Alexithymia in Chronic Pain Disorders

Facial recognition, laterality judgement, alexithymia and resulting central nervous system adaptations in chronic primary headache and facial pain-A systematic review and meta-analysis

INTRODUCTION

Patients with chronic headaches and chronic oro-facial pain commonly present psychosocial issues that can affect social interactions. A possible reason could be that patients with these disorders might present impairments in facial recognition, laterality judgement and also alexithymia. However, a systematic review summarizing the effects of facial emotion recognition, laterality judgement and alexithymia in individuals with headaches and oro-facial pain is still not available.

AIM

The main objective of this systematic review (SR) and meta-analysis (MA) was to compile and synthesize the evidence on the occurrence of alexithymia, deficits in laterality or left-right (LR) recognition and/or facial emotion recognition (FER) in patients with chronic headache and facial pain.

METHODS

Electronic searches were conducted in five databases (up to September 2023) and a manual search to identify relevant studies. The outcomes of interest were alexithymia scores, speed and accuracy in LR and/or FER, or any other quantitative data assessing body image distortions. The screening process, data extraction, risk of bias and data analysis were performed by two independent assessors following standards for systematic reviews.

RESULTS

From 1395 manuscripts found, only 34 studies met the criteria. The overall quality/certainty of the evidence was very low. Although the results should be interpreted carefully, individuals with chronic headaches showed significantly higher levels of alexithymia when compared to healthy individuals. No conclusive results were found for the other variables of interest.

CONCLUSION

Although the overall evidence from this review is very low, people with chronic primary headaches and oro-facial pain could be regularly screened for alexithymia to guarantee appropriate management.

Alexithymia, intolerance to uncertainty and mental health difficulties in adolescents with Type 1 diabetes mellitus

BACKGROUND

Type 1 Diabetes Mellitus (T1DM) represents a serious chronic condition affecting a wide number of people. Discussion of the physical issues associated with T1DM pervades the literature, however, there is less discussion of the psychological consequences. Mental health difficulties, alexithymia and uncertainty are present in this population, and known to be harmful for the onset, maintenance and worsening of T1DM. This study aimed to evaluate the presence of these phenomena in people with T1DM.

METHODS

105 participants aged between 11 and 17 years old (M: 13.88; SD: 2.16) affected by T1DM were included in the sample. To assess the presence of mental health difficulties, SAFA scales (Depression, Anxiety and Somatic symptoms) were included in the protocol together with TAS-20 and IUS-12, which evaluate the presence and role of alexithymia and intolerance to uncertainty in the sample, respectively.

RESULTS

A concerning presence of anxiety, depression and somatic symptoms was found in the sample. Mental health difficulties appeared to be consistently present in the sample, often overcoming pathological thesholds. Alexithymia and uncertainty were also common, highlighting their role in T1DM.

CONCLUSIONS

Active mental health difficulties together with high rates of alexithymia and intolerance to uncertainty were prevalent in the sample of adolescents with diabetes.

Alexithymia Increases Pericranial and Cervical Muscle Tenderness in Women with Migraine

Background/Objectives: Alexithymia is characterized by a deficit in identifying and communicating feelings. Emerging evidence suggests that alexithymia is highly prevalent in migraine, in a complex interplay with psychiatric comorbidity. Pericranial/cervical muscle tenderness is a remarkable clinical feature in a large proportion of migraine patients. This pilot study aimed at investigating the relationship between alexithymia and pericranial/cervical muscle tenderness in female migraineurs. Methods: A total of 42 female patients fulfilling the diagnostic criteria for migraine were enrolled into this pilot, observational, cross-sectional study after informed consent was obtained. Each patient underwent a psychological assessment to identify any alexithymia by means of TAS-20, anxiety/mood comorbidity (by means of STAI-Y1 STAI-Y2, BDI-II), and migraine-related disability (by means of HIT-6), and a physical cranial/cervical musculoskeletal examination. Palpation of pericranial and cervical muscles was carried out in the standardized manner. A Cumulative Muscle Tenderness (CUM) score (0-6) was calculated for each patient. A multivariate analysis was performed to investigate any association amongst the TAS-20 score, the CUM score, and the following covariates: BDI-II, STAI-Y1, STAI-Y2, and HIT-6 scores, age, disease duration, monthly migraine days, and average head pain intensity in the previous three months. Results: Overall, 35.6% of the sample had alexithymia. The multivariate analysis detected a linear and independent relationship between the TAS-20 and CUM scores, with a statistically significant (p = 0.017) association. Conclusions: This pilot study suggests that alexithymia plays a role in increasing pericranial/cervical muscle tenderness in migraine, independently from psychiatric comorbidity. A novel therapeutical approach, targeting alexithymia, may well reduce muscular tenderness in female migraineurs.

An important contributing factor in dry eye disease: somatization

PURPOSE

Somatization is an important mental process that may causes medically unexplained and treatment-resistant somatic symptoms. The aim of the study is assess the presence of somatization in patients with dry eye disease (DED).

METHODS

Eighty-eight patients with no objective DED finding and ongoing DED treatment were included in this prospective and observational study. Patients with subjective symptoms formed the symptom group and patients without subjective symptoms formed the control group. All patients were scored with the Turkish version of the Ocular Surface Disease Index (OSDI), Hamilton Depression Rating Scale (HAM-D), Hamilton Anxiety Rating Scale (HAM-A), Symptom Checklist-90-R (SCL-90R) somatization subscale, Toronto Alexithymia Scale (TAS), Pain Catastrophizing Scale (PCS), and Symptom Interpretation Questionnaire (SIQ).

RESULTS

Mean OSDI score was significantly higher in the symptom group than in the control group. The mean HAM-D and HAM-A outcomes did not differ between the groups. The mean SCL-90R somatization subscale, TAS, and PCS scores were significantly higher in the symptom group than in the control group. In the SIQ, somatic attributional style score was significantly higher in the symptom group than in the control group. The SCL-90R somatization subscale, PCS, and somatic attributional style scores had positive and mild-moderate correlation with OSDI scores in the symptom group. The TAS score had positive and moderate correlation with OSDI scores in all sample analyses.

CONCLUSION

Somatization should be considered in patients with DED with chronic ocular surface symptoms. Presence of subjective symptoms resistant to treatment may be an indicator of somatization.

Chronic Pain in Autistic Youth: Clinical Prevalence and Reflections on Tailoring Evidence-Based Interventions from an Interdisciplinary Treatment Team

Though there is growing awareness of the overrepresentation of autistic patients in chronic pain clinics, potential adaptations for the assessment and treatment of chronic pain in this population have not yet been established. To address this gap, a retrospective review of electronic medical records and discussions by an interdisciplinary pain treatment team were summarized to inform potential biopsychosocial factors affecting the presentation, assessment, and treatment of chronic pain in autistic youth. Our sample included a record review of 95 patients receiving treatment in an interdisciplinary outpatient pediatric pain clinic. Results indicated that 9% (n = 9) of the patients presented to the clinic with a prior diagnosis of autism, but an additional 21% (n = 20) were identified as likely meeting criteria for autism based on the clinical assessment of the developmental history, behaviors observed during the clinical encounter(s), and expert clinical judgment, suggesting that the prevalence rate of autism may be closer to 30% in our outpatient pediatric pain clinic. Over half (52%) of the autistic youth presented to the clinic with widespread pain, 60% identified as female, and 6% identified as gender expansive or transgender. Qualitative insights revealed that most of the autistic patients had co-occurring sensory-processing challenges and difficulty in describing their pain, emotions, and somatic experiences and exhibited cognitive inflexibility and social challenges. We summarize our team's clinical reflections on how autism-relevant biopsychosocial vulnerability factors may contribute to the experience of pain in autistic youth and propose treatment targets and adaptations for the assessment and treatment of pain in this population. Finally, we recommend the need for interventions focused on sensorimotor integration, especially for autistic youth, and describe how pain clinics may be particularly helpful for identifying and supporting autistic females, for whom the potential role of autism in pain experiences had not been considered until receiving treatment in our clinic.

The influence of alexithymia on disease activity and quality of life in patients with axial spondyloarthritis: A cross-sectional study

OBJECTIVE

To evaluate the prevalence of alexithymia and its influence on disease activity, quality of life, and clinical outcomes in axial spondyloarthritis (axSpA) patients.

PATIENTS AND METHODS

This cross-sectional study included 110 (59 men and 51 women) consecutive axSpA patients who agreed to participate at our rheumatology outpatient clinic. Patient demographics, pain, disease activity measures, functionality, quality of life, alexithymia, psychological status, neuropathic pain, and fibromyalgia were evaluated. Patients were divided into 2 groups (without vs with alexithymia) and compared. The risk factors for alexithymia were evaluated.

