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Exploring Emotion Control and Alexithymia in Autistic Adults: An Ecological Momentary Assessment Study

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Title: Exploring Emotion Control and Alexithymia in Autistic Adults: An Ecological Momentary Assessment Study
Language: English
Authors: Mădălina Elena Costache (ORCID 0000-0002-1204-3521), Federica Gioia, Nicola Vanello, Alberto Greco, François Lefebvre, Antonio Capobianco, Sébastien Weibel, Luisa Weiner
Source: Journal of Autism and Developmental Disorders. 2026 56(2):587-601.
Availability: Springer. Available from: Springer Nature. One New York Plaza, Suite 4600, New York, NY 10004. Tel: 800-777-4643; Tel: 212-460-1500; Fax: 212-460-1700; e-mail: customerservice@springernature.com; Web site: https://link.springer.com/
Peer Reviewed: Y
Page Count: 15
Publication Date: 2026
Document Type: Journal Articles
Reports - Research
Descriptors: Emotional Response, Self Control, Autism Spectrum Disorders, Emotional Problems, Adults, Arousal Patterns
DOI: 10.1007/s10803-024-06551-8
ISSN: 0162-3257
1573-3432
Abstract: Difficulties in controlling emotions--a proxy for emotion dysregulation (ED)--and difficulties in expressing feelings in words--'absence of emotion labelling' or alexithymia--co-exist in autism and contribute to elevated levels of impulsive and suicidal behaviour. To date, studies linking the two phenomena have relied on retrospective self-reported measures, lacking support for generalizability to real-life situations. The present study investigated in vivo emotion labelling and its impact on emotion control in 29 autistic adults without intellectual disability (ASC) and 28 neurotypical (NT) individuals of similar age, sex, and educational level. Participants were trained in an Ecological Momentary Assessment (EMA) to label their emotions, the arousal dimension, and their emotion control via smartphone over a one-week period. Findings showed that the ASC group experienced more instances of 'having an emotion that I cannot name' and, when they were able to label their emotions, they reported higher rates of negative and conflicting (simultaneously positive and negative) emotions. In both groups, the absence of emotion labelling, and intense negative emotions were associated with impaired emotion control. However, the association between lack of emotional awareness--'I have no emotion'--and impaired emotion control was only evident in ASC individuals. Our study highlights a nuanced facet of emotional processing in the ASC population. Further research is needed to gain a deeper understanding of the complex relationship between ED and alexithymia in autism.
Abstractor: As Provided
Entry Date: 2026
Accession Number: EJ1504717
Database: ERIC
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  Value: <anid>AN0191290370;aut01feb.26;2026Feb04.02:38;v2.2.500</anid> <title id="AN0191290370-1">Exploring Emotion Control and Alexithymia in Autistic Adults: An Ecological Momentary Assessment Study </title> <p>Difficulties in controlling emotions – a proxy for emotion dysregulation (ED)—and difficulties in expressing feelings in words—'absence of emotion labelling' or alexithymia—co-exist in autism and contribute to elevated levels of impulsive and suicidal behaviour. To date, studies linking the two phenomena have relied on retrospective self-reported measures, lacking support for generalizability to real-life situations. The present study investigated in vivo emotion labelling and its impact on emotion control in 29 autistic adults without intellectual disability (ASC) and 28 neurotypical (NT) individuals of similar age, sex, and educational level. Participants were trained in an Ecological Momentary Assessment (EMA) to label their emotions, the arousal dimension, and their emotion control via smartphone over a one-week period. Findings showed that the ASC group experienced more instances of 'having an emotion that I cannot name' and, when they were able to label their emotions, they reported higher rates of negative and conflicting (simultaneously positive and negative) emotions. In both groups, the absence of emotion labelling, and intense negative emotions were associated with impaired emotion control. However, the association between lack of emotional awareness—'I have no emotion'—and impaired emotion control was only evident in ASC individuals. Our study highlights a nuanced facet of emotional processing in the ASC population. Further research is needed to gain a deeper understanding of the complex relationship between ED and alexithymia in autism.</p> <p>Keywords: Autism spectrum condition; Emotion labelling; Emotion control; Ecological momentary assessment; Multilevel modelling; Psychology and Cognitive Sciences Psychology Medical and Health Sciences Public Health and Health Services</p> <p>Supplementary Information The online version contains supplementary material available at https://doi.org/10.1007/s10803-024-06551-8.</p> <hd id="AN0191290370-2">Introduction</hd> <p>Emotion regulation (ER) is an intricate process, defined as the "art" of modulating the experience and expression of emotions, which is crucial for overall well-being and quality of life (Gross, [<reflink idref="bib33" id="ref1">33</reflink>]; Thompson, [<reflink idref="bib86" id="ref2">86</reflink>]). Effective ER strategies involve recognising emotional responses and controlling their intensity, frequency and duration (Braunstein et al., [<reflink idref="bib9" id="ref3">9</reflink>]; Torre & Lieberman, [<reflink idref="bib88" id="ref4">88</reflink>]), enabling individuals to act in accordance with their desired goals (Linehan, [<reflink idref="bib58" id="ref5">58</reflink>]; Thompson, [<reflink idref="bib86" id="ref6">86</reflink>]). By contrast, difficulties in ER, often referred to as emotion dysregulation (ED), manifest as intense, inappropriate and enduring emotional experiences (Thompson, [<reflink idref="bib86" id="ref7">86</reflink>]). The lack of control on these out of proportion emotional responses is the reason why ED is seen as problematic to overall health. For example, ED has been consistently linked to self-harm (Brereton & McGlinchey, [<reflink idref="bib10" id="ref8">10</reflink>]), substance use (Weiss et al., [<reflink idref="bib96" id="ref9">96</reflink>]), and suicidality (Hatkevich et al., [<reflink idref="bib38" id="ref10">38</reflink>]) in both non-clinical and clinical populations. Extensively studied in the context of Borderline Personality Disorder (BPD), ED is being increasingly acknowledged as a transdiagnostic process that is present in various psychiatric and neurodevelopmental conditions, including autism spectrum condition[<reflink idref="bib1" id="ref11">1</reflink>] (ASC) (Cai et al., [<reflink idref="bib13" id="ref12">13</reflink>]; Conner et al., [<reflink idref="bib17" id="ref13">17</reflink>]; Dell'Osso et al., [<reflink idref="bib21" id="ref14">21</reflink>]; Mazefsky et al., [<reflink idref="bib62" id="ref15">62</reflink>]; Samson et al., [<reflink idref="bib80" id="ref16">80</reflink>]). In this article, we will explore how ED has been studied in ASC, with a particular focus on the challenges associated with the presence of negative emotions and the lack of emotional labelling (i.e., difficulty identifying emotions).</p> <p>Although the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) does not classify ED as a primary feature of ASC (American Psychiatric Association, 2013), recent research indicates that it is a prevalent issue, affecting between 50 and 80% of autistic youth (Conner et al., [<reflink idref="bib17" id="ref17">17</reflink>]; Keluskar et al., [<reflink idref="bib49" id="ref18">49</reflink>]; Mazefsky & White, [<reflink idref="bib64" id="ref19">64</reflink>]). Autistic children may experience elevated levels of negative emotions, such as fear, sadness, anger, shame and irritability, but also fewer positive emotions than neurotypical (NT) individuals (Garon et al., [<reflink idref="bib28" id="ref20">28</reflink>]; Keluskar et al., [<reflink idref="bib49" id="ref21">49</reflink>]; Samson et al., [<reflink idref="bib80" id="ref22">80</reflink>]). Regarding behavioural problems possibly associated with ED, meltdowns and outbursts have been linked to the use of ineffective ER strategies, such as avoidance and self-isolation (Lewis & Stevens, [<reflink idref="bib55" id="ref23">55</reflink>]). Typically, adaptive emotion regulation strategies, including cognitive reappraisal and social support seeking, tend to increase from adolescence to adulthood (Isaacowitz, [<reflink idref="bib44" id="ref24">44</reflink>]). However, in some cases, ED can persist and have severe consequences in adulthood (Cassidy et al., [<reflink idref="bib15" id="ref25">15</reflink>]; Dell'Osso et al., [<reflink idref="bib21" id="ref26">21</reflink>]). For instance, like in BPD, ED in autistic adults may present as self-harming and suicidal behaviours aimed at reducing emotional distress (Bemmouna & Weiner, [<reflink idref="bib4" id="ref27">4</reflink>]; Newell et al., [<reflink idref="bib71" id="ref28">71</reflink>]). These behaviours can have a significant negative impact on daily functioning and long-term outcomes (Thompson, [<reflink idref="bib87" id="ref29">87</reflink>]).</p> <p>According to a growing body of literature, ED in ASC might be explained by the presence of alexithymia (e.g., Bird & Cook, [<reflink idref="bib6" id="ref30">6</reflink>]; Gormley et al., [<reflink idref="bib31" id="ref31">31</reflink>]; Hassen et al., [<reflink idref="bib37" id="ref32">37</reflink>]). Alexithymia affects approximately 50% of autistic individuals (Hill et al., [<reflink idref="bib40" id="ref33">40</reflink>]) and is defined as the difficulty identifying and describing emotions (i.e. absence of emotion labelling), distinguishing them from bodily sensations (i.e., emotional awareness), and a tendency to focus more on external stimuli rather than internal emotional states (i.e., externally-oriented thinking) (Luminet et al., [<reflink idref="bib59" id="ref34">59</reflink>]; Sifneos, 1973). Efficient emotion labelling is thought to trigger the activation of emotion regulatory systems, thereby enhancing intentional ER (Mauss et al., [<reflink idref="bib61" id="ref35">61</reflink>]; Torre & Lieberman, [<reflink idref="bib88" id="ref36">88</reflink>]). Interestingly, one study found that anxiety in autistic adults without intellectual disability was primarily mediated by the lack of emotional differentiation and emotional acceptance associated with alexithymia, and the intolerance of uncertainty that is a feature of ASC (i.e., change-related anxiety) (Maisel et al., [<reflink idref="bib60" id="ref37">60</reflink>]). Additionally, in ASC, alexithymia has been identified as a significant predictor of self-harm, supporting its association with difficulties in ER processes (Moseley et al., [<reflink idref="bib70" id="ref38">70</reflink>]).