Objective: Symptom overreporting is often considered to be moderated by external incentives, such as financial or legal advantages, although other factors may also play a role. Preliminary studies have suggested a connection between symptom overreporting and alexithymia, i.e., trait-like difficulties in recognizing and describing internal sensations. This study aimed to further clarify the relationships among external gain expectations, alexithymia, and symptom overreporting. Specifically, we examined whether alexithymia is related to overreporting in patients without self-reported external gain expectations. Method: Using a cross-sectional design, patients referred for psychological assessments in a hospital setting completed a questionnaire about external gain expectations (e.g., regarding work, housing, legal issues). We differentiated between those with self-reports of external gain expectations (n = 73) and those without (n= 84). Both subsamples were administered the Toronto Alexithymia Scale-20 (TAS-20), the Structured Inventory of Malingered Symptomatology (SIMS), and the Minnesota Multiphasic Personality Inventory-2 Restructured Form (MMPI-2-RF). Results: Across the full sample, alexithymia showed a positive and statistically significant association with symptom overreporting on the SIMS and the Infrequent somatic responses scale (Fs) of the MMPI-2-RF: r = .44 and r = .31, respectively. These positive associations were also evident in the subgroup without self-reported external gain expectations (i.e., r = .35, 95% CI [.14, .52] and r = .35, 95% CI [.15, .53], respectively). Regression analysis indicated that self-reported external gain expectations did not account for the relationship between symptom overreporting and alexithymia. Conclusion: These findings suggest that alexithymia is associated with symptom overreporting independently of self-reported external gain expectations. More broadly, the results raise the possibility that alexithymic traits may compromise the accuracy of symptom reporting itself. If so, this has implications not only for the interpretation of symptom validity tests, but also for the broader use of self-report measures in clinical assessment.