Childhood abuse, distress disclosure, resilience, and alexithymia: testing a moderated mediation model

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However, the mediating mechanisms underlying the relationship between childhood abuse and alexithymia (particularly in non-Western cultural contexts) remain unclear. This study aimed to investigate whether distress disclosure mediates the relationship between childhood abuse and alexithymia, as well as the moderating role of resilience. A cross-sectional survey was conducted among 899 middle school students using the Childhood Trauma Questionnaire-Short Form (CTQ-SF), Distress Disclosure Index (DDI), Connor-Davidson Resilience Scale (CD-RISC), and Toronto Alexithymia Scale (TAS-20). The results showed that: Childhood abuse directly and positively predicted alexithymia; distress disclosure significantly mediated the relationship between childhood abuse and alexithymia; Resilience positively moderated the association between childhood abuse and distress disclosure, with highly resilient individuals exhibiting greater capacity to mitigate the negative impact of childhood abuse on distress disclosure. The findings emphasize the need to jointly examine the mechanisms of risk factors and protective factors in abused individuals with comorbid alexithymia. Childhood abuse Distress disclosure Resilience Alexithymia Middle school students Figures Figure 1 ‌Introduction Alexithymia, characterized by difficulties in identifying and describing emotions, alongside an externally oriented thinking style (excessive focus on mundane details rather than internal emotional states)[ 1 ], affects approximately 13–19% of the general population and 30–50% of clinical samples, with higher prevalence observed in males[ 2 ]. Notably, alexithymia is not classified as a psychiatric disorder in the Diagnostic and Statistical Manual of Mental Disorders (DSM). It is conceptualized as a dimensional construct following a normal distribution and categorized into two subtypes: primary alexithymia (a stable personality trait) and secondary alexithymia (triggered by traumatic events or chronic psychological stressors such as childhood abuse or persistent pain) [ 3 ]. Originally identified in psychosomatic disorders (e.g., somatic conditions linked to psychological distress), alexithymia has since been implicated as a transdiagnostic risk factor. It is strongly associated with externalizing problem behaviors (e.g., internet addiction, alcohol dependence, aggression, self-harm, and suicidal ideation) [ 4 , 5 ] and psychiatric disorders, including depression, anxiety, eating disorders, personality disorders, and substance use disorders [ 6 , 7 ]. Emerging evidence highlights its sociocultural underpinnings,suggesting that alexithymia arises from interactions between sociocultural environmental factors and individual psychological protective mechanisms[ 8 ]. Cultural norms play a pivotal role in shaping emotional experience and expression. Societies that discourage the cultivation of emotional awareness and communication skills may predispose individuals to alexithymic traits. Cross-cultural studies reveal that East Asian cultures, which often prioritize emotional restraint, exhibit higher alexithymia levels compared to Western cultures. For instance, Chinese Canadians demonstrate elevated alexithymia scores relative to their European Canadian counterparts[ 9 ]. These findings underscore the critical need to investigate the interplay between sociocultural contexts and psychological protective mechanisms in shaping alexithymia within Chinese populations, where cultural norms of emotional expression diverge markedly from Western paradigms. Childhood Maltreatment and Alexithymia‌ Emerging evidence highlights childhood maltreatment as a key socioenvironmental factor associated with alexithymia‌[ 10 ], though its role within Chinese cultural contexts remains underexplored. Cultural variations in emotional socialization practices may limit the generalizability of Western findings, necessitating rigorous investigation of culturally-specific mechanisms linking childhood maltreatment to alexithymia in Chinese populations. Childhood maltreatment encompasses physical abuse, emotional abuse, sexual abuse, physical neglect, and emotional neglect‌[1 1 ], all recognized as transdiagnostic risk factors for psychopathology across the lifespan. The ‌Family Risk Model‌ posits that dysfunctional family systems—characterized by cumulative stressors or maladaptive interactions—heighten vulnerability to psychological disorders and socioemotional deficits through disrupted emotional development[12]. Empirical evidence suggests that neglectful, conflictual, or hostile family environments impair emotion recognition and regulation capacities‌10. Notably, Sabine Aust and colleagues demonstrated that subclinical emotional neglect—insufficient to meet diagnostic thresholds for mental disorders yet pervasive enough to disrupt emotional processing—may precipitate alexithymic traits by constraining emotional expression and interpersonal attunement[13]. Emotional neglect, the most prevalent form of childhood maltreatment, undermines emotion socialization by depriving individuals of familial emotional reciprocity, empathy, and affective communication. This deprivation fosters enduring deficits in emotional awareness and regulation, core features of alexithymia. Similarly, exposure to chronic familial stressors (e.g., physical/emotional abuse, domestic violence) may induce dysregulated cortisol responses[14], while coercive contingencies (e.g., punishment for emotional displays) reinforce emotional suppression as a maladaptive coping strategy. The concept of ‌learned helplessness[15], later validated in human studies[16], offers a mechanistic lens for understanding alexithymia development. Children subjected to recurrent failures in emotion regulation (e.g., inability to alleviate parental distress or escape abusive situations) may internalize helplessness, disengaging from emotional experiences altogether. This process manifests as hyperrational interpersonal strategies—weighing relational costs/benefits while avoiding emotional investment—and diminished expectations of mutual emotional fulfillment. The Mediating Role of Distress disclosuredistress disclosure Distress disclosure, defined as the willingness to express distressing emotions to others, serves as an adaptive mechanism to alleviate psychological distress and mitigate risks of severe physiological or mental health deterioration[ 17 ]. According to the ‌Dynamic Interaction Theory‌, parent-child interaction patterns—and children’s expectations of parental responses—are shaped by cumulative relational experiences[18]. Childhood maltreatment may foster insecure attachment patterns (e.g., fear of intimacy, dependency anxiety, or rejection sensitivity), which reinforce maladaptive internal working models that suppress distress disclosure to avoid anticipated relational disappointment[19]. For instance, maltreated individuals often adopt emotional avoidance strategies in turbulent family contexts, inhibiting emotional expression as a self-protective mechanism. Longitudinal studies indicate that punitive parental responses to children’s emotions (e.g., criticism or dismissal) progressively reduce distress disclosure over time[20]. Conversely, adolescents who perceive parental acceptance and warmth demonstrate enhanced emotional openness, facilitating substantive parent-child communication and immediate emotional expression[21]. Empirical evidence highlights a bidirectional relationship between distress disclosure and parent-child relationship quality. Higher levels of adolescent distress disclosure correlate strongly with improved relational trust and warmth[2 2 ], while hostile or dismissive parental communication (e.g., derogatory language) exacerbates distrust and disclosure inhibition. Critically, dysfunctional emotion regulation—marked by impaired working memory control over negative content—predisposes individuals to rumination, chronic worry, and affective disorders[23]. Alexithymia, as a deficit in emotional cognition and processing, amplifies vulnerability to substance abuse, panic disorders, somatic symptom disorders, and post-traumatic stress pathology while diminishing treatment responsiveness[24]. The ‌Distress Disclosure Inhibition Model‌ posits that suppressing traumatic experiences perpetuates psychological suffering. Avoidant coping strategies deprive individuals of corrective interpersonal feedback, stunting emotional awareness development and reinforcing maladaptive cycles, thereby exacerbating alexithymic[22]. These findings underscore the need to address relational and emotional processing deficits in interventions targeting trauma-related alexithymia[23]. The Moderating Role of Resilience Adolescents exposed to childhood maltreatment are not a homogeneous group; significant variability exists in their mental health outcomes, behavioral adaptations, and emotional functioning. For instance, while some children exhibit developmental delays or psychosocial issues under adverse conditions (e.g., parental separation), others demonstrate normative or even enhanced growth trajectories, highlighting the role of ‌resilience‌ in buffering risk[25]. Rooted in positive psychology, resilience emphasizes the internal strengths and adaptive capacities that enable individuals to thrive despite adversity.The ‌Protective Model‌ elucidates how resilience interacts dynamically with environmental risks through two primary mechanisms: ‌Risk Buffering‌: Protective factors mitigate the activation or impact of risk factors[26] .For example, childhood maltreatment exerts weaker inhibitory effects on distress disclosure among individuals with high resilience. Cognitive flexibility (e.g., dialectical thinking) enables reframing adversities (e.g., workplace stress) to reduce depressive symptoms by altering problem appraisals[27]. ‌Risk Amplification‌: Synergistic interactions between protective traits and contextual resources may paradoxically heighten distress[26]. Highly resilient individuals may experience intensified psychological conflict when maltreatment experiences clash with self-concept (e.g., perceiving abuse as incongruent with their identity), thereby amplifying emotional pain. While limited evidence exists on these dual pathways, this study posits that resilience moderates the ‌childhood maltreatment–distress disclosure link‌, with exploratory analyses to clarify its buffering vs. amplifying effects. Current study Recent studies indicate that the prevalence of alexithymia among adolescents ranges from 10–15%, serving both as a precursor to maladaptive behaviors and a comorbid factor for psychiatric disorders[ 28 , 29 ]. Investigating correlates of adolescent alexithymia is therefore of significant practical importance. Existing literature suggests that childhood maltreatment may contribute to alexithymia; however, not all maltreated adolescents develop this condition, implying potential modulation by multiple factors. The mechanisms underlying how childhood maltreatment influences alexithymia through pathways such as distress disclosure and resilience remain unclear, necessitating an analytical framework integrating risk-protective factor interactions. This study aims to explore the relationship between childhood maltreatment and alexithymia, while examining the mediating role of distress disclosure and the moderating role of resilience. Such research holds theoretical value for elucidating the mechanisms of alexithymia and practical implications for prevention strategies.