When Your Body Is Talking and Your Brain Can't Translate: Alexithymia, the Insula, and What Perimenopause Does to Neurodivergent Women

I made a painting about it before I had a name for it.

I called it Quiet Before the Storm. It's a portrait to visually explain what my younger self felt as the emotions rolled in while I appeared calm and still on the outside, wearing an Evil Eye necklace for protection before I even knew what the "Evil Eye" was. The clouds are rolling in, building up energy and confusion in the background. The little girl in the painting doesn't know what's coming. She looks fine on the outside, but she's not fine on the inside. There's a storm brewing that she has no language for yet.

That's what alexithymia feels like from the inside. It's chaos without falling apart. It's quiet dissociation while functioning or, better yet, performing. Moving through the day, doing the work, and using logic to maneuver and manage tasks. However, underneath the surface, something was building. Emotions I had no name for were swirling without names. Not because they aren't real, but because the bridge between what the body is carrying and what the mind can say about it hasn't been built.

I made a second painting too. I called it Dysregulated. It's an abstract expression of the intensity of those feelings I had inside me but couldn't come out to be heard. I used colors and chaotic brushstrokes to provide a voice to the storm that eventually arrives, not as a breakdown I could point to, but as an overwhelming flood of unnamed emotions. It's something that feels both too much and completely elusive at the same time. You're inside it and you still can't tell someone what it is.

I didn't know I was autistic when I made those paintings. I only knew I had alexithymia. What I knew is that I had been a surgeon, I was a physician, and a woman who functioned at the highest levels of my field, yet I couldn't tell you what I was feeling. Logical processing and expression was what I knew best. Emotion was somewhere else entirely, in a room I didn't have the key to.

When I finally found the word, it wasn't alarming. It was a relief. It had a name. That means other people live in it too. That means it's real.

What I know now that I didn't know when I first wrote about this is that it's not just a communication challenge or an emotional processing quirk. It's neurological. It's hormonal. And for women who are autistic or ADHD and moving into perimenopause, the storm that was already quiet and unnamed gets a whole lot louder.

That's what this post is about.

What Alexithymia Actually Is — and What It Isn't

Here's what I want you to understand first. Alexithymia is not the absence of emotion. It's the absence of access to those emotions.

For some people, alexithymia shows up as physical sensations they can catalog but not name. For others, it shows up differently than it does for me. My logical brain runs like an atomic clock. I can be in a meeting, in a surgery, in a conversation, or moving through my day with complete competence. But what I'm actually feeling about something that requires emotions is in a locked room I can't get into until something forces the door wide open, and by then it comes out as overwhelm, crying, or looking like the deer in the headlights down a dark road, not words.

That's the quiet before the storm. Not shutdown. Not visible distress. Just the emotional processing going somewhere else while the rest of you keeps moving.

This distinction matters enormously, because alexithymia in women, especially neurodivergent women, has been read for decades as coldness, detachment, not caring, and being difficult. I've heard versions of that during my lifetime. What was really happening was that the translation system between what my body was carrying and what my mind could say about it was running on a different circuit than the one people expected.

It helps to understand the two parts of what's supposed to happen when you feel something.

Interoception is the awareness of your internal body state — the signals your body sends about its own condition. As Dr. Kelly Mahler — one of the world's foremost researchers on interoception science, and a guest on my podcast — describes it: body signals are what give emotion words their meaning. When I asked her what interoception actually is in everyday language, she said something that stayed with me: if you authentically understand what "excited" means, you describe it from your own internal body sensation experience. You don't script back a memorized answer. You feel it first. The word comes after. That's interoception working. (Episode 9: Emotionally Numb in Midlife? Interoception ft. Dr. Kelly Mahler)

Alexithymia is what happens when the signal doesn't complete that translation. The body signal arrives. The emotional meaning doesn't. Therapies built on using emotion words fail for exactly this reason — they start at the word level and skip the body entirely. Dr. Mahler said this directly: a lot of therapies throw around emotion words and fail to realize those words don't have concrete meaning for someone who's disconnected from the body signals that would give them meaning.

