Alexithymia refers to a condition where individuals are unable to recognize, explicitly define, and articulate their own emotions (Nemiah, 1977; Hogeveen and Grafman, 2021), although, at an implicit psychophysiological level, variations can be observed (Panayiotou et al., 2018).

Self-reporting is a commonly used method to study alexithymia, providing information about its characteristics and connections to psychological and neurological conditions (Luminet et al., 2018). However, there are concerns that self-report assessments may not accurately capture contextualized behavioral tendencies (Buchanan, 2016), as they can be influenced by subjects’ self-judgment, self-consciousness, and generalization processes (Wilson and Dunn, 2004; Averbeck, et al., 2013). Relying solely on self-report tools leads to a huge gap in the understanding of the neural and behavioral mechanisms underlying emotional awareness and its breakdown in cases of alexithymia. In addition, self-report questionnaires provide a picture detached from the situational and social level in which alexithymia manifests itself.

In the diagnostic phase it is necessary to have a snapshot, albeit initial, of the individual’s functioning in relation to contextual stimuli; but how can this be observed in the clinical environment? One challenge might be recreating the complex psychological and emotional experiences that individuals encounter in their daily lives in a clinical setting. Technologies like virtual reality (VR) are valuable in recreating specific environments and situations that can evoke emotions and feelings, enabling researchers and clinicians to observe and analyze a subject’s behavior during these conditions (Mancuso et al., 2023). Another crucial point concerns the practicality of a particular instrument in a clinical setting; assessment tools must be quick and simple to administer and correct, while at the same time providing a comprehensive picture about a particular condition.

To address all these needs, this paper proposes the development of an alternative method for assessing alexithymia that exploits 360° video technology. This particular form of technology is specifically designed for immersive viewing through VR headsets or on conventional devices (Borghesi et al., 2022). Despite not being able to directly interact with the narrative, users develop their own sense of the story/situation by selecting where to look, which gives them “agency” over the narrative. These spherical videos provide a chance for individuals to be fully engrossed in genuine natural settings (Borgnis et al., 2021). As compared to VR, 360° videos overcome the costs’ issue, while guaranteeing the presence of ecological environments.

Employing 360° videos as an assessment tool for alexithymia might offer a more direct understanding of an individual’s abilities to recognize and describe his own feelings when faced with emotional scenarios, allowing the clinician to detect specific strengths and weaknesses to guide the subsequent treatment. In the present perspective we will propose a new ecological and practical approach for alexithymia assessment that takes advantage of 360° video technology.

As salient internal states, emotions can promote the subject’s adaptive behavior toward various stimuli (Russell, 2003; Barrett et al., 2007). Emotions aid in responding effectively to the environment, such as evading danger or displaying rivalry, thus allowing individuals to respond flexibly based on their experiences (Damasio, 2004; LeDoux, 2012). The malfunctioning of these mechanisms is the basis of conditions such as autism spectrum disorders and alexithymia (Hogeveen and Grafman, 2021).

The emotional process can be subdivided into implicit valence and arousal signals that are generated primarily via subcortical and autonomic circuits, and a more complex explicit dimension primarily computed via cortical circuits (LeDoux and Pine, 2016). However, the neural circuits necessary for generating emotional awareness remain unclear and there is a lack of consensus on the fundamental question of whether emotional awareness represents an epiphenomenon or a functional dimension that mobilizes adaptive cognitive-behavioral responses to felt emotions (Adolphs et al., 2019).

In the current article, we focus on alexithymia, a condition characterized by an impaired ability to recognize, label, and describe one’s feelings (Nemiah, 1977). Individuals with alexithymia exhibit a dissociation between implicit and explicit emotional responses (Nielson and Meltzer, 2009; Gaigg et al., 2018). Notably, this trait is considered a dimensional attribute with a typical distribution in the general population (Parker et al., 2008). Additionally, studies (Duddu et al., 2003) have substantiated heightened alexithymia levels in psychosomatic patients, identifying it as a transdiagnostic risk factor for various psychopathologies, including depression (Honkalampi et al., 2001), anxiety disorders (Zeitlin and McNally, 1993), personality disorders (Berenbaum, 1996), eating disorders (Taylor et al., 1996), and substance use (Thorberg et al., 2009).

Over the past decade, VR technology has significantly advanced the healthcare sector (Riva, 2005; Freeman et al., 2017; Kyaw et al., 2019; Riva et al., 2020), enhancing user-friendly and visually engaging settings for experimentation, clinical work, assessments, and rehabilitation (Cipresso et al., 2018). Nevertheless, despite its potential, VR also comes with technical and psychometric challenges. Firstly, most VR systems require a computer and external tracking devices, thus limiting the user’s movement and necessitating complex setups. Additionally, developing VR environments is often resource-intensive and costly, as each experiment requires customization (Borghesi et al., 2022). Secondly, there is a lack of literature on the test–retest reliability and usability of VR tools. Limited studies have examined applicability, showing that these instruments are generally usable, intuitive, engaging and safe, but more research is needed (Freeman et al., 2017; Borgnis et al., 2022).

To address some of these challenges, 360° videos have emerged as a potential solution. They consist of a series of images capturing a full 360-degree view, with specific time interval between them (Borghesi et al., 2022). 360° videos are designed to be viewable through VR headsets; however, they can also be enjoyed on flat-screen devices, such as phones or computers, by simply moving the viewpoint with a mouse or a finger. The subject cannot interact directly with the environment but has the possibility to choose where to focus his attention, structuring his personal understanding of the virtual context. The opportunity to create a sense of presence in the user is a feature that distinguishes 360° videos from 2D videos, giving the subject the feeling of being within the virtual environment. Consequently, 360° videos can evoke strong emotional responses, making users feel physically present and even giving them the illusion of interacting and reacting as if they were in the real world (Chirico et al., 2017; Ventura et al., 2019; Borghesi et al., 2022, 2023a).