RESULTS

The prevalence of alexithymia in axSpA patients was 31.8% according to a Toronto Alexithymia Scale-20 cutoff of ≥61. The mean age and body mass index of patients were 41.25 ± 9.64 years and 27.73 ± 4.51 kg/m² , respectively. Most patients with alexithymia were women. Patients with alexithymia had significantly high scores for depression, anxiety, fibromyalgia, disease activity, enthesitis, worse quality of life, and poor functionality (all P < 0.05). Female gender (odds ratio [OR] = 22.359), patient global assessment (OR = 7.873), Bath Ankylosing Spondylitis Functional Index (OR = 1.864), and fibromyalgia symptom severity (OR = 1.303) were found to be independent risk factors for alexithymia.

CONCLUSION

The present study results showed that about one-third of axSpA patients had alexithymia, and the patients with alexithymia had higher disease activity, worse quality of life, and worse functional status than those without alexithymia. Female gender, patient global assessment, functional status, and fibromyalgia symptom severity were found to be important contributing factors to alexithymia.

Alexithymia in a Chinese Patient with Chronic Pain and Associated Factors: A Cross-Sectional Study

BACKGROUND

Alexithymia is more prevalent among those with patients living with chronic pain. Information on the prevalence of alexithymia in Chinese patients with chronic pain and associated factors is limited.

AIM

The primary objective of this study was to determine the prevalence of alexithymia, as defined by a score of 61 or greater in the 20-item Toronto Alexithymia Scale (TAS-20), in a Chinese patient with chronic pain. The secondary objective was to investigate the relationship between alexithymia and the clinical and psychological aspects of chronic pain.

METHODS

A cross-sectional observational study used the TAS-20 to assess alexithymia of Chinese patients with chronic pain. Sociodemographic and clinical information were obtained and participants filled in the Fear Avoidance Beliefs Questionnaire, Hospital Anxiety and Depression Scale, Pain Catastrophizing Scale, and General Self-efficacy Scale.

RESULTS

Of the 346 patients screened, 321 patients living with chronic pain were enrolled into the study. The prevalence of alexithymia among the study population (TAS-20 score ≥61) was 19.6% (95% confidence interval [CI]: 15.3-24.0). The findings showed anxiety (odds ratio [OR] = 2.474; 95% CI, 1.241-4.935), pain catastrophizing (2.649; 1.014-6.921), and self-efficacy (0.952; 0.908-0.988) as independent predictors of alexithymia in patients living with chronic pain.

CONCLUSIONS

Patients with chronic pain exhibiting alexithymia were at higher risk of pain catastrophizing, anxiety, and lower self-efficacy, compared with patients without alexithymia. It is important to identify and pay a special attention in clinical practice to patients with chronic pain exhibiting alexithymia, as these individuals are unable to properly express their emotions.

Alexithymia and psychological distress in fibromyalgia and chronic migraine: A cross-sectional study

OBJECTIVE

Several studies have shown a strong association between alexithymia and psychological distress in both healthy and clinical populations. The aim of this study was to investigate the prevalence and association between alexithymia and psychological distress in individuals with fibromyalgia (FM) and chronic migraine (CM) compared with healthy controls (HC).

METHODS

A cross-sectional study was conducted. Two hundred fifty women with FM (age: 51.2 ± 10.5) and 250 women with CM (age: 46.1 ± 11.5) were assessed with the Toronto Alexithymia Scale (TAS-20) and the Hospital Anxiety and Depression Scale (HADS) and compared with HCs (n = 280; age: 51.8 ± 9.0) by one-way analyses of variance. A moderation analysis was performed to examine the moderation effect of groups on the relationship between alexithymia and psychological distress.

RESULTS

Differences between groups showed significantly higher scores for TAS-20 [F(2,755) = 11.7, p < .001] and HADS [F(2,763) = 31.7, p < .001] in FM, compared with CM and HCs. The moderation analysis showed that both clinical groups and TAS-20 (β = 0.20, p < .001) were significant predictors, as well as the interaction terms. The slope of the correlation curve was more pronounced in the patient groups, indicating that the degree of alexithymia had a significantly higher influence on the HADS total score in the patient groups.

CONCLUSION

The results suggest a common psychological dysregulation in FM and CM, with a slight but greater prevalence of alexithymia and psychological distress in FM. These data suggest that although there is a similar psychological substrate, it is expressed in a different expression of somatic symptoms.

Alexithymia Among People Living with HIV: A Scoping Review

The present scoping review aimed to identify studies that investigated alexithymia, defined as a difficulty in identifying and describing one's own emotions, in people living with HIV (PLWH).A literature search, in line with the guidelines of PRISMA-ScR, was conducted in the following bibliographic databases: PubMed, PsycINFO, and Web of Science. The databases were queried using the following strings (using Boolean operators): ("alexithymia" OR "alexithymic") AND ("HIV" OR "Human Immunodeficiency Virus"). In line with the eligibility criteria, fourteen articles were found.Ten studies showed the involvement of alexithymia in disease severity (e.g., viral load levels), and adherence to antiretroviral therapy. Three studies revealed an association between alexithymia and cardiovascular disease, and three studies highlighted the implication of alexithymia in cognitive impairment.This review revealed the complex role of alexithymia in HIV disease. A careful clinical assessment of the emotional regulation process of PLWH can provide useful prognostic information.

Effect of Aerobic Exercise on the Levels of Pain, Quality of Life, and Alexithymia in Alexithymic Individuals With Chronic Pain: A Single-Blinded Randomized Controlled Trial

OBJECTIVE

This study aimed to investigate the effects of aerobic exercise on pain, degree of alexithymia, and quality of life in individuals with alexithymia and chronic pain.

METHODS

A total of 40 participants who scored 61 or higher on the Toronto Alexithymia Scale-20 (TAS-20) were included in the study. The sample was subdivided into 2 groups using a computerized randomization program: an aerobic exercise group (n = 20) and a control group (n = 20). Participants in the aerobic exercise group underwent a 30-minute jogging protocol at 60% to 90% of maximum heart rate 3 days per week for 8 weeks under the supervision of a physiotherapist. Participants in the control group continued their daily physical activities. Outcome measures were the TAS-20, visual analog scale, Graded Chronic Pain Scale, and 36-Item Short Form Health Survey.

RESULTS

There was no statistically significant difference between the demographics of the 2 groups (P > .05). There was a statistically significant improvement in TAS-20, Graded Chronic Pain Scale, visual analog scale, and 36-Item Short Form Health Survey scores of the participants in the aerobic exercise group compared to the control group (P ˂ .05).

CONCLUSION

Aerobic exercise had a positive effect on pain, quality of life, and degree of alexithymia in individuals with alexithymia and chronic pain.

Endometriosis and Sexual Functioning: How Much Do Cognitive and Psycho-Emotional Factors Matter?

Women with endometriosis often suffer from genito-pelvic pain. The objective of the present study was to analyze the relationship between cognitive and psycho-emotional factors and sexual functioning of women with endometriosis, comparing women with and without endometriosis. A total of 87 women with endometriosis (EG) and 100 women without endometriosis (CG) completed a socio-demographic questionnaire; the short-form of McGill Pain Questionnaire (SF-MPQ); the Female Sexual Functioning Index (FSFI); the Sexual Distress Scale (SDS); the Symptoms Checklist (SCL-90-R); the Toronto Alexithymia Scale (TAS-20); the Positive and Negative Affects Scale (PANAS); the Sexual Dysfunctional Belief Questionnaire (SDBQ); the Sexual Modes Questionnaire (SMQ); and the Questionnaire of Cognitive Schema Activation in Sexual Context (QCSASC). EG obtained worse scores than CG in SF-MPQ, Pain subscale of FSFI, and SDS. EG reached higher scores than CG on almost all scales of SCL-90-R and lower scores in the “Identifying Feelings” scale of TAS-20. Furthermore, EG reported more negative emotions toward sexuality than CG (PANAS) higher scores on the “Affection Primacy” scale of SDBQ and the “Helpless” sexual cognitive schema of QCSASC than CG. No significant differences were found in SMQ. Sexual health professionals should address psychological, emotional, and cognitive factors since they seem involved in patients’ sexual experiences.

Associations between alexithymia, parental rearing styles, and frequency of drug use in male methamphetamine dependence patients

BACKGROUND

Alexithymia, which is characterized by difficulty identifying and describing feelings, is a stable personality trait and it has been associated with early life experiences. Methamphetamine dependence patients with high level of alexithymia may be particularly vulnerable to engaging in more frequent methamphetamine use. Therefore, we aimed to evaluate whether alexithymia was associated with frequency of methamphetamine use. Additionally, the current study sought to examine early-life factors associated with the development of alexithymia, i.e., parental rearing styles.

METHOD

Participants were 108 non-injecting methamphetamine dependent patients from a male compulsory detoxification center. The level of alexithymia was assessed by Toronto Alexithymia Scale-20(TAS-20). In addition, we applied Egna Minneu av. Bardndosnauppforstran (EMBU) to assess the parental rearing styles, including the dimensions of warmth, rejection, punishment/strictness, overinvolvement, overprotection, and favoring.

