interoception and alexithymia, and you get gauges that are lying for multiple reasons simultaneously. The clinically important thing is that these don’t need to be teased apart. They need to be approached together.

One more thing worth knowing: alexithymia isn’t a fixed, static state. Stress, burnout, and trauma activation significantly amplify it — which means the experience of “I don’t know what I’m feeling” tends to get worse exactly when it matters most. 

On a regulated, low-demand day, you might have some access. During burnout or crisis, essentially none. That’s not a failure of will. That’s how a complicated nervous system works.

The Volume Knob Problem

Interoception is about the internal world. Sensory processing is about the external one — how you experience sound, light, touch, smell, taste, movement. And for many neurodivergent people, the volume knob on sensory input is set either too high or too low. Sometimes both, depending on the type of input.

When it’s turned up too high, ordinary sensory experiences become genuinely painful or incapacitating. The tag on a shirt. The seams in jeans. Black pepper. Fluorescent lights. Unexpected touch. Crowds where people keep moving toward you in ways you can’t predict. 

These aren’t preferences or sensitivity. They occupy enough of the nervous system’s bandwidth that there’s little left for anything else.

I’m in this camp with certain sounds — high-frequency instruments, deep bass at volume, just loudness in general. I enjoy live music, but I travel with earplugs. 

Too many visual signals at once will cause me to dissociate over time. Sports bars are a genuine problem. 

And sudden movement in my peripheral vision is a real trigger — my kids know not to play-fight near my head the way they might with each other. My reaction is pretty extreme, probably shaped in part by being beaten up several times in adolescence. The nervous system remembers what the conscious mind tries to move past.

When the volume knob is turned down too low, the problem is different but equally real. Food tastes bland unless it has serious spiciness. Injuries go unnoticed. The nervous system needs intense input just to feel regulated.

My wife is Peruvian, and her family find it remarkable that I not only enjoy but crave extremely spicy food. They call me “el gringo picante.” My mother, on the other hand, grew up in Michigan where food was reliably bland. Black pepper burns her tongue. Deviled eggs are hellfire. We make her a separate potato salad at family gatherings. 

Same genetics. Different expression.

Sensory thresholds also shift with burnout. A person who can usually tolerate a busy grocery store may find it completely unbearable during autistic burnout. When everything suddenly becomes too much — when the sounds and lights and people you could handle last month are now impossible — that’s not regression. Your nervous system is running low. The buffer is gone.

Why “Just Notice What You’re Feeling” Often Fails

Most mainstream therapy is built on a model: thoughts lead to feelings, which lead to behaviors. Change the thoughts, and you change the feelings. This is the basis for Cognitive Behavioral Therapy, which has dominated the field for decades, and its close relatives — DBT, ACT, ERP, MBCT.

For neurotypical people without significant trauma histories, these approaches can be genuinely effective. But they share an underlying assumption: that you can reliably identify and access your emotional states as a starting point. For many ND people with alexithymia or interoceptive differences, that starting point often isn’t available. And when behavior is being driven by sensory input or limbic activation rather than conscious thought, examining the thought isn’t going to change what the nervous system is doing.

Even body-based approaches — which are generally better suited to ND and trauma clients — need significant modification. EMDR, Brainspotting, Somatic Experiencing, Internal Family Systems all involve asking the client to locate a body sensation or emotion connected to what they’re working on. “Where do you feel that in your body?” 

For many ND clients, the honest answer is: I don’t know. I can’t find anything.

Two things tend to happen. The client makes something up — not consciously, but because the therapeutic context creates pressure to produce an expected answer. (“I feel it in my chest, I guess?”) Or the opposite: if they do manage to tune in, the signal is so overwhelming that they become immediately dysregulated. 

Both patterns are common. Neither means the approach is wrong. It means it needs to be adapted.

If you’re working with a therapist who is only offering unmodified CBT or DBT and you’re not finding it useful, that’s worth naming out loud. The approaches that tend to work better as a foundation — or alongside carefully modified cognitive work — include Brainspotting, IFS, Somatic Experiencing, EMDR with ND adaptations, and polyvagal-informed therapy. 

These are nervous-system-first rather than cognition-first. They meet you where you actually are.