Research published in Frontiers in Psychology confirms that in autism spectrum conditions specifically, interoceptive deficits show up in three key areas: emotional awareness, trusting your body's signals, and noticing body cues in the first place. (DOI: 10.3389/fpsyg.2024.1244701) These aren't separate problems. They're three points in the same circuit.

And that circuit runs through a specific structure in the brain.

The Part Nobody Told You About: Your Insula

The anterior insula is a fold of cortex tucked inside the brain — not visible from the outside, easy to overlook in a survey anatomy course. But it is one of the most important structures for what we're talking about here.

The anterior insula is one of the brain's primary integration hubs — a structure where body sensation and subjective emotional awareness begin to converge. It's where "my chest is tight" starts to become "I'm afraid" or "I'm angry" or "I'm grieving." Without that convergence happening cleanly, you can register the physical signal and still have no idea what it means.

Dr. A.D. Craig, whose foundational paper on the insula and human awareness is one of the most cited pieces of neuroscience on this topic, describes it as the structure responsible for your subjective awareness of how you feel. Not just that you feel — but the felt quality of it. The meaning-making layer. (DOI: 10.1038/nrn2555)

In autistic people, the insula is present and active. It isn't missing. Research from the University of Southern California published in Neuropsychologia found that in autistic youth with higher alexithymia, there is reduced connectivity between the left anterior insula and other emotion-related brain regions during emotional processing. The insula isn't absent from the conversation. It's less connected — working harder to make the bridge, doing it with less efficient routing. (DOI: 10.1016/j.neuropsychologia.2023.108469)

Not a deficit. A wiring difference that requires more energy and more effort to accomplish what neurotypical brains do without thinking about it.

When I talked with Dr. Mahler about rebuilding interoceptive awareness, she was clear about one thing: go slow. The research on what actually helps people improve their interoceptive connection points toward adapted body mindfulness — not the Westernized version pushed in schools and corporate wellness programs, but something trauma-informed, slowed down, presented with care. The goal is to get the body into a regulated state first, then bring gentle attention to a neutral body part — not the whole emotional landscape at once. And whatever word or color or image comes up when you pay attention to your body, she said, is valid. There's no wrong way to describe what you're experiencing. (Episode 9: Emotionally Numb in Midlife? Interoception ft. Dr. Kelly Mahler)

She also said something that I want every perimenopausal woman reading this to hear: when she searched the literature to prepare for our conversation, she could not find a single study on interoception and menopause. Not one. The research doesn't exist yet. Which means everything we've been told about menopause — all the hormone protocols, all the symptom management, all of it — is being asked and answered without ever addressing whether a woman can actually feel and report what's happening in her body clearly enough to know if the treatment is working.

What Perimenopause Does to This Already-Complex System

Here is where the clinical picture gets important.

Estrogen is not just a reproductive hormone. It is a neuroactive molecule. It has estrogen receptors throughout the brain — including in the structures involved in emotional processing, interoception, and the connections the insula depends on to do its job.

When estrogen fluctuates during perimenopause — not just declines, but swings up and down unpredictably — those brain connections get noisier. The signal-to-noise ratio in your interoceptive system changes. Body sensations that you may have been able to interpret before become harder to read. The mild alexithymia you managed for decades through pattern and routine and compensation suddenly feels like it got louder.

A 2024 pharmaco-fMRI study published in the Journal of Affective Disorders showed that estradiol directly modulates resting-state connectivity between brain regions — including meaningful changes in insula connectivity — in perimenopausal women. When estradiol levels shifted, so did the functional connections between the insula and other emotion-processing structures. (DOI: 10.1016/j.jad.2024.11.068)

That's not abstract. That's estrogen talking directly to the bridge.

A study in Psychoneuroendocrinology that followed women across the menopause transition found that as women move from perimenopause into postmenopause, the brain actually recruits more cognitive association regions to process emotion — not fewer. (DOI: 10.1016/j.psyneuen.2016.08.026) The brain is working harder to accomplish emotional processing during this transition. More regions involved. More coordination required.

For a woman who was already working harder than average just to translate her own body signals — because autistic, because her insula connectivity was already more effortful — this added load is not trivial. It is exhausting in a way that is real and measurable and not at all in her head.