RESULTS

The total score of TAS-20 was positively correlated with frequency of methamphetamine use (r = 0.26, p < 0.01). Specifically, except for externally oriented thinking, difficulty identifying feelings (r = 0.23, p < 0.05) and difficulty describing feelings (r = 0.25, p < 0.05) were positively correlated with frequency of methamphetamine use. Multiple linear regression showed that more maternal rejection (B = 0.59, p = 0.002), or less maternal warmth (B = -0.22, p = 0.004) was associated with higher levels of alexithymia. Ordinal logistic regression showed that for every 1 score increase in the total score of TAS-20, there was a 1.06 times risk of a one level increase in the level of methamphetamine use frequency (OR = 1.06, p = 0.01).

CONCLUSIONS

These results have major implications for understanding the role of alexithymia in craving and addiction, while providing a further and explicit entry point for addiction treatment. Moreover, more attention should be focused on parenting in relation to early experiences.

eDOL mHealth App and Web Platform for Self-monitoring and Medical Follow-up of Patients With Chronic Pain: Observational Feasibility Study

BACKGROUND

Chronic pain affects approximately 30% of the general population, severely degrades quality of life (especially in older adults) and professional life (inability or reduction in the ability to work and loss of employment), and leads to billions in additional health care costs. Moreover, available painkillers are old, with limited efficacy and can cause significant adverse effects. Thus, there is a need for innovation in the management of chronic pain. Better characterization of patients could help to identify the predictors of successful treatments, and thus, guide physicians in the initial choice of treatment and in the follow-up of their patients. Nevertheless, current assessments of patients with chronic pain provide only fragmentary data on painful daily experiences. Real-life monitoring of subjective and objective markers of chronic pain using mobile health (mHealth) programs can address this issue.

OBJECTIVE

We hypothesized that regular patient self-monitoring using an mHealth app would lead physicians to obtain deeper understanding and new insight into patients with chronic pain and that, for patients, regular self-monitoring using an mHealth app would play a positive therapeutic role and improve adherence to treatment. We aimed to evaluate the feasibility and acceptability of a new mHealth app called eDOL.

METHODS

We conducted an observational study to assess the feasibility and acceptability of the eDOL tool. Patients completed several questionnaires using the tool over a period of 2 weeks and repeated assessments weekly over a period of 3 months. Physicians saw their patients at a follow-up visit that took place at least 3 months after the inclusion visit. A composite criterion of the acceptability and feasibility of the eDOL tool was calculated after the completion of study using satisfaction surveys from both patients and physicians.

RESULTS

Data from 105 patients (of 133 who were included) were analyzed. The rate of adherence was 61.9% (65/105) after 3 months. The median acceptability score was 7 (out of 10) for both patients and physicians. There was a high rate of completion of the baseline questionnaires and assessments (mean 89.3%), and a low rate of completion of the follow-up questionnaires and assessments (63.8% (67/105) and 61.9% (65/105) respectively). We were also able to characterize subgroups of patients and determine a profile of those who adhered to eDOL. We obtained 4 clusters that differ from each other in their biopsychosocial characteristics. Cluster 4 corresponds to patients with more disabling chronic pain (daily impact and comorbidities) and vice versa for cluster 1.

CONCLUSIONS

This work demonstrates that eDOL is highly feasible and acceptable for both patients with chronic pain and their physicians. It also shows that such a tool can integrate many parameters to ensure the detailed characterization of patients for future research works and pain management.

TRIAL REGISTRATION

ClinicalTrial.gov NCT03931694; http://clinicaltrials.gov/ct2/show/NCT03931694.

The Link between Fibromyalgia Syndrome and Anger: A Systematic Review Revealing Research Gaps

Anger has been associated with increased pain perception, but its specific connection with Fibromyalgia Syndrome (FMS) has not yet been established in an integrated approach. Therefore, the present systematic review focuses on exploring this connection, and based on this connection, delimiting possible gaps in the research, altogether aimed at improving FMS clinical intervention and guiding future research lines. Anger is considered a basic negative emotion that can be divided into two dimensions: anger-in (the tendency to repress anger when it is experienced) and anger-out (the leaning to express anger through verbal or physical means). The current systematic review was performed based on the guidelines of the PRISMA and Cochrane Collaborations. The Prospective Register of Systematic Reviews (PROSPERO) international database was forehand used to register the review protocol. The quality of chosen articles was assessed and the main limitations and research gaps resulting from each scientific article were discussed. The search included PubMed, Scopus, and Web of Science databases. The literature search identified 13 studies eligible for the systematic review. Levels of anger-in have been shown to be higher in FMS patients compared to healthy participants, as well as patients suffering from other pain conditions (e.g., rheumatoid arthritis). FMS patients had also showed higher levels of state and trait anxiety, worry and angry rumination than other chronic pain patients. Anger seems to amplify pain especially in women regardless FMS condition but with a particularly greater health-related quality of life´s impact in FMS patients. In spite of the relevance of emotions in the treatment of chronic pain, including FMS, only two studies have proposed intervention programs focus on anger treatment. These two studies have observed a positive reduction in anger levels through mindfulness and a strength training program. In conclusion, anger might be a meaningful therapeutic target in the attenuation of pain sensitivity, and the improvement of the general treatment effects and health-related quality of life in FMS patients. More intervention programs directed to reduce anger and contribute to improve well-being in FMS patients are needed.

Alexithymia and facial emotion recognition in patients with craniofacial pain and association of alexithymia with anxiety and depression: a systematic review with meta-analysis

Background

We aimed to determine the presence of alexithymia in patients with craniofacial pain (CFP) compared with asymptomatic individuals. Our secondary aims were to assess the relationship of alexithymia with anxiety and depression levels, as well as to assess the presence of facial emotion recognition deficit.

Methods

Medline, Scielo and Google Scholar were searched, with the last search performed in 8 September 2021. Standardized mean differences (SMDs) and 95% CIs were calculated for relevant outcomes and were pooled in a meta-analysis using the random effects model. In addition, meta-analyses of correlations and a meta-regression of alexithymia with depression and anxiety were performed.

Results

Regarding alexithymia, assessed through the Toronto Alexithymia Scale (TAS), the results showed significant differences, with higher values in patients compared with asymptomatic individuals, with a large clinical effect (SMD 0.46; 95% CI [0.22–0.71]; heterogeneity-Q 66.86; p < 0.001; inconsistency (I²) = 81%). We found statistically significant correlations with a small clinical effect of alexithymia with anxiety and depression. The meta-regression showed no significant association between the TAS and anxiety or depression. With respect to facial emotion recognition, the results showed statistically significant differences, with greater recognition difficulty in patients compared with asymptomatic individuals, with a large clinical effect (SMD −1.17; 95% CI [−2.01 to −0.33]; heterogeneity-Q 2.97; p = 0.080; I² = 66%).

Conclusions

Patients with CFP showed alexithymia with moderate evidence. There was also moderate evidence indicating that these patients had significant deficits in facial emotion recognition compared with asymptomatic individuals. Furthermore, alexithymia showed statistically significant correlations with anxiety and depression levels.

Alexithymia is a mediating factor in the relationship between adult attachment and severity of depression and social anxiety

BACKGROUND

Major depressive disorder (MDD) and social anxiety disorder (SAD) are commonly occurring conditions, either alone or together (MDD-SAD). Recent research linked insecure attachment and alexithymia to MDD and/or SAD, indicating that the way affected individuals relate interpersonally and their ability to identify and communicate emotions are pertinent issues. The current study investigated the mediating role of alexithymia in the relationship between insecure attachment and severity of MDD and SAD symptoms.

METHOD

Using the SCID-I, participants (N=159) were identified as MDD-only (n=43), MDD-SAD (n=56), or a healthy control (n=60). Participants completed measures of adult attachment, depression, social anxiety and alexithymia (defined as difficulty identifying and describing feelings). A two-step mediation analysis approach recommended by Shrout and Bolger determined if alexithymia mediates the relationship between attachment-depression and attachment-social anxiety.

RESULTS

While alexithymia was high in MDD-only and MDD-SAD groups, individuals with MDD-SAD had significantly greater difficulty describing feelings. Alexithymia was a full mediator between attachment avoidance and depression, but only a partial mediator between attachment anxiety and depression. Meanwhile, alexithymia was a partial mediator for both attachment dimensions and social anxiety.

LIMITATIONS

Causal inferences regarding insecure attachment, alexithymia, and MDD and SAD cannot be assumed given the cross-sectional data. The 'externally oriented thinking' component in alexithymia was also excluded from analyses due to low reliability.

CONCLUSION

The results suggest emotional awareness and expression play a role in the illness severity for MDD and SAD-particularly in those with high attachment avoidance, offering a possible target for treatment and prevention strategies.