What Does Help

The environment comes first. If sensory overload is contributing to dysregulation, the first intervention is environmental. Reduce the load before trying to process what it’s doing to you. 

This means deliberate choices about where you spend time and what you decline — not white-knuckling through situations that are genuinely dysregulating because you “should” be able to handle them. Many ND adults have spent decades masking — holding it together on the outside while flooded on the inside. Giving yourself permission to design your life around your nervous system rather than the other way around often feels like failure. It isn’t. It’s what actually works.

Build interoceptive awareness slowly — very slowly. You can develop better access to your internal states. But this takes time and needs to be approached carefully, especially if dissociation has been a significant coping strategy. 

Brief, gentle check-ins work better than deep dives. Instead of asking “what am I feeling,” try “what is my body doing?” 

Heartrate, breathing, jaw tension, stomach — these can be more accessible entry points than emotional labels. Wearables that track physiological data can function as external interoception. Not a workaround — a legitimate accessibility tool. And many ND people process better in retrospect: asking “how did that feel?” 24 hours later sometimes yields more than asking in the moment.

Consistent small habits, not dramatic overhauls. The goal isn’t to fix alexithymia. It’s to build enough regulatory capacity that you have some reserve when things get difficult. 

Sleep, movement, time in nature, nourishing food, genuine rest. These aren’t luxuries for ND nervous systems — they’re closer to medicine. 

The New Year’s Resolution model almost always fails and produces shame. What works is 1% improvements. One small change, done consistently, until it becomes routine. Then one more. All-or-nothing thinking is real, and also very expensive in the sense of failure and shame it creates.

Find a neurodivergent-affirming OT if you can. A good occupational therapist who works with adults and understands sensory processing can help you build a sensory diet — a planned set of sensory inputs designed to regulate your nervous system rather than overwhelm it. ND-affirming OTs who work with adults (not just children) are genuinely rare, but Kelly Mahler’s work and Neurodivergent Insights are good places to start for self-guided resources.

Know what to ask for in a therapist. Look for someone who is familiar with ND sensory and interoceptive differences and doesn’t treat them as resistance. Who uses body-based and nervous-system-informed approaches rather than purely cognitive ones. Who understands complex trauma and can hold both pictures simultaneously. Who will pace the work to your window of tolerance. And who takes your self-report of your experience seriously, even when it doesn’t fit the standard presentation.

A Few Questions Worth Sitting With

You don’t have to answer these right now. They’re more useful as things to return to over time, or to bring to a therapist.

When you notice you’re struggling emotionally, where does it show up first? In your body? In your behavior? In a vague sense that something is wrong? Or not at all until it’s already a crisis?

Are there sensory inputs that reliably regulate you — that make you feel more settled, more yourself? Are there ones that reliably dysregulate you? Are there situations you’ve been white-knuckling through that you could actually just avoid?

Have you ever made up an emotional state because someone expected you to have one — “I guess I feel sad” — when you didn’t actually know?

And finally: if your nervous system were a gauge on a dashboard right now, what would it be reading?

Where to Go From Here

The full clinical handout that accompanies this article — When Your Instruments Lie: Understanding Alexithymia and Interoception in Neurodivergent Adults — goes deeper on the research, the three interoceptive profiles, Sensory Processing Disorder subtypes, why specific therapeutic modalities struggle or work with this population, and reflection prompts for use in your own processing or with your therapist.

A few resources worth knowing:

Dr. Megan Anna Neff at neurodivergentinsights.com — some of the best accessible material on interoception and alexithymia from a neurodivergent-affirming lens. Her interoception workbook is excellent.

Kelly Mahler, OTD — the leading OT researcher and practitioner on interoception. Resources at kelly-mahler.com.

Dr. Mel Houser at allbrainsbelong.org — focused on ND-affirming medical care and patient advocacy.

K. David Smith, LCSW, CASDCS, CCTP, CFTP 

K. David Smith is a neurodiversity-affirming therapist specializing in autism, ADHD, and complex trauma. He is the founder of Thriving Family Therapy and is himself a late-identified autistic adult with complex PTSD. He lives in Oregon and is working on a book.

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