The perimenopause connection: Estrogen modulates the brain structures that support interoception and emotional translation — including the insula. When estrogen fluctuates, that translation system becomes less reliable. For neurodivergent women who were already working harder to access their own emotional experience, the perimenopausal hormone shift removes a buffer they didn't know they were depending on.

The Masking Tax and What van der Kolk Got Right

There is one more layer that I have to name because I see it in every neurodivergent woman who comes to me in midlife.

If you grew up undiagnosed — and most autistic women who are in perimenopause right now did, because the diagnostic criteria were built around white boys and never updated to catch how autism presents in girls — then you learned early that your natural responses weren't acceptable. You learned to read the room, mirror what others expected, suppress what your body was actually doing, and perform a version of yourself that the world found tolerable.

That is called masking. And it is not a strategy. It is a physiological expense.

Every day you spent modulating your natural responses, suppressing sensory reactions, performing neurotypicality in meetings and grocery stores and doctor's offices — that cost your nervous system something real. It ran up a tab that didn't get paid in real time. It got deferred, and deferred, and deferred.

Bessel van der Kolk — whose work on trauma and the body I have been studying closely through his certification program — put it plainly: trauma doesn't disappear. It lives in the body. It surfaces as chronic pain, as fatigue, as disconnection from physical sensation, as the inability to feel safe enough to be present in your own skin. The body keeps score. And for a woman who has been masking since childhood, that score is high by the time perimenopause arrives.

Add to that the reality that alexithymia itself often got reinforced by the masking. When you can't read your own body signals clearly, and the environment is telling you your responses are wrong anyway, the path of least resistance is to stop trying to read them at all. To go numb not as pathology but as efficiency. The system learned that asking "what am I feeling" was a question that produced confusion and sometimes punishment, so it stopped asking.

That's not weakness. That is your nervous system doing exactly what it was trained to do.

The neurodivergent consideration: For autistic and ADHD women, the alexithymia and interoception challenges of perimenopause don't arrive in a neutral context. They arrive on top of decades of masking, years of medical dismissal, and a nervous system that has been running at high effort for its entire life. The perimenopausal hormone shift doesn't create the disconnection. It exposes what was already there, removes the compensatory mechanisms, and makes it impossible to keep pretending everything is fine. That moment of apparent unraveling is not falling apart. It is the body finally refusing to be ignored.

What the Autistic Brain Knows That Medicine Is Just Catching Up To

I have been a fly on the wall my entire life. I don't have to interact to be fully present in a room — I'm scanning it. Systems, patterns, the structure underneath the surface of things, the incongruence between what someone says and how they're actually carrying themselves. The body-level signal arrives before any conscious interpretation. I feel when something is off before I have language for it.

I always thought that was just me. It is not just me.

A meta-analysis of functional imaging studies published in Human Brain Mapping found that autistic people show consistently stronger engagement of visual and perceptual processing regions compared to non-autistic people — across visual search, pattern detection, discrimination tasks, and embedded figure recognition. More activity in the temporal, occipital, and parietal regions associated with perceptual processing. Less in the frontal cortex regions associated with top-down suppression of perceptual detail. This is the Enhanced Perceptual Functioning model — the idea that the autistic brain allocates more neural resources to sensory and perceptual processing, not fewer. (DOI: 10.1002/hbm.21307)

What that looks like in a person is not a superpower narrative. It's precision. It's detail orientation. It's the ability to detect inconsistency, pattern, and structure in environments where neurotypical processing smooths those details out. You see what other people miss because your brain is not suppressing the perceptual input — it's engaging it fully.

Now hold that alongside what the alexithymia literature shows.

A landmark study published in Psychological Science found that alexithymia — not autism — predicts poor recognition of emotional facial expressions. Autism severity on its own was unrelated to expression recognition ability. What tracked with emotional recognition difficulty was alexithymia severity. Separable. Not the same thing. (DOI: 10.1177/0956797612463582)

A systematic review and meta-analysis in European Psychiatry found alexithymia in approximately 50% of autistic people — compared to under 5% of neurotypical people — but explicitly concluded that alexithymia is common in autism, not universal, and that the emotional processing difficulties long attributed to autism as a core feature may actually belong to co-occurring alexithymia running alongside it. (DOI: 10.1016/j.eurpsy.2018.09.004)

Put those two things together and you get the clinical argument that I think is the most important thing in this post:

Autism may enhance recognition of external patterns. Alexithymia may disrupt recognition of internal affective patterns.