‌ This cross-sectional study investigates direct and indirect associations between variables but is limited in establishing causal relationships due to the non-temporal nature of the data. As an exploratory investigation, its contributions include: (a) uncovering developmental pathways of alexithymia among Chinese adolescents within cultural contexts, and (b) proposing a moderated mediation model to guide future research. The study constructs a theoretical model with childhood maltreatment as the predictor, distress disclosure as the mediator, resilience as the moderator, and alexithymia as the outcome. Three hypotheses are proposed: ‌Hypothesis 1‌: Childhood maltreatment is positively associated with alexithymia. ‌Hypothesis 2‌: The association between childhood maltreatment and alexithymia is mediated by distress disclosure. ‌Hypothesis 3‌: resilience moderates the mediating pathway from childhood maltreatment to distress disclosure. ‌Methods‌ ‌Participants and Procedure ‌ The study protocol was approved by the Research Ethics Committee of Hubei Normal University. A cross-sectional survey was conducted in October 2020 across three public middle schools in Henan Province, China. Using convenience sampling, 970 students meeting inclusion and exclusion criteria were recruited. Inclusion criteria required written informed consent from both participants and their parents. Exclusion criteria encompassed severe physical conditions (self-reported), visual/hearing impairments, neurological disorders, or incomplete questionnaires. Prior to data collection, participants received a detailed explanation of the study’s objectives and ethical considerations. Written informed consent was obtained in classroom settings, after which participants completed the Childhood Trauma Questionnaire-Short Form (CTQ-SF), Distress Disclosure Index (DDI), Connor-Davidson Resilience Scale (CD-RISC), and the 20-item Toronto Alexithymia Scale (TAS-20). Of the initial 970 questionnaires, 71 incomplete responses were excluded, yielding a final analytic sample of 899 participants. The sample comprised 433 males (48.16%) and 466 females (51.84%), aged 12–16 years (M = 13.95, SD = 1.10), distributed across Grade 7 (43.49%), Grade 8 (24.69%), and Grade 9 (31.81%). Participants’ residential backgrounds included rural (27.36%), township (34.15%), and urban (38.49%) areas, ensuring broad demographic representativeness. For structural equation modeling (SEM), a minimum of 20 participants per latent variable factor was required. This study exceeded this threshold, with 240 participants as the lower bound. A post-hoc power analysis using G*Power (version 3.1) was performed, with parameters set to f² = 0.24, α = 0.05, total sample size N = 899, and three predictors. The analysis yielded a power of 1 (100%), substantially exceeding the conventional threshold of 0.80, confirming sufficient statistical power and robustness of the findings. ‌Measures ‌ ‌Childhood Trauma Questionnaire-Short Form (CTQ-SF)‌ The Childhood Trauma Questionnaire-Short Form (CTQ-SF) consists of 28 items assessing five dimensions: emotional abuse, emotional neglect, physical abuse, physical neglect, and sexual abuse [ 30 , 31 ]. Participants rated items on a 5-point Likert scale ranging from 1 (never) to 5 (always). The total score for each dimension was calculated by summing the corresponding item scores, and the overall questionnaire score was the sum of all dimension scores. Higher scores indicate more severe childhood maltreatment. The scale demonstrated a Cronbach’s α coefficient of 0.79, indicating good internal consistency and validity. ‌Distress Disclosure Index (DDI)‌ The Distress Disclosure Index (DDI) measures individuals’ tendency to disclose distress, comprising 12 items [ 32 , 33 ]. Participants responded on a 5-point Likert scale from 1 (strongly disagree) to 5 (strongly agree). Dimension scores were calculated by summing relevant items, and the total score was the sum of all dimension scores. Higher scores reflect greater distress disclosure. The scale showed a Cronbach’s α coefficient of 0.79, supporting its reliability and validity. ‌Connor-Davidson Resilience Scale (CD-RISC)‌ The Chinese version of the Connor-Davidson Resilience Scale (CD-RISC), translated and revised by Yu and Zhang (2007) [ 34 , 35 ], was used. This 25-item scale includes three dimensions: tenacity, strength, and optimism. Items were rated on a 5-point Likert scale from 0 (never) to 4 (always). Dimension and total scores were derived by summing corresponding items, with higher scores indicating greater psychological resilience. The Chinese version demonstrated excellent internal consistency (Cronbach’s α = 0.91) and criterion validity. In this study, its Cronbach’s α was 0.90. ‌Toronto Alexithymia Scale (TAS-20)‌ The Toronto Alexithymia Scale (TAS-20) contains 20 items assessing three dimensions: difficulty identifying feelings, difficulty describing feelings, and externally oriented thinking [ 36 ]. Participants rated items on a 5-point Likert scale from 1 (strongly disagree) to 5 (strongly agree). Dimension and total scores were calculated by summing relevant items, with higher scores indicating greater alexithymia. The scale exhibited a Cronbach’s α coefficient of 0.74, indicating acceptable reliability and validity. ‌Data Analysis ‌ Data were analyzed using SPSS 21.0. First, descriptive statistics (e.g., means, standard deviations) and bivariate correlations were computed. Second, the PROCESS macro (Model 4) developed by Hayes was employed to test mediation effects, examining whether childhood maltreatment indirectly influenced alexithymia through distress disclosure, while controlling for gender and grade. Bias-corrected bootstrapping (5,000 resamples) was used to estimate the standard error and 95% confidence interval (CI) of the indirect effect. Third, the PROCESS macro (Model 7) was applied to test a moderated mediation model, examining whether resilience moderated the association between childhood maltreatment and distress disclosure, with gender and grade as covariates. Results Descriptive statistics The mean value, standard deviation and correlation coefficient of each variable were shown in Table 1 . As can be seen from Table 1 , childhood abuse was negatively correlated with distress disclosure and resilience, and positively correlated with alexithymia (r=-0.14, r=-0.15, r = 0.25, p < 0.01). distress disclosure was positively correlated with resilience and negatively correlated with alexithymia (r = 0.20, r=-0.30, p < 0.01). Resilience was negatively correlated with alexithymia (r=-0.33, p < 0.01). Table 1 Means, Standard Deviations and Correlations for the Variables (N = 899) M ± SD 1 2 3 4 1childhood abuse 47.88 ± 9.36 — 2 distress disclosure 38.50 ± 7.87 -0.14 ** — 3 resilience 56.25 ± 15.79 -0.15 ** 0.20 ** — 4 alexithymia 55.77 ± 9.72 0.25 ** -0.30 ** -0.33 ** — Note. ** p < .01. *** p < .001. Testing for mediation effect The first step involved testing the simple mediation model (model 4). The results (see Fig. 1 ) showed that childhood abuse had a significant predictive effect on alexithymia (b = 0.22, SE = 0.03, p < 0.001), and negatively predicted distress disclosure (b=-0.12, SE = 0.04, p < 0.01), and distress disclosure negatively predicted alexithymia (b=-0.28, SE = 0.03, p < 0.01). In addition, the upper and lower limits of the Bootstrap 95% confidence interval of the mediating effect of distress disclosure do not contain 0 (b = 0.03, SE = 0.01, 95% CI=[0.01,0.06]). The mediating effect (0.03) accounted for 12% of the total effect (b = 0.25, SE = 0.03, 95% CI=[0.19,0.31]). Testing for moderated mediation effect Model 7 from SPSS macro was used to test the moderated mediation model under the condition of controlling gender and grade. The results (see Table 2 ) showed that when resilience was added to the model, childhood abuse (β =-0.11, SE = 0.03, p < 0.001) and resilience (β = 0.23, SE = 0.04, p < 0.001) had a significant predictive effect on distress disclosure, resilience had a significant moderating effect on the relationship between childhood abuse and distress disclosure (β =-0.06, SE = 0.03, p < 0.05). Further simple slope analysis showed that (see Fig. 2), for subjects with high resilience ( b simple =-0.17, t=-3.68, p 0 0.05), the predictive effect of childhood abuse on distress disclosure was not significant. To sum up, distress disclosure played a mediating role between childhood abuse and alexithymia, and resilience had a significant moderating effect on the relationship between childhood abuse and distress disclosure. Specifically, in comparison with low resilience, childhood abuse can significantly negatively predict alexithymia through distress disclosure in high resilience. Table 2 Testing the moderated mediation effect of childhood abuse on alexithymia predictors Alexithymia distress disclosure B t B t gender 0.08 2.48 * 0.12 3.67 *** senior −0.08 −2.48 * 0.06 1.79 childhood abuse 0.22 6.88 *** −0.11 −3.31 *** distress disclosure −0.27 −8.34 *** resilience 0.23 6.50 ** childhood abuse×resilience −0.07 −2.13 * Note. **p < .01. ***p < .001. ‌‌Discussion Although prior research has confirmed childhood maltreatment as a significant predictor of alexithymia[ 10 , 11 ], the underlying mechanisms remain unclear. This study addresses this gap by constructing a moderated mediation model, revealing for the first time that distress disclosure mediates this relationship, while psychological resilience moderates the pathway between childhood maltreatment and distress disclosure. Specifically, psychological resilience buffers the negative impact of childhood maltreatment on distress disclosure among adolescents. These findings offer actionable insights for interventions targeting alexithymia and individuals with childhood maltreatment histories, potentially alleviating emotion-processing deficits linked to internalizing (e.g., depression) and externalizing (e.g., aggression) psychopathological problems. This study demonstrates that childhood maltreatment significantly and positively influences alexithymia, supporting the first hypothesis. By validating the association between childhood maltreatment and alexithymia within a Chinese cultural context, it extends previous evidence and strengthens the universality of this relationship. Substantial research has established that childhood maltreatment, particularly psychological abuse such as emotional neglect, exerts profound and lasting effects on an individual's emotional-cognitive processing[ 37 , 38 ]. Young and Widom(2014) indicates childhood maltreatment increases susceptibility to developing maladaptive emotion regulation strategies and suppressive coping styles, ultimately leading to deficits in emotional processing[ 39 ]. From a neurobiological perspective, traumatic childhood experiences result in aberrant activation patterns within brain regions critical for emotional processing (e.g., amygdala, prefrontal cortex). Abnormal functional connectivity between the amygdala and prefrontal cortex may impair emotion recognition, causing individuals to struggle in differentiating emotional states such as anxiety and anger, and frequently misattribute emotional experiences as somatic discomfort[ 40 ]. Concurrently, concerning cognitive schema formation, individuals subjected to prolonged childhood maltreatment tend to develop negative self-cognitive models, predisposing them to interpret external information as hostile or rejecting, thereby intensifying withdrawal tendencies in emotional expression[ 14 ]. The research by Aust, Sabine et al. (2013) demonstrates that environments demanding premature independence during critical developmental periods (e.g., assuming excessive life responsibilities in preschool years), especially when coupled with a lack of emotional interaction, hinder the normative development of emotion identification abilities, gradually diminishing the individual's capacity for awareness of internal feelings[ 13 ]. Crucially, these cognitive-emotional processing deficits exhibit cross-situational stability and may perpetuate a "cycle of maltreatment" through intergenerational transmission. Research indicates that childhood maltreatment can directly influence alexithymia and may also affect it through the mediating effect of distress disclosure. Childhood maltreatment impacts individuals' distress disclosure primarily through the automatization of expressive suppression. Culturally, individuals raised in Chinese contexts are socialized from an early age with notions such as "family disgrace should not be made public," "strict corporal discipline fosters filial piety," and "parental authority is indisputable," leading them to habitually suppress discussion of personal suffering[ 41 ]. Typically, children rely on family members as confidants for distress disclosure. However, those chronically subjected to harsh discipline or maltreatment instinctively internalize self-blame—interpreting parental punishment as justified retribution for their own wrongdoing. Simultaneously, they adopt the belief that disclosing such experiences would bring shame upon their family and invite social contempt. Consequently, individuals enduring prolonged physical or emotional neglect/abuse develop an adaptive defense mechanism characterized by hypervigilance toward negative information[ 19 ]. This fosters a maladaptive belief system where "disclosure equals danger," causing overestimation of potential adverse outcomes from expressing distress. Through chronic overreliance on cognitive dissociation strategies, they sever connections between emotional experience and verbal expression. These expressive suppression tactics gradually solidify into automatized response patterns, with neural pathways inhibiting distress disclosure undergoing repeated reinforcement. Ultimately, this results in persistent difficulty voluntarily expressing vulnerability—even in objectively safe environments—during adulthood[ 20 ]. The mediating pathway in this study indicates that distress disclosure influences alexithymia. Quillman's research demonstrates that chronic suppression of distress disclosure strengthens excessive prefrontal cortical inhibition over the limbic system, leading to functional dissociation in the neural pathways between emotion recognition and verbal expression [ 42 ]. When individuals repeatedly suppress crying behaviors, activation of the insula (responsible for emotional experience) progressively diminishes, while activity in the dorsolateral prefrontal cortex (responsible for cognitive control) intensifies, ultimately forming a "emotional experience-verbal expression" conduction block [ 43 ]. Such neuroadaptive changes render individuals with alexithymia unable to translate perceived distress into describable vocabulary, even when consciously aware of their suffering. Individuals exposed to childhood maltreatment automatically tend to inhibit emotional expression, causing them to convey distress signals more readily through somatic symptoms (e.g., headaches) than verbal communication. Furthermore, suppressing distress disclosure reduces emotion differentiation and recognition capacities. Individuals who chronically use vague terms like "feeling unwell" to describe diverse painful experiences exhibit significantly weaker anterior cingulate cortex responses to emotional stimuli compared to healthy controls. This further exacerbates the "affective aphasia" characteristic in those with alexithymia [ 44 ]. As mentioned in the introduction, few studies have explored the moderating mechanisms in the relationship between childhood maltreatment and alexithymia. Guided by the ‌person-environment interaction model‌, this study reveals that psychological resilience significantly moderates the association between childhood maltreatment and distress disclosure. Specifically, the negative predictive effect of childhood maltreatment on distress disclosure (and consequently on alexithymia) is stronger among adolescents with low psychological resilience compared to those with high resilience. This aligns with the ‌risk enhancement model‌—diminished protective effects in low-resilience individuals amplify the negative impact of childhood maltreatment. Conversely, among individuals with higher psychological resilience, distress disclosure levels remain stable even as childhood maltreatment severity increases, consistent with the ‌protection model‌. Furthermore, psychological resilience mobilizes adaptive psychological resources (e.g., self-esteem, self-control, mindfulness) to foster positive adaptation to adversity, thereby amplifying the protective effects of supportive relationships [ 45 ]. On one hand, highly resilient individuals overcome ‌defensive detachment‌ stemming from childhood maltreatment and proactively seek secure attachment figures (e.g., counselors or trusted friends) as "external regulators". Receiving empathic responses to distress disclosure significantly reduces alexithymia-related somatic symptoms. On the other hand, maltreated individuals with high resilience activate extensive positive resources for self-help. By observing effective demonstrations of distress expression (e.g., role-playing in group therapy), they reshape the connection between linguistic emotional expression and positive reinforcement, thereby reversing the automatization of expressive suppression strategies in cognitive schemas[46]. Clinical Implications ‌ Our findings hold significant clinical implications for practitioners working with individuals affected by alexithymia. The results demonstrate that childhood maltreatment influences alexithymia through the mediating role of distress disclosure, with psychological resilience serving as a moderating factor. Alexithymia represents an impairment in emotional cognition, processing, and regulation[ 24 ]. Consequently, clinical interventions should not only focus on enhancing distress disclosure but also leverage positive psychological traits (e.g., resilience) while mitigating risk factors such as childhood maltreatment. Clinicians may employ cognitive reappraisal, expressive writing, emotion labeling training, and emotion recognition training to cultivate emotional cognition, processing, or regulation in affected individuals[ 47 , 48 ].Neuroplasticity research supports interventions targeting distress disclosure, which can effectively disrupt the pathological cycle of alexithymia[ 49 ]. Cognitive behavioral therapy (CBT) combined with emotion recognition training restores prefrontal cortex regulation of the amygdala; integrating reward-sensitivity enhancement modules (e.g., positive perception training) into CBT reshapes neural responses to positive stimuli, aligning with left mesotemporal spontaneous activity predictive of emotional processing[ 50 ]. Emotion labeling training (e.g., replacing "uncomfortable" with "sting of rejection") strengthens functional connectivity between the anterior insula and language centers[ 51 ]; expressive writing interventions reduce amygdala hyperreactivity to distress cues[ 52 ]. These findings advocate for multidimensional intervention models integrating individual psychological factors and socio-environmental variables. Sustained therapeutic effects emerge from synergistic neuroplasticity modulation and reconstruction of social connections. Limitations and Future Directions ‌ This study has several limitations. The temporal ambiguity of cross-sectional data impedes establishing causal relationships, urgently warranting longitudinal tracking designs to parse the developmental trajectories of maltreatment experiences and the dynamic interplay of psychological resilience across growth stages. Regarding measurement validity, self-reporting may systematically underestimate the true incidence of stigmatized experiences (e.g., sexual abuse); subsequent research should integrate multi-source data (e.g., parent/teacher behavioral reports combined with stress biomarkers like salivary cortisol concentrations) to enhance ecological validity. Culturally, while the study reveals unique mechanisms of family intergenerational interactions in Confucian contexts, significant urban-rural disparities in parenting styles and psychological adaptation indicators highlight the need to investigate divergent subcultural adaptation patterns arising from the deconstruction and reconstruction of traditional ethical values amid rapid urbanization. Declarations Ethics approval and consent to participate Ethics approval This study’s methodologies and procedures involving human participants were meticulously designed to comply with ethical standards. The entire research protocol underwent a comprehensive review and received approval from the Research Ethics Committee at the College of Education Science, Hubei Normal University. Consent to participate This study has obtained informed consent to participate from the parents or legal guardians of participants under 16 years of age. Consent for publication Not Applicable Dual publication The results/data/figures in this manuscript have not been published elsewhere, nor are they under consideration by another publisher. Availability of data The data supporting the findings of this study are available from the corresponding authors upon reasonable request. Competing interests I declare that the authors have no competing interests as defined by BMC, or other interests that might be perceived to influence the results and/or discussion reported in this paper. Funding This study was funded by the Henan Provincial Social Science Planning Office, specifically the Project "A study on the behavioral and brain mechanisms of emotion labeling in students with subtypes of alexithymia" (Grant No. 2018BJY025). Authors’ contribution statements All authors contributed to the study conception and design. Material preparation, data collection and analysis were performed by Guiping Dou, Min Zhang and Mengmeng Shi. Pengfei Yue provided project support for this article. All authors commented on previous versions of the manuscript. All authors read and approved the final manuscript. Third Party Material All of the material is owned by the authors and/or no permissions are required. Acknowledgments We express our heartfelt gratitude to the participants who took part in this study, and to the editors and peer reviewers who dedicated their efforts to the publication of this paper. References Taylor G. Recent develops in alexithymia theory and research. 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Julia Ruiz-Fernández,Marie-Laure Paillère MartinotResilience and Adolescent Brain Structure Protective Features: A Confirmation and Machine Learning Study[J].Biological Psychiatry, 2025; 97(9):S267-S268. Zhang CY, Zhang JF, Zhang JQ, et al. A review of researches on cognitive and social mechanism of alexithymia. Adv Psychol Sci. 2011;19:398–409. Owusu SA, .Enhancing Resilience in Adolescents With Chronic Medical Illnesses Through Patient-Centered Care. A Call to Action on Thriving and not Only Surviving[J]. J Adolesc Health. 2025;76(2):337–8. Masten AS. Ordinary magic. resilience processes in development. Am Psychol. 2001;56:227–38. Abate BB, Sendekie AK, Tadesse AW, et al. Resilience after adversity: an umbrella review of adversity protective factors and resilience-promoting interventions[J]. Front Psychiatry. 2024;10(8):139–42. 10.3389/fpsyt.2024.1391312 . Mahapatra A, Sharma P. Association of internet addiction and alexithymia - A scoping review. Addict Behav. 2018;81:175–82. Edwards ER, Wupperman P. Emotion regulation mediates effects of alexithymia and emotion differentiation on impulsive aggressive behavior. Deviant Behav. 2017;38:1160–71. Xu H, Song X, Wang S, et al. Mediating effect of Social Support in the Relationship Between Childhood Abuse and Non-Suicidal Self-Injury Among Chinese Undergraduates: The Role of Only-Child Status. Int J Environ Res Public Health. 2019;16:1–12. Liu S, Zhou N, Dong S, et al. Maternal childhood emotional abuse predicts Chinese infant behavior problems: examining mediating and moderating processes. Child Abuse Negl. 2019;88:307–16. Kahn JH, Hessling RM. Measuring the tendency to conceal versus disclose psychological distress. J Social Clin Psychol. 2001;20:41–65. Wang Z, Tang L, Wu CY. Self-disclosure and its influencing factors in patients with breast cancer during treatment. China Prev Med. 2019;20:1076–80. Shen K, Zeng Y. The association between resilience and survival among chinese elderly. Demographic Res. 2010;23:103–16. Niu GF, Sun XJ, Tian Y, et al. Resilience moderates the relationship between ostracism and depression among Chinese adolescents. Pers Indiv Differ. 2016;99:77–80. Jia L, Zhang Y, Yu S. Relation between interparental conflict and non-suicidal self-injury in adolescents: mediating role of alexithymia and moderating role of resilience. Int J Mental Health Promotion. 2024;26(10):837–46. Pan Z, Zhang D, Bian X, Li H. The relationship between childhood abuse and suicidal ideation among chinese college students: the mediating role of core self-evaluation and negative emotions. Behav Sci. 2024;14(2):10. Sarah KS, Dewayne PW, Julian FTKZ. Differential associations of childhood abuse and neglect with adult autonomic regulation and mood-related pathology. Psychosom Medicine: J Am Psychosom Soc. 2023;85(8):682–90. Young JC, Widom CS. Long-term effects of child abuse and neglect on emotion processing in adulthood. Child Abuse Negl. 2014;38(8):1369–81. Matthew O, Goodyer IM, Paul W et al. 5-HTTLPR and Early Childhood Adversities Moderate Cognitive and Emotional Processing in Adolescence[J].PLoS ONE, 2012; 7(11):e48482. Chen JC, Danish SJ. .Acculturation, distress disclosure, and emotional self-disclosure within Asian populations.[J]. Asian Am J Psychol. 2010;1(3):200–11. Quillman T. Neuroscience and Therapist Self-Disclosure: Deepening Right Brain to Right Brain Communication Between Therapist and Patient[J]. Clin Soc Work J. 2012;40(1):1–9. Dillon J, Johnstone L, Longden E. .Trauma, dissociation, attachment and neuroscience: A new paradigm for understanding severe mental distress[. J] Palgrave Macmillan UK. 2014. 10.1057/9781137304667_14 . Matti J, Luutonen S, Reventlow HV et al. Alexithymia and childhood abuse among patients attending primary and psychiatric care: results of the RADEP Study.[J].Psychosomatics, 2008, 49(4):317–25. 10.1176/appi.psy.49.4.317 Tang Y, Liu T, Wang Y, et al. Child abuse and resilience influence belief in a just world: A moderated mediation model[J]. Social Behav Personality: Int J. 2024;52(5). 10.2224/sbp.13125 . Upenieks L. Resilience in the Aftermath of Childhood Abuse? Changes in Religiosity and Adulthood Psychological Distress[J]. J Relig Health. 2021;610.1007/s10943-020-01155-9. Ogrodniczuk JS, Sochting I, Piper WE. ,et al.A naturalistic study of alexithymia among psychiatric outpatients treated in an integrated group therapy program[J]. Psychol Psychotherapy: Theory Res Pract. 2012. 10.1111/j.2044-8341.2011.02032.x . Salles BM, Souza WMD, Santos VAD, et al. Effects of DBT-based interventions on alexithymia: a systematic review[J]. Cogn Behav Ther. 2023;52(2):110–31. 10.1080/16506073.2022.2117734 . Zotey V, Andhale A, Shegekar T et al. Adaptive Neuroplasticity in Brain Injury Recovery: Strategies and Insights[J].Cureus, 2023. 10.7759/cureus.45873 Rufer M, Hand I, Braatz A. ,et al.A Prospective Study of Alexithymia in Obsessive-Compulsive Patients Treated with Multimodal. Cognitive-Behavioral Therapy[J] Psychother Psychosom. 2004;73(2):101–6. Lee JY, Chi MW. .Relation among Emotional Labors's Job Stress, Role Conflict, Ego-Resilience and Job Turnover[J]. J Korea Contents Association. 2012;12(6). 10.5392/JKCA.2012.12.06.191 . Soltanpour B, Pourmovahed Z, Alavi M. The Effect of Expressive Writing on Post-traumatic Stress Disorder and Hopelessness in Mothers with Premature Neonates Hospitalized in NICU[J]. Iran J Nurs Midwifery Res. 2025;30(2). 10.4103/ijnmr.ijnmr_390_23 . Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6858058","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":485959422,"identity":"860429a2-e41d-4a0a-a15d-6bd758cfd907","order_by":0,"name":"Min Zhang","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA3ElEQVRIiWNgGAWjYHACZoYEAwk7fhDzAQODAXFaHlRYJEs2MDA2JBCrhfHBmQrGDQeI1SI/7YyxQWKbBLPx8R7zBwkVNsYM7IePbsCnhXF2jnECUAuf2Zkzhg0JZ9LMGHjS0m7gdZV0jvEBkC1mN3IMGxLbDtswSPCY4dXCBtXCuHkGsVp4gFoSEs5IMG6QgGgxI6hFQjqt2CChQiJZ4syxwhlAvxizEfKL/OzkzZI/DOrs+NubN3z4UGFj2M9++BheLQwMHGgxwYZfOQiwPyCsZhSMglEwCkY2AABfcEhTAC+j2AAAAABJRU5ErkJggg==","orcid":"","institution":"Zhoukou Normal University","correspondingAuthor":true,"prefix":"","firstName":"Min","middleName":"","lastName":"Zhang","suffix":""},{"id":485959423,"identity":"ca961ecd-5dd2-4633-bbe3-4fdd27e738bd","order_by":1,"name":"Guiping Dou","email":"","orcid":"","institution":"Zhoukou Normal University","correspondingAuthor":false,"prefix":"","firstName":"Guiping","middleName":"","lastName":"Dou","suffix":""},{"id":485959424,"identity":"8b0eb742-17c0-4d30-9f89-7a043b0a9bcd","order_by":2,"name":"Mengmeng Shi","email":"","orcid":"","institution":"Henan Normal University","correspondingAuthor":false,"prefix":"","firstName":"Mengmeng","middleName":"","lastName":"Shi","suffix":""},{"id":485959425,"identity":"37859ec5-548b-4d01-82c7-226e7a5ac7a1","order_by":3,"name":"Pengfei Yue","email":"","orcid":"","institution":"Hubei Normal University","correspondingAuthor":false,"prefix":"","firstName":"Pengfei","middleName":"","lastName":"Yue","suffix":""}],"badges":[],"createdAt":"2025-06-10 01:53:21","currentVersionCode":1,"declarations":{"humanSubjects":false,"vertebrateSubjects":false,"conflictsOfInterestStatement":false,"humanSubjectEthicalGuidelines":false,"humanSubjectConsent":false,"humanSubjectClinicalTrial":false,"humanSubjectCaseReport":false,"vertebrateSubjectEthicalGuidelines":false},"doi":"10.21203/rs.3.rs-6858058/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6858058/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":86970271,"identity":"5039bbd5-fc40-4fb5-a5ac-9b001dc0e866","added_by":"auto","created_at":"2025-07-17 18:45:57","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":15511,"visible":true,"origin":"","legend":"\u003cp\u003eThe moderating effect of resilience on the association between child abuse and distress disclosure.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eNote\u003c/em\u003e. L(H)R=low(high)resilience. L(H) CA=low(high)child abuse.\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-6858058/v1/211ed5e8204f4735a8b38119.png"},{"id":88609520,"identity":"6924b845-4924-4c92-8d6a-18ab18a74a43","added_by":"auto","created_at":"2025-08-08 09:24:29","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":671221,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6858058/v1/2651d420-9d4d-4ebc-9dd5-221d2b15c7b4.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Childhood abuse, distress disclosure, resilience, and alexithymia: testing a moderated mediation model","fulltext":[{"header":"‌Introduction","content":"\u003cp\u003eAlexithymia, characterized by difficulties in identifying and describing emotions, alongside an externally oriented thinking style (excessive focus on mundane details rather than internal emotional states)[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e], affects approximately 13\u0026ndash;19% of the general population and 30\u0026ndash;50% of clinical samples, with higher prevalence observed in males[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Notably, alexithymia is not classified as a psychiatric disorder in the Diagnostic and Statistical Manual of Mental Disorders (DSM). It is conceptualized as a dimensional construct following a normal distribution and categorized into two subtypes: primary alexithymia (a stable personality trait) and secondary alexithymia (triggered by traumatic events or chronic psychological stressors such as childhood abuse or persistent pain) [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Originally identified in psychosomatic disorders (e.g., somatic conditions linked to psychological distress), alexithymia has since been implicated as a transdiagnostic risk factor. It is strongly associated with externalizing problem behaviors (e.g., internet addiction, alcohol dependence, aggression, self-harm, and suicidal ideation) [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e] and psychiatric disorders, including depression, anxiety, eating disorders, personality disorders, and substance use disorders [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Emerging evidence highlights its sociocultural underpinnings,suggesting that alexithymia arises from interactions between sociocultural environmental factors and individual psychological protective mechanisms[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Cultural norms play a pivotal role in shaping emotional experience and expression. Societies that discourage the cultivation of emotional awareness and communication skills may predispose individuals to alexithymic traits. Cross-cultural studies reveal that East Asian cultures, which often prioritize emotional restraint, exhibit higher alexithymia levels compared to Western cultures. For instance, Chinese Canadians demonstrate elevated alexithymia scores relative to their European Canadian counterparts[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. These findings underscore the critical need to investigate the interplay between sociocultural contexts and psychological protective mechanisms in shaping alexithymia within Chinese populations, where cultural norms of emotional expression diverge markedly from Western paradigms.\u003c/p\u003e\n\u003ch3\u003eChildhood Maltreatment and Alexithymia‌\u003c/h3\u003e\n\u003cp\u003eEmerging evidence highlights childhood maltreatment as a key socioenvironmental factor associated with alexithymia\u0026zwnj;[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e], though its role within Chinese cultural contexts remains underexplored. Cultural variations in emotional socialization practices may limit the generalizability of Western findings, necessitating rigorous investigation of culturally-specific mechanisms linking childhood maltreatment to alexithymia in Chinese populations. Childhood maltreatment encompasses physical abuse, emotional abuse, sexual abuse, physical neglect, and emotional neglect\u0026zwnj;[1\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e], all recognized as transdiagnostic risk factors for psychopathology across the lifespan.\u003c/p\u003e\u003cp\u003eThe \u0026zwnj;Family Risk Model\u0026zwnj; posits that dysfunctional family systems\u0026mdash;characterized by cumulative stressors or maladaptive interactions\u0026mdash;heighten vulnerability to psychological disorders and socioemotional deficits through disrupted emotional development[12]. Empirical evidence suggests that neglectful, conflictual, or hostile family environments impair emotion recognition and regulation capacities\u0026zwnj;10. Notably, Sabine Aust and colleagues demonstrated that subclinical emotional neglect\u0026mdash;insufficient to meet diagnostic thresholds for mental disorders yet pervasive enough to disrupt emotional processing\u0026mdash;may precipitate alexithymic traits by constraining emotional expression and interpersonal attunement[13]. Emotional neglect, the most prevalent form of childhood maltreatment, undermines emotion socialization by depriving individuals of familial emotional reciprocity, empathy, and affective communication. This deprivation fosters enduring deficits in emotional awareness and regulation, core features of alexithymia. Similarly, exposure to chronic familial stressors (e.g., physical/emotional abuse, domestic violence) may induce dysregulated cortisol responses[14], while coercive contingencies (e.g., punishment for emotional displays) reinforce emotional suppression as a maladaptive coping strategy. The concept of \u0026zwnj;learned helplessness[15], later validated in human studies[16], offers a mechanistic lens for understanding alexithymia development. Children subjected to recurrent failures in emotion regulation (e.g., inability to alleviate parental distress or escape abusive situations) may internalize helplessness, disengaging from emotional experiences altogether. This process manifests as hyperrational interpersonal strategies\u0026mdash;weighing relational costs/benefits while avoiding emotional investment\u0026mdash;and diminished expectations of mutual emotional fulfillment.\u003c/p\u003e\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eThe Mediating Role of Distress disclosuredistress disclosure\u003c/h2\u003e\u003cp\u003eDistress disclosure, defined as the willingness to express distressing emotions to others, serves as an adaptive mechanism to alleviate psychological distress and mitigate risks of severe physiological or mental health deterioration[\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. According to the \u0026zwnj;Dynamic Interaction Theory\u0026zwnj;, parent-child interaction patterns\u0026mdash;and children\u0026rsquo;s expectations of parental responses\u0026mdash;are shaped by cumulative relational experiences[18]. Childhood maltreatment may foster insecure attachment patterns (e.g., fear of intimacy, dependency anxiety, or rejection sensitivity), which reinforce maladaptive internal working models that suppress distress disclosure to avoid anticipated relational disappointment[19]. For instance, maltreated individuals often adopt emotional avoidance strategies in turbulent family contexts, inhibiting emotional expression as a self-protective mechanism. Longitudinal studies indicate that punitive parental responses to children\u0026rsquo;s emotions (e.g., criticism or dismissal) progressively reduce distress disclosure over time[20]. Conversely, adolescents who perceive parental acceptance and warmth demonstrate enhanced emotional openness, facilitating substantive parent-child communication and immediate emotional expression[21]. Empirical evidence highlights a bidirectional relationship between distress disclosure and parent-child relationship quality. Higher levels of adolescent distress disclosure correlate strongly with improved relational trust and warmth[2\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e], while hostile or dismissive parental communication (e.g., derogatory language) exacerbates distrust and disclosure inhibition. Critically, dysfunctional emotion regulation\u0026mdash;marked by impaired working memory control over negative content\u0026mdash;predisposes individuals to rumination, chronic worry, and affective disorders[23]. Alexithymia, as a deficit in emotional cognition and processing, amplifies vulnerability to substance abuse, panic disorders, somatic symptom disorders, and post-traumatic stress pathology while diminishing treatment responsiveness[24]. The \u0026zwnj;Distress Disclosure Inhibition Model\u0026zwnj; posits that suppressing traumatic experiences perpetuates psychological suffering. Avoidant coping strategies deprive individuals of corrective interpersonal feedback, stunting emotional awareness development and reinforcing maladaptive cycles, thereby exacerbating alexithymic[22]. These findings underscore the need to address relational and emotional processing deficits in interventions targeting trauma-related alexithymia[23].\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eThe Moderating Role of Resilience\u003c/h3\u003e\n\u003cp\u003eAdolescents exposed to childhood maltreatment are not a homogeneous group; significant variability exists in their mental health outcomes, behavioral adaptations, and emotional functioning. For instance, while some children exhibit developmental delays or psychosocial issues under adverse conditions (e.g., parental separation), others demonstrate normative or even enhanced growth trajectories, highlighting the role of \u0026zwnj;resilience\u0026zwnj; in buffering risk[25]. Rooted in positive psychology, resilience emphasizes the internal strengths and adaptive capacities that enable individuals to thrive despite adversity.The \u0026zwnj;Protective Model\u0026zwnj; elucidates how resilience interacts dynamically with environmental risks through two primary mechanisms: \u0026zwnj;Risk Buffering\u0026zwnj;: Protective factors mitigate the activation or impact of risk factors[26] .For example, childhood maltreatment exerts weaker inhibitory effects on distress disclosure among individuals with high resilience. Cognitive flexibility (e.g., dialectical thinking) enables reframing adversities (e.g., workplace stress) to reduce depressive symptoms by altering problem appraisals[27]. \u0026zwnj;Risk Amplification\u0026zwnj;: Synergistic interactions between protective traits and contextual resources may paradoxically heighten distress[26]. Highly resilient individuals may experience intensified psychological conflict when maltreatment experiences clash with self-concept (e.g., perceiving abuse as incongruent with their identity), thereby amplifying emotional pain.\u003c/p\u003e\u003cp\u003eWhile limited evidence exists on these dual pathways, this study posits that resilience moderates the \u0026zwnj;childhood maltreatment\u0026ndash;distress disclosure link\u0026zwnj;, with exploratory analyses to clarify its buffering vs. amplifying effects.\u003c/p\u003e\n\u003ch3\u003eCurrent study\u003c/h3\u003e\n\u003cp\u003eRecent studies indicate that the prevalence of alexithymia among adolescents ranges from 10\u0026ndash;15%, serving both as a precursor to maladaptive behaviors and a comorbid factor for psychiatric disorders[\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. Investigating correlates of adolescent alexithymia is therefore of significant practical importance. Existing literature suggests that childhood maltreatment may contribute to alexithymia; however, not all maltreated adolescents develop this condition, implying potential modulation by multiple factors. The mechanisms underlying how childhood maltreatment influences alexithymia through pathways such as distress disclosure and resilience remain unclear, necessitating an analytical framework integrating risk-protective factor interactions. This study aims to explore the relationship between childhood maltreatment and alexithymia, while examining the mediating role of distress disclosure and the moderating role of resilience. Such research holds theoretical value for elucidating the mechanisms of alexithymia and practical implications for prevention strategies.\u0026zwnj;\u003c/p\u003e\u003cp\u003eThis cross-sectional study investigates direct and indirect associations between variables but is limited in establishing causal relationships due to the non-temporal nature of the data. As an exploratory investigation, its contributions include: (a) uncovering developmental pathways of alexithymia among Chinese adolescents within cultural contexts, and (b) proposing a moderated mediation model to guide future research.\u003c/p\u003e\u003cp\u003eThe study constructs a theoretical model with childhood maltreatment as the predictor, distress disclosure as the mediator, resilience as the moderator, and alexithymia as the outcome. Three hypotheses are proposed:\u003c/p\u003e\u003cp\u003e\u0026zwnj;Hypothesis 1\u0026zwnj;: Childhood maltreatment is positively associated with alexithymia.\u003c/p\u003e\u003cp\u003e\u0026zwnj;Hypothesis 2\u0026zwnj;: The association between childhood maltreatment and alexithymia is mediated by distress disclosure.\u003c/p\u003e\u003cp\u003e\u0026zwnj;Hypothesis 3\u0026zwnj;: resilience moderates the mediating pathway from childhood maltreatment to distress disclosure.\u003c/p\u003e"},{"header":"‌Methods‌","content":"\u003cp\u003e\u003cb\u003e\u0026zwnj;Participants and Procedure\u003c/b\u003e\u0026zwnj;\u003c/p\u003e\u003cp\u003e The study protocol was approved by the Research Ethics Committee of Hubei Normal University. A cross-sectional survey was conducted in October 2020 across three public middle schools in Henan Province, China. Using convenience sampling, 970 students meeting inclusion and exclusion criteria were recruited. Inclusion criteria required written informed consent from both participants and their parents. Exclusion criteria encompassed severe physical conditions (self-reported), visual/hearing impairments, neurological disorders, or incomplete questionnaires. Prior to data collection, participants received a detailed explanation of the study\u0026rsquo;s objectives and ethical considerations. Written informed consent was obtained in classroom settings, after which participants completed the Childhood Trauma Questionnaire-Short Form (CTQ-SF), Distress Disclosure Index (DDI), Connor-Davidson Resilience Scale (CD-RISC), and the 20-item Toronto Alexithymia Scale (TAS-20). Of the initial 970 questionnaires, 71 incomplete responses were excluded, yielding a final analytic sample of 899 participants. The sample comprised 433 males (48.16%) and 466 females (51.84%), aged 12\u0026ndash;16 years (M\u0026thinsp;=\u0026thinsp;13.95, SD\u0026thinsp;=\u0026thinsp;1.10), distributed across Grade 7 (43.49%), Grade 8 (24.69%), and Grade 9 (31.81%). Participants\u0026rsquo; residential backgrounds included rural (27.36%), township (34.15%), and urban (38.49%) areas, ensuring broad demographic representativeness. For structural equation modeling (SEM), a minimum of 20 participants per latent variable factor was required. This study exceeded this threshold, with 240 participants as the lower bound. A post-hoc power analysis using G*Power (version 3.1) was performed, with parameters set to f\u0026sup2; = 0.24, α\u0026thinsp;=\u0026thinsp;0.05, total sample size N\u0026thinsp;=\u0026thinsp;899, and three predictors. The analysis yielded a power of 1 (100%), substantially exceeding the conventional threshold of 0.80, confirming sufficient statistical power and robustness of the findings.\u003c/p\u003e\u003cp\u003e\u003cb\u003e\u0026zwnj;Measures\u003c/b\u003e\u0026zwnj;\u003c/p\u003e\u003cp\u003e\u0026zwnj;Childhood Trauma Questionnaire-Short Form (CTQ-SF)\u0026zwnj;\u003c/p\u003e\u003cp\u003eThe Childhood Trauma Questionnaire-Short Form (CTQ-SF) consists of 28 items assessing five dimensions: emotional abuse, emotional neglect, physical abuse, physical neglect, and sexual abuse [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. Participants rated items on a 5-point Likert scale ranging from 1 (never) to 5 (always). The total score for each dimension was calculated by summing the corresponding item scores, and the overall questionnaire score was the sum of all dimension scores. Higher scores indicate more severe childhood maltreatment. The scale demonstrated a Cronbach\u0026rsquo;s α coefficient of 0.79, indicating good internal consistency and validity.\u003c/p\u003e\u003cp\u003e\u0026zwnj;Distress Disclosure Index (DDI)\u0026zwnj;\u003c/p\u003e\u003cp\u003eThe Distress Disclosure Index (DDI) measures individuals\u0026rsquo; tendency to disclose distress, comprising 12 items [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. Participants responded on a 5-point Likert scale from 1 (strongly disagree) to 5 (strongly agree). Dimension scores were calculated by summing relevant items, and the total score was the sum of all dimension scores. Higher scores reflect greater distress disclosure. The scale showed a Cronbach\u0026rsquo;s α coefficient of 0.79, supporting its reliability and validity.\u003c/p\u003e\u003cp\u003e\u0026zwnj;Connor-Davidson Resilience Scale (CD-RISC)\u0026zwnj;\u003c/p\u003e\u003cp\u003eThe Chinese version of the Connor-Davidson Resilience Scale (CD-RISC), translated and revised by Yu and Zhang (2007) [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e], was used. This 25-item scale includes three dimensions: tenacity, strength, and optimism. Items were rated on a 5-point Likert scale from 0 (never) to 4 (always). Dimension and total scores were derived by summing corresponding items, with higher scores indicating greater psychological resilience. The Chinese version demonstrated excellent internal consistency (Cronbach\u0026rsquo;s α\u0026thinsp;=\u0026thinsp;0.91) and criterion validity. In this study, its Cronbach\u0026rsquo;s α was 0.90.\u003c/p\u003e\u003cp\u003e\u0026zwnj;Toronto Alexithymia Scale (TAS-20)\u0026zwnj;\u003c/p\u003e\u003cp\u003eThe Toronto Alexithymia Scale (TAS-20) contains 20 items assessing three dimensions: difficulty identifying feelings, difficulty describing feelings, and externally oriented thinking [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e]. Participants rated items on a 5-point Likert scale from 1 (strongly disagree) to 5 (strongly agree). Dimension and total scores were calculated by summing relevant items, with higher scores indicating greater alexithymia. The scale exhibited a Cronbach\u0026rsquo;s α coefficient of 0.74, indicating acceptable reliability and validity.\u003c/p\u003e\u003cp\u003e\u003cb\u003e\u0026zwnj;Data Analysis\u003c/b\u003e\u0026zwnj;\u003c/p\u003e\u003cp\u003eData were analyzed using SPSS 21.0. First, descriptive statistics (e.g., means, standard deviations) and bivariate correlations were computed. Second, the PROCESS macro (Model 4) developed by Hayes was employed to test mediation effects, examining whether childhood maltreatment indirectly influenced alexithymia through distress disclosure, while controlling for gender and grade. Bias-corrected bootstrapping (5,000 resamples) was used to estimate the standard error and 95% confidence interval (CI) of the indirect effect. Third, the PROCESS macro (Model 7) was applied to test a moderated mediation model, examining whether resilience moderated the association between childhood maltreatment and distress disclosure, with gender and grade as covariates.\u003c/p\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\u003ch2\u003eDescriptive statistics\u003c/h2\u003e\u003cp\u003eThe mean value, standard deviation and correlation coefficient of each variable were shown in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. As can be seen from Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e, childhood abuse was negatively correlated with distress disclosure and resilience, and positively correlated with alexithymia (r=-0.14, r=-0.15, r\u0026thinsp;=\u0026thinsp;0.25, p\u0026thinsp;\u0026lt;\u0026thinsp;0.01). distress disclosure was positively correlated with resilience and negatively correlated with alexithymia (r\u0026thinsp;=\u0026thinsp;0.20, r=-0.30, p\u0026thinsp;\u0026lt;\u0026thinsp;0.01). Resilience was negatively correlated with alexithymia (r=-0.33, p\u0026thinsp;\u0026lt;\u0026thinsp;0.01).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eMeans, Standard Deviations and Correlations for the Variables (N\u0026thinsp;=\u0026thinsp;899)\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"6\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cem\u003eM\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/em\u003e\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e1childhood abuse\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e\u003cp\u003e47.88\u0026thinsp;\u0026plusmn;\u0026thinsp;9.36\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u0026mdash;\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e2 distress disclosure\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e\u003cp\u003e38.50\u0026thinsp;\u0026plusmn;\u0026thinsp;7.87\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e-0.14\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u0026mdash;\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e3 resilience\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e\u003cp\u003e56.25\u0026thinsp;\u0026plusmn;\u0026thinsp;15.79\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e-0.15\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.20\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u0026mdash;\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e4 alexithymia\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e\u003cp\u003e55.77\u0026thinsp;\u0026plusmn;\u0026thinsp;9.72\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.25\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e-0.30\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e-0.33\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u0026mdash;\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"6\"\u003e\u003cem\u003eNote.\u003c/em\u003e \u003csup\u003e**\u003c/sup\u003e\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.01.\u003csup\u003e***\u003c/sup\u003e\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.001.\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eTesting for mediation effect\u003c/h3\u003e\n\u003cp\u003eThe first step involved testing the simple mediation model (model 4). The results (see Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e ) showed that childhood abuse had a significant predictive effect on alexithymia (b\u0026thinsp;=\u0026thinsp;0.22, SE\u0026thinsp;=\u0026thinsp;0.03, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), and negatively predicted distress disclosure (b=-0.12, SE\u0026thinsp;=\u0026thinsp;0.04, p\u0026thinsp;\u0026lt;\u0026thinsp;0.01), and distress disclosure negatively predicted alexithymia (b=-0.28, SE\u0026thinsp;=\u0026thinsp;0.03, p\u0026thinsp;\u0026lt;\u0026thinsp;0.01). In addition, the upper and lower limits of the Bootstrap 95% confidence interval of the mediating effect of distress disclosure do not contain 0 (b\u0026thinsp;=\u0026thinsp;0.03, SE\u0026thinsp;=\u0026thinsp;0.01, 95% CI=[0.01,0.06]). The mediating effect (0.03) accounted for 12% of the total effect (b\u0026thinsp;=\u0026thinsp;0.25, SE\u0026thinsp;=\u0026thinsp;0.03, 95% CI=[0.19,0.31]).\u003c/p\u003e\n\u003ch3\u003eTesting for moderated mediation effect\u003c/h3\u003e\n\u003cp\u003eModel 7 from SPSS macro was used to test the moderated mediation model under the condition of controlling gender and grade. The results (see Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e) showed that when resilience was added to the model, childhood abuse (β =-0.11, SE\u0026thinsp;=\u0026thinsp;0.03, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) and resilience (β\u0026thinsp;=\u0026thinsp;0.23, SE\u0026thinsp;=\u0026thinsp;0.04, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) had a significant predictive effect on distress disclosure, resilience had a significant moderating effect on the relationship between childhood abuse and distress disclosure (β =-0.06, SE\u0026thinsp;=\u0026thinsp;0.03, p\u0026thinsp;\u0026lt;\u0026thinsp;0.05). Further simple slope analysis showed that (see Fig.\u0026nbsp;2), for subjects with high resilience ( b simple =-0.17, t=-3.68, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), childhood abuse had a significant negative predictive effect on distress disclosure. For subjects with low levels of resilience ( b simple =-0.04, t=-1.01, p\u0026thinsp;\u0026gt;\u0026thinsp;0 0.05), the predictive effect of childhood abuse on distress disclosure was not significant.\u003c/p\u003e\u003cp\u003eTo sum up, distress disclosure played a mediating role between childhood abuse and alexithymia, and resilience had a significant moderating effect on the relationship between childhood abuse and distress disclosure. Specifically, in comparison with low resilience, childhood abuse can significantly negatively predict alexithymia through distress disclosure in high resilience.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eTesting the moderated mediation effect of childhood abuse on alexithymia\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"5\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003epredictors\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003eAlexithymia\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u003cp\u003edistress disclosure\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cem\u003eB\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cem\u003et\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cem\u003eB\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u003cem\u003et\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003egender\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.08\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2.48\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.12\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e3.67\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003esenior\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u0026minus;0.08\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u0026minus;2.48\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.06\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1.79\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003echildhood abuse\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.22\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e6.88\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u0026minus;0.11\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u0026minus;3.31\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003edistress disclosure\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u0026minus;0.27\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u0026minus;8.34\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eresilience\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.23\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e6.50\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003echildhood abuse\u0026times;resilience\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u0026minus;0.07\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u0026minus;2.13\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003eNote. **p\u0026thinsp;\u0026lt;\u0026thinsp;.01. ***p\u0026thinsp;\u0026lt;\u0026thinsp;.001.\u003c/em\u003e\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e"},{"header":"‌‌Discussion","content":"\u003cp\u003eAlthough prior research has confirmed childhood maltreatment as a significant predictor of alexithymia[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e], the underlying mechanisms remain unclear. This study addresses this gap by constructing a moderated mediation model, revealing for the first time that distress disclosure mediates this relationship, while psychological resilience moderates the pathway between childhood maltreatment and distress disclosure. Specifically, psychological resilience buffers the negative impact of childhood maltreatment on distress disclosure among adolescents. These findings offer actionable insights for interventions targeting alexithymia and individuals with childhood maltreatment histories, potentially alleviating emotion-processing deficits linked to internalizing (e.g., depression) and externalizing (e.g., aggression) psychopathological problems.\u003c/p\u003e\u003cp\u003eThis study demonstrates that childhood maltreatment significantly and positively influences alexithymia, supporting the first hypothesis. By validating the association between childhood maltreatment and alexithymia within a Chinese cultural context, it extends previous evidence and strengthens the universality of this relationship. Substantial research has established that childhood maltreatment, particularly psychological abuse such as emotional neglect, exerts profound and lasting effects on an individual's emotional-cognitive processing[\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e, \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e]. Young and Widom(2014) indicates childhood maltreatment increases susceptibility to developing maladaptive emotion regulation strategies and suppressive coping styles, ultimately leading to deficits in emotional processing[\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e]. From a neurobiological perspective, traumatic childhood experiences result in aberrant activation patterns within brain regions critical for emotional processing (e.g., amygdala, prefrontal cortex). Abnormal functional connectivity between the amygdala and prefrontal cortex may impair emotion recognition, causing individuals to struggle in differentiating emotional states such as anxiety and anger, and frequently misattribute emotional experiences as somatic discomfort[\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e]. Concurrently, concerning cognitive schema formation, individuals subjected to prolonged childhood maltreatment tend to develop negative self-cognitive models, predisposing them to interpret external information as hostile or rejecting, thereby intensifying withdrawal tendencies in emotional expression[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. The research by Aust, Sabine et al. (2013) demonstrates that environments demanding premature independence during critical developmental periods (e.g., assuming excessive life responsibilities in preschool years), especially when coupled with a lack of emotional interaction, hinder the normative development of emotion identification abilities, gradually diminishing the individual's capacity for awareness of internal feelings[\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Crucially, these cognitive-emotional processing deficits exhibit cross-situational stability and may perpetuate a \"cycle of maltreatment\" through intergenerational transmission.\u003c/p\u003e\u003cp\u003eResearch indicates that childhood maltreatment can directly influence alexithymia and may also affect it through the mediating effect of distress disclosure. Childhood maltreatment impacts individuals' distress disclosure primarily through the automatization of expressive suppression. Culturally, individuals raised in Chinese contexts are socialized from an early age with notions such as \"family disgrace should not be made public,\" \"strict corporal discipline fosters filial piety,\" and \"parental authority is indisputable,\" leading them to habitually suppress discussion of personal suffering[\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e]. Typically, children rely on family members as confidants for distress disclosure. However, those chronically subjected to harsh discipline or maltreatment instinctively internalize self-blame\u0026mdash;interpreting parental punishment as justified retribution for their own wrongdoing. Simultaneously, they adopt the belief that disclosing such experiences would bring shame upon their family and invite social contempt. Consequently, individuals enduring prolonged physical or emotional neglect/abuse develop an adaptive defense mechanism characterized by hypervigilance toward negative information[\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. This fosters a maladaptive belief system where \"disclosure equals danger,\" causing overestimation of potential adverse outcomes from expressing distress. Through chronic overreliance on cognitive dissociation strategies, they sever connections between emotional experience and verbal expression. These expressive suppression tactics gradually solidify into automatized response patterns, with neural pathways inhibiting distress disclosure undergoing repeated reinforcement. Ultimately, this results in persistent difficulty voluntarily expressing vulnerability\u0026mdash;even in objectively safe environments\u0026mdash;during adulthood[\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe mediating pathway in this study indicates that distress disclosure influences alexithymia. Quillman's research demonstrates that chronic suppression of distress disclosure strengthens excessive prefrontal cortical inhibition over the limbic system, leading to functional dissociation in the neural pathways between emotion recognition and verbal expression [\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e]. When individuals repeatedly suppress crying behaviors, activation of the insula (responsible for emotional experience) progressively diminishes, while activity in the dorsolateral prefrontal cortex (responsible for cognitive control) intensifies, ultimately forming a \"emotional experience-verbal expression\" conduction block [\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e]. Such neuroadaptive changes render individuals with alexithymia unable to translate perceived distress into describable vocabulary, even when consciously aware of their suffering. Individuals exposed to childhood maltreatment automatically tend to inhibit emotional expression, causing them to convey distress signals more readily through somatic symptoms (e.g., headaches) than verbal communication. Furthermore, suppressing distress disclosure reduces emotion differentiation and recognition capacities. Individuals who chronically use vague terms like \"feeling unwell\" to describe diverse painful experiences exhibit significantly weaker anterior cingulate cortex responses to emotional stimuli compared to healthy controls. This further exacerbates the \"affective aphasia\" characteristic in those with alexithymia [\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eAs mentioned in the introduction, few studies have explored the moderating mechanisms in the relationship between childhood maltreatment and alexithymia. Guided by the \u0026zwnj;person-environment interaction model\u0026zwnj;, this study reveals that psychological resilience significantly moderates the association between childhood maltreatment and distress disclosure. Specifically, the negative predictive effect of childhood maltreatment on distress disclosure (and consequently on alexithymia) is stronger among adolescents with low psychological resilience compared to those with high resilience. This aligns with the \u0026zwnj;risk enhancement model\u0026zwnj;\u0026mdash;diminished protective effects in low-resilience individuals amplify the negative impact of childhood maltreatment. Conversely, among individuals with higher psychological resilience, distress disclosure levels remain stable even as childhood maltreatment severity increases, consistent with the \u0026zwnj;protection model\u0026zwnj;.