</p> <p>Furthermore, accurately labelling emotions is crucial for successful social interactions and communication (Kauhanen et al., [<reflink idref="bib48" id="ref39">48</reflink>]; Trevisan & Birmingham, [<reflink idref="bib90" id="ref40">90</reflink>]). Autistic adults, particularly those affected by alexithymia, may have hostile attributional biases (Meyer et al., [<reflink idref="bib67" id="ref41">67</reflink>]), leading to secondary emotions such as frustration or anger, and, in some cases, to impulsive actions (Moseley et al., [<reflink idref="bib70" id="ref42">70</reflink>]), and perceived social isolation (Okruszek et al., [<reflink idref="bib73" id="ref43">73</reflink>]). Using an ambulatory assessment, Gerber and colleagues ([<reflink idref="bib29" id="ref44">29</reflink>]) found that alexithymia was the principal contributor of reduced social interactions in autistic adults, providing further evidence that social isolation may be more related to alexithymia than to the severity of autistic traits (Gerber et al., [<reflink idref="bib29" id="ref45">29</reflink>]). These findings align with neuroimaging literature indicating that specific emotion labels (e.g., 'sad', 'anger') in comparison with control tasks (e.g., general affect words such as 'unpleasant') are associated with higher activation of the right ventrolateral prefrontal cortex (rvlPFC) and subsequent higher downregulation of amygdala – a region commonly activated by negative emotions (Brooks et al., [<reflink idref="bib11" id="ref46">11</reflink>]; Torrisi et al., [<reflink idref="bib89" id="ref47">89</reflink>]). Through top-down control mechanisms, the rvlPFC can inhibit the amygdala, thereby reducing self-reported negative emotions (Berboth & Morawetz, [<reflink idref="bib5" id="ref48">5</reflink>]; Brooks et al., [<reflink idref="bib11" id="ref49">11</reflink>]). Correspondingly, other studies suggest similar effects of emotion labelling in reducing negative affect, when compared to other intentional ER strategies, such as cognitive reappraisal (reinterpreting a potentially emotion-eliciting situation to change its emotional impact) or distraction (diverting attention away from the emotional stimulus) (Lieberman et al., [<reflink idref="bib56" id="ref50">56</reflink>]).</p> <p>Along with the absence of emotion labelling, reduced emotional awareness has also been described in alexithymic patients (Sifneos, [<reflink idref="bib82" id="ref51">82</reflink>]). For example, Silani and colleagues (2008) suggested that 'the awareness of the self who has emotions' may be less active in ASC with co-occurring alexithymia (Silani et al., [<reflink idref="bib83" id="ref52">83</reflink>]). In their study, impaired self-awareness of emotions was highly correlated with alexithymia and with atypical responses of anterior insula – a region thought to be implicated in the conscious awareness of bodily and emotional states (Silani et al., [<reflink idref="bib83" id="ref53">83</reflink>]). In another study proposing emotion evoking situations, autistic children reported poorer emotion differentiation and declared feeling no emotions more often than their NT peers (Rieffe et al., [<reflink idref="bib76" id="ref54">76</reflink>]). Altogether, these results are consistent with alexithymia's characteristic of externally orienting thoughts <uline>(</uline>Parker et al., [<reflink idref="bib74" id="ref55">74</reflink>]; Sifneos, [<reflink idref="bib82" id="ref56">82</reflink>]<uline>)</uline>, as well as with models of alexithymia that propose a 'decoupling' between physiological arousal emerging from an emotional state and the conscious representation of the arousal (Eastabrook et al., [<reflink idref="bib22" id="ref57">22</reflink>]; Gaigg et al., [<reflink idref="bib27" id="ref58">27</reflink>]).</p> <p>Despite its known impact on overall quality of life, the relationship between emotion labelling and ED in autistic adults without intellectual disability remains understudied, with existing studies presenting several methodological limitations. Recently, measures of ED—the Difficulties in Emotion Regulation Scale (DERS) (McVey et al., [<reflink idref="bib66" id="ref59">66</reflink>]) -, and alexithymia—the General Alexithymia Factor Score (GAFS-8) (Williams & Gotham, [<reflink idref="bib98" id="ref60">98</reflink>])—have been validated among a sample of autistic adolescents and adults. However, these retrospective self-report measures have significant limitations since alexithymia affects the ability to recall and report emotions (Bradburn et al., [<reflink idref="bib8" id="ref61">8</reflink>]; Ellison et al., [<reflink idref="bib24" id="ref62">24</reflink>]; Mazefsky et al., [<reflink idref="bib63" id="ref63">63</reflink>]). Acknowledging that the retrospective recall of emotional states can be challenging, some studies have used experimental methods to tackle ED and address these limitations (e.g., Christou-Champi et al., [<reflink idref="bib16" id="ref64">16</reflink>]; Samson et al., [<reflink idref="bib80" id="ref65">80</reflink>]). However, translating findings from controlled laboratory settings to real-life situations can be complex and reduce the generalizability of results (McManus et al., [<reflink idref="bib65" id="ref66">65</reflink>]). To overcome these challenges, Ecological Momentary Assessment (EMA) methodology can be used to collect data in naturalistic environments over extended durations spanning multiple days or weeks (Damiano et al., [<reflink idref="bib19" id="ref67">19</reflink>]; Shiffman et al., [<reflink idref="bib81" id="ref68">81</reflink>]). EMA initially relied on pencil and paper diaries, but with technological advancements, mobile devices have facilitated the assessment of dynamic emotional experiences in real-life settings (Shiffman et al., [<reflink idref="bib81" id="ref69">81</reflink>]). However, to our knowledge, no EMA study has explored aspects related to emotion labelling and ER in autistic adults. Yet, EMA has proven feasible among autistic adolescents and adults in studies examining social interactions (Feller et al., [<reflink idref="bib26" id="ref70">26</reflink>]; Gerber et al., [<reflink idref="bib29" id="ref71">29</reflink>]), predictors of negative affect (Dallman et al., [<reflink idref="bib18" id="ref72">18</reflink>]) and positive affect (Kovac et al., [<reflink idref="bib52" id="ref73">52</reflink>]).</p> <p>The aim of this study is to investigate the impact of alexithymia (i.e., absence of emotion labelling and emotional awareness) on ER processes presented by autistic adults. To achieve this, we used an EMA methodology in combination with baseline retrospective self-report measurements. Given that ER has been defined as the ability to control one's emotional experiences (Christou-Champi et al., [<reflink idref="bib16" id="ref74">16</reflink>]; Dell'Osso et al., [<reflink idref="bib21" id="ref75">21</reflink>]; Gross, [<reflink idref="bib33" id="ref76">33</reflink>]; Mauss et al., [<reflink idref="bib61" id="ref77">61</reflink>]; Webb et al., [<reflink idref="bib93" id="ref78">93</reflink>]), we adopted an emotion control framework for ER. In alignment with the previously mentioned clinical models, we hypothesize that, compared to NT controls, autistic individuals with high levels of ED will report: H1a) higher frequencies of negative emotions (such as sadness, anxiety, and anger), and lower frequencies of positive emotions (such as joy, and calm), and H1b) an increased absence of emotion labelling (including the experience of unnamed emotions 'I have an emotion that I cannot name', or a lack of emotions – 'I have no emotion'). Secondly, we hypothesize that reduced emotion control (i.e., a proxy of ED) will be linked to H2) intense negative emotions, and H3) difficulties in emotion labelling, particularly within the ASC group, due to their high baseline ED. This association is expected to persist when controlling for the influence of demographic (i.e., sex, age), clinical variables related to common co-occurring disorders (i.e., depression, anxiety, and BPD), ASC trait characteristics (i.e., camouflaging, and sensorial sensitivity), fatigue, and ongoing social interactions.</p> <hd id="AN0191290370-3">Methods</hd> <p></p> <hd id="AN0191290370-4">Participants' Characteristics</hd> <p>In total, 29 autistic adults and 28 NT individuals were recruited for this study, resulting in a total of 57 participants. Their ages ranged from 18 to 67 years, and the two groups were matched in terms of sex, and within approximately two years in terms of age and educational background. A detailed overview of the participants' demographics variables, co-occurring psychiatric diagnoses and psychotropic medication is presented in Online Resource 1.</p> <p>Autistic participants were recruited through a collaborative procedure involving clinicians from a screening centre for ASC, mutual aid associations, and the adult outpatient clinic of the Psychiatric Unit at the University Hospital of Strasbourg, France. Licensed clinical psychologists and psychiatrists identified and referred individuals who had a formal diagnosis of ASC and exhibited high levels of ED. More precisely, these diagnoses were supported by Autism Diagnostic Interview-Revised (Rutter et al., [<reflink idref="bib79" id="ref79">79</reflink>]) and the Autism Diagnostic Observation Schedule-2 (Hus & Lord, [<reflink idref="bib43" id="ref80">43</reflink>]; Volkmar, [<reflink idref="bib92" id="ref81">92</reflink>]). Furthermore, a comprehensive evaluation was conducted in accordance with the DSM-5 criteria in order to ascertain the presence of co-occurring psychiatric disorders. To be eligible for participation, they had to meet the specific inclusion conditions: (i) Experiencing suicidal thoughts and/or engaging in impulsive behaviours (such as alcohol, drug, or pharmaceutical abuse), non-suicidal self-injury, or a documented history of suicidal ideation and/or attempts within the 12 months leading up to the recruitment; (ii) Having difficulties in regulating emotions, as assessed using the DERS (Dan-Glauser & Scherer, [<reflink idref="bib20" id="ref82">20</reflink>]), with a cut-off score exceeding 95; (iii) Having an intellectual quotient above the cut-off score of 70, as evaluated by the Wechsler Adult Intelligence Scale-IV – WAIS-IV (Wechsler, [<reflink idref="bib94" id="ref83">94</reflink>]); (iv) Presenting no co-occurring psychotic disorders.</p> <p>The control group was recruited by responding to an announcement posted by the University Hospital of Strasbourg, France. To be eligible for the study, NT individuals had to meet the following conditions: (i) No reported difficulties with regulating their emotions, as assessed by the DERS (Dan-Glauser & Scherer, [<reflink idref="bib20" id="ref84">20</reflink>]); participants with low scores on this measure were subsequently invited to a 20-min semi-structured phone interview to further assess their eligibility, ensuring: (ii) No history of psychiatric or neurological disorders; and (iii) Not currently using any psychiatric medications.</p> <hd id="AN0191290370-5">Procedure</hd> <p>All participants were invited to the laboratory, where they received detailed information about the study's objectives and provided written informed consent. Following this, the first author conducted an in-depth demonstration of the EMA protocol, where participants promptly responded to EMA questions under the guidance of the experimenter. Previous literature has linked ED in ASC with co-occurring psychiatric conditions, such as depression, anxiety and BPD (Lai et al., [<reflink idref="bib53" id="ref85">53</reflink>]), or autistic traits, including camouflaging (Cassidy et al., [<reflink idref="bib15" id="ref86">15</reflink>]) and sensory sensitivity (Gillott & Standen, [<reflink idref="bib30" id="ref87">30</reflink>]). To control for these factors, all participants completed a comprehensive battery of self-reported assessments. To minimize participants burden, NT participants completed the questionnaires in the laboratory, taking approximately 20 min, with the option to take breaks and ask the experimenter questions. Autistic participants, had the opportunity to complete the self-assessments at home a few days before the experimental procedure, allowing them to proceed at their own pace and in a comfortable environment. The self-reported assessments included The Autism-Spectrum Quotient – AQ (Lepage et al., [<reflink idref="bib54" id="ref88">54</reflink>]), The General Alexithymia Factor Score—GAFS-8 (Williams & Gotham, [<reflink idref="bib98" id="ref89">98</reflink>]), The Beck Depression Inventory, 2nd edition – BDI-II (Beck et al., [<reflink idref="bib2" id="ref90">2</reflink>], [<reflink idref="bib3" id="ref91">3</reflink>]), The Beck Anxiety Inventory – BAI (Beck et al., [<reflink idref="bib2" id="ref92">2</reflink>], [<reflink idref="bib3" id="ref93">3</reflink>]), The Short Version of the Borderline Symptom List—BSL-23 (Bohus et al., [<reflink idref="bib7" id="ref94">7</reflink>]), The Camouflaging Autistic Trait Questionnaire—CAT-Q (Hull et al., [<reflink idref="bib42" id="ref95">42</reflink>]) and The Glasgow Sensory Questionnaire—GSQ (Robertson & Simmons, [<reflink idref="bib77" id="ref96">77</reflink>]). For details of the measures and between-group comparisons, see Online Resource 2. To enhance the study's precision and account for possible IQ discrepancies between the two participant groups, we administered the Matrix Reasoning and Information subtests of the WAIS-IV (Wechsler, [<reflink idref="bib94" id="ref97">94</reflink>]). Finally, a 15-min post-experimental paradigm was proposed to all participants to gain a deeper knowledge of the user's experience and to verify possible stress-related effects. Data for this study was collected between May 2022 to July 2023, and all participants were compensated with €200 for their participation. The present research was conducted as part of a larger study that included additional tasks, which are not detailed here. The regional ethics committee of the East of France approved this study as a preliminary step for a randomized control trial on dialectical behaviour therapy (DBT) and ED (Reference: SI 21.01.21.41923).