She recognizes the pattern in the room before she can name the pattern in her body.

That's not a contradiction. That's two aspects of the same underlying wiring — the same perceptual precision that scans external environments with accuracy has not been trained to scan the interior with the same fluency. The insula is involved in both directions. And the work of building interoceptive awareness — through the rituals below, through slowing down enough to bring the body back into conscious range — is not asking the autistic brain to do something foreign to it. It is asking it to turn the same perceptual attention it uses on the external world toward the one environment it has been taught to ignore: itself.

This is not fully in the literature yet in one clean connected form. The conversation is beginning. I'm watching it. And I'll write more about it as the research develops. What I want you to hold for now is this: the way your brain is wired may not be purely a liability. The difficulty with internal emotional translation and the heightened sensitivity to external patterns may be two sides of the same coin — and the work of perimenopause, as hard as it is, may be asking this brain to finally turn its precision on itself.

Four Rituals to Start Training the Bridge

These are not wellness tips. They are the clinical foundation of a framework I developed called TLC-SAY™ — a body-first translation protocol I built because nothing like it existed for women wired the way we are.

The premise is simple. When the verbal-emotional system is offline — because of alexithymia, because of perimenopause, because of decades of masking — you don't start with words. You start with body data. You collect the signal first. Then you give it the minimum language needed to be heard.

TLC-SAY™ has two parts. TLC collects the data. SAY makes it speakable.

TLC-SAY™ — the detail:

TLC — the data collection:

• T is Temperature. Not "what am I feeling?" Just: am I warm or cool right now? Warm signals activation — anxiety, overwhelm, anger. Cool signals shutdown — numbness, freeze, disconnect. That's it. That's all you need to start.

• L is Location. Where in your body do you notice something? Not the emotion. Just the address. My chest. My jaw. My belly. That's data. That's enough.

• C is Color. If this feeling had a color, what would it be? Your visual-spatial processing stays accessible even when your verbal-emotional system goes quiet. Gray. Red. Blue-green. You're not labeling the emotion. You're translating the signal into a format your brain can actually process.

SAY — the translation into speech:

• S is Sensation. One word. "Warm." "Heavy." "Tight."

• A is Area. One spot. "Chest." "Jaw." "Shoulders."

• Y is Yield. One ask. "Give me twenty seconds." "I need to start with body data." "Words loading."

In practice it sounds like this: "Warm — chest — give me twenty seconds." That's not failure. That is fluency in a language your nervous system has been trying to teach you your whole life.

Do this gently. The nervous system that learned to go quiet did so for a reason, and you're not going to override that with force. You're going to give it a reason to trust that you're paying attention.

The four practices below are how you build the TLC-SAY™ skill set over time — one layer at a time, never all at once.

The Hand-to-Heart Pause — getting regulated enough to listen. One hand on your chest. One hand on your belly. Slow breath in, slow breath out. Ask yourself: am I on edge, shut down, or steady? Just those three options. This activates the vagus nerve and may help shift the nervous system toward a more regulated state — which can support interoceptive awareness and the body-sensation processing the insula is involved in. You're not checking in yet. You're creating the conditions under which checking in becomes possible. This is what you do before you start TLC.

The Color Check-In — the C in TLC-SAY™. At the end of the day, ask yourself one question: if my body had a color right now, what would it be? Don't explain it. Don't justify it. Let the color stand in for whatever is happening without requiring a label. Color can provide a nonverbal sensory anchor when verbal-emotional processing feels inaccessible — visual-symbolic processing tends to remain more available when the word-finding system is offline. You're not using language to access the feeling. You're using sensation. This is your daily practice for building the C skill.

The Sensation Journal — building L and S. Instead of asking "how do I feel?" ask "what is my body telling me right now?" Write down the physical: my shoulders are up. My stomach feels hollow. My jaw is tight. Warmth in my chest. Emotions often reveal themselves after you've named the sensations, not before. You're not forcing translation. You're collecting the raw material that TLC runs on. Over time this builds your Location and Sensation vocabulary without requiring emotional fluency first.