Within any 360° videos, users have the option to adopt either a first-person or third-person perspective (Borghesi et al., 2022). Some recent studies (Higuera-Trujillo et al., 2017; Chirico and Gaggioli, 2019; Brivio et al., 2021) have shown that 360° videos are able to elicit similar psychological and physiological responses to those produced by the real physical environment. Specifically, it emerged that the virtual and natural environments generated the same emotional responses in terms of valence, although with reduced intensity (Chirico and Gaggioli, 2019).

Through 360° video technology, healthcare professionals can enhance ecological assessments, mitigating biases associated with self-reported measures. Constructing assessment tools with higher ecological validity addresses challenges stemming from subjects’ self-evaluation and self-awareness during examiner interaction (Parsons, 2015). Previous studies have exploited the potential of 360° videos to assess personality and cognitive functioning such as executive functions and memory (Cipresso and Riva, 2016; Realdon et al., 2019; Stramba-Badiale et al., 2020; Borgnis et al., 2021; Della Libera et al., 2023; Bruni et al., 2023a,b).

Cipresso and Riva (2016) introduced a novel approach that utilized immersive scenarios to evaluate personality traits. Realdon et al. (2019) used a 360° version of the Picture Interpretation Test (PIT) to detect executive dysfunction, showing promise in identifying issues in individuals with Multiple Sclerosis and Parkinson’s disease. Moreover, Borgnis et al. (2021) introduced EXIT 360°, an innovative tool designed to assess executive functions (EFs) in an engaging and enjoyable manner. This tool evaluates executive impairments affecting daily life and independence within real-world scenarios, aligning with the need for contextual EF assessments. Lastly, Della Libera et al. (2023) explored the utility of 360° immersive videos in evaluating common psychological symptoms in a naturalistic cafe setting. The study revealed that the immersive experience effectively triggered the emergence of these symptoms, and participants’ predispositions played a role in their experiences.

These contributions highlight that offer healthcare professionals a more ecologically valid assessment environment, enabling the collection of richer and more accurate data on various aspects of psychological and cognitive functioning.

The present perspective aims at proposing and discussing the design, creation and implementation of ALEX-360°, a 360° videos tool for an innovative and ecologically valid assessment of alexithymia.

As noted previously, although self-administered assessment measures attempt to provide a general picture of the person’s current situation, they are decontextualized. They also presuppose that the subject has good abstraction and awareness skills to answer questions as accurately as possible about his moods. However, the person with alexithymia has difficulties precisely in this, that is, in recognizing and describing his feelings. For this reason, the new approach that we intend to propose involves the creation of environmental, social and non-social contexts, in the form of 360° videos, with which the subject can come into contact.

The theoretical assumptions consider the three factors that characterize the construct of alexithymia: DIF, DDF, and EOT. Furthermore, the attention-appraisal model proposed by Preece et al. (2017) and the theory of emotional awareness by Lane and Schwartz (1987) are taken up again.

This perspective endorses the proposal to develop a novel tool, ALEX-360°, designed to assess alexithymia. ALEX-360°, leveraging 360° videos as stimuli, shows promise in elucidating the underlying processes of alexithymia. Specifically, this tool enables the clinician to obtain additional insights into the subject’s functioning by observing behavior in a more ecologically valid context. Furthermore, ALEX-360° facilitates the identification of difficulties and the collection of physiological data, informing future treatment approaches.

Creating 360° videos ad hoc poses technical challenges that need to be addressed from the very beginning. A further potential limitation of this tool is its capacity to encompass and identify all aspects of alexithymia; it is uncertain if milder forms of alexithymia will be detected by the tool. In addition, laboratory experiments with both healthy subjects and individuals with alexithymia are required to confirm the efficiency of ALEX-360°.

A tool as ALEX-360° holds potential in shaping personalized and user-centered medicine. Regarding this guidance on using the tool will be offered to ensure it is user-friendly and clinician-friendly. Indeed, using artificial intelligence algorithms, the detection of alexithymic traits could be automated and personalized: based on a training dataset, the app could integrate automated scoring inherent to the areas most compromised in terms of recognition and emotional expression (Picard, 2003; Cipresso et al., 2021; Borghesi et al., 2023b).

The accessibility and clinical usability of ALEX-360° could redefine the evaluation process for individuals with alexithymia, delineating different severity levels and pinpointing the subjects’ emotional experiences. In other words, what they feel, how they feel. On the other hand, the nature of the test will involve the subject in a more dynamic activity compared to completing a self-report questionnaire, engaging his attention and interest for a relatively limited time, about 15 min. This feature is fundamental in the context of clinical and neuropsychological evaluation characterized by the administration of multiple tests; a long battery of tests can in fact influence not only the individual’s attention but also their motivation and collaboration. ALEX-360°, thanks to its strong engagement and dynamism, would solve this problem, engaging the patient in an almost playful activity.

In conclusion, ALEX-360°, with its capacity to gather informative data, emerges as a noteworthy and innovative aid in the diagnostic process, as well as in formulating treatment and rehabilitation strategies based on the patient’s unique resources.

The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author.

GS: Conceptualization, Methodology, Writing – original draft. FB: Conceptualization, Methodology, Writing – review & editing. VM: Writing – review & editing. EP: Writing – review & editing. PC: Conceptualization, Writing – review & editing.