Development of the Pain Responses Scale: A measure informed by the BIS-BAS model of pain

BACKGROUND

The behavioural inhibition system and activation system (BIS-BAS) model of pain focusses on two clusters of responses to pain-escape/avoidance (BIS) and approach (BAS) behaviours. While the BIS-BAS model emphasizes active responses to pain, deactivation responses such as despondence and relaxation are also common. This study sought to develop self-report scales assessing cognitive, behavioural intentions and affective responses to pain consistent with this extended BIS-BAS framework. We also sought to develop short-forms of the emerging scales.

METHODS

Confirmatory factor analysis was performed to derive scales from a large item pool administered to a community sample with heterogeneous chronic pain (N = 476).

RESULTS

The items resulted in 16 scales assessing Thoughts, Affective responses, Behavioural Intentions and Valence-Associated Thoughts, which loaded on to the four theorized types of pain responses-Escape, Approach, Despondence and Relaxation-with the four emerging short-form scales assessing these overarching factors. The internal consistency reliabilities of the long-forms generally ranged from good to excellent (αs ≥ 0.83), with the exception of the Relaxation-Behavioural Intentions scale (α = 0.64). The four short-forms demonstrated at least adequate internal consistency reliability (αs ≥ 0.79). An initial test of the construct validity of the scales in relation to pain-related outcomes is also reported.

CONCLUSIONS

We anticipate that the Pain Responses Scale (PRS) developed from this research will be useful for assessing mechanisms targeted by many psychosocial pain treatments and will provide a nuanced understanding of the shared versus specific nature of these mechanisms.

SIGNIFICANCE

The Pain Responses Scale emerging from this research assesses four theorized, overarching responses to pain: Escape, Approach, Giving Up and Relaxation. This measure will afford the capacity to test a reconceptualized BIS-BAS model of pain and inform treatments that are adapted based on this framework.

Do Patients of Chronic Low Back Pain have Psychological Comorbidities?

Background Individuals with chronic pain have been reported to have an increased incidence of psychological morbidities. We aimed to examine the prevalence of anxiety, depression, disability, alexithymia, insomnia, and sleep quality in patients having chronic low back pain (LBP) and study their association with the severity of pain and any disability arising from it. Methods This descriptive study was conducted in a tertiary care teaching hospital setting. Fifty adults with nonspecific LBP of > 6-week duration were included. Study instruments employed were patient health questionnaire-9 for depression, generalized anxiety disorder-7 for anxiety, visual analogue scale (VAS) score for pain, Oswestry disability index (ODI) to assess disability, Toronto alexithymia scale-20 for alexithymia, and insomnia severity index and Pittsburgh sleep quality index for insomnia. Descriptive results were expressed as numbers, means, and proportions. Association study between variables was performed using Fisher's exact test. Results Mean ODI score was 31.54% (95% CI, 26.09-36.99); mean VAS score was 6.08 (95% CI, 5.35-6.81). Insomnia of varying severity was found in 29 patients. Sleep quality was reported as good by 23 patients. One patient had alexithymia. There was significant association between the level of disability and depression, anxiety, insomnia, and sleep quality. The severity of pain had significant association with insomnia but the association with anxiety, depression, alexithymia, and sleep quality was not significant. Conclusions Patients with chronic LBP do have associated psychological comorbidities of varying extent. A "patient-centric" approach when treating patients with chronic LBP is necessary, so that appropriate evaluation of psychiatric and psychosocial comorbidities, sleep problems, and quality of life is done as part of their routine management to ensure the desired outcomes.

Systematic Review of Alexithymia in the Population of Hemodialysis Patients

Alexithymia is a construct defined as the inability to differentiate between emotional experiences and bodily sensations. According to existing knowledge, alexithymia may have a major effect on the process of treatment and the outcome of the hemodialysis disease. The objective of this literature review was to determine the significance that alexithymia has for compliance and variables of clinical and mental health in the population of hemodialysis patients. For the above purpose, bibliographic databases “MEDLINE” and “Web of Science” were searched. The matrix method was used in analysis of articles. Searching both databases resulted in 248 articles. After applying exclusion and inclusion criteria, we included results of 13 articles in the literature review. The results of the search are findings regarding the prevalence and correlation of alexithymia with variables of clinical and mental health in hemodialysis patients. Alexithymia is significantly more common in the population of hemodialysis patients, and it has a negative effect on their mental and somatic health. Alexithymia levels in hemodialysis patients are more pronounced in cases where there is a greater number of comorbidities. Alexithymia is the predictor of high mortality rate in the population of hemodialysis patients, independent of other comorbidities.

Evaluation of alexithymia in individuals with chronic pain in a Mexican population: Alexithymia in a Mexican population

INTRODUCTION

Alexithymia is the difficulty in identifying and describing feelings. Several studies have suggested that chronic pain can be linked to alexithymia. The aims of this study were to determine the presence of alexithymia in a sample of Mexican individuals who attended public health services, to assess if alexithymia is higher in medically ill individuals with pain than in those without pain, and to determine which alexithymia dimensions are more affected by the presence of pain.

METHODS

Demographic and clinical features were evaluated in 250 Mexican outpatients of the General Hospital of Comalcalco, Tabasco. Pain was evaluated using the Visual Analogue Scale for Pain Assessment (VAS-P) and alexithymia was evaluated using the Toronto Alexithymia Scale (TAS-20).

RESULTS

38.8% of the sample was identified with probable/definite alexithymia and up to 61.2% of individuals were currently experiencing pain. Individuals with pain exhibited higher scores in the TAS-20 dimensions: difficulty describing feelings (p = 0.02), difficulty identifying feelings (p < 0.001) and higher total TAS-20 score (p < 0.001). Also, Probable/definite alexithymia was more frequently reported in individuals with pain (49% vs. 21.6%, p < 0.001).

CONCLUSIONS

Our results show that a large proportion of individuals who attend public health services in a Mexican population present pain. We also identified that pain could be associated with alexithymia, in particular with a difficulty in describing and identifying feelings. An early identification and treatment of alexithymia could help in reducing the clinical burden of chronic pain in Mexican outpatients.

Behavioral Restriction Determines Left Attentional Bias: Preliminary Evidences From COVID-19 Lockdown

During the COVID-19 lockdown, individuals were forced to remain at home, hence severely limiting the interaction within environmental stimuli, reducing the cognitive load placed on spatial competences. The effects of the behavioral restriction on cognition have been little examined. The present study is aimed at analyzing the effects of lockdown on executive function prominently involved in adapting behavior to new environmental demands. We analyze non-verbal fluency abilities, as indirectly providing a measure of cognitive flexibility to react to spatial changes. Sixteen students (mean age 20.75; SD 1.34), evaluated before the start of the lockdown (T1) in a battery of psychological tasks exploring different cognitive domains, have been reassessed during lockdown (T2). The assessment included the modified Five-Point Test (m-FPT) to analyze non-verbal fluency abilities. At T2, the students were also administered the Toronto Alexithymia Scale (TAS-20). The restriction of behaviors following a lockdown determines increased non-verbal fluency, evidenced by the significant increase of the number of new drawings. We found worsened verbal span, while phonemic verbal fluency remained unchanged. Interestingly, we observed a significant tendency to use the left part of each box in the m-FPT correlated with TAS-20 and with the subscales that assess difficulty in describing and identifying feelings. Although our data were collected from a small sample, they evidence that the restriction of behaviors determines a leftward bias, suggesting a greater activation of the right hemisphere, intrinsically connected with the processing of non-verbal information and with the need to manage an emotional situation.

Das Fibromyalgiesyndrom aus der psychosomatischen Perspektive: Ein Überblick

Das Fibromyalgiesyndrom (FMS) wird im psychosomatischen Kontext als stressinduzierte Schmerzerkrankung durch eine Sensibilisierung der zentralnervösen schmerzverarbeitenden Systeme verstanden. Das FMS zeigt hohe Komorbiditäten mit psychischen bzw. psychosomatischen Störungen wie Depression, Angststörungen, somatoformen Störungen und Persönlichkeitsstörungen. Biografisch frühe Stresserfahrungen und Traumatisierungen wie körperlicher oder sexueller Missbrauch in der Kindheit bilden eine Vulnerabilität für die spätere Entwicklung eines FMS. Die Gruppe der FMS-Patient/innen ist hinsichtlich der pathophysiologischen Entstehungswege heterogen, weshalb eine mechanismenbasierte Differenzierung von Subgruppen sinnvoll erscheint. Typische Teufelskreise der Chronifizierung des FMS werden beschrieben und die Wichtigkeit einer gelingenden Arzt-Patient/in-Beziehung herausgestellt. Schwergegradgestuftes Vorgehen und Kommunikationsstrategien werden am Fallbeispiel dargestellt.

Relationship between alexithymia and depression: A narrative review

Alexithymia has been described as difficulty in expressing as well as experiencing feelings. It has been studied in relation with medical as well as psychological conditions and has been seen to impact treatment outcomes. The current review focuses on the relationship of alexithymia with depression and the role of culture in this relationship. The keywords for literature included terms such as depression, alexithymia, depression and alexithymia, Toronto Alexithymia Scale, assessing alexithymia and depression, and alexithymia as a trait. The main findings of the review were that alexithymia and depression are highly correlated, and severity of depression and gender are independently associated with alexithymia and may interfere with treatment outcomes.

Interoception and alexithymia are related to differences between the self-reported and the objectively measured physical activity in patients with chronic musculoskeletal pain

OBJECTIVE

Patients with chronic musculoskeletal pain (CMP) have difficulty estimating their level of physical activity (PA). Factors associated with this difficulty have yet to be identified; however, identification could allow for increased accuracy in large-scale PA surveys, and enhanced self-management. The purpose of this study was to determine the relationship of interoception and alexithymia with differences between self-reported and objectively measured PA, and investigate factors as they relate to accurately self-reporting PA.

METHODS

A cross-sectional survey of 33 patients with CMP and 32 healthy individuals was conducted from July 2018 to June 2019. We measured differences in Moderate to Vigorous Physical Activity (D-MVPA) using an accelerometer and self-report. A heartbeat tracking task (HTT) was used to measure interoception, and alexithymia was measured using the 20-item Toronto Alexithymia Scale (TAS-20).

RESULTS

The CMP group (median 43.5 min/day, IQR 20.6-77.6) showed significantly higher D-MVPA values than the control group (median 22.5 min/day, IQR 6.7-34.9) (p < .001). In patients with CMP, D-MVPA positively correlated with TAS-20 (rho = 0.470, p = .006) and correlated negatively with HTT (rho = -0.390, p = .025).

CONCLUSION

Inaccurate self-reported measurements of PA in patients with CMP are associated with alexithymia and interoception. This finding suggests that behavioral interventions targeting alexithymia and interoception in CMP patients could lead to improved self-monitoring.

Alexithymia and pain experience among patients using methadone-maintenance therapy

BACKGROUND

Alexithymia, difficulty identifying and describing one's emotions coupled with a tendency to externalize, is a potentially important yet understudied treatment target for patients with opioid use disorder. The aim of this study was to examine the role of alexithymia in pain experience among individuals with opioid use disorder.

METHODS

One-hundred-and-sixty-four patients receiving methadone maintenance treatment completed a battery of self-report measures related to alexithymia, drug use, and pain experiences. Comparisons were performed on the full sample between those with or without clinically significant levels of alexithymia. For a subsample reporting pain (n = 138), intercorrelations were performed to test whether drug use history, pain catastrophizing, pain acceptance, and alexithymia were related to pain severity and pain interference. Regression analyses were performed to test for serial mediation of pain catastrophizing and pain acceptance on the relationship between alexithymia and pain interference in this subsample.

RESULTS

Individuals with alexithymia showed increased pain catastrophizing and interference, and intercorrelations indicated that increased alexithymia was associated with increased pain interference, more pain catastrophizing, and reduced pain acceptance. A serial regression model among a subset of patients with pain indicated that pain catastrophizing and pain acceptance mediated the effect of alexithymia on pain interference.

CONCLUSIONS

These findings suggest that alexithymia, as well as both pain catastrophizing and pain acceptance, contribute to interference associated with pain and are potentially important intervention targets among methadone-treated patients with pain.

The relationship between alexithymia, sensory phenotype and neurophysiological parameters in patients with chronic upper limb neuropathy

In this study, we investigated the relationship between sensory abnormalities evaluated by quantitative sensory testing (QST) and alexithymia, depression and anxiety in patients with neuropathic pain involving the upper limbs. We enrolled 62 patients (34 with carpal tunnel syndrome, 7 with brachial plexopathy, 3 with cervical painful radiculopathy, 5 with ulnar entrapment neuropathy at elbow and 13 with post-burn hypertrophic scars) and 48 healthy controls. All underwent nerve conduction studies (NCS), evaluation of cold, heat pain and vibration detection threshold (VDT) by QST and evaluation of alexithymia by Toronto Alexithymia Scale (TAS-20), depression by Beck Depression Inventory II (BDI-II), anxiety by State-Trait Anxiety Inventory (STAI-Y), level of psychological distress by 12-item General Health Questionnaire (GHQ-12) and perceived social support by the Multidimensional Scale of Perceived Social Support (MSPSS). The general linear model analysis revealed a significant relationship between TAS-20 overall and TAS-20 sub-score for difficulty identifying feelings and VDT z-scores in the left index with no interaction by year of education and sensory NCS results. Our results demonstrated the association between impairment of vibratory sensation of the left hand, reflecting cutaneous mechanoceptor dysfunction, and alexithymia, particularly the difficulty to identify feelings. The importance of delivering to patients with neuropathic pain personalized care that takes into account not only the neurophysiological aspects but also the aspects of mental functioning is discussed.

Imaging Brain Mechanisms of Functional Somatic Syndromes: Potential as a Biomarker?

When patients present with persistent bodily complaints that cannot be explained by a symptom-linked organic pathology (medically unexplained symptoms), they are diagnosed with 'functional' somatic syndromes (FSS). Despite their prevalence, the management of FSS is notoriously challenging in clinical practice. This may be because FSS are heterogeneous disorders in terms of etiopathogenesis. They include patients with primarily peripheral dysfunction, primarily centrally driven somatic symptoms, and a mix of both. Brain-imaging studies, particularly data-driven pattern recognition methods using machine learning algorithms, could provide brain-based biomarkers for these clinical conditions. In this review, we provide an overview of our brain imaging data on brain-body interactions in one of the most well-known FSS, irritable bowel syndrome (IBS), and discuss the possible development of a brain-based biomarker for FSS. Anticipation of unpredictable pain, which commonly elicits fear in FSS patients, induced increased activity in brain areas associated with hypervigilance during rectal distention and non-distention conditions in IBS. This was coupled with dysfunctional inhibitory influence of the medial prefrontal cortex (mPFC) and pregenual anterior cingulate cortex (pACC) on stress regulation systems, resulting in the activated autonomic nervous system (ANS) and neuroendocrine system stimulated by corticotropin-releasing hormone (CRH). IBS subjects with higher alexithymia, a risk factor for FSS, showed stronger activity in the insula during rectal distention but reduced subjective sensitivity. Reduced top-down regulation of the ANS and CRH system by mPFC and pACC, discordance between the insula response to stimulation and subjective sensation of pain, and stronger threat responses in hypervigilance-related areas may be a candidate brain-based biomarker.

Psychopathological Comorbidities and Clinical Variables in Patients With Medication Overuse Headache

The psychopathological profile of patients with medication overuse headache (MOH) appears to be particularly complex. To better define it, we evaluated their performance on a targeted psychological profile assessment. We designed a case-control study comparing MOH patients and matched healthy controls (HC). Headache frequency, drug consumption, HIT-6, and MIDAS scores were recorded. All participants filled in the following questionnaires: Beck Depression Inventory-II Edition (BDI-2), trait subtest of State-Trait Anxiety Inventory (STAI-Y), Difficulties in Emotion Regulation Scale (DERS), Barratt Impulsiveness Scale (BIS-11), Toronto Alexithymia Scale (TAS-20). The primary endpoint was to establish if MOH patients have an altered psychopathological profile. The secondary endpoint was to establish whether the worst profile correlates with the worsening of headache and disability measures. We enrolled 48 consecutive MOH patients and 48 HC. MOH patients showed greater difficulty in recognition/regulation of emotions (DERS, TAS-20), depression (BDI-2), anxiety (STAI-Y), and impulsiveness (BIS-11). We found a positive correlation among DERS, BDI-2, STAI-Y, and BIS scores and MIDAS and HIT-6 scores and among DERS and headache frequency and drug consumption. MOH patients showed a high rate of emotion regulation difficulties, depression, and anxiety, which may negatively affect their headaches. The ability to regulate/recognize emotions may play a central role in sustaining medication overuse.

Alexithymia and Somatization in Chronic Pain Patients: A Sequential Mediation Model

OBJECTIVE

To investigate whether chronic pain (CP) patients with somatization reported higher alexithymic traits than those without somatization and to study the different relationships between psychological characteristics, pain, health-related quality of life (HRQL), and somatization.

METHOD

A consecutive sample of 134 CP treatment-seeking outpatients were evaluated for alexithymia (TAS-20), somatization (PHQ-15), distress (HADS), HRQL (SF-12), and pain (BPI).

RESULTS

Patients with somatization (37.04%) reported significantly higher TAS-20 total scores (p < 0.001) and difficulty in identifying feelings (DIF) (p < 0.001) than those without somatization. The somatizer group had also a significantly higher disease duration, severity and interference of pain, distress, and lower HRQL than the non-somatizer group. Hierarchical regression analysis showed that although distress, pain interference and the mental HRQL component are closely related to somatization (R 2 = 0.55), DIF was the strongest predictor of severity of somatization (β = 0.31). A sequential indirect effect from DIF to somatization via distress symptoms and pain interference turned out to be significant [95% CI (0.01, 0.09)]. Support was also found for sequential mediation paths from DIF to somatization via distress and mental HRQL [95% CI (0.01, 0.11)].

