Depression is characterized by persistent low mood, anhedonia, reduced volition, increased fatigue and slowed cognitive processing. Individuals with severe depression may develop suicidal ideation and even behaviors that severely impact quality of life and daily functioning. Depression is a prevalent mental health condition, affecting over 280 million people worldwide as reported by the World Health Organization. In China, the number of individual with depression exceeds 95 million, surpassing the global average and ranking as the second leading cause of disease burden in the country (World Health Organization, 2022). In recent years, the incidence of depression has shown a trend of younger populations, with a lifetime prevalence of 15–20% among adolescents, making it one of the most burdensome psychiatric disorders (American Psychiatric Association, 2013). Despite the availability of advanced therapeutic technologies for depression, there remains a lack of systematic prevention and intervention strategies for this chronic condition. Therefore, exploring novel preventative interventional approaches for a more systematic management of depression is of crucial importance.

The development of a healthy worldview and robust self-concept in children generally requires comprehensive physical and emotional nurturance, opportunities for play and spontaneous exploration, coupled with a secure environment and age-appropriate boundaries (Young et al., 2003). Based on Bowlby and Ainsworth’s attachment theory, the interaction patterns between early caregivers and children are internalized as internal working models. When caregivers consistently fail to meet the child’s fundamental needs, these maladaptive internal representations may disrupt lifelong emotional regulation, interpersonal functioning, and psychological adaptation (Nivison et al., 2021). Early childhood trauma represents one of the most significant risk factors capable of compromising both physiological and emotional integrity in children, and serves as a fundamental etiological contributor to a spectrum of psychopathological outcomes including depression and anxiety (Kuzminskaite et al., 2022). Childhood trauma is typically categorized into five distinct types: sexual abuse, physical abuse, emotional abuse, emotional neglect, and physical neglect. A recent study reported that 59.6% of male participants and 40.0% of female participants had experienced at least one form of childhood trauma. Among these, physical neglect was the most prevalent (44.7%), followed by emotional abuse (40.3%), physical abuse (31.8%), sexual abuse (30.4%), and emotional neglect (30.0%) (Moustafa et al., 2021). Early childhood trauma exerts both short- and long-term impacts across multiple developmental domains (Kendall-Tackett and Marshall, 1998; Moustafa et al., 2021; Yiğit et al., 2021). This type of trauma particularly disrupts the formation of cognitive schemas regarding the self and others (Boyda et al., 2018; Duru and Balkıs, 2022; Wuth et al., 2022). For instance, individuals with a history of witnessing or experiencing violence often exhibit diminished self-esteem in adulthood and display a persistent lack of trust toward others (Branden, 2001). In interpersonal contexts, they tend to interpret others’ intentions as negative and untrustworthy, frequently experiencing heightened fear of intimacy and a marked tendency to avoid forming deep emotional connections (Drapeau and Perry, 2004). Moreover, especially sexually abused children may start to perceive the whole world as a dangerous place. Therefore, it is crucial to understand its outcomes and how it leads to various intra and interpersonal problems. According to the schema theory,

children develop such mental representations, namely Early Maladaptive Schemas (EMS) to understand and interpret their negative experiences (Young et al., 2003). While EMS enables children to maintain vigilance and avoid potential harm in the face of recurring adverse experiences, the prolonged persistence and over-generalization of such anticipatory patterns may lead to the development of maladaptive coping strategies. Consequently, individuals may exhibit unnecessary interpersonal avoidance or aggressive behaviors (Hayes and Parsonnet, 2016; Mojallal et al., 2015; Van Wijk-Herbrink et al., 2021). Concordantly, children who are exposed to traumatic or adverse events, have been found to be at higher risk of depression (Wang et al., 2021), suicide (De Berardis et al., 2018; Orsolini et al., 2020), anxiety, and dissociative disorders (Wildschut et al., 2019). Recent research further supports these pathways, indicating that early maladaptive schemas play a critical role in linking childhood adversity to various forms of psychopathology in vulnerable child populations (Tsouvelas et al., 2023).

