We prospectively examined the association between alexithymia and risk of death over an average follow-up time of nearly 5.5 years in 42- to 60-year-old men (N = 2297) participating in the Kuopio Ischemic Heart Disease Risk Factor Study (KIHD). Alexithymia, impairment in identification, processing, and verbal expression of inner feelings, was assessed by the validated Toronto Alexithymia Scale (TAS) In age-adjusted survival analyses, men in the highest alexithymia quintile had a twofold greater risk of all-cause death (p<0.001) and a threefold greater risk of death from accidents, injury, or violence (p<0.02) relative to the men in the three lowest alexithymia quintiles. There was little evidence for confounding by behavioral factors (smoking, alcohol consumption, physical activity), physiological risk factors (LDL, HDL, body mass index, hypertension), socioeconomic status, marital status, perceived health, prior diseases and diagnoses, depressive symptoms or social connections. Consistent and even stronger associations between alexithymia and all-cause death were found in a healthy subgroup (N = 1650). Why difficulties in dealing with emotions associate with increased mortality remains unclear. Our findings suggest that the association is independent from the effect of well-known behavioral, biological, and psychosocial risk factors.