</p> <hd id="AN0191290370-6">Ecological Momentary Assessment Protocol</hd> <p>The EMA protocol required participants to respond to 12 semi-randomized smartphone text messages per day for a continuous 7-day period. Each message contained a prompt asking the participants to click on an attached link to participate in a survey. The survey assessed their current emotional state from a predefined list of emotions, including two options related to difficulties in emotion labelling: '<emph>I have an emotion that I cannot name'</emph>, and '<emph>I have no emotion</emph>'. To prevent participants from selecting these options simply because they could not find their specific emotion on the list, we included a wide spectrum of emotions. This list was compiled based on previous studies that used EMA to gain a deeper understanding of the emotional dynamics in clinical groups with ED and alexithymia, such as BPD (e.g., Ebner-Priemer et al., [<reflink idref="bib23" id="ref98">23</reflink>]), as well as based on studies on basic emotions (Linehan, [<reflink idref="bib58" id="ref99">58</reflink>]).The final list consisted of 12 emotional options: 'joy', 'anxiety', 'anger', 'interest', 'shame', 'disgust', 'calm', 'sadness', 'surprise', 'guilt', 'I have an emotion that I cannot name', and 'I have no emotion'. Participants were instructed to report all emotions they were experiencing at the time. For each selected emotional state, they rated the intensity (i.e., the dimension of '<emph>Arousal</emph>'), and the emotion regulation needs, specifying whether they intended to decrease, maintain, or increase their emotion (referred to as '<emph>Need for ER'</emph>). The main objective of this study was to improve understanding of the factors contributing to reduced ER in ASC. To accomplish this goal, we used an EMA query to evaluate participants' perceived self-efficacy in '<emph>Emotion Control'.</emph> Finally, to reduce the impact of potential confounding variables such as fatigue and stress derived from social interactions, particularly in the ASC group, we included these questions in the survey. Details for the EMA questions are given in Online Resource 3.</p> <p>Text message scheduling was customized to each participant's circadian rhythm and occurred within specified timeframes (8 am—8 pm, 9 am—9 pm, 10 am—10 pm, or 11 am—11 pm). Participants received a total of 84 text messages over 7 days, with intervals ranging from 43 to 84 min between messages (mean = 65 min). They were instructed to respond at their earliest convenience by clicking on the link generated using Qualtrics software (Qualtrics, Provo, UT). Text messages were scheduled using the Textra app on a Samsung Galaxy XCover 5 device. In addition, participants were also given the option to report their emotional state if they were experiencing strong emotions. This spontaneous self-assessment survey included the same set of questions as the initial survey and was accessed via a separate Qualtrics survey.</p> <hd id="AN0191290370-7">Data Transformation</hd> <p>As described in Table 1, the 12 emotional responses were grouped based on their labelling and valence. All labelled emotions were further categorized within the variable '<emph>Emotional Valence</emph>', including <emph>'Negative Emotions'</emph> (i.e., unpleasant emotions), <emph>Positive Emotions</emph>' (i.e., pleasant emotions); and '<emph>Conflicting Emotions'</emph> (i.e., concomitant two opposing emotions, e.g., '<emph>anxiety'</emph> and '<emph>joy'</emph>). The categorization of the neutral emotion, '<emph>surprise',</emph> was dependent on the valence of other emotional responses or the '<emph>Need for ER'</emph>. The responses '<emph>I have no emotion</emph>' and '<emph>I have an emotion that I cannot name</emph>' were categorized among the variable '<emph>Absence of Emotion Labelling</emph>'. Additional information is provided in Online Resource 3.</p> <p>Table 1 Categorization of the EMA emotional responses</p> <p> <ephtml> <table rules="groups"><thead><tr><th align="left"><p>Labelled negative emotions</p></th><th align="left"><p>Labelled positive emotions</p></th><th align="left"><p>Labelled conflicting emotions</p></th><th align="left"><p>Absence of emotion labelling</p></th></tr></thead><tbody><tr><td align="left"><p>Anxiety</p></td><td align="left"><p>Joy</p></td><td align="left"><p>e.g., Anxiety and Joy</p></td><td align="left"><p>I have no emotion</p></td></tr><tr><td align="left"><p>Anger</p></td><td align="left"><p>Interest</p></td><td align="left" /><td align="left"><p>I have an emotion that I cannot name</p></td></tr><tr><td align="left"><p>Shame</p></td><td align="left"><p>Calm</p></td><td align="left" /><td align="left" /></tr><tr><td align="left"><p>Disgust</p></td><td align="left"><p>Surprise</p></td><td align="left" /><td align="left" /></tr><tr><td align="left"><p>Sadness</p></td><td align="left" /><td align="left" /><td align="left" /></tr><tr><td align="left"><p>Guilt</p></td><td align="left" /><td align="left" /><td align="left" /></tr><tr><td align="left"><p>Surprise</p></td><td align="left" /><td align="left" /><td align="left" /></tr></tbody></table> </ephtml> </p> <hd id="AN0191290370-8">Data Analysis and Statistical Procedure</hd> <p>Jamovi (The jamovi project, [<reflink idref="bib85" id="ref100">85</reflink>]) and R (R Core Team, [<reflink idref="bib75" id="ref101">75</reflink>]) were used for all statistical analyses. First, descriptive statistics examined frequencies of survey responses and differences between the ASC and NT groups in terms of demographic, clinical, and EMA variables (i.e., <emph>'Need for ER'</emph>; <emph>'Social Interactions')</emph>. Independent t-tests, and Mann Whitney U tests were calculated for continuous variables, and chi-square (χ<sups>2</sups>) was used for nominal variables. To test our first hypothesis, which suggests that autistic adults would experience higher frequencies of negative emotions and lower frequencies of positive emotions (H1a), and that they would have a higher absence of emotion labelling (H1b), we calculated chi-square tests (χ<sups>2</sups>).</p> <p>To assess further hypotheses regarding the factors contributing to reduced <emph>'Emotion Control'</emph>, such as demographics, co-occurring disorders, ASC-related traits, negative emotions, and alexithymia, and to account for the interdependence of data at the individual level, we applied multilevel modelling (MLM). We followed recommended practices for EMA and employed a restricted maximum likelihood (REML) estimation method (Singer & Willett, [<reflink idref="bib84" id="ref102">84</reflink>]). This hierarchical structure allowed us to explore variations in '<emph>Emotion Control'</emph> across different levels, including occasions within a day, days within a person, and among different individuals. An additive hierarchical multiple regression framework was used to create models. Subsequently, nested models with additional parameters were compared to the previous model using Akaike Information Criterion (AIC) and log likelihood ratio tests.</p> <p>Before examining Hypotheses H2) and H3), empty means models with random intercepts were used to partition the variability in <emph>'Emotion Control'</emph> and to determine the correct number of levels for the MLM. Consistent with prior work (Kahn & Schneider, [<reflink idref="bib47" id="ref103">47</reflink>]), we used Intraclass Correlation Coefficient (ICC) and log likelihood ratio tests to compare the non-nested and two-level models.</p> <p>To control for the influence of demographic, group status (i.e., ASC vs NT), clinical variables related to common co-occurring disorders, ASC trait characteristics, fatigue, and social interactions, these variables were added to the model as between-person fixed effects. To test hypothesis H2), that higher levels of intense negative emotions would be related to reduced <emph>'Emotion Control',</emph> especially within the ASC group, <emph>Arousal</emph>, '<emph>Emotional Valence'</emph> and their interaction with the group status (ASC vs NT) were added to the model. Finally, to assess H3), that increased difficulties in emotion labelling (<emph>'I have no emotion'</emph> and <emph>'I have an emotion that I cannot name</emph>') would be negatively associated with reduced <emph>'Emotion Control'</emph>, particularly in autistic individuals, this categorical variable and its interaction with the group was added to the model. To improve interpretability and reduce multicollinearity, particularly when dealing with interaction effects, continuous between-person predictors and outcome variable were centred, while categorical variables were not centred (Enders & Tofighi, [<reflink idref="bib25" id="ref104">25</reflink>]). The final multi-level regression model aims to predict '<emph>Emotion Control</emph>' score ranging from 0 to 10, based on a combination of predictor variables and their interactions as in Eq. 1:</p> <p> <ephtml> <math display="block" xmlns="http://www.w3.org/1998/Math/MathML"><mrow><mi>E</mi><mi>m</mi><mi>o</mi><mi>t</mi><mi>i</mi><mi>o</mi><mi>n</mi><mspace width="0.166667em" /><mi>C</mi><mi>o</mi><mi>n</mi><mi>t</mi><mi>r</mi><mi>o</mi><mi>l</mi><mo>∼</mo><mn>1</mn><mo>+</mo><mi>A</mi><mi>g</mi><mi>e</mi><mo>+</mo><mi>S</mi><mi>e</mi><mi>x</mi><mo>+</mo><mi>G</mi><mi>r</mi><mi>o</mi><mi>u</mi><mi>p</mi><mo>+</mo><mi>A</mi><mi>Q</mi><mo>+</mo><mi>G</mi><mi>A</mi><mi>F</mi><mi>S</mi><mn>8</mn><mo>+</mo><mi>B</mi><mi>D</mi><mi>I</mi><mo>-</mo><mi>I</mi><mi>I</mi><mo>+</mo><mi>B</mi><mi>A</mi><mi>I</mi><mo>+</mo><mi>C</mi><mi>A</mi><mi>T</mi><mi>Q</mi><mo>+</mo><mi>B</mi><mi>S</mi><mi>L</mi><mn>23</mn><mo>+</mo><mi>G</mi><mi>S</mi><mi>Q</mi><mo>+</mo><mi>S</mi><mi>o</mi><mi>c</mi><mi>i</mi><mi>a</mi><mi>l</mi><mspace width="0.166667em" /><mi>I</mi><mi>n</mi><mi>t</mi><mi>e</mi><mi>r</mi><mi>a</mi><mi>c</mi><mi>t</mi><mi>i</mi><mi>o</mi><mi>n</mi><mi>s</mi><mo>+</mo><mi>F</mi><mi>a</mi><mi>t</mi><mi>i</mi><mi>g</mi><mi>u</mi><mi>e</mi><mo>+</mo><mi>W</mi><mi>e</mi><mi>e</mi><mi>k</mi><mi>d</mi><mi>a</mi><mi>y</mi><mo>+</mo><mi>A</mi><mi>r</mi><mi>o</mi><mi>u</mi><mi>s</mi><mi>a</mi><mi>l</mi><mo>+</mo><mi>V</mi><mi>a</mi><mi>l</mi><mi>e</mi><mi>n</mi><mi>c</mi><mi>e</mi><mo>+</mo><mi>L</mi><mi>a</mi><mi>b</mi><mi>e</mi><mi>l</mi><mi>l</mi><mi>i</mi><mi>n</mi><mi>g</mi><mo>+</mo><mi>A</mi><mi>r</mi><mi>o</mi><mi>u</mi><mi>s</mi><mi>a</mi><mi>l</mi><mo>:</mo><mi>G</mi><mi>r</mi><mi>o</mi><mi>u</mi><mi>p</mi><mo>+</mo><mi>V</mi><mi>a</mi><mi>l</mi><mi>e</mi><mi>n</mi><mi>c</mi><mi>e</mi><mo>:</mo><mi>G</mi><mi>r</mi><mi>o</mi><mi>u</mi><mi>p</mi><mo>+</mo><mi>L</mi><mi>a</mi><mi>b</mi><mi>e</mi><mi>l</mi><mi>l</mi><mi>i</mi><mi>n</mi><mi>g</mi><mo>:</mo><mi>G</mi><mi>r</mi><mi>o</mi><mi>u</mi><mi>p</mi><mo>+</mo><mo stretchy="false">(</mo><mn>1</mn><mo stretchy="false">|</mo><mi>D</mi><mi>a</mi><mi>y</mi><mo stretchy="false">)</mo><mo>+</mo><mo stretchy="false">(</mo><mn>1</mn><mo stretchy="false">|</mo><mi>I</mi><mi>D</mi><mo stretchy="false">)</mo></mrow></math> </ephtml> </p> <p>Here, (<emph>1|Day</emph>) and (<emph>1|ID</emph>) denote random intercepts for the variables '<emph>Day</emph>' and '<emph>ID</emph>', respectively. The model allows for variability in the intercepts across days and subjects. The variable '<emph>Day</emph>', ranging from 1 to 7, indicates the day of the experiment; the '<emph>ID</emph>' is the identification code of the subject. The terms '<emph>Arousal: Group</emph>', '<emph>Valence: Group'</emph>, '<emph>Labelling: Group</emph>' represent the interactions between variable '<emph>Group</emph>' and the predictors '<emph>Arousal</emph>', '<emph>Valence</emph>' and '<emph>Labelling</emph>' respectively. The predictors are described in Online Resource 4.