CONCLUSIONS

Our results pointed-out that alexithymia, particularly DIF, may be major factor for somatization risk in CP patients. Longitudinal observations are needed for evaluating the role of alexithymia in clinical outcomes.

The role of alexithymia in social cognition: Evidence from a non-clinical population

BACKGROUND

Alexithymia is a personality construct characterised by difficulty in identifying and describing one's emotions. We investigated whether people with alexithymia, who struggle with emotion-processing abilities, have diminished emotion-related social cognitive competencies, where social cognition encompasses the set of abilities that allows one to navigate one's social environment.

METHODS

We assessed alexithymia and four components of social cognition: recognition of others' emotions, representation of others' affective and cognitive mental states, empathy, and regulation of one's own feelings. We investigated whether alexithymia could significantly predict each of these components, beyond the effect of other individual difference variables (i.e., anxiety/depressive symptoms), which have been previously associated with both social cognition and alexithymia. Two hundred six participants were recruited. Multiple hierarchical regression analyses were performed to assess the possible relationships between alexithymia and social cognition skills.

RESULTS

Alexithymia significantly predicted emotion recognition, empathy, and emotional regulation, even after controlling for the effect of potentially competing factors (i.e., anxiety/depressive symptoms). Alexithymia did not predict representation of others' affective and cognitive mental states.

LIMITATIONS

The present study adopted a cross-sectional design, which does not permit us to draw firm conclusions about the causality of the emergent relationships.

CONCLUSIONS

These data provide support for the argument that recognising others' emotions and feelings relies on the ability to identify correctly one's own feelings. Our results also indicate the importance of taking into consideration individual differences in levels of alexithymia when investigating social cognition in non-clinical populations, as alexithymia appears to be clearly related to social cognitive functioning.

Evaluating Interoceptive Crossover between emotional and physical symptoms

Symptom perception is complex and influenced by a number of psychological factors, including interoceptive ability and alexithymia. Some individuals may have difficulty distinguishing between internal signals, such as emotions and physical symptoms, however research in this area is sparse. The current study aimed to explore the incidence and nature of this phenomenon, labelled, 'Interoceptive Crossover'. 239 individuals completed an online survey and rated the perceived similarity between a range of emotions (e.g., Sad, Happy, Afraid and Calm) and physical symptoms (e.g., Stomach Pain, Fatigue/Tiredness, Headache and Abnormal Heartbeat) to assess the incidence and nature of Interoceptive Crossover. Individuals demonstrated crossover between emotions and physical symptoms. Some crossovers were more unsurprising and reported by a greater proportion of the sample, such as Afraid and Abnormal Heartbeat (74.5%); Sad and Fatigue (29.4%) and Afraid and Shortness of Breath (58.5%). Other crossovers were less prevalent in the sample and more unexpected such as Satisfied with Headache (1.2%); Bored with Back Pain (5.95%) and Happy and Back Pain (0.4%). Overall, individuals demonstrate Interoceptive Crossover of emotions and physical symptoms and some crossovers are more prevalent whilst others are rare and unexpected. This phenomenon needs further study with respect to relevant constructs including alexithymia and interoception.

The effect of alexithymia and depressive feelings on pain perception in somatoform pain disorder

OBJECTIVE

To investigate the relationship between alexithymia and depression and their influence on the subjective versus experimental pain perception in somatoform pain disorder.

METHODS

Three groups consisting of 40 patients with somatoform pain disorder, 40 patients with depression, and 40 healthy controls were matched. They completed questionnaires regarding alexithymia (TAS26) and depressive feelings (BDI-II). In addition, pain patients rated their subjective pain intensity (NRS). Quantitative sensory testings were conducted in all participants examining temperature (CPT, HPT) and mechanical (MPT, PPT) thresholds.

RESULTS

Analysis of variance showed that alexithymia was significantly increased in both patient groups compared to healthy controls, but with the highest amount in somatoform pain. Regression analyses confirmed that this finding was in part due to a high comorbidity of depressive feelings in both patient groups. We found a discrepancy between increased clinical pain ratings and elevated pressure pain thresholds, indicating a less intense mechanical pain perception in somatoform pain. Correlation analyses demonstrated a significant connection of subjective pain ratings and pressure pain thresholds with depressive feelings.

CONCLUSION

Contrary to the results of other experimental pain studies on chronic muskuloskeletal pain syndromes, we could not confirm central sensitization in somatoform pain disorder. Our findings place the somatoform pain disorder more in the direction of affective disorder such as depression. These findings may improve a better understanding of the disease and also have direct therapeutic implications. The high occurrence of alexithymia and depressive feelings in somatoform pain should be considered in diagnostic and therapeutic regimens of these patients.

Psychosocial Underpinnings of Pain and Sleep Disturbance in Safety-Net Primary Care Patients

Objective

The aim of this study was to uncover possible psychosocial underpinnings of pain and sleep disturbance in a safety-net primary care sample.

Methods

Patients (n = 210) awaiting care in a safety-net primary care clinic waiting room completed measures of cynical hostility, social support, mental health, sleep disturbance, and pain. This study was cross-sectional and observational.

Results

A structural equation model suggested that higher cynical hostility was associated with lower social support, which in turn was associated with poorer mental health, which then corresponded with higher pain and sleep disturbance. All possible indirect (mediational) effects within this model were statistically significant, suggesting a possible route through which cynical hostility may shape pain and sleep, two common presenting problems in primary care.

Conclusions

These findings illustrate the interplay of psychosocial factors with chronic pain and sleep disturbance in a sample of low-income, predominantly African-American patients seeking care at a safety-net primary care clinic. The findings support integrated primary care as a way to target not only behavioral health issues but also the psychosocial factors entangled with physical health.

Alexithymia, empathy, negative affect and physical symptoms in patients with asthma

Although alexithymia has been found to be associated with physical symptoms in psychosomatic disorders such as asthma, mechanisms linking this association are unknown. However, affective alexithymic features may be associated with physical symptoms in the presence of deficits in affective characteristics such as low empathy and high negative affect. This study aimed to assess direct effects of alexithymic traits on physical symptoms and indirect effects of these subscales through empathy and negative affect (e.g. depressive, anxious and stress symptoms) by controlling for asthma severity in patients with asthma. Three hundred patients with asthma completed the Toronto Alexithymia Scale-20 (TAS-20), the Basic Empathy Scale (BES), the Depression Anxiety Stress Scales-21 (DASS-21) and the Physical Symptoms Inventory (PSI). After controlling for asthma severity, the results showed that alexithymia subscales of the TAS-20 had no direct effects on physical symptoms, but the difficulty in identifying feelings (DIF) subscale of the TAS-20 was associated with affective empathy and negative affect. Affective empathy was significantly related to negative affect. Affective empathy and negative affect were associated with physical symptoms. The affective subscale of alexithymia on the TAS-20, that is DIF, indirectly affected physical symptoms through affective empathy and negative affect. Findings suggest that patients with asthma who have high levels of DIF may show high physical symptoms in the presence of low affective empathy and high negative affect.

Alexithymia in individuals with chronic pain and its relation to pain intensity, physical interference, depression, and anxiety: a systematic review and meta-analysis

Numerous studies have examined how alexithymia (difficulty identifying and describing one's emotions and a preference for externally oriented thinking) relates to chronic pain and associated disability. We conducted a systematic review and meta-analysis to summarize individual studies that either assessed alexithymia in individuals with chronic pain vs controls or related alexithymia to pain intensity, physical interference, depression, and anxiety. We searched MEDLINE, Embase, and PsycINFO from inception through June 2017; 77 studies met the criteria (valid assessment of alexithymia in adults or children with any chronic pain condition) and were included in analyses (n = 8019 individuals with chronic pain). Primary analyses indicated that chronic pain samples had significantly higher mean alexithymia scores compared with nonclinical (d = 0.81) and clinical nonpain (d = 0.55) controls. In chronic pain samples, alexithymia was significantly positively associated with pain intensity (d = 0.20), physical interference (d = 0.17), depression (d = 0.46), and anxiety (d = 0.43). Secondary meta-analyses of 14 studies that conducted partial correlations that controlled for negative affect-related measures revealed that alexithymia was no longer significantly related to pain intensity or interference. Meta-analysis findings demonstrated that alexithymia is elevated in individuals with chronic pain and related to greater pain intensity and physical interference, although the latter relationships may be accounted for by negative affect. Critical future work is needed that examines alexithymia assessed using non-self-report measures, develops a person-centered perspective on this construct, and identifies how alexithymia is relevant to the assessment and treatment of individuals with chronic pain.

Alexithymia in Family Caregivers of Advanced Cancer Patients Is Associated with High Personalized Pain Goal Scores: A Pilot Study

Background: Alexithymia, or difficulty identifying and describing emotions and sensations, contributes to an increased risk of chronic pain, and low help-seeking. Objective: To investigate whether family caregivers of advanced cancer patients visiting a palliative care department had alexithymia, and whether this was related to their pain intensity, personalized pain goals, and help-seeking for chronic musculoskeletal pain. Design: A single-center cross-sectional survey. Measurements: Pain intensity was evaluated using a numerical rating scale. Pain improvement was evaluated against personal goals. Alexithymia was assessed using the Toronto Alexithymia Scale-20 (TAS-20), and anxiety and depression using the Hospital Anxiety and Depression Scale. Setting/Subjects: Of 320 family caregivers visiting the palliative care department, 152 (47.5%) had chronic musculoskeletal pain; all 152 were included in the study. Results: Alexithymia was observed in 36.2% of participants. Participants with higher scores on the TAS-20 tended to have higher pain intensity scores and personal pain goal scores. TAS-20 score had the strongest correlation with personal pain goals, with a correlation coefficient of 0.555 (p < 0.001). Conclusions: Pain intensity in family caregivers with alexithymia tended to be high. These participants set higher personal pain goals (lower goals for symptom improvement) than those without alexithymia. We found no difference in personal pain goal response between family caregivers with and without alexithymia. When we examine pain in family members with alexithymia who are caring for cancer patients, we need to recognize that they may set higher personal pain goals and seek less help.

Using the Body When There Are No Words for Feelings: Alexithymia and Somatization in Self-Harming Adolescents

The present case-control study aimed to investigate the relationship between alexithymia and somatic complaints in the psychopathological setting of non-suicidal self-injury (NSSI). A clinical sample of 134 adolescents (115 females; 85.5%) from 12 to 18 years old engaging in NSSI was compared with a control group of 243 high-school students (157 females; 64.6%) from 13 to 18 years old. Data were collected using two questionnaires: The Youth Self-Report 11-18 and the 20 Toronto Alexithymia Scale. In both cases and controls, the presence of somatization and alexithymia was associated with more severe psychopathological problems. Analyses were conducted to explore the association between somatic disorders and alexithymia. In the clinical group, somatic complaints were reported by 95.9% of alexithymic individuals, whereas only 44.3% of alexithymic adolescents reported somatic complaints. A one-way relationship emerged between somatization and alexithymia: while alexithymia would seem to be a factor associated with self-injury, somatic disorders were strongly associated with alexithymia, but not necessarily with self-injury. Among the self-harming adolescents, those with both alexithymia and somatization had a more severe psychopathological picture than the individuals with alexithymia but no somatization. This would suggest that, in the setting of NSSI, greater difficulty with identifying feelings is associated with somatization, and alexithymia would be an attribute common to self-harming behavior and somatization, both of which are characterized by the body being used to express psychological and emotional problems. Future research could further investigate alexithymia in self-harming individuals, in relation to any presence or absence of somatic disorders, with longitudinal assessments on any differences in their manifestation of self-injury and its psychopathological correlates.

Insula Activity to Visceral Stimulation and Endocrine Stress Responses as Associated With Alexithymia in Patients With Irritable Bowel Syndrome

OBJECTIVE

Few studies have investigated associations between alexithymia and physiological mechanisms in psychosomatic diseases. We examined associations between alexithymia and 1) perception and brain processing of visceral stimulation and 2) the endocrine responses to corticotrophin-releasing hormone (CRH) in healthy individuals and patients with irritable bowel syndrome (IBS).

METHODS

The study included 29 patients with IBS and 35 age- and sex-matched healthy controls (HCs). Alexithymia was measured using the 20-item Toronto Alexithymia Scale (TAS-20). Brain responses to rectal distention and its anticipation were measured by functional magnetic resonance imaging and analyzed at a voxel-level threshold of puncorrected < .001 combined with a cluster-level threshold of pFWE-corrected < .05. On a different day, plasma adrenocorticotropic hormone and cortisol responses after intravenous CRH administration were measured.

RESULTS

TAS-20 scores did not differ significantly between patients with IBS and HCs (p = .18). TAS-20 scores correlated positively with the individual rectal discomfort thresholds (βrobust = 0.49, p = .03) and negatively with the rating of fear before rectal distention (βrobust = -1.63, p = .04) in patients with IBS but not in HCs. Brain responses to rectal distention in the right insula and other brain regions were positively associated with TAS-20 scores to a greater extent in patients with IBS than in HCs. Individuals with higher TAS-20 scores (both patients with IBS and HCs) demonstrated stronger adrenocorticotropic hormone responses to CRH administration (F(4,224) = 3.54, p = .008).

CONCLUSION

Higher alexithymia scores are associated with stronger physiological responses, but lower anticipatory fear ratings and higher discomfort thresholds, particularly in patients with IBS.

Emotional intelligence impairments in women with fibromyalgia: Associations with widespread pain

This study aimed at testing the differences in emotional intelligence ability between women with fibromyalgia (cases) and their age-matched counterparts not with fibromyalgia from the general population (controls) and analysing the association between emotional intelligence ability and widespread pain in women with fibromyalgia. A total of 133 cases and 77 controls participated in this cross-sectional study. Controls performed better than cases on emotion understanding. Higher emotion perception and management were significantly associated with lower widespread pain. Therefore, women with fibromyalgia may experience difficulties in understanding emotional information. In fibromyalgia, higher emotion perception and management abilities are independently related to lower widespread pain.

Where does it hurt? Location of pain, psychological distress, and alexithymia among outpatients seeking psychotherapy

Objectives: Physical pain is prevalent among psychiatric outpatients, yet there has been little research regarding the types of pain reported. The purpose of this study was to survey outpatients seeking psychotherapy regarding pain locations and to examine associations between number of pain locations and psychiatric distress and alexithymia.Methods: Two hundred and seventeen patients were recruited from three Canadian hospitals that offer outpatient psychiatry services and short-term therapies. Participants were surveyed about their current physical pain using the Brief Pain Inventory. Participants also completed measures of psychiatric distress (Brief Symptom Inventory-18) and alexithymia (Toronto Alexithymia Scale-20).Results: The three most commonly reported pain locations were lower back, head, and neck. Findings revealed that anxiety, depression and alexithymia were associated with number of reported pain locations. Specifically, participants with three or more pain locations reported significantly higher depression, anxiety and alexithymia in comparison to those with no pain.Conclusions: Back, head and neck pains are highly prevalent among psychiatric outpatients. Multiple pain sites may reflect higher levels of psychiatric distress and greater impairment in emotional processing among psychiatric outpatients.

The Impact of Emotional Regulation Strategies on Pain Catastrophizing in the Context of Interpersonal Relationships

OBJECTIVES

The Communal Coping Model suggests that pain catastrophizing may serve to elicit support from others. What is not known is how emotional regulation, namely emotional inhibition, impacts pain catastrophizing within the context of an interpersonal relationship. Individuals who have a greater tendency to emotionally inhibit may have a greater likelihood to use catastrophizing as a means for seeking support, particularly in relationships characterized by satisfaction and emotional validation.

METHODS

Data were collected from 50 undergraduate couples at the University of Michigan-Dearborn. Participants were videotaped during the completion of an acute pain cold pressor task and completed measures involving pain catastrophizing, emotional inhibition, and relationship dynamics (ie, Ambivalence Over Emotional Expressiveness Questionnaire, White Bear Suppression Inventory, Dyadic Adjustment Scale). In addition, the videotaped interactions were coded for both invalidation/validation and overt expressions of pain catastrophizing.

RESULTS

Emotional inhibition, and both validation and invalidation were associated with pain catastrophizing. Observed validation and invalidation were not, however, directly associated with relationship satisfaction. Hierarchical linear regression showed a significant interaction between thought suppression and relationship satisfaction to predict pain catastrophizing.

DISCUSSION

Results show relationship satisfaction moderates the association between pain catastrophizing and thought suppression in a manner in which couples with high levels of relationship satisfaction who also engage in thought suppression are more likely to use pain catastrophizing as a cognitive strategy to elicit support. This study offers direction into treatment and suggests that couples based cognitive-behavioral treatments that aim to utilize adaptive cognitive and behavioral coping strategies, as well as emotional exploration and validation, may be beneficial.

Biased Competition Favoring Physical Over Emotional Pain: A Possible Explanation for the Link Between Early Adversity and Chronic Pain

BACKGROUND

Early adversity predisposes to chronic pain, but a mechanistic explanation is lacking. Survivors of early adversity with chronic pain often seem impaired in their ability to be aware of, understand, and express distressing emotions such as anger and fear in social contexts. In this context, it has been proposed that pain may at times serve as a "psychic regulator" by preventing awareness of more intolerable emotions.

METHOD

This narrative review builds on the premise that physical pain and emotional pain are conscious experiences that can compete for selective attention. We highlight mechanisms whereby the consequences of early adversity may put emotional pain at a competitive disadvantage. A case history, supportive research findings, and an evidence-based neurobiological model are presented.

RESULTS

Arising from abuse or neglect in childhood, impairments in the adult capacity to attend to and/or conceptualize the emotional meaning of felt distress may be associated with impaired engagement of the default network and impaired top-down modulation of affective response generation processes. Persistent and poorly conceptualized affective distress may be associated with reduced emotion regulation ability, reduced vagal tone, increased inflammation, and amplified nociceptive signals. Attention to physical pain may be reinforced by the temporary reduction in negative emotions that it causes.

CONCLUSIONS

These processes jointly promote biased competition favoring attention to physical pain and away from one's own emotions. They may constitute an unintentional analog of the phenomenon of self-injury in patients with borderline personality disorder in whom the intentional infliction of physical pain serves to downregulate intense emotional distress. Attending to, expressing, and understanding previously unacknowledged psychological distress unrelated to pain may facilitate recovery from chronic pain after early adversity. Mechanistic studies that can validate this clinically derived neurobiological hypothesis are urgently needed.

Relationship between alexithymia and variability of blood pressure measured with ABPM in hypertensive patients

OBJECTIVE

Studies indicates that dysregulation of emotions plays an important role in the etiology of elevated blood pressure (BP). One of the signatures of emotional dysregulation is alexithymia defined as an impaired ability to experience and express emotions. Previous work indicated that primary hypertension (HT) is marked by higher alexithymia, but little research examined the relationship between alexithymia and variability of evaluated BP with 24 h Ambulatory Blood Pressure Monitoring (ABPM) in HT patients.

METHOD

Fifty-five participants diagnosed with hypertension and a matched group of thirty-nine healthy participants filled in The Toronto Alexithymia Scale (TAS-20), a clinical-demographic questionnaire, and were assessed with 24 h ABPM.

RESULTS

After removing those with white coat HT, as expected, hypertensive individuals had a higher total score and all three alexithymia subscales. Furthermore, alexithymia was positively correlated with average values of systolic BP.

CONCLUSION

These findings provided support for the contention that alexithymia is associated with elevated BP, the higher level of alexithymia the higher systolic BP in 24 h BP measurement. Future studies may examine the causal relationship between alexithymia and HT and evaluate the effectiveness of emotional regulation training interventions to reduce BP in people suffering from primary hypertension.

Higher Emotional Awareness Is Associated With Reduced Pain in Irritable Bowel Syndrome Patients: Preliminary Results

OBJECTIVE

Recent evidence indicates that interventions designed to improve emotional awareness reduce pain in irritable bowel syndrome. This preliminary study sought to determine whether trait emotional awareness is associated with typical pain in patients with irritable bowel syndrome.

METHODS

Healthy volunteers (n = 66) and irritable bowel syndrome patients (n = 50) were asked to self-report their typical levels of pain intensity and complete both the Levels of Emotional Awareness Scale and the Somatization Scale of the Brief Symptom Inventory.

RESULTS

Levels of Emotional Awareness Scale scores in irritable bowel syndrome patients did not differ from scores in healthy participants; however, higher Levels of Emotional Awareness Scale scores in irritable bowel syndrome patients predicted lower levels of typical pain intensity (r(45) = -.36, p = .01, 95% CI [-.59, -.08]) and lower levels of somatization (r(45)= -.31, p = .03, 95% CI [-.55, -.02]).

CONCLUSIONS

This inverse relationship between emotional awareness and both pain and somatization symptoms is consistent with evidence that irritable bowel syndrome patients experience reduced pain from therapies designed to improve emotional awareness. The Levels of Emotional Awareness Scale could potentially be used to identify patients who could benefit from such therapy and could potentially be a moderator of response to efficacious psychological therapies.

Alexithymia and Psychological Distress in Patients With Fibromyalgia and Rheumatic Disease

BACKGROUND

Fibromyalgia syndrome (FMS) is a chronic rheumatologic disease characterized by widespread musculoskeletal pain and other psychopathological symptoms which have a negative impact on patients' quality of life. FMS is frequently associated with alexithymia, a multidimensional construct characterized by difficulty in identifying feelings (DIF) and verbally communicating them difficulty describing feelings (DDF) and an externally oriented cognitive thinking style (EOT). The aim of the present study was to investigate the relationship between alexithymia, anxious and depressive symptoms and pain perception, in patients with FMS and other rheumatic diseases (RD).

METHODS

The sample consisted of 127 participants (M = 25, F = 102; mean age: 51.97; SD: 11.14), of which 48 with FMS, 41 with RD and 38 healthy control group (HC). All groups underwent to a test battery investigating anxiety and depressive symptoms (HADS), pain (VAS; QUID-S/-A) and alexithymia (TAS-20).

RESULTS

A high prevalence of alexithymia (TAS ≥ 61) was found in FMS (47.9%) and RD (41.5%) patients, compared to the HC group (2.6%). FMS patients showed significant higher scores than HC on DIF, DDF, EOT, anxiety and depression. The clinical sample, FMS and RD groups combined (n = 89), alexithymic patients (AL, n = 40) exhibited higher scores in pain and psychological distress compared to non-alexithymic patients (N-AL, n = 34). Regression analysis found no relationship between alexithymia and pain in AL, meanwhile pain intensity was predicted by anxiety in N-AL.

CONCLUSION

While increasing clinical symptoms (pain intensity and experience, alexithymia, anxiety, and depression) in patients with fibromyalgia or rheumatic diseases, correlations were found on the one side, between alexithymia and psychological distress, on the other side, between pain experience and intensity. Meanwhile, when symptoms of psychological distress and alexithymia were subthreshold, correlations with pain experience and intensity became stronger.

Emotion regulation in patients with somatic symptom and related disorders: A systematic review

Background

Somatic symptoms and related disorders (SSD) are prevalent phenomena in the health-care system. Disturbances in emotion regulation (ER) are commonly observed in patients suffering from SSD.

Objectives

This review aimed to examine ER processes that characterize SSD by a systematic analysis of the available empirical studies.

Data sources

PsycINFO and PubMed databases for the articles published between January 1985 and June 2018.

Search terms

“emotion/al regulation” or “affect regulation” and various forms of SSD.

Study eligibility criteria

Empirical studies that a) assigned adolescent or adult patients suffering from SSD based on a clinical diagnosis, and b) examined the relationship between ER and SSD, were included.

Study synthesis methods

A tabular summary of the articles was generated according to study characteristics, study quality, variables, and findings. The findings were organized based on ER variables used in the articles and diagnoses of SSD, which were then re-organized under the main constituents of ER (attention, body, and knowledge).

Results

The findings of the 64 articles largely supported the association between SSD and disturbances in ER, which are usually shared by different diagnoses of SSD. The results indicate that patients show a reduced engagement with cognitive content of emotions. On the other hand, bodily constituents of ER seem to depict an over-reactive pattern. Similarly, the patients tend to encounter difficulties in flexibly disengaging their (spontaneous) attention from emotional material.

Limitations

There is a scarcity of longitudinal designs, randomized controlled trials, experiments, and diary studies suited to investigate the short- and long-term causal relationship between ER and SSD. Symptoms of SSD and measures to assess emotion regulation are heterogeneous.

Conclusions and implications

Assessment of ER processes is potentially useful to understand SSD and for treatment planning. Furthermore, a concurrent investigation of the dynamic interaction of the ER modalities promises insights for better understanding of the role of ER in development, course, and maintenance of SSD.

To know or not to know? Mentalization as protection from somatic complaints

Somatization processes are usually associated with a lack of insight or with emotional unawareness, especially in adolescents where the ability for self-reflection is beginning to mature. However, the extent to which different levels of insight explain variations in somatization remains understudied. This study aimed to evaluate whether high-level emotional awareness (comprehension) but not low-level awareness (only attention) is needed to psychologically cope with suffering, thus leading to lower somatization. Specific predictions were: 1) High attention along with High comprehension will be associated with significantly lower frequency of somatic complaints than other combinations (Low attention and Low comprehension, or High attention but Low comprehension); 2) In absence of comprehension, no attention will be more optimal than attention only, because only-attention might work as an amplificatory of suffering without the possibility of processing it. Self-reports of meta-cognitive processes, somatization, and control variables were obtained from 264 adolescents from a non-clinical population (54.5% female; aged 12-18, M = 14.7, SD = 1.7). In line with expectations, results revealed significant differences in the effects of insight positions on somatization: Attention+Comprehension (M = 4.9, SE = 0.9) < Nothing (M = 7.1, SE = 0.3) < Only attention (M = 8.9, SE = 0.7). Compared to Nothing, Attention+comprehension was associated with significantly reduced somatic complaints (B = -2.2, p = 0.03, 95% CI -4,1 to 0.2). However, Only attention was associated with increased somatic complaints compared to the other two conditions (B = 1.8, p = 0.03, 95% CI 0.2 to 3.4; B = 4, CI 95% 1.6-6.3, p = 0.001, respectively). This highlights the role of higher-order awareness (i.e., comprehension or clarity) in the processing of suffering and stresses its value in the adaptive coping of emotional distress.