Wordless Sharing — SAY without words. For the women in relationship who find the pressure to verbalize feelings exhausting or impossible — instead of conversation, each of you picks an object, a color, or an image that reflects your current state. No explanation required. This is SAY without the Yield ask. It keeps connection alive without triggering the shutdown that comes from being asked to perform emotional fluency you don't have access to yet.

The full TLC-SAY™ practice — including your Color Archetype-specific scripts and the deeper interoceptive work — lives inside the Color Reset Series. The quiz below tells you which archetype you are and where to start.

When to Escalate Clinically

If what you're reading here is resonating — if the description of alexithymia, interoception, and the perimenopausal hormone connection feels like someone finally put language to something you've been living in — that's worth investigating properly.

I work with women navigating exactly this intersection: the neurodivergent layer, the hormonal transition, the decades of masking and deferred nervous system load, and the stress, gut, and sleep disruption that travels with it. I order comprehensive labs before our first meeting so I have the full picture of what your hormones, your thyroid, your metabolic markers, and your stress response are actually doing — not what they did at your last annual exam. If you're in California, Georgia, Kentucky, Maryland, Ohio, Texas, or Virginia, we can work together directly.

Take the Next Step

Your body has been talking to you for a long time. You haven't been ignoring it out of carelessness — you've been working with a translation system that was never fully supported, and you've been doing it during one of the most neurologically demanding transitions of a woman's life.

The Color Archetype Quiz is the first step in understanding how your nervous system is actually wired — not how you've been performing it. It's the entry point into the NRM, and it gives you something concrete to start working with.

Take the Free Color Archetype Quiz →👇🏽

Sources

• Craig AD. How do you feel — now? The anterior insula and human awareness. Nature Reviews Neuroscience. 2009. DOI: 10.1038/nrn2555

• Samson F, Mottron L et al. Enhanced visual functioning in autism: an ALE meta-analysis. Human Brain Mapping. 2011. DOI: 10.1002/hbm.21307

• Cook R et al. Alexithymia, not autism, predicts poor recognition of emotional facial expressions. Psychological Science. 2013. DOI: 10.1177/0956797612463582

• Butera C et al. The relationship between alexithymia, interoception, and neural functional connectivity during facial expression processing in autism spectrum disorder. Neuropsychologia. 2023. DOI: 10.1016/j.neuropsychologia.2023.108469

• Kinnaird E et al. Investigating alexithymia in autism: a systematic review and meta-analysis. European Psychiatry. 2019. DOI: 10.1016/j.eurpsy.2018.09.004

• Solano Durán P et al. Interoceptive awareness in a clinical setting: the need to bring interoceptive perspectives into clinical evaluation. Frontiers in Psychology. 2024. DOI: 10.3389/fpsyg.2024.1244701

• Hynd M et al. Estradiol modulates resting-state connectivity in perimenopausal depression. Journal of Affective Disorders. 2024. DOI: 10.1016/j.jad.2024.11.068

• Berent-Spillson A et al. Metabolic and hormone influences on emotion processing during menopause. Psychoneuroendocrinology. 2016. DOI: 10.1016/j.psyneuen.2016.08.026

• Goerlich KS and Votinov M. Hormonal abnormalities in alexithymia. Frontiers in Psychiatry. 2023. DOI: 10.3389/fpsyt.2022.1070066

• Murphy J, Catmur C, Bird G. Alexithymia is associated with a multidomain, multidimensional failure of interoception: evidence from novel tests. Journal of Experimental Psychology: General. 2018. DOI: 10.1037/xge0000361

• McQuarrie AM, Smith SD, Jakobson LS. Alexithymia and sensory processing sensitivity account for unique variance in the prediction of emotional contagion and empathy. Frontiers in Psychology. 2023. DOI: 10.3389/fpsyg.2022.1008040

Dr. Stacey Denise is a board-certified surgeon transitioned into lifestyle medicine specializing in the menopause transition. She sees patients in California, Georgia, Kentucky, Maryland, Ohio, Texas, and Virginia.