</p> <hd id="AN0191290370-9">Results</hd> <p>A total of 4,496 Ecological Momentary Assessment (EMA) surveys were completed by all participants <ephtml> <math xmlns="http://www.w3.org/1998/Math/MathML"><mrow><mo stretchy="false">(</mo><mi>n</mi><mi>A</mi><mi>S</mi><mi>C</mi><mo>=</mo><mn>2257</mn><mo>;</mo><mi>n</mi><mi>N</mi><mi>T</mi><mo>=</mo><mn>2239</mn><mo stretchy="false">)</mo></mrow></math> </ephtml> . Over the course of seven days, each participant completed an average of 78.88 responses <ephtml> <math xmlns="http://www.w3.org/1998/Math/MathML"><mrow><mo stretchy="false">(</mo><mtext>SD</mtext><mo>=</mo><mn>7.46</mn><mo stretchy="false">)</mo></mrow></math> </ephtml> , equating to approximately <ephtml> <math xmlns="http://www.w3.org/1998/Math/MathML"><mrow><mn>11.27</mn><mo stretchy="false">(</mo><mi>S</mi><mi>D</mi><mo>=</mo><mn>1.44</mn></mrow></math> </ephtml> ) responses per day. No differences were found between the two groups with respect to daily self-reports <ephtml> <math xmlns="http://www.w3.org/1998/Math/MathML"><mrow><mo stretchy="false">(</mo><mi>A</mi><mi>S</mi><mi>C</mi><mo>,</mo><mi>M</mi><mo>±</mo><mi>S</mi><mi>D</mi><mo>=</mo><mn>11.12</mn><mo>±</mo><mn>1.69</mn><mo>;</mo><mi>N</mi><mi>T</mi><mo>,</mo><mi>M</mi><mo>±</mo><mi>S</mi><mi>D</mi><mo>=</mo><mn>11.42</mn><mo>±</mo><mn>1.11</mn><mo>;</mo><mi>p</mi><mo>=</mo><mo>.</mo><mn>284</mn><mo stretchy="false">)</mo><mo>.</mo></mrow></math> </ephtml> Participants spent approximately 59 sec <ephtml> <math xmlns="http://www.w3.org/1998/Math/MathML"><mrow><mo stretchy="false">(</mo><mtext>SD</mtext><mo>=</mo><mn>39</mn><mtext>sec</mtext><mo stretchy="false">)</mo></mrow></math> </ephtml> responding to each survey. To maintain consistency with previous EMA protocols (Moran et al., [<reflink idref="bib68" id="ref105">68</reflink>]), participants who completed less than 30% of the surveys were excluded from the analyses. Our study achieved an average compliance rate of 94% (MIN = 50%), resulting in the inclusion of all participants in the analysis.</p> <hd id="AN0191290370-10">Emotion Labelling: Frequencies Between Groups</hd> <p>In testing the Hypothesis 1a), the results revealed a distinct pattern in emotional valence, indicating significant differences between the ASC and the NT groups <ephtml> <math xmlns="http://www.w3.org/1998/Math/MathML"><mfenced close=")" open="("><mi>p</mi><mo><</mo><mo>.</mo><mn>001</mn></mfenced></math> </ephtml> (see Table 2). Compared to the NT group, ASC individuals had a higher prevalence of overall negative emotions (47% compared to 22%). This discrepancy was particularly evident in the higher rates of specific emotions, namely '<emph>sadness'</emph> (14% versus 1%), and '<emph>anxiety'.</emph> (26% versus 2%). Notably, there were no significant differences between the two groups in reports of '<emph>anger'</emph> (9% versus 10%), '<emph>shame'</emph> (3% versus 2%), '<emph>disgust'</emph> (2% versus 1%), and '<emph>guilt'</emph> (4% versus 2%). Furthermore, all participants reported having experienced mixed or '<emph>Conflicting Emotions'</emph>, which involved the simultaneous presence of positive and negative emotions <ephtml> <math xmlns="http://www.w3.org/1998/Math/MathML"><mo>.</mo></math> </ephtml> In particular, ASC individuals reported 8%, compared to 5% in the NT group. In contrast, positive emotions, such as '<emph>joy'</emph>, '<emph>interest'</emph>, and '<emph>calm'</emph>, were reported significantly less frequently by the ASC group than the NT group (45% compared to 74%). Specifically, '<emph>joy'</emph> was reported in 12% of ASC cases compared to 29% in the NT group, '<emph>interest'</emph> in 8% compared to 14%, and '<emph>calm'</emph> in 26% compared to 34%. All participants reported '<emph>surprise'</emph> at comparable rates (see Table 2).</p> <p>Table 2 Frequencies of EMA responses for Emotion Labelling, and Need for Emotion Regulation</p> <p> <ephtml> <table rules="groups"><thead><tr><th align="left" rowspan="2" /><th align="left" colspan="2"><p><bold>ASC</bold></p></th><th align="left" colspan="2"><p><bold>NT</bold></p></th><th align="left" rowspan="2"><p><bold>χ</bold><sup><bold>2</bold></sup><bold> / Fischer's exact</bold></p></th><th align="left" rowspan="2"><p><bold><italic>p</italic></bold></p></th></tr><tr><th align="left"><p><bold>n</bold></p></th><th align="left"><p><bold>%</bold></p></th><th align="left"><p><bold>n</bold></p></th><th align="left"><p><bold>%</bold></p></th></tr></thead><tbody><tr><td align="left" colspan="7"><p>Emotion labelling</p></td></tr><tr><td align="left"><p> Labelled positive emotions</p></td><td align="left"><p>796</p></td><td align="left"><p>45.2</p></td><td align="left"><p>1358</p></td><td align="left"><p>73.6</p></td><td align="left" /><td align="left" /></tr><tr><td align="left"><p> Joy</p></td><td align="left"><p>274</p></td><td align="left"><p>12.1</p></td><td align="left"><p>641</p></td><td align="left"><p>28.6</p></td><td align="left" /><td align="left" /></tr><tr><td align="left"><p> Interest</p></td><td align="left"><p>175</p></td><td align="left"><p>7.7</p></td><td align="left"><p>321</p></td><td align="left"><p>14.3</p></td><td align="left" /><td align="left" /></tr><tr><td align="left"><p> Calm</p></td><td align="left"><p>592</p></td><td align="left"><p>26.2</p></td><td align="left"><p>762</p></td><td align="left"><p>34.0</p></td><td align="left" /><td align="left" /></tr><tr><td align="left"><p> Surprise (as positive)</p></td><td align="left"><p>11</p></td><td align="left"><p>0.5</p></td><td align="left"><p>18</p></td><td align="left"><p>0.8</p></td><td align="left" /><td align="left" /></tr><tr><td align="left"><p> Labelled negative emotions</p></td><td align="left"><p>827</p></td><td align="left"><p>47.0</p></td><td align="left"><p>402</p></td><td align="left"><p>22.0</p></td><td align="left" /><td align="left" /></tr><tr><td align="left"><p> Sadness</p></td><td align="left"><p>306</p></td><td align="left"><p>13.6</p></td><td align="left"><p>52</p></td><td align="left"><p>1.2</p></td><td align="left" /><td align="left" /></tr><tr><td align="left"><p> Anxiety</p></td><td align="left"><p>585</p></td><td align="left"><p>25.9</p></td><td align="left"><p>173</p></td><td align="left"><p>2.3</p></td><td align="left" /><td align="left" /></tr><tr><td align="left"><p> Anger</p></td><td align="left"><p>202</p></td><td align="left"><p>8.9</p></td><td align="left"><p>222</p></td><td align="left"><p>9.9</p></td><td align="left" /><td align="left" /></tr><tr><td align="left"><p> Shame</p></td><td align="left"><p>61</p></td><td align="left"><p>2.7</p></td><td align="left"><p>36</p></td><td align="left"><p>1.6</p></td><td align="left" /><td align="left" /></tr><tr><td align="left"><p> Disgust</p></td><td align="left"><p>38</p></td><td align="left"><p>1.7</p></td><td align="left"><p>17</p></td><td align="left"><p>0.7</p></td><td align="left" /><td align="left" /></tr><tr><td align="left"><p> Guilt</p></td><td align="left"><p>87</p></td><td align="left"><p>3.8</p></td><td align="left"><p>36</p></td><td align="left"><p>1.6</p></td><td align="left" /><td align="left" /></tr><tr><td align="left"><p> Surprise (as negative)</p></td><td align="left"><p>12</p></td><td align="left"><p>.53</p></td><td align="left"><p>19</p></td><td align="left"><p>.84</p></td><td align="left" /><td align="left" /></tr><tr><td align="left"><p> Labelled conflicting emotions</p></td><td align="left"><p>136</p></td><td align="left"><p>7.7</p></td><td align="left"><p>86</p></td><td align="left"><p>4.6</p></td><td align="left" /><td align="left" /></tr><tr><td align="left" colspan="7"><p>Absence of emotion labelling</p></td></tr><tr><td align="left"><p> I have an emotion that I cannot name</p></td><td align="left"><p>231</p></td><td align="left"><p>10.2</p></td><td align="left"><p>113</p></td><td align="left"><p>5.0</p></td><td align="left" /><td align="left" /></tr><tr><td align="left"><p> I have no emotion</p></td><td align="left"><p>338</p></td><td align="left"><p>15.0</p></td><td align="left"><p>313</p></td><td align="left"><p>14.0</p></td><td align="left" /><td align="left" /></tr><tr><td align="left" colspan="7"><p>Need for ER</p></td></tr><tr><td align="left"><p> Need to decrease</p></td><td align="left"><p>842</p></td><td align="left"><p>65.1</p></td><td align="left"><p>452</p></td><td align="left"><p>34.9</p></td><td align="left"><p>8.86</p></td><td align="left"><p> <.05</p></td></tr><tr><td align="left"><p> Positive emotions</p></td><td align="left"><p>24</p></td><td align="left"><p>2.8</p></td><td align="left"><p>19</p></td><td align="left"><p>4.2</p></td><td align="left" /><td align="left" /></tr><tr><td align="left"><p> Negative emotions</p></td><td align="left"><p>748</p></td><td align="left"><p>88.8</p></td><td align="left"><p>375</p></td><td align="left"><p>83.0</p></td><td align="left" /><td align="left" /></tr><tr><td align="left"><p> Conflicting emotions</p></td><td align="left"><p>70</p></td><td align="left"><p>8.3</p></td><td align="left"><p>58</p></td><td align="left"><p>12.8</p></td><td align="left" /><td align="left" /></tr><tr><td align="left"><p> Need to maintain</p></td><td align="left"><p>654</p></td><td align="left"><p>36.1</p></td><td align="left"><p>1157</p></td><td align="left"><p>63.9</p></td><td align="left"><p>116.91</p></td><td align="left"><p> <.001</p></td></tr><tr><td align="left"><p> Positive emotions</p></td><td align="left"><p>522</p></td><td align="left"><p>79.8</p></td><td align="left"><p>1107</p></td><td align="left"><p>95.7</p></td><td align="left" /><td align="left" /></tr><tr><td align="left"><p> Negative emotions</p></td><td align="left"><p>62</p></td><td align="left"><p>9.5</p></td><td align="left"><p>27</p></td><td align="left"><p>2.3</p></td><td align="left" /><td align="left" /></tr><tr><td align="left"><p> Conflicting emotions</p></td><td align="left"><p>70</p></td><td align="left"><p>10.5</p></td><td align="left"><p>23</p></td><td align="left"><p>2.0</p></td><td align="left" /><td align="left" /></tr><tr><td align="left"><p> Need to Increase</p></td><td align="left"><p>288</p></td><td align="left"><p>55.0</p></td><td align="left"><p>236</p></td><td align="left"><p>45.0</p></td><td align="left"><p>22.52</p></td><td align="left"><p> <.001</p></td></tr><tr><td align="left"><p> Positive emotions</p></td><td align="left"><p>250</p></td><td align="left"><p>86.8</p></td><td align="left"><p>231</p></td><td align="left"><p>97.9</p></td><td align="left" /><td align="left" /></tr><tr><td align="left"><p> Negative emotions</p></td><td align="left"><p>16</p></td><td align="left"><p>5.55</p></td><td align="left"><p>0</p></td><td align="left"><p>–</p></td><td align="left" /><td align="left" /></tr><tr><td align="left"><p> Conflicting emotions</p></td><td align="left"><p>22</p></td><td align="left"><p>7.6</p></td><td align="left"><p>5</p></td><td align="left"><p>2.1</p></td><td align="left" /><td align="left" /></tr></tbody></table> </ephtml> </p> <p> <emph>Note</emph>. Frequencies were computed with the assumption that every participant had chosen the emotion at least once</p> <p>Although the entire sample reported the need to decrease negative emotions and maintain or increase positive emotions, there was a significant difference between the two groups <ephtml> <math xmlns="http://www.w3.org/1998/Math/MathML"><mfenced close=")" open="("><mi>p</mi><mo><</mo><mo>.