In the schema theory, Young et al. (2003) proposed that children who experience early adversity may develop 18 distinct early maladaptive schemas. These schemas are categorized into five different domains based on five core unmet psychological needs: disconnection and rejection (DR), impaired autonomy and performance (IAP), other-directedness (OD), over-vigilance and inhibition (OVI), and impaired limits (IL). Research indicates that children who experience emotional and physical neglect are particularly prone to developing schemas associated with the disconnection and rejection and impaired autonomy and performance domains (Pilkington et al., 2021). According to schema theory, children who experience prolonged deprivation of consistent care and emotional nurturance, along with sustained neglect, abuse, rejection, and humiliation within unstable family environments, develop profound feelings of need frustration. This may lead to the formation of EMS within the disconnection and rejection domain, accompanied by persistent feelings of insecurity, worthlessness, and social isolation (Young et al., 2003). Despite a strong desire for love and attention from others, they often struggle to express their emotions and needs effectively. According to Young et al. (2003), neglected children whose uniqueness, needs, and emotions are consistently ignored or undermined may develop EMS within the impaired autonomy and performance domain. These children often experience pervasive feelings of incompetence and helplessness, and demonstrate a lack of confidence in their own abilities and emotions when navigating daily tasks and responsibilities. Supporting this theoretical framework, research by Pilkington et al. (2021) found that children who experienced emotional and physical neglect were particularly prone to developing schema domains of disconnection and rejection as well as impaired autonomy and performance.

Alexithymia often described as an inability to express emotions,is characterized by three primary dimensions: difficulty recognizing emotions, difficulty expressing emotions and externally oriented thinking. Alexithymia has been recognized as a significant long-term consequence of childhood maltreatment (Güleç et al., 2013; Taylor, 1984). Early childhood trauma is modeled as a distal antecedent, which indirectly contributes to subsequent alexithymia through the disruption of attachment security and neuropsychological development (Zdankiewicz-Ścigała and Ścigała, 2020). Bermond et al. (2008) showed thatpeople who were sexually abused during their childhood obtained higher scores of alexithymia compared to the control group. Consistent with the findings of Zlotnick et al. (2001), severe emotional neglect and physical neglect were significantly associated with elevated levels of alexithymia, with emotional neglect identified as the strongest predictor of alexithymic traits. Thus, childhood trauma impairs the capacity for emotional development and disrupts both biological and psychological processes underlying affect regulation, which may further contribute to the emergence of alexithymia.

Besides, research demonstrate that early maladaptive schemas predict the alexithymia level of individuals. Studies indicate that not only do scores in the Impaired autonomy and performance and over-vigilance and inhibition domains predict alexithymia, but all schema domains are positively correlated with with the alexithymia levels of individuals (Ameri et al., 2014; Abdolmohammadi et al., 2016; Pinna et al., 2020; Mahta and Saeed, 2022). Among these, Saariaho et al. (2015). demonstrated a significant correlation between individuals’ level of alexithymia and scores in the disconnection and rejection schema domain. Furthermore, other studies have identified the Impaired autonomy and performance schema domain as a key predictor of alexithymia; individuals with such schemas tend to hold maladaptive expectations of themselves and their environment, which adversely affect their perceived ability to function independently (Ekinci and Kandemir, 2015). These findings collectively suggest a link between EMS and alexithymia. In the over-vigilance and inhibition schema domain, schemas such as emotional inhibition and unrelenting Standards lead individuals to actively suppress, ignore, or minimize emotional experiences in order to fulfill their needs for control or perfection (Abdolmohammadi et al., 2016). This directly results in difficulties in identifying and describing emotions. However, some studies have refuted the existence of such a relationship, indicating that individuals with EMS do not necessarily develop alexithymia later in life, suggesting that EMS may not directly lead to the onset of alexithymia (van der Velde et al., 2015). These inconsistent findings underscore the need for further research to clarify the relationship between EMS and alexithymia.

