Blind to feelings, lost in self: alexithymia and personality dysfunction in suicidality

Dimensional models of personality pathology are increasingly emphasized in contemporary psychiatry. The DSM-5 Alternative Model for Personality Disorders (AMPD) captures personality pathology through impairments in domains of personality functioning: identity, self-directedness, empathy, and intimacy. Importantly, impairments in personality functioning are not only associated with general psychological distress but might also play a critical role in the emergence of suicidal behavior. Suicidality is rarely an isolated phenomenon; rather, it often reflects underlying deficits in self-regulation, identity integration, interpersonal connectedness, and goal-directed behavior.

This study aimed to examine the predictive value of AMPD personality functioning domains and alexithymia in relation to suicidal behavior and its severity across different levels. We further examined whether alexithymia moderates the association between impairments in personality functioning and suicidal risk.

Personality functioning was assessed using SCID-5-AMPD domains, alexithymia was measured with the Toronto Alexithymia Scale (TAS-20), and suicidal behavior was derived from selected SCID-5-PD items, which were graded on a 3-point scale (0–2) reflecting symptom severity. Ordinal logistic regression and analyses of covariance (ANCOVA) were performed using standardized predictors in R.

A significant main effect of suicidality severity was observed across all domains of personality functioning, including identity (F(2,45) = 27.60, p < 0.001), self-directedness (F(2,45) = 30.70, p < 0.001), empathy (F(2,45) = 12.13, p < 0.001), and intimacy (F(2,45) = 17.13, p < 0.001). In contrast, alexithymia showed a significant association only with self-directedness (F(1,45) = 6.52, p = 0.014), while no significant effects were observed for identity (p = 0.17), empathy (p = 0.17), or intimacy (p = 0.12). At the global level, suicidality severity was also significantly associated with overall personality dysfunction (F(2,45) = 20.54, p < 0.001), whereas alexithymia showed only a trend-level association (p = 0.067).

To further examine predictors of suicidality severity, an ordinal logistic regression model (0 < 1 < 2) was conducted. Both alexithymia (β = 2.77, p < 0.001) and overall personality dysfunction (β = 2.35, p < 0.001) emerged as significant independent predictors of higher levels of suicidality. The interaction between alexithymia and personality functioning was not significant (p = 0.76).

The present findings suggest that both alexithymia and impairments in personality functioning are significantly associated with suicidality severity, although in partially distinct ways. While overall personality dysfunction showed a broad and robust relationship with suicidality across all domains, alexithymia demonstrated a more selective pattern, with its strongest association observed in self-directedness. This suggests that impairments in goal-directed behavior, self-regulation, and internal coherence may represent a key point of convergence between emotional processing deficits and elevated suicidality risk. Integrating AMPD-based assessments with measures of alexithymia may improve risk stratification and facilitate more targeted, mechanism-informed interventions. In particular, interventions that enhance emotional awareness and strengthen self-directedness may help reduce the risk of suicidality.

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