</mo><mn>001</mn></mfenced></math> </ephtml> . ASC reported higher '<emph>Need to Decrease'</emph> (65% versus 35%) and '<emph>Need to Increase'</emph> (55% versus 45%), and lower '<emph>Need to Maintain'</emph> (36% versus 64%). Moreover, unlike the NT individuals, ASC participants also occasionally selected '<emph>Negative Emotions'</emph> (5.5%) and '<emph>Conflicting Emotions'</emph> (8%) under the '<emph>Need to Increase</emph>' category.</p> <hd id="AN0191290370-11">Absence of Emotion Labelling: Frequencies Between Groups</hd> <p>In investigating Hypothesis 1b), the findings revealed that 10% of ASC responses included the statement '<emph>I have an emotion that I cannot name</emph>', compared to the corresponding rate of 5% among NT individuals (see Table 2). In contrast, the frequency of '<emph>I have no emotion'</emph> was similar in both groups (15% versus 14%).</p> <hd id="AN0191290370-12">Multilevel Model Analysis Predicting the Lack of Emotion Control</hd> <p>To examine the variability in <emph>'Emotion Control'</emph> across different levels, we used MLM, considering the hierarchical structure of our data. Initially, we tested a model that examined <emph>'Emotion Control'</emph> within observations (i.e., the 12 EMA queries per day), and treated observations as a random intercept. However, this did not yield a significant improvement in the model fit <ephtml> <math xmlns="http://www.w3.org/1998/Math/MathML"><mfenced close=")" open="("><mrow><mo>-</mo><mn>2</mn><mi mathvariant="normal">Δ</mi><mi>L</mi><mi>L</mi><mfenced close=")" open="("><mn>1</mn></mfenced><mo>=</mo><mn>3.27</mn><mi>e</mi><mo>-</mo><mn>11</mn><mo>,</mo><mi>p</mi><mo>-</mo><mn>1.000</mn></mrow></mfenced></math> </ephtml> . Additionally, the ICC indicated that only a small proportion of the variance in <emph>'Emotion Control'</emph> could be attributed to differences between EMA queries (ICC<subs>L1</subs> = 5.87e-15). Given these results, we investigated <emph>'Emotion Control'</emph> within days, treating days as a random intercept. Although the results showed that only a small proportion of the variance was accounted for by differences between days (ICC<subs>L1</subs> = 0.005), the likelihood ratio test yielded a significant result <ephtml> <math xmlns="http://www.w3.org/1998/Math/MathML"><mfenced close=")" open="("><mrow><mo>-</mo><mn>2</mn><mi mathvariant="normal">Δ</mi><mi>L</mi><mi>L</mi><mfenced close=")" open="("><mn>1</mn></mfenced><mo>=</mo><mn>12.8</mn><mo>,</mo><mi>p</mi><mo>=</mo><mo><</mo><mo>.</mo><mn>001</mn></mrow></mfenced></math> </ephtml> . This indicates that including the random intercept for days significantly improved the model fit compared to the previous model. Furthermore, to explore the variation in <emph>'Emotion Control'</emph> within days and individuals, we included individuals as a random intercept. The results showed that 63% of the variance was accounted for by differences between individuals (ICC<subs>L2</subs> = 0.63). Furthermore, likelihood ratio tests indicated that this improved the model fit over a baseline model <ephtml> <math xmlns="http://www.w3.org/1998/Math/MathML"><mfenced close=")" open="("><mrow><mo>-</mo><mn>2</mn><mi mathvariant="normal">Δ</mi><mi>L</mi><mi>L</mi><mfenced close=")" open="("><mn>1</mn></mfenced><mo>=</mo><mn>427.5</mn><mo>,</mo><mi>p</mi><mo>=</mo><mo><</mo><mo>.</mo><mn>001</mn></mrow></mfenced></math> </ephtml> . Overall, the results indicated a hierarchical structure in the data, with <emph>'Emotion Control'</emph> varying significantly within days and individuals. Therefore, a two-level model was selected as the primary model sequence. Due to the inclusion of many predictors, fixed slopes were used to avoid increased model complexity, still allowing for random intercepts.</p> <p>To account for demographic, clinical, and fatigue effects, as well as for the influence of the presence of social interactions, we included individual-level demographic factors such as age and sex, group status, baseline self-reported clinical measures, EMA measures of '<emph>Fatigue'</emph>, presence of '<emph>Social interactions',</emph> and day of the week (i.e., weekday versus weekend day) as fixed effects in the model. Among the clinical measures, we assessed weather the severity of autistic symptoms, autistic-like traits (including camouflaging and sensory sensitivity), alexithymia, borderline traits, depression, and anxiety played a significant role in predicting a lack of emotion control in our sample. Although the likelihood ratio test statistic for the model with predictors was lower than for the null model <ephtml> <math xmlns="http://www.w3.org/1998/Math/MathML"><mfenced close=")" open="("><mrow><mi>M</mi><mi>o</mi><mi>d</mi><mi>e</mi><mi>l</mi><mspace width="0.166667em" /><mn>1</mn><mo>,</mo><mo>-</mo><mn>2</mn><mi mathvariant="normal">Δ</mi><mi>L</mi><mi>L</mi><mfenced close=")" open="("><mn>13</mn></mfenced><mo>=</mo><mspace width="0.166667em" /><mn>2744.2</mn><mo>,</mo><mspace width="0.166667em" /><mi>p</mi><mo>=</mo><mo><</mo><mo>.</mo><mn>001</mn></mrow></mfenced></math> </ephtml> , the AIC value suggested that the inclusion of predictors significantly improved fit to the data, compared to the null model without predictors <ephtml> <math xmlns="http://www.w3.org/1998/Math/MathML"><mfenced close=")" open="("><mrow><mi>N</mi><mi>u</mi><mi>l</mi><mi>l</mi><mspace width="0.166667em" /><mi>M</mi><mi>o</mi><mi>d</mi><mi>e</mi><mi>l</mi><mo>,</mo><mspace width="0.166667em" /><mi>A</mi><mi>I</mi><mi>C</mi><mo>=</mo><mn>22119</mn><mo>;</mo><mspace width="0.166667em" /><mi>M</mi><mi>o</mi><mi>d</mi><mi>e</mi><mi>l</mi><mspace width="0.166667em" /><mn>1</mn><mo>,</mo><mspace width="0.166667em" /><mi>A</mi><mi>I</mi><mi>C</mi><mo>=</mo><mn>19960</mn></mrow></mfenced></math> </ephtml> . However, among the 13 variables, only '<emph>Fatigue'</emph> emerged as a significant predictor of '<emph>Emotion Control </emph><ephtml> <math xmlns="http://www.w3.org/1998/Math/MathML"><mfenced close=")" open="("><mrow><mi>b</mi><mo>=</mo><mo>-</mo><mo>.</mo><mn>12</mn><mfenced close=")" open="("><mrow><mo>.</mo><mn>01</mn></mrow></mfenced><mo>,</mo><mi>p</mi><mo><</mo><mo>.</mo><mn>001</mn></mrow></mfenced></math> </ephtml> , as shown in Model 1, Table 3.</p> <p>Table 3 Estimates of fixed effects for models predicting Emotion Control</p> <p> <ephtml> <table rules="groups"><thead><tr><th align="left"><p>Effect</p></th><th align="left"><p>Model 1</p></th><th align="left"><p>Model 2</p></th><th align="left"><p>Model 3</p></th></tr></thead><tbody><tr><td align="left"><p>Intercept</p></td><td align="left"><p>.08 (.25)</p></td><td align="left"><p>−.14 (.25)</p></td><td align="left"><p>−.35 (.26)</p></td></tr><tr><td align="left"><p>Age</p></td><td align="left"><p>−.01 (.03)</p></td><td align="left"><p>−.00 (.03)</p></td><td align="left"><p>−.00 (.03)</p></td></tr><tr><td align="left"><p>Sex</p></td><td align="left"><p>−.82 (.50)</p></td><td align="left"><p>−.84 (.50)</p></td><td align="left"><p>−.86 (.49)</p></td></tr><tr><td align="left"><p>Group</p></td><td align="left"><p>.28 (1.26)</p></td><td align="left"><p>.19 (1.26)</p></td><td align="left"><p>.11 (1.26)</p></td></tr><tr><td align="left"><p>AQ</p></td><td align="left"><p>−.09 (.05)</p></td><td align="left"><p>−.10 (.05)</p></td><td align="left"><p>−.10 (.05)</p></td></tr><tr><td align="left"><p>GAFS-8</p></td><td align="left"><p>−.02 (.05)</p></td><td align="left"><p>−.02 (.05)</p></td><td align="left"><p>−.02 (.05)</p></td></tr><tr><td align="left"><p>BDI-II</p></td><td align="left"><p>−.04 (.04)</p></td><td align="left"><p>−.03 (.04)</p></td><td align="left"><p>−.03 (.04)</p></td></tr><tr><td align="left"><p>BAI</p></td><td align="left"><p>.01 (.03)</p></td><td align="left"><p>.02 (.03)</p></td><td align="left"><p>.02 (.03)</p></td></tr><tr><td align="left"><p>CAT-Q</p></td><td align="left"><p>.03 (.02)</p></td><td align="left"><p>.03 (.02)</p></td><td align="left"><p>.03 (.02)</p></td></tr><tr><td align="left"><p>BSL-23</p></td><td align="left"><p>−.43 (.49)</p></td><td align="left"><p>−.44 (.49)</p></td><td align="left"><p>−.46 (.49)</p></td></tr><tr><td align="left"><p>GSQ</p></td><td align="left"><p>.01 (.02)</p></td><td align="left"><p>.01 (.02)</p></td><td align="left"><p>.01 (.02)</p></td></tr><tr><td align="left"><p>Fatigue<sup>a</sup></p></td><td align="left"><p>−.12 (.01) ***</p></td><td align="left"><p>−.06 (.01) ***</p></td><td align="left"><p>−.06 (.01) ***</p></td></tr><tr><td align="left"><p>Social interactions<sup>a</sup></p></td><td align="left"><p>.02 (.06)</p></td><td align="left"><p>.00 (.05)</p></td><td align="left"><p>.00 (.05)</p></td></tr><tr><td align="left"><p>Weekend</p></td><td align="left"><p>.05 (.06)</p></td><td align="left"><p>−.04 (.05)</p></td><td align="left"><p>−.05 (.05)</p></td></tr><tr><td align="left"><p>Emotional valence<sup>a</sup></p></td><td align="left" /><td align="left" /><td align="left" /></tr><tr><td align="left"><p> Negative emotions</p></td><td align="left" /><td align="left"><p>−1.53 (.07) ***</p></td><td align="left"><p>−1.50 (.07) ***</p></td></tr><tr><td align="left"><p> Conflicting emotions</p></td><td align="left" /><td align="left"><p>−1.05 (.12) ***</p></td><td align="left"><p>−1.05 (.12) ***</p></td></tr><tr><td align="left"><p>Group * Emotional valence<sup>a</sup></p></td><td align="left" /><td align="left" /><td align="left" /></tr><tr><td align="left"><p> Group * Negative emotions</p></td><td align="left" /><td align="left"><p>−.29 (.13) *</p></td><td align="left"><p>−.31 (.13) *</p></td></tr><tr><td align="left"><p> Group * Conflicting emotions</p></td><td align="left" /><td align="left"><p>.45 (.24)</p></td><td align="left"><p>.41 (.24)</p></td></tr><tr><td align="left"><p>Arousal<sup>a</sup></p></td><td align="left" /><td align="left"><p>−.09 (.01) ***</p></td><td align="left"><p>−.10 (.01) ***</p></td></tr><tr><td align="left"><p>Group * Arousal</p></td><td align="left" /><td align="left"><p>−.08 (.03) **</p></td><td align="left"><p>−.14 (.03) ***</p></td></tr><tr><td align="left"><p>Absence of emotion labelling<sup>a</sup></p></td><td align="left" /><td align="left" /><td align="left" /></tr><tr><td align="left"><p> I have no emotion</p></td><td align="left" /><td align="left" /><td align="left"><p>−.47 (.21) *</p></td></tr><tr><td align="left"><p> I have an emotion I cannot name</p></td><td align="left" /><td align="left" /><td align="left"><p>−.54 (.19) **</p></td></tr><tr><td align="left"><p>Group * Absence of emotion labelling<sup>a</sup></p></td><td align="left" /><td align="left" /><td align="left" /></tr><tr><td align="left"><p> Group * I have no emotion</p></td><td align="left" /><td align="left" /><td align="left"><p>−.92 (.43) *</p></td></tr><tr><td align="left"><p> Group * I have an emotion I cannot name</p></td><td align="left" /><td align="left" /><td align="left"><p>.31 (.38)</p></td></tr></tbody></table> </ephtml> </p> <p> <sups>a</sups>Ecological Momentary Assessment variables <sups>*</sups><emph>p</emph> <.05; **<emph>p</emph> <.01; ***<emph>p</emph> <.001; <emph>AQ</emph> Autism-Spectrum Quotient, <emph>BAI</emph> Beck Anxiety Scale, <emph>BDI-II</emph> Beck Depression Inventory, <emph>BSL-23</emph> Borderline Symptom List, short form, <emph>CAT-Q</emph> The Camouflaging Autistic Trait Questionnaire, <emph>GAFS-8</emph> General Alexithymia Factor Score, <emph>GSQ</emph> The Glasgow Sensory Questionnaire</p> <p>In the context of Hypothesis 2), examining '<emph>Emotional Valence'</emph> and '<emph>Arousal'</emph> improved model fit over Model 1 <ephtml> <math xmlns="http://www.w3.org/1998/Math/MathML"><mrow><mo>-</mo><mn>2</mn><mi mathvariant="normal">Δ</mi><mi>L</mi><mi>L</mi><mfenced close=")" open="("><mn>4</mn></mfenced><mo>=</mo><mn>2951.8</mn><mo>,</mo><mi>p</mi><mo><</mo><mo>.