As early maladaptive schemas lead individuals to form maladaptive coping strategies including unhealthy emotional states, behaviors, and attitudes (Young et al., 2003), alexithymia might be understood as one of them, which helps individuals to get alienated from painful emotions related to destructive events and relationships. According to survey results, the prevalence of alexithymia in the general population is approximately 10–13% (Terock et al., 2020). The incidence of alexithymia is even higher in clinical populations. The latest research by Ricciardi et al. (2015) found that the prevalence of alexithymia among individuals with mental disorders ranges from 40 to 60%, with anxiety disorders accounting for 13–58%, depressive disorders for 32–51%, eating disorders for 24–77%, and substance abuse disorders for 30–50%. Extensive research has demonstrated a significant association between childhood trauma and alexithymia in adulthood. Notably, this association is not observed in healthy populations, nor is it confined to a single diagnostic category. Instead, it functions as a transdiagnostic pathway prevalent across multiple psychiatric spectra. Specifically, childhood traumatic experiences have been consistently linked to difficulties in emotional identification, description, and externally oriented thinking—the core features of alexithymia—in adult patients. This holds true across mood disorders (e.g., bipolar disorder), anxiety and stress-related disorders, trauma and personality-related disorders, psychotic disorders, as well as in patient groups primarily presenting with somatic symptoms (Takım et al., 2024a; Takım et al., 2024b). This suggests that the progression from childhood trauma to later impairments in emotional expression and identification may represent a common psychopathological mechanism transcending traditional diagnostic boundaries. Therefore, investigating the pathways through which childhood trauma and early maladaptive schemas contribute to alexithymia holds significant theoretical and clinical importance for understanding transdiagnostic vulnerability factors. Understanding the root causes of diseases can aid in developing more effective prevention and intervention strategies for various mental disorders (De Berardis et al., 2017). In summary, existing research primarily has the following limitations: there are relatively few studies on the relationships between childhood trauma, EMS, and alexithymia. Although the detrimental effects of EMS on alexithymia have been confirmed in healthy populations, the mediating role of EMS has not been tested when clinical factors are taken into account.

Comparing the differences in childhood trauma, EMS, and alexithymia between individuals with depression and healthy groups can help therapists conduct a more comprehensive assessment of patients’ childhood trauma, EMS, and alexithymia during disease intervention. When applying schema therapy, therapists can better understand patients’ childhood experiences and pay attention to the manifestations of specific EMS and alexithymia. Studies have found that patients with depression exhibit significant alexithymia. Investigating the relationship between EMS, childhood trauma, and alexithymia helps to understand how schemas and childhood trauma influence alexithymia in patients with depression. This provides new directions for subsequent psychotherapy and intervention, effectively reducing alexithymia levels and alleviating the severity of the disease.

Building upon schema theory and extant research on trauma related psychopathology, we propose an integrated mechanistic model to explain the differential mediating roles of specific EMS domains and their variation across clinical and non-clinical populations. Childhood trauma is conceptualized as a distal vulnerability factor that disrupts normative affective development through two primary pathways: (1) by compromising attachment security and the formation of internal working models of self and others, and (2) by inducing neurobiological and cognitive alterations that hinder emotional awareness and integration. EMS emerge as enduring cognitive-affective representations of these disruptions, serving as proximal mechanisms that organize subsequent emotional processing and regulation strategies. Recent work reinforces that EMS are pivotal in translating early adverse experiences into lasting emotional processing deficits, including alexithymia (Tsouvelas et al., 2023).

The disconnection and rejection domain comprising schemas such as mistrust/abuse and abandonment—is theoretically rooted in interpersonal trauma (e.g., maltreatment, neglect) and perpetuates profound interpersonal alienation and emotional hyper-vigilance. This dynamic may manifest clinically as alexithymia, mediated through the suppression of emotional expression and impaired ability to recognize emotions in social contexts. The over-vigilance and inhibition domain—which includes schemas such as emotional inhibition, unrelenting standards, and pessimism—is conceptualized as reflecting a coping style characterized by cognitive hyper-vigilance and experiential avoidance, core processes underlying depressive and anxiety disorders. Individuals with over-vigilance and inhibition domain may actively suppress or avoid emotional experience in an effort to maintain control or meet perfectionistic demands, thereby directly exacerbating alexithymic traits such as difficulty identifying and describing feelings. Multi-group analysis enabled us to test whether these mechanistic pathways are amplified in clinical depression. We hypothesized stronger indirect effects through the over-vigilance and inhibition and disconnection and rejection schema domains in the clinical group, attributable to their potentially heightened attachment insecurity, elevated comorbid anxiety, and more entrenched patterns of cognitive avoidance and rumination factors that may exacerbate the association between specific schemas and alexithymia (Cano-Lopez et al., 2022). In contrast, other schema domains may represent more generalized vulnerability factors that operate similarly across populations. This framework not only informs our specific hypotheses but also situates the present study within a broader trans-diagnostic perspective on emotion-processing deficits.

Based on theoretical considerations and prior empirical findings, the following hypotheses are proposed:

Chronic exposure to traumatic environments during childhood can engender profound negative emotions and insecurities, leading individuals to perceive the world as inherently dangerous (Snyder et al., 2024). Persistent physical and emotional neglect, coupled with inconsistent care, can result in unmet emotional needs, fostering the development of the disconnection and rejection, autonomy and incapacity domains of Early Maladaptive Schemas (EMS) (Wang et al., 2023). These schemas precipitate maladaptive coping strategies, whereby individuals become convinced that their core emotional needs cannot be met in relationships, subsequently impairing their ability to express emotions and needs, which contributes to elevated levels of alexithymia (May et al., 2022). The present study found that the disconnection and rejection schema domain significantly mediated the relationship between childhood trauma and alexithymia in the non-clinical sample. Specifically, experiences such as verbal, physical, or emotional abuse may foster schemas such as distrust/abuse and abandonment/instability, which are associated with alexithymia (Lim and Barlas, 2019). Consistent with recent findings, Feyzioğlu et al. (2022) investigated 435 healthy individuals (excluding those diagnosed with psychological disorders or using psychiatric medications) and demonstrated that childhood trauma serves as a predictive factor for alexithymia. When mediating variables were introduced to examine the indirect effects of childhood trauma on alexithymia, all five schema domains were found to significantly mediate this relationship. Specifically, caregiver abuse and neglect were associated with the development of the Disconnection and Rejection schema domain. Within this schema domain, individuals come to believe that their needs for belonging, love, care, safety, and stability cannot be met in any relationship, which predisposes them to higher levels of alexithymia (Bach et al., 2018). This is consistent with recent research emphasizing the role of EMS as a critical mechanism linking early adversity to emotional processing deficits, including alexithymia, across diverse populations (Tsouvelas et al., 2023).

Using multi-group path analysis, this study examined differences in the mediation model between clinical (depressed) and non-clinical (healthy) groups. Results revealed that the disconnection and rejection, impaired autonomy and performance, other-directedness, and impaired limits schema domains significantly mediated the relationship between childhood trauma and alexithymia in both samples. Therefore, regardless of whether an individual is diagnosed with depression, traumatic experiences in childhood may contribute to the formation of maladaptive schemas, thereby leading to the development of alexithymia. These findings are consistent with prior research indicating that alexithymia is not merely a symptom of depression or anxiety but a stable trait that increases vulnerability to psychiatric disorders (Kajanoja et al., 2021). Moreover, they align with longitudinal evidence highlighting the enduring and trans-diagnostic nature of the pathway from childhood trauma to alexithymia and subsequent mental distress (Anagnostopoulou et al., 2024).

These findings suggest that in the clinical sample, childhood trauma exhibits a more potent effect in activating both the disconnection and rejection and over-vigilance and inhibition schema domains. Notably, multi-group analyses highlighted a stronger association between the over-vigilance and inhibition schema domains and alexithymia in the clinical sample compared to the non-clinical sample.

This finding extends beyond mere group mean differences and points to qualitatively distinct psychopathological processes operating in depression. The more pronounced mediating role of the disconnection and rejection schema domain in the clinical group may reflect the interpersonal and attachment related complexities often comorbid with depression. Childhood trauma involving abuse or neglect can shape the disconnection and rejection schema domain, which encompasses an individual’s mistrust of others and anticipation of relational harm. In depression, these schemas may interact with social withdrawal and anhedonia, further undermining the motivation for emotional communication and exacerbating feelings of isolation key contributors to alexithymia. It is plausible that the clinical sample includes a subgroup with more severe relational trauma or underlying personality pathology, for whom the disconnection and rejection pathway is particularly salient. The potentiated role of the over-vigilance and inhibition schema domain aligns with cognitive models of depression that emphasize experiential avoidance and cognitive fusion. Individuals with depression often exhibit heightened sensitivity to negative internal states coupled with a propensity to suppress or ruminate on these experiences—a process directly mirrored in the over-vigilance and inhibition schema domain (Roelofs et al., 2016). Within the clinical context, these schemas may not only represent cognitive content but also active regulatory strategies that perpetuate alexithymia by chronically diverting attention away from emotional experience and toward cognitive control or performance standards. This creates a vicious cycle where emotional suppression is reinforced by schema driven beliefs about the danger or unacceptability of emotional expression. Notably, the lack of significant group differences in pathways through impaired autonomy, other-directedness, and impaired limits suggests these schemas may operate as more generalized trans-diagnostic vulnerability factors. They likely contribute to alexithymia through mechanisms such as low self-efficacy, excessive focus on others’ needs at the expense of self-awareness, or poor impulse and boundary regulation, which may be less specific to the depressive phenotype.

Previous studies have found that individuals in the depression group tend to exhibit relatively higher levels in the over-vigilance and inhibition schema domain, which exerts a persistent impact on the individual (Yarrington et al., 2023). Based on psychopathological research on depression, among individuals with comorbid depression and alexithymia, emotional distress may arise not only from cognitive difficulties in identifying feelings but also from a fear of emotional experiences and active suppression of such experiences, leading to heightened vigilance toward negative life events (Terock et al., 2020). From a psychopathological perspective, this aligns with the models of cognitive rumination and experiential avoidance observed in individuals with depression. Patients may exhibit hypervigilance toward internal emotional signals, perceiving them as threatening and uncontrollable. Consequently, they engage in emotional suppression in an attempt to regulate these experiences. However, such suppression may paradoxically lead to the accumulation of emotional distress, anhedonia, and increased cognitive load, thereby perpetuating a maladaptive cycle (Hessler and Everaert, 2023). Schemas such as negativity/pessimism, emotional inhibition, unrelenting standards, and punitiveness fall within this domain, reflecting a pervasive preoccupation with negative aspects of life (e.g., loss, guilt, betrayal) (Aydin and Kaya, 2024). Individuals with these schemas often prioritize perfectionistic standards over personal well-being, limiting emotional expression and interpersonal interactions, which further exacerbates alexithymia. The childhood environments of such individuals are often repressive, cold, and demanding, fostering hypervigilance toward negative events and negative emotionality, such as pessimism. This, in turn, impairs emotional regulation, paving the way for alexithymia (Mahta and Saeed, 2022; Bishop et al., 2022).

This study underscores the role of EMS as a cognitive vulnerability factor that may elevate the risk of psychiatric disorders, particularly among individuals with a history of childhood trauma. For healthy adults, early intervention targeting the effects of childhood trauma and maladaptive schemas could mitigate the development of alexithymia and associated psychological issues. Clinicians should prioritize assessing and addressing EMS to enhance emotional regulation and reduce vulnerability to affective disorders.

The study provides an etiological model of alexithymia within the framework of schema theory. Based on this model, clinicians treating depression should routinely assess not only standard symptoms but also childhood trauma, global alexithymia, and specific schema domains, with particular attention to the over-vigilance and inhibition and disconnection and rejection domains. The standardized YSQ can provide a detailed profile of cognitive vulnerabilities. When the over-vigilance and inhibition schema domain predominates in an individual, it alerts the clinician to potential issues such as emotional avoidance, perfectionism, and cognitive over-control. This may necessitate the integration of techniques beyond traditional cognitive restructuring, including mindfulness practices, acceptance-based strategies, and targeted emotion exposure exercises. When the over-vigilance and inhibition schema domain predominates in an individual, it alerts the clinician to potential issues such as emotional avoidance, perfectionism, and cognitive over-control. This may necessitate the integration of techniques beyond traditional cognitive restructuring, including mindfulness practices, acceptance and commitment therapy (ACT), and targeted emotion exposure exercises. For patients with a core disconnection and rejection schema, initial therapeutic efforts should be concentrated on establishing safety and trust within the therapeutic relationship. Schema therapy techniques, such as limited reparenting, can assist in addressing the unmet core needs for security and connection. Subsequent treatment can gently encourage appropriate emotional expression within this secure environment by employing Emotion-Focused Therapy (EFT) techniques. The trans-diagnostic role of other schemas suggests that interventions targeting self-efficacy, a healthy sense of self, and balanced attention to one’s own needs offer broad utility in reducing alexithymic traits across diverse clinical presentations.

For starters,the data in this research were primarily collected through subjective retrospective questionnaires, which assessed individuals’ recollections of childhood trauma. Participants may have experienced memory lapses, avoidance, distortions, or acceptance biases, potentially leading to discrepancies between the collected data and reality. Future studies could incorporate methods such as interviews to enhance data collection. A portion of the participants in this study were recruited from adult populations in hospital settings, which may affect the generalizability of the findings. This study is a cross-sectional investigation. Although it demonstrates the correlations between childhood trauma, early maladaptive schemas, and various dimensions of alexithymia, the limitations of the research design preclude the establishment of causal relationships. Future longitudinal studies could be conducted to explore the causal links among these three variables as well as their connections with the disease. An important limitation of this study is that the patient group with depression was not further stratified based on symptomatic presentations, severity levels, comorbid conditions, or treatment stages. Given the substantial heterogeneity of depression itself, our sample likely comprised individuals with various subtypes or comorbid conditions. Such heterogeneity could have confounded the observed strength of the mediating pathways, particularly the prominent role of the over-vigilance and inhibition schema domain in the clinical group. For example, the enhanced mediation via this pathway may be partly driven by the presence of individuals with comorbid anxiety or trauma-related disorders in the sample. Therefore, future studies are needed to examine the differential validity of this model across distinct subtypes of depression and various comorbid states (depression alone vs. depression with comorbid anxiety) through larger, prospectively stratified samples, in order to establish more targeted psychopathological models and intervention targets.

This study draws the following conclusions: First, patients with depression exhibit higher levels of childhood trauma, early maladaptive schemas, and alexithymia compared to healthy individuals. Second, the early maladaptive schema domains—disconnection and rejection,impaired autonomy and performance, other-directedness, over-vigilance and inhibition, and impaired limits—fully mediate the relationship between childhood trauma and alexithymia in depressive patients. Third, compared to the healthy group, the association between the over-vigilance and inhibition schema domain and alexithymia is stronger in patients with depression.