\u003c/p\u003e\u003cp\u003eFurthermore, psychological resilience mobilizes adaptive psychological resources (e.g., self-esteem, self-control, mindfulness) to foster positive adaptation to adversity, thereby amplifying the protective effects of supportive relationships [\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e]. On one hand, highly resilient individuals overcome \u0026zwnj;defensive detachment\u0026zwnj; stemming from childhood maltreatment and proactively seek secure attachment figures (e.g., counselors or trusted friends) as \"external regulators\". Receiving empathic responses to distress disclosure significantly reduces alexithymia-related somatic symptoms. On the other hand, maltreated individuals with high resilience activate extensive positive resources for self-help. By observing effective demonstrations of distress expression (e.g., role-playing in group therapy), they reshape the connection between linguistic emotional expression and positive reinforcement, thereby reversing the automatization of expressive suppression strategies in cognitive schemas[46].\u003c/p\u003e\u003cp\u003e\u003cb\u003eClinical Implications\u003c/b\u003e\u0026zwnj;\u003c/p\u003e\u003cp\u003eOur findings hold significant clinical implications for practitioners working with individuals affected by alexithymia. The results demonstrate that childhood maltreatment influences alexithymia through the mediating role of distress disclosure, with psychological resilience serving as a moderating factor. Alexithymia represents an impairment in emotional cognition, processing, and regulation[\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. Consequently, clinical interventions should not only focus on enhancing distress disclosure but also leverage positive psychological traits (e.g., resilience) while mitigating risk factors such as childhood maltreatment. Clinicians may employ cognitive reappraisal, expressive writing, emotion labeling training, and emotion recognition training to cultivate emotional cognition, processing, or regulation in affected individuals[\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e, \u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e].Neuroplasticity research supports interventions targeting distress disclosure, which can effectively disrupt the pathological cycle of alexithymia[\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e]. Cognitive behavioral therapy (CBT) combined with emotion recognition training restores prefrontal cortex regulation of the amygdala; integrating reward-sensitivity enhancement modules (e.g., positive perception training) into CBT reshapes neural responses to positive stimuli, aligning with left mesotemporal spontaneous activity predictive of emotional processing[\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e]. Emotion labeling training (e.g., replacing \"uncomfortable\" with \"sting of rejection\") strengthens functional connectivity between the anterior insula and language centers[\u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e]; expressive writing interventions reduce amygdala hyperreactivity to distress cues[\u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e]. These findings advocate for multidimensional intervention models integrating individual psychological factors and socio-environmental variables. Sustained therapeutic effects emerge from synergistic neuroplasticity modulation and reconstruction of social connections.\u003c/p\u003e\u003cp\u003e\u003cb\u003eLimitations and Future Directions\u003c/b\u003e\u0026zwnj;\u003c/p\u003e\u003cp\u003eThis study has several limitations. The temporal ambiguity of cross-sectional data impedes establishing causal relationships, urgently warranting longitudinal tracking designs to parse the developmental trajectories of maltreatment experiences and the dynamic interplay of psychological resilience across growth stages. Regarding measurement validity, self-reporting may systematically underestimate the true incidence of stigmatized experiences (e.g., sexual abuse); subsequent research should integrate multi-source data (e.g., parent/teacher behavioral reports combined with stress biomarkers like salivary cortisol concentrations) to enhance ecological validity. Culturally, while the study reveals unique mechanisms of family intergenerational interactions in Confucian contexts, significant urban-rural disparities in parenting styles and psychological adaptation indicators highlight the need to investigate divergent subcultural adaptation patterns arising from the deconstruction and reconstruction of traditional ethical values amid rapid urbanization.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEthics approval\u003c/p\u003e\n\u003cp\u003eThis study\u0026rsquo;s methodologies and procedures involving human participants were meticulously designed to comply with ethical standards. The entire research protocol underwent a comprehensive review and received approval from the Research Ethics Committee at the College of Education Science, Hubei Normal University.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eConsent to participate\u003c/p\u003e\n\u003cp\u003eThis study has obtained informed consent to participate from the parents or legal guardians of participants under 16 years of age.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot Applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDual publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe results/data/figures in this manuscript have not been published elsewhere, nor are they under consideration by another publisher.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe data supporting the findings of this study are available from the corresponding authors upon reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eI declare that the authors have no competing interests as defined by BMC, or other interests that might be perceived to influence the results and/or discussion reported in this paper.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was funded by the Henan Provincial Social Science Planning Office, specifically the Project \u0026quot;A study on the behavioral and brain mechanisms of emotion labeling in students with subtypes of alexithymia\u0026quot; (Grant No. 2018BJY025).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contribution statements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll authors contributed to the study conception and design. Material preparation, data collection and analysis were performed by Guiping Dou, Min Zhang and Mengmeng Shi. Pengfei Yue provided project support for this article. All authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eThird Party Material\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll of the material is owned by the authors and/or no permissions are required.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgments\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe express our heartfelt gratitude to the participants who took part in this study, and to the editors and peer reviewers who dedicated their efforts to the publication of this paper.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eTaylor G. Recent develops in alexithymia theory and research. Canadian journal of psychiatry. 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Iran J Nurs Midwifery Res. 2025;30(2). \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.4103/ijnmr.ijnmr_390_23\u003c/span\u003e\u003cspan address=\"10.4103/ijnmr.ijnmr_390_23\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":true,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Childhood abuse, Distress disclosure, Resilience, Alexithymia, Middle school students","lastPublishedDoi":"10.21203/rs.3.rs-6858058/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6858058/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"Previous studies have suggested that childhood abuse plays a significant role in the occurrence of alexithymia. However, the mediating mechanisms underlying the relationship between childhood abuse and alexithymia (particularly in non-Western cultural contexts) remain unclear. This study aimed to investigate whether distress disclosure mediates the relationship between childhood abuse and alexithymia, as well as the moderating role of resilience. A cross-sectional survey was conducted among 899 middle school students using the Childhood Trauma Questionnaire-Short Form (CTQ-SF), Distress Disclosure Index (DDI), Connor-Davidson Resilience Scale (CD-RISC), and Toronto Alexithymia Scale (TAS-20). The results showed that: Childhood abuse directly and positively predicted alexithymia; distress disclosure significantly mediated the relationship between childhood abuse and alexithymia; Resilience positively moderated the association between childhood abuse and distress disclosure, with highly resilient individuals exhibiting greater capacity to mitigate the negative impact of childhood abuse on distress disclosure. The findings emphasize the need to jointly examine the mechanisms of risk factors and protective factors in abused individuals with comorbid alexithymia.","manuscriptTitle":"Childhood abuse, distress disclosure, resilience, and alexithymia: testing a moderated mediation model","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-07-17 18:45:52","doi":"10.21203/rs.3.rs-6858058/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"b02c1cce-7ab8-4b97-a3c1-70c7b0809179","owner":[],"postedDate":"July 17th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-08-08T09:24:17+00:00","versionOfRecord":[],"versionCreatedAt":"2025-07-17 18:45:52","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6858058","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6858058","identity":"rs-6858058","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}