</mo><mn>001</mn><mo>,</mo><mi>A</mi><mi>I</mi><mi>C</mi><mo>=</mo><mn>19594</mn></mrow></math> </ephtml> . The analysis revealed that '<emph>Emotion Control'</emph> in both the ASC and the NT groups was significantly influenced by the presence of intense (i.e., '<emph>Arousal'</emph>) ( <ephtml> <math xmlns="http://www.w3.org/1998/Math/MathML"><mrow><mi>b</mi><mo>=</mo><mo>-</mo><mo>.</mo><mn>09</mn><mo stretchy="false">(</mo><mo>.</mo><mn>01</mn><mo stretchy="false">)</mo><mo>,</mo><mi>p</mi><mo><</mo><mo>.</mo><mn>001</mn><mo stretchy="false">)</mo></mrow></math> </ephtml> , '<emph>Negative'</emph> ( <ephtml> <math xmlns="http://www.w3.org/1998/Math/MathML"><mrow><mi>b</mi><mo>=</mo><mo>-</mo><mn>1.53</mn><mo stretchy="false">(</mo><mo>.</mo><mn>07</mn><mo stretchy="false">)</mo><mo>,</mo><mi>p</mi><mo><</mo><mo>.</mo><mn>001</mn><mo stretchy="false">)</mo></mrow></math> </ephtml> , and '<emph>Conflicting Emotions</emph>' ( <ephtml> <math xmlns="http://www.w3.org/1998/Math/MathML"><mrow><mi>b</mi><mo>=</mo><mo>-</mo><mn>1.05</mn><mo stretchy="false">(</mo><mo>.</mo><mn>12</mn><mo stretchy="false">)</mo><mo>,</mo><mi>p</mi><mo><</mo><mo>.</mo><mn>001</mn><mo stretchy="false">)</mo></mrow></math> </ephtml> (see Model 2, Table 3). After considering potential group interactions, '<emph>Arousal'</emph> ( <ephtml> <math xmlns="http://www.w3.org/1998/Math/MathML"><mrow><mi>b</mi><mo>=</mo><mo>-</mo><mo>.</mo><mn>08</mn><mfenced close=")" open="("><mo>.</mo><mn>03</mn></mfenced><mrow><mo>,</mo><mi>p</mi><mo>=</mo><mo>.</mo><mn>002</mn><mo stretchy="false">)</mo></mrow></mrow></math> </ephtml> , and '<emph>Negative Emotions'</emph> ( <ephtml> <math xmlns="http://www.w3.org/1998/Math/MathML"><mrow><mi>b</mi><mo>=</mo><mo>-</mo><mo>.</mo><mn>29</mn><mo stretchy="false">(</mo><mo>.</mo><mn>13</mn><mo stretchy="false">)</mo><mo>,</mo><mi>p</mi><mo>=</mo><mo>.</mo><mn>029</mn><mo stretchy="false">)</mo></mrow></math> </ephtml> remained significant negative predictors. Bonferroni post-hoc analysis revealed no significant differences in <emph>'Emotion Control'</emph> predictors between NT and ASC groups. However, within group differences showed that in the NT group, experiencing '<emph>Negative'</emph><ephtml> <math xmlns="http://www.w3.org/1998/Math/MathML"><mrow><mo stretchy="false">(</mo><mtext>difference</mtext><mo>=</mo><mo>-</mo><mn>1.38</mn><mo stretchy="false">(</mo><mo>.</mo><mn>10</mn><mo stretchy="false">)</mo><mo>,</mo><mi>p</mi><mo><</mo><mo>.</mo><mn>001</mn><mo stretchy="false">)</mo></mrow></math> </ephtml> and <emph>'Conflicting Emotions'</emph><ephtml> <math xmlns="http://www.w3.org/1998/Math/MathML"><mrow><mo stretchy="false">(</mo><mtext>difference</mtext><mo>=</mo><mo>-</mo><mn>1.28</mn><mo stretchy="false">(</mo><mo>.</mo><mn>18</mn><mo stretchy="false">)</mo><mo>,</mo><mi>p</mi><mo><</mo><mo>.</mo><mn>001</mn><mo stretchy="false">)</mo></mrow></math> </ephtml> was associated with reduced '<emph>Emotion Control'</emph> compared to '<emph>Positive Emotions</emph>'<emph>.</emph> In contrast, the ASC group not only showed the same pattern but also demonstrated a negative relationship between <emph>'Negative Emotions'</emph> and <emph>'Emotion Control',</emph> compared to <emph>'Conflicting Emotions'</emph><ephtml> <math xmlns="http://www.w3.org/1998/Math/MathML"><mrow><mo stretchy="false">(</mo><mtext>difference</mtext><mo>=</mo><mo>-</mo><mo>.</mo><mn>85</mn><mo stretchy="false">(</mo><mo>.</mo><mn>16</mn><mo stretchy="false">)</mo><mo>,</mo><mi>p</mi><mo><</mo><mo>.</mo><mn>001</mn><mo stretchy="false">)</mo></mrow></math> </ephtml> .</p> <p>In testing the Hypothesis 3), which proposed that the '<emph>Absence of Emotion Labelling'</emph> would predict a lack of '<emph>Emotion Control'</emph>, the EMA responses '<emph>I have an emotion that I cannot name</emph>' and '<emph>I have no emotion</emph>' were included in the analysis (see Model 3, Table 3). This model showed an improved fit over Model 2 ( <ephtml> <math xmlns="http://www.w3.org/1998/Math/MathML"><mrow><mo>-</mo><mn>2</mn><mi mathvariant="normal">Δ</mi><mi>L</mi><mi>L</mi><mfenced close=")" open="("><mn>2</mn></mfenced><mrow><mo>=</mo><mn>2946.4</mn><mo>,</mo><mi>p</mi><mo><</mo><mo>.</mo><mn>001</mn><mo>,</mo><mi>A</mi><mi>I</mi><mi>C</mi><mo>=</mo><mn>19568</mn><mo stretchy="false">)</mo></mrow></mrow></math> </ephtml> . Both statements '<emph>I have no emotion'</emph> ( <ephtml> <math xmlns="http://www.w3.org/1998/Math/MathML"><mrow><mi>b</mi><mo>=</mo><mo>-</mo><mo>.</mo><mn>47</mn><mo stretchy="false">(</mo><mo>.</mo><mn>21</mn><mo stretchy="false">)</mo><mo>,</mo><mi>p</mi><mo>=</mo><mo>.</mo><mn>030</mn><mo stretchy="false">)</mo></mrow></math> </ephtml> and '<emph>I have an emotion that I cannot name</emph>' ( <ephtml> <math xmlns="http://www.w3.org/1998/Math/MathML"><mrow><mi>b</mi><mo>=</mo><mo>-</mo><mo>.</mo><mn>54</mn><mo stretchy="false">(</mo><mo>.</mo><mn>19</mn><mo stretchy="false">)</mo><mo>,</mo><mi>p</mi><mo>=</mo><mo>.</mo><mn>004</mn><mo stretchy="false">)</mo></mrow></math> </ephtml> showed a significant negative association with '<emph>Emotion Control'</emph> when compared to the 10 labelled emotions. After introducing interactions between these response patterns and group membership into our analytical model, only '<emph>I have no emotion</emph>' became significant as a predictor, particularly within the ASC group ( <ephtml> <math xmlns="http://www.w3.org/1998/Math/MathML"><mrow><mi>b</mi><mo>=</mo><mo>-</mo><mo>.</mo><mn>92</mn><mo stretchy="false">(</mo><mo>.</mo><mn>43</mn><mo stretchy="false">)</mo><mo>,</mo><mi>p</mi><mo>=</mo><mo>.</mo><mn>032</mn><mo stretchy="false">)</mo></mrow></math> </ephtml> . Bonferroni post-hoc analysis revealed no statistically significant difference between the groups overall. However, distinct patterns emerged within each group. In the NT group, the comparison between <emph>'I have no emotion' and 'I have an emotion that I cannot name</emph>' showed that the latter was a stronger predictor of reduced '<emph>Emotion Control'</emph><ephtml> <math xmlns="http://www.w3.org/1998/Math/MathML"><mrow><mo stretchy="false">(</mo><mtext>difference</mtext><mo>=</mo><mo>-</mo><mo>.</mo><mn>69</mn><mo stretchy="false">(</mo><mo>.</mo><mn>22</mn><mo stretchy="false">)</mo><mo>,</mo><mi>p</mi><mo>=</mo><mo>.</mo><mn>021</mn><mo stretchy="false">)</mo></mrow></math> </ephtml> . Conversely, in the ASC group, the statement <emph>'I have no emotion'</emph> was marginally negatively associated with reduced <emph>'Emotion Control'</emph> when compared to' <emph>I have an emotion that I cannot name</emph>' <ephtml> <math xmlns="http://www.w3.org/1998/Math/MathML"><mrow><mo stretchy="false">(</mo><mtext>difference</mtext><mo>=</mo><mo>-</mo><mo>.</mo><mn>54</mn><mo stretchy="false">(</mo><mo>.</mo><mn>19</mn><mo stretchy="false">)</mo><mo>,</mo><mi>p</mi><mo>=</mo><mo>.</mo><mn>060</mn><mo stretchy="false">)</mo><mo>.</mo></mrow></math> </ephtml> In addition, a statistically significant difference was found between <emph>'I have no emotion'</emph> and all the other labelled emotions <ephtml> <math xmlns="http://www.w3.org/1998/Math/MathML"><mrow><mo stretchy="false">(</mo><mtext>difference</mtext><mo>=</mo><mo>-</mo><mo>.</mo><mn>93</mn><mo stretchy="false">(</mo><mo>.</mo><mn>27</mn><mo stretchy="false">)</mo><mo>,</mo><mi>p</mi><mo>=</mo><mo>.</mo><mn>008</mn><mo stretchy="false">)</mo></mrow></math> </ephtml> .</p> <hd id="AN0191290370-13">Discussion</hd> <p>This study is the first to use a combination of retrospective self-report measures and prospective EMA to examine the relationship between recognising and labelling one's own emotions and emotion control in autistic adults with ED compared to a group of neurotypical controls. The findings reveal a significant association between the absence of emotion labelling and reduced emotion control, extending beyond the ASC population (i.e., the effect was partially ASC specific). In both groups, the statements '<emph>I have an emotion that I cannot name</emph>' and <emph>'I have no emotion'</emph> were associated with challenges in emotion control – a proxy for ED –, despite being partially more prevalent in the ASC group. However, post-hoc analysis of group interaction revealed that, only in autistic adults, '<emph>I have no emotion</emph>' was related to difficulties in emotion control. Interestingly, when autistic adults could label their emotions, rates of negative and conflicting (simultaneously positive and negative) emotions were higher. Furthermore, the presence of intense negative and conflicting emotions was associated with reduced emotion control.</p> <p>Based on previous research (Hill et al., [<reflink idref="bib40" id="ref106">40</reflink>]; Rieffe et al., [<reflink idref="bib76" id="ref107">76</reflink>]; Silani et al., [<reflink idref="bib83" id="ref108">83</reflink>]), we hypothesized that when compared to NT, autistic individuals would experience increased alexithymia, as exemplified by statements '<emph>I have an emotion that I cannot name</emph>' and '<emph>I have no emotion</emph>'. Consistent with the hypotheses, autistic individuals reported higher levels of alexithymia, as measured by the GAFS-8, and an increased frequency of the absence of emotion labelling during EMA, but only as expressed by the statement '<emph>I have an emotion that I cannot name</emph>'. While this finding is consistent with previous studies indicating a difficulty in verbally expressing emotions within ASC (Jacques et al., [<reflink idref="bib46" id="ref109">46</reflink>]), it is important to note that the most common definition of alexithymia includes not only challenges in identifying and describing one's own emotions, but also difficulties in distinguishing between different emotions and bodily sensations, with a tendency to focus on external rather than internal experiences (Sifneos, [<reflink idref="bib82" id="ref110">82</reflink>]). This theoretical framework finds support in neural research, which proposes a decoupling model of alexithymia (Eastabrook et al., [<reflink idref="bib22" id="ref111">22</reflink>]; Gaigg et al., [<reflink idref="bib27" id="ref112">27</reflink>]). This model suggests a lack of integration between physiological arousal and conscious awareness, providing a conceptual basis for understanding emotional processing challenges through the hypothesis of a diminished emotional awareness in individuals presenting with alexithymia (Gaigg et al., [<reflink idref="bib27" id="ref113">27</reflink>]). Studies associating difficulties in emotional awareness to hypoactivity of the anterior insula (Klein et al., [<reflink idref="bib51" id="ref114">51</reflink>]), a region thought to be involved in the conscious representation of internal bodily states such as emotions (Moriguchi & Komaki, [<reflink idref="bib69" id="ref115">69</reflink>]), as well as findings related to atypical skin conductance in alexithymic individuals (e.g., Hickman et al., [<reflink idref="bib39" id="ref116">39</reflink>]; Roedema & Simons, [<reflink idref="bib78" id="ref117">78</reflink>]), are also consistent with this model. Our research contributes to this understanding by conceptualising reduced emotional awareness in ASC through the statement '<emph>I have no emotion</emph>'. Contrary to our initial hypothesis and the wider research landscape on alexithymia, we did not find significant differences in the prevalence of '<emph>I have no emotion</emph>' between ASC and NT groups. However, these results should be interpreted with caution. It is plausible that both groups may have used this response to either indicate the lack of recognition of their emotions or the absence of an intense emotion. Despite statistically significant differences on the alexithymia measures, both ASC and control groups showed considerable heterogeneity in emotional awareness. This suggests that even in the NT group, some individuals had high and comparable levels of alexithymia traits compared to autistic individuals. To expand our understanding, future research should explore the nuanced meaning of '<emph>I have no emotion</emph>' as this could help distinguish between the inability to verbalise emotions and the possible unawareness of emotions in ASC.</p> <p>Emerging research situates emotion labelling as an implicit form of ER representing a promising mechanism for the downregulation of negative emotions (Braunstein et al., [<reflink idref="bib9" id="ref118">9</reflink>]; Torre & Lieberman, [<reflink idref="bib88" id="ref119">88</reflink>]). Studies show that emotion labelling activates the rvlPFC, and subsequently modulates regions associated with the generation of negative emotions, such as the amygdala (Torre & Lieberman, [<reflink idref="bib88" id="ref120">88</reflink>]). Therefore, we hypothesised that difficulties in emotion control, would be associated with alexithymia, particularly in ASC. Consistently, our MLM analysis revealed that, in both groups, difficulties with emotion control were better explained in relation to the absence of emotion labelling, as exemplified by the statements '<emph>I have an emotion that I cannot name'</emph> and <emph>'I have no emotion'.</emph> These findings support the theory of emotion labelling as an ER strategy (Braunstein et al., [<reflink idref="bib9" id="ref121">9</reflink>]; Torre & Lieberman, [<reflink idref="bib88" id="ref122">88</reflink>]), suggesting an association between the challenge of verbally expressing emotions and self-reported lack of emotion control. However, the introduction of the post-hoc group interaction (autistic versus NT) in our MLM model produced a significant shift. The response '<emph>I have no emotion</emph>' became the only significant predictor for emotion control, specifically in the autistic group. This suggests a unique influence of '<emph>I have no emotion</emph>' on ER within the autistic population, implying distinct emotional processes not observed in the NT group. The impact of reporting '<emph>I have no emotion</emph>' may have a greater significance or a different connotation in the context of the autistic experience. Some researchers suggest that labelling emotional states may reduce uncertainty (Lindquist et al., [<reflink idref="bib57" id="ref123">57</reflink>]; Torre & Lieberman, [<reflink idref="bib88" id="ref124">88</reflink>]), which is consistent with findings of hyperactivation of the amygdala in response to uncertainty of stimuli (Whalen, [<reflink idref="bib97" id="ref125">97</reflink>]). Conversely, the inability to label emotions, particularly in ASC, may lead to distress, consistent with the well-known challenges in processing and managing uncertainty associated with ASC (Hodgson et al., [<reflink idref="bib41" id="ref126">41</reflink>]). Furthermore, this finding is consistent with studies linking the inability to label emotions with the experience of distress (Ebner-Priemer et al., [<reflink idref="bib23" id="ref127">23</reflink>]) and aligns with evidence-based psychotherapies such as DBT (Linehan, [<reflink idref="bib58" id="ref128">58</reflink>]), which emphasizes the identification of emotions as a foundational step in ER, prior to the use of other strategies such as mindfulness and cognitive reappraisal (Mauss et al., [<reflink idref="bib61" id="ref129">61</reflink>]).</p> <p>We also hypothesised that when autistic individuals were able to label their emotions, they would report higher frequencies of negative emotions, such as '<emph>sadness'</emph>, '<emph>anger'</emph>, and '<emph>anxiety'</emph>, and lower frequencies of positive emotions such as '<emph>calm'</emph>, '<emph>joy'</emph>, and '<emph>interest'</emph> compared to NTs. Our findings are consistent with previous research indicating a reduced presence of positive emotions (Garon et al., [<reflink idref="bib28" id="ref130">28</reflink>]) and increased negative emotions (Keluskar et al., [<reflink idref="bib49" id="ref131">49</reflink>]; Samson et al., [<reflink idref="bib80" id="ref132">80</reflink>]) early in the development of ASC. In particular, autistic individuals reported higher overall levels of negative emotions, such as '<emph>sadness'</emph> and '<emph>anxiety'</emph>. Interestingly, in contrast with previous literature based on parental perspectives suggesting higher levels of anger and externalized behaviour such as temper tantrums, irritability, and aggressive behaviour in autistic children and adolescents compared to NT (Capps et al., [<reflink idref="bib14" id="ref133">14</reflink>]), our study found no significant difference in terms of '<emph>anger'</emph>. We speculate that this discrepancy may be due to the methodological differences, namely self-report versus parental report. Furthermore, it is also possible that, in adults, the external manifestations of meltdowns may be more discreet, as individuals are more cautious to adhere to social norms (Lewis & Stevens, [<reflink idref="bib55" id="ref134">55</reflink>]). For the category of positive emotions, our findings revealed lower rates of '<emph>joy'</emph>, '<emph>interest'</emph> and '<emph>calm'</emph> in autistic participants. According to the existing literature, labelling emotions can reduce negative emotions (Brooks et al., [<reflink idref="bib11" id="ref135">11</reflink>]; Lieberman et al., [<reflink idref="bib56" id="ref136">56</reflink>]; Torre & Lieberman, [<reflink idref="bib88" id="ref137">88</reflink>]) and increase positive emotions (Vlasenko et al., [<reflink idref="bib91" id="ref138">91</reflink>]). Conversely, alexithymia, which refers to the inability to identify and describe emotions, is considered a risk factor for suicidal tendencies (Moseley et al., [<reflink idref="bib70" id="ref139">70</reflink>]). Based on these findings, it is plausible that the absence of emotion labelling found in our study may be associated with higher rates of negative emotions and lower frequencies of positive emotions in autistic people. However, future research should determine the relationship between alexithymia and emotional valence in ecological settings.</p> <p>To our surprise, simultaneous positive and negative emotions – labelled conflicting emotions – were reported by both groups. However, ASC had higher rates. Since previous research reported high prevalence of conflicting emotions in clinical populations, such as BPD (Ebner-Priemer et al., [<reflink idref="bib23" id="ref140">23</reflink>]), it is possible that this category is related to ED. Previous studies have indicated that the ability to comprehend and regulate conflicting emotions may be associated with the development of social competence, which is a key factor in effective interpersonal interactions and emotion regulation strategies (Harwood & Farrar, [<reflink idref="bib36" id="ref141">36</reflink>]; O'Brien et al., [<reflink idref="bib72" id="ref142">72</reflink>]). In our study, reduced emotion control was associated with conflicting and intense negative emotions in both groups. However, a specific effect was observed only in ASC in relation to negative emotions, not only in comparison to positive but also to conflicting emotions. Negative emotions may be more intense and immediate, activating the body's fight or flight response. Since the amygdala is more responsive to negative stimuli (Berboth & Morawetz, [<reflink idref="bib5" id="ref143">5</reflink>]; Torre & Lieberman, [<reflink idref="bib88" id="ref144">88</reflink>]), stronger emotional reactions might be cued by negative events, making it harder to regulate the corresponding negative emotions. Moreover, humans tend to exhibit a negativity bias, whereby negative information tends to have a stronger impact on cognition and behaviour than positive information (Ito et al., [<reflink idref="bib45" id="ref145">45</reflink>]). The association between reduced emotion control and intense negative emotions may be explained by the inherent challenge humans face in redirecting attention away from negative information (Ito et al., [<reflink idref="bib45" id="ref146">45</reflink>]).</p> <p>To the best of our knowledge, this is the first research investigating the relationship between alexithymia and ED in the daily lives of autistic adults. In ASC, ED has been traditionally linked to co-occurring psychiatric diagnoses (Lai et al., [<reflink idref="bib53" id="ref147">53</reflink>]), and characteristics associated with autistic-traits (Cassidy et al., [<reflink idref="bib15" id="ref148">15</reflink>]; Gillott & Standen, [<reflink idref="bib30" id="ref149">30</reflink>]). Moreover, noteworthy distinctions in ED have been observed based on sex and age in both the general population and in autistic individuals (Gross et al., [<reflink idref="bib34" id="ref150">34</reflink>]; Isaacowitz, [<reflink idref="bib44" id="ref151">44</reflink>]; Weiner et al., [<reflink idref="bib95" id="ref152">95</reflink>]). Therefore, in our study we accounted for demographic variables (i.e., sex, age), clinical characteristics (i.e., depression, anxiety, BPD), and core autistic features (i.e., sensorial sensitivity, camouflaging and social interactions effects). However, contrary to previous studies, none of these factors emerged as significant predictors. Notably, our findings show that the absence of emotion labelling, and intense negative emotions continued to predict difficulties in emotion control even after accounting for these factors. This adds to the current body of literature, emphasizing that impairment in emotion control is more closely linked to alexithymia and the experience of intense negative emotions rather than to the core characteristics of ASC or to symptoms of frequent co-occurring disorders (Bird & Cook, [<reflink idref="bib6" id="ref153">6</reflink>]; Gormley et al., [<reflink idref="bib31" id="ref154">31</reflink>]). Interestingly, when contextual factors (e.g., fatigue, weekend days) were considered, only fatigue emerged as a statistically significant predictor of emotion control impairments. However, this finding applied to both autistic and neurotypical individuals, suggesting that fatigue may pose a general risk factor for emotion control, extending beyond individuals with difficulties in ER. This is consistent with previous research suggesting a relationship between emotion regulation and mental fatigue (Grillon et al., [<reflink idref="bib32" id="ref155">32</reflink>]).</p> <hd id="AN0191290370-14">Limitations and Future Directions</hd> <p>This study has several strengths, such as a well-defined ASC sample, the use of EMA methodology, modern data collection techniques, and advanced analytical methods (Harari et al., [<reflink idref="bib35" id="ref156">35</reflink>]). However, it is imperative to interpret our findings in the context of certain limitations. First, our data collection covered only one week and omitted assessments during the late night and early morning hours. Second, in our model, the clinical variables (i.e., depression, anxiety, BPD traits, sensory sensitivity, and camouflaging) were uniquely assessed by retrospective measures that target a trait rather than a state characteristic, which may explain their lack of significance in relation to emotion control. To better control for the impact of these variables, future studies should include them within the EMA assessments. Another limitation of the present study is the requirement for participants to have a mobile phone with internet access for the EMA procedures, which may introduce a socio-economic bias. As a result, these findings may not be fully representative of the autistic population, particularly for those from different socioeconomic backgrounds. In addition, the issue of generalizability of our findings also relates to the inclusion of autistic adults without intellectual disability and self-reports of ED, self-harm, and suicidality, enrolled prior to participation in DBT. While increased ED has been reported in other samples of autistic adolescents and adults (Conner et al., [<reflink idref="bib17" id="ref157">17</reflink>]), the extent to which those with lower IQs may experience similar problems compared to their higher functioning peers remains unclear. In particular, the robustness and generalizability of our findings are due to the rigorous diagnostic assessment that autistic adults received to confirm their ASC diagnosis. Finally, we acknowledge that although our EMA design limits the biases inherent to retrospective measures, individuals with high levels of alexithymia may have found it hard to label their emotions (Bradburn et al., [<reflink idref="bib8" id="ref158">8</reflink>]; Mazefsky et al., [<reflink idref="bib63" id="ref159">63</reflink>]). To determine whether the absence of emotion labelling is due to alexithymia, we highlight the need for future research to explore the correspondence between self-report indices and more objective measures, such as physiological indicators.</p> <hd id="AN0191290370-15">Conclusions</hd> <p>This pioneering study explored the everyday nuances of emotion regulation in autistic adults compared to neurotypical individuals similar in terms of sex, age, and educational level. Our findings revealed a unique facet of emotional processing in ASC, characterised by heightened negative, conflicting, and unlabelled emotions. Importantly, even after accounting for co-occurring psychiatric conditions or autistic traits, our study highlighted that the absence of emotion labelling along with negative emotions emerged as the only significant predictors of diminished emotion control. These findings underscore the need for therapeutic interventions targeting ED in autistic adults, highlighting the importance of addressing alexithymia and intense negative emotions such as anxiety and sadness.</p> <hd id="AN0191290370-16">Acknowledgements</hd> <p>We express our sincere gratitude to the participants and medical professionals whose cooperation made this research possible.</p> <hd id="AN0191290370-17">Author Contribution</hd> <p> <bold>MEC</bold>: Conceptualisation, Methodology, Project administration, Data collection, Data curation, Software, Data analysis, Writing – original draft, Writing – review and editing; <bold>FG</bold>: Software, Data curation, Data analysis; <bold>NV, AG, FL</bold>: Data curation, Supervision; <bold>AC</bold>: Conceptualisation, Methodology, Funding acquisition; <bold>SW</bold> & <bold>LW</bold>: Conceptualisation, Methodology, Funding acquisition, Data curation, Supervision, Writing – review and editing. All authors read and approved the final manuscript.</p> <hd id="AN0191290370-18">Funding</hd> <p>Funding for this project was provided by the John Bost Foundation.</p> <hd id="AN0191290370-19">Data Availability</hd> <p>De-identified data is available at: https://osf.io/p3vm4/?view_only=974b02935b6a45eb82064deb3cc776b8.</p> <hd id="AN0191290370-20">Declarations</hd> <p></p> <hd id="AN0191290370-21">Competing interests</hd> <p>The authors declare that they have no competing interests.</p> <hd id="AN0191290370-22">Ethical Approval</hd> <p>The regional ethics committee of the East of France approved this study as a preliminary step for a randomized control trial on dialectical behaviour therapy (DBT) and ED (Reference: SI 21.01.21.41923).</p> <hd id="AN0191290370-23">Informed Consent</hd> <p>Participants provided written informed consent to participate in the study.</p> <hd id="AN0191290370-24">Supplementary Information</hd> <p>Below is the link to the electronic supplementary material.</p> <p>Graph: Supplementary file1 (PDF 200 kb)</p> <p>Graph: Supplementary file2 (PDF 316 kb)</p> <p>Graph: Supplementary file3 (PDF 176 kb)</p> <p>Graph: Supplementary file4 (PDF 141 kb)</p> <hd id="AN0191290370-25">Abbreviations</hd> <p></p> <p>• AIC</p> <p></p> <ulist> <item> Akaike information criterion</item> <p></p> </ulist> <p>• AQ</p> <p></p> <ulist> <item> The autism-spectrum quotient</item> <p></p> </ulist> <p>• ASC</p> <p></p> <ulist> <item> Autism spectrum condition</item> <p></p> </ulist> <p>• BAI</p> <p></p> <ulist> <item> Beck anxiety inventory</item> <p></p> </ulist> <p>• BDI-II</p> <p></p> <ulist> <item> The beck depression inventory, 2nd edition</item> <p></p> </ulist> <p>• BPD</p> <p></p> <ulist> <item> Borderline personality disorder</item> <p></p> </ulist> <p>• BSL-23</p> <p></p> <ulist> <item> The short version of the borderline symptom list</item> <p></p> </ulist> <p>• CAT-Q</p> <p></p> <ulist> <item> Camouflaging autistic trait questionnaire</item> <p></p> </ulist> <p>• DERS</p> <p></p> <ulist> <item> The difficulties in emotion regulation scale</item> <p></p> </ulist> <p>• DBT</p> <p></p> <ulist> <item> Dialectical behaviour therapy</item> <p></p> </ulist> <p>• DSM-5</p> <p></p> <ulist> <item> Diagnostic and statistical manual of mental disorders</item> <p></p> </ulist> <p>• EMA</p> <p></p> <ulist> <item> Ecological momentary assessment</item> <p></p> </ulist> <p>• ED</p> <p></p> <ulist> <item> Emotion dysregulation</item> <p></p> </ulist> <p>• ER</p> <p></p> <ulist> <item> Emotion regulation</item> <p></p> </ulist> <p>• GAFS-8</p> <p></p> <ulist> <item> The general alexithymia factor score</item> <p></p> </ulist> <p>• GSQ</p> <p></p> <ulist> <item> The glasgow sensory questionnaire</item> <p></p> </ulist> <p>• ICC</p> <p></p> <ulist> <item> Intraclass correlation coefficient</item> <p></p> </ulist> <p>• MLM</p> <p></p> <ulist> <item> Multilevel modelling</item> <p></p> </ulist> <p>• NT</p> <p></p> <ulist> <item> Neurotypical individuals</item> <p></p> </ulist> <p>• REML</p> <p></p> <ulist> <item> Restricted maximum likelihood</item> <p></p> </ulist> <p>• rvlPFC</p> <p></p> <ulist> <item> Right ventrolateral prefrontal cortex</item> <p></p> </ulist> <p>• WAIS-IV</p> <p></p> <ulist> <item> Wechsler adult intelligence scale, fourth edition</item> </ulist> <hd id="AN0191290370-26">Publisher's Note</hd> <p>Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.</p> <ref id="AN0191290370-27"> <title> References </title> <blist> <bibl id="bib1" idref="ref11" type="bt">1</bibl> <bibtext> American Psychiatric Association. 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  Label: Authors
  Group: Au
  Data: <searchLink fieldCode="AR" term="%22Mădălina+Elena+Costache%22">Mădălina Elena Costache</searchLink> (ORCID <externalLink term="http://orcid.org/0000-0002-1204-3521">0000-0002-1204-3521</externalLink>)<br /><searchLink fieldCode="AR" term="%22Federica+Gioia%22">Federica Gioia</searchLink><br /><searchLink fieldCode="AR" term="%22Nicola+Vanello%22">Nicola Vanello</searchLink><br /><searchLink fieldCode="AR" term="%22Alberto+Greco%22">Alberto Greco</searchLink><br /><searchLink fieldCode="AR" term="%22François+Lefebvre%22">François Lefebvre</searchLink><br /><searchLink fieldCode="AR" term="%22Antonio+Capobianco%22">Antonio Capobianco</searchLink><br /><searchLink fieldCode="AR" term="%22Sébastien+Weibel%22">Sébastien Weibel</searchLink><br /><searchLink fieldCode="AR" term="%22Luisa+Weiner%22">Luisa Weiner</searchLink>
– Name: TitleSource
  Label: Source
  Group: Src
  Data: <searchLink fieldCode="SO" term="%22Journal+of+Autism+and+Developmental+Disorders%22"><i>Journal of Autism and Developmental Disorders</i></searchLink>. 2026 56(2):587-601.
– Name: Avail
  Label: Availability
  Group: Avail
  Data: Springer. Available from: Springer Nature. One New York Plaza, Suite 4600, New York, NY 10004. Tel: 800-777-4643; Tel: 212-460-1500; Fax: 212-460-1700; e-mail: customerservice@springernature.com; Web site: https://link.springer.com/
– Name: PeerReviewed
  Label: Peer Reviewed
  Group: SrcInfo
  Data: Y
– Name: Pages
  Label: Page Count
  Group: Src
  Data: 15
– Name: DatePubCY
  Label: Publication Date
  Group: Date
  Data: 2026
– Name: TypeDocument
  Label: Document Type
  Group: TypDoc
  Data: Journal Articles<br />Reports - Research
– Name: Subject
  Label: Descriptors
  Group: Su
  Data: <searchLink fieldCode="DE" term="%22Emotional+Response%22">Emotional Response</searchLink><br /><searchLink fieldCode="DE" term="%22Self+Control%22">Self Control</searchLink><br /><searchLink fieldCode="DE" term="%22Autism+Spectrum+Disorders%22">Autism Spectrum Disorders</searchLink><br /><searchLink fieldCode="DE" term="%22Emotional+Problems%22">Emotional Problems</searchLink><br /><searchLink fieldCode="DE" term="%22Adults%22">Adults</searchLink><br /><searchLink fieldCode="DE" term="%22Arousal+Patterns%22">Arousal Patterns</searchLink>
– Name: DOI
  Label: DOI
  Group: ID
  Data: 10.1007/s10803-024-06551-8
– Name: ISSN
  Label: ISSN
  Group: ISSN
  Data: 0162-3257<br />1573-3432
– Name: Abstract
  Label: Abstract
  Group: Ab
  Data: Difficulties in controlling emotions--a proxy for emotion dysregulation (ED)--and difficulties in expressing feelings in words--'absence of emotion labelling' or alexithymia--co-exist in autism and contribute to elevated levels of impulsive and suicidal behaviour. To date, studies linking the two phenomena have relied on retrospective self-reported measures, lacking support for generalizability to real-life situations. The present study investigated in vivo emotion labelling and its impact on emotion control in 29 autistic adults without intellectual disability (ASC) and 28 neurotypical (NT) individuals of similar age, sex, and educational level. Participants were trained in an Ecological Momentary Assessment (EMA) to label their emotions, the arousal dimension, and their emotion control via smartphone over a one-week period. Findings showed that the ASC group experienced more instances of 'having an emotion that I cannot name' and, when they were able to label their emotions, they reported higher rates of negative and conflicting (simultaneously positive and negative) emotions. In both groups, the absence of emotion labelling, and intense negative emotions were associated with impaired emotion control. However, the association between lack of emotional awareness--'I have no emotion'--and impaired emotion control was only evident in ASC individuals. Our study highlights a nuanced facet of emotional processing in the ASC population. Further research is needed to gain a deeper understanding of the complex relationship between ED and alexithymia in autism.
– Name: AbstractInfo
  Label: Abstractor
  Group: Ab
  Data: As Provided
– Name: DateEntry
  Label: Entry Date
  Group: Date
  Data: 2026
– Name: AN
  Label: Accession Number
  Group: ID
  Data: EJ1504717
PLink https://search.ebscohost.com/login.aspx?direct=true&site=eds-live&db=eric&AN=EJ1504717
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        Value: 10.1007/s10803-024-06551-8
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      – Text: English
    PhysicalDescription:
      Pagination:
        PageCount: 15
        StartPage: 587
    Subjects:
      – SubjectFull: Emotional Response
        Type: general
      – SubjectFull: Self Control
        Type: general
      – SubjectFull: Autism Spectrum Disorders
        Type: general
      – SubjectFull: Emotional Problems
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      – SubjectFull: Adults
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      – SubjectFull: Arousal Patterns
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    Titles:
      – TitleFull: Exploring Emotion Control and Alexithymia in Autistic Adults: An Ecological Momentary Assessment Study
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            – D: 01
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              Type: published
              Y: 2026
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            – Type: issn-print
              Value: 0162-3257
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            – TitleFull: Journal of Autism and Developmental Disorders
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