Alexithymia and emotional awareness in females with Painful Rheumatic Conditions

Comorbidities in Psoriatic Arthritis: A Narrative Review

PURPOSE

Psoriatic arthritis (PsA) is a common type of inflammatory arthritis. Patients with PsA present with certain extra-articular manifestations and comorbidities (often collectively called psoriatic disease). The purpose of the present review was to highlight the main comorbidities in the setting of PsA.

METHODS

A narrative review was performed using data from articles found in a search of PubMed and Scopus using the terms psoriatic arthritis and comorbidities.

FINDINGS

Cardiovascular disease (CVD), as well as metabolic and mental health disorders, are the most common comorbidities in patients with PsA. In most cases, underlying inflammation seems to be involved in the increased risk for CVD in PsA, while a bidirectional relationship seems to operate between mental health disorders and psoriatic disease. The treatment of patients with PsA, especially with biologic disease-modifying antirheumatic drugs, has been shown to lead to favorable outcomes regarding the CVD risk. However, it is debatable whether specific drug classes are more effective than others or should be avoided in patients with CVD risk factors. Comorbidity of mental health disorders is even more complex, given the difficulties in measuring and reporting these comorbidities in clinical trials and in clinical practice.

IMPLICATIONS

Future studies are needed for a better understanding of the pathogenic mechanisms of, and the development of better protocols for the identification and treatment of patients with, comorbidities in patients with PsA. The education of clinicians, health care professionals in rheumatology, and patients could be useful in achieving this goal.

Development and validation of a computer program for measuring emotional awareness in German-The geLEAS (German electronic Levels of Emotional Awareness Scale)

Introduction

Emotional awareness is the ability to identify, interpret, and verbalize the emotional responses of oneself and those of others. The Levels of Emotional Awareness Scale (LEAS) is an objective performance inventory that accurately measures an individual's emotional awareness. LEAS assessments are typically scored manually and are therefore both time consuming and cognitively demanding. This study presents a German electronic scoring program for the LEAS (geLEAS), the first non-English computerized assessment approach of the LEAS.

Methods

Data were collected from a healthy German community sample (N = 208). We developed a modern software for computerizing LEAS scoring, an open-source text-based emotion assessment tool called VETA (Verbal Emotion in Text Assessment). We investigated if the software would arrive at similar results as hand scoring in German and if emotional awareness would show similar associations to sociodemographic information and psychometric test results as in previous studies.

Results

The most frequently used scoring method of the geLEAS shows excellent internal consistency (α = 0.94) and high correlations with hand scoring (r = 0.97, p < 0.001). Higher emotional awareness measured by the geLEAS is associated with female gender, older age, and higher academic achievement (all p < 0.001). Moreover, it is linked to the ability to identify emotions in facial expressions (p < 0.001) and more accurate theory of mind functioning (p < 0.001).

Discussion

An automated method for evaluating emotional awareness greatly expands the ability to study emotional awareness in clinical care and research. This study aims to advance the use of emotional awareness as a clinical and scientific parameter.

Emotional awareness and other emotional processes: implications for the assessment and treatment of chronic pain

Emotional awareness (EA) is a key emotional process that is related to the presence and severity of chronic pain (CP). In this report, we describe primary and secondary emotions, discuss the distinction between emotional states and emotional regulation/processing, and summarize theory and research highlighting the significance of EA for CP. We describe ways to assess EA and diagnose centrally-mediated CP, for which emotional processes appear most relevant. We review several psychological interventions designed to enhance EA as well as several broader emotional processing treatments developed to address trauma and psychosocial conflicts underlying many patients' pain. We conclude by offering our perspective on how future integration of emotional processing into pain care could promote recovery from CP.

Emotion regulation as a transdiagnostic factor underlying co-occurring chronic pain and problematic opioid use

Chronic pain is a common and costly condition, and some people with chronic pain engage in problematic opioid use. There is a critical need to identify factors underlying this co-occurrence, so that treatment can be targeted to improve outcomes. We propose that difficulty with emotion regulation (ER) is a transdiagnostic factor that underlies the co-occurrence of chronic pain and problematic opioid use (CP-POU). In this narrative review, we draw from prominent models of ER to summarize the literature characterizing ER in chronic pain and CP-POU. We conclude that chronic pain is associated with various ER difficulties, including emotion identification and the up- and down-regulation of both positive and negative emotion. Little research has examined ER specifically in CP-POU; however, initial evidence suggests CP-POU is characterized by difficulties with ER that are similar to those found in chronic pain more generally. There is great potential to expand the treatment of ER to improve pain-related outcomes in chronic pain and CP-POU. More research is needed, however, to elucidate ER in CP-POU and to determine which types of ER strategies are optimal for different clinical presentations and categories of problematic opioid use. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Alexithymia may explain the relationship between autistic traits and eating disorder psychopathology

BACKGROUND

Autistic people are disproportionately vulnerable to anorexia nervosa and other eating disorders (ED), and within the general population, autistic traits correlate with ED psychopathology. A putative mechanism which may underpin this heightened risk is alexithymia, a difficulty identifying and describing emotional states which is observed in both autism and ED. In two experiments with independent non-clinical samples, we explored whether alexithymia might mediate the heightened risk of eating psychopathology in individuals high in autistic traits.

METHODS

Our first experiment used the PROCESS macro for SPSS to examine relationships between alexithymia (measured by the Toronto Alexithymia Scale (TAS-20)), autistic traits (autism quotient (AQ)), and eating psychopathology (Eating Attitudes Test (EAT-26)) in 121 participants. Our second experiment (n = 300) replicated and furthered this analysis by examining moderating effects of sex and controlling for anxiety and depression as covariates. We also included an additional performance-based measure of alexithymia, the Levels of Emotional Awareness Scale (LEAS).

RESULTS

Study 1 suggested that TAS-20 scores mediated the relationship between heightened autistic traits and eating psychopathology. Replication and further scrutiny of this finding, in study 2, revealed that this mediation effect was partial and specific to the female participants in this sample. The mediation effect appeared to be carried by the difficulty identifying feelings subscale of the TAS-20, even when depression and anxiety were controlled for. LEAS scores, however, were not significantly related to autistic traits or eating psychopathology.

LIMITATIONS

Cross-sectional data prevents any conclusions around the direction and causality of relationships between alexithymia, autistic traits, and eating psychopathology (alongside depression and anxiety), necessitating longitudinal research. Our non-clinical sample was predominantly Caucasian undergraduate students, so it remains to be seen if these results would extrapolate to clinical and/or autistic samples. Divergence between the TAS-20 and LEAS raises crucial questions regarding the construct validity of these measures.

CONCLUSIONS

Our findings with respect to autistic traits suggest that alexithymia could partially explain the prevalence of ED in autistic people and may as such be an important consideration in the pathogenesis and treatment of ED in autistic and non-autistic people alike. Further research with clinical samples is critical to explore these ideas. Differences between men and women, furthermore, emphasize the importance of looking for sex-specific as well as generic risk factors in autistic and non-autistic men and women.

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.

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.

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.

Evaluation of alexithymia in patients affected by rheumatoid arthritis and psoriatic arthritis: A cross-sectional study

Rheumatoid arthritis (RA) and psoriatic arthritis (PsA) are chronic autoimmune diseases leading to joint damage, functional limitation, and disability and are typically associated with several comorbidities. Alexithymia is a personality trait characterized by a disregulation of emotion processing and regulation of emotions that involves a dissociation of emotional and physical responses to life events. A broad association between alexithymia and symptoms as depression, inflammation, and pain has been demonstrated. We aimed at evaluate an association among inflammatory arthritis, as RA and PsA, and alexithymia, and a possible link with clinical characteristics and disease activity.In this cross-sectional study, we enrolled, from January to December 2017, patients affected by RA or PsA referring to the outpatient's clinic of the Rheumatology Unit of the University of Rome Tor Vergata. The 20-item Toronto Alexithymia Scale (TAS-20) was used to assess alexithymia. Disease activity, function, quality of life, and clinimetric indexes were assessed.A total of 50 RA patients and 51 PsA patients were enrolled. The TAS-20 score showed 38.6% (39/101) patients had alexithymia, 26.7% (27/101) patients were in the borderline of alexithymia and 34.7% (35/101) patients did not have alexithymia. A statistical significant association was observed between alexithymia and inflammatory indices (ESR: P = .029, CRP: P = .043) and between alexithymia and clinimetric parameters (ptVAS, pVAS, GH, P < .0001 for all comparisons). A significant trend of association has been demonstrated between alexithymia and female gender and concomitant steroid therapy. No correlations among variables such as age, duration of disease, and comorbidities and alexithymia status were observed.This study suggests that alexithymia assessment should be a part of the comprehensive management of RA and PsA patients.

Measurement Invariance of English and French Language Versions of the 20-Item Toronto Alexithymia Scale

Abstract. The alexithymia construct is commonly measured with the 20-Item Toronto Alexithymia Scale (TAS-20), with more than 20 different language translations. Despite replication of the factor structure, however, it cannot be assumed that observed differences in mean TAS-20 scores can be interpreted similarly across different languages and cultural groups. It is necessary to also demonstrate measurement invariance (MI) for language. The aim of this study was to evaluate MI of the English and French versions of the TAS-20 using data from 17,866 Canadian military recruits; 71% spoke English and 29% spoke French as their first language. We used confirmatory factor analyses (CFAs) to establish a baseline model of the TAS-20, and four increasingly restrictive multigroup CFA analyses to evaluate configural, metric, scalar, and residual error levels of MI. The best fitting factor structure in both samples was an oblique 3-factor model with an additional method factor comprised of negatively-keyed items. MI was achieved at all four levels of invariance. There were only small differences in mean scores across the two samples. Results support MI of English and French versions of the TAS-20, allowing meaningful comparisons of findings from investigations in Canadian French-speaking and English-speaking groups.

Emotional State Can Affect Inflammatory Responses to Pain Among Rheumatoid Arthritis Patients: Preliminary Findings

In a novel pilot study, we investigated how emotional state is related to inflammatory responses to acute pain among women with rheumatoid arthritis. Nine women completed four 5-hour visits that varied only by manipulation of emotion (anger, sadness, happiness, vs. control); in each visit, acute pain was elicited, with blood draws at baseline, 10 minutes, 60 minutes, and 100 minutes post-pain. We examined the effects of within-subjects factors on circulating inflammatory biomarkers interleukin (IL)-6, IL-10, tumor necrosis factor-α, C-reactive protein, and cortisol. There was a main effect of state anger on IL-6, with higher reported anger associated with higher IL-6 across conditions. Further, there were several interactions between state emotion and condition. For example, when individuals reported higher state anger in the sadness condition compared to their own average, they showed higher levels of IL-6 and cortisol. Findings are discussed within a larger literature suggesting that mixed emotional states can contribute to psychological stress and inflammatory responses.

The impact of attachment distress on affect-centered mentalization: An experimental study in psychosomatic patients and healthy adults

Introduction

We investigated the impact of attachment distress on affect-centered mentalization in a clinical and a non-clinical sample, comparing mentalization in a baseline condition to mentalization under a condition of attachment distress.

Methods

The sample consisted of 127 adults who underwent inpatient psychosomatic treatment, and 34 mentally healthy adults. Affect-centered mentalization was assessed by analyzing participants’ narratives on interpersonal situations in a baseline condition with the Levels of Emotional Awareness Scale (LEAS), and an experimental condition inducing attachment distress with the Adult Attachment Projective Picture System (AAP). Unlike the LEAS, the AAP is specifically designed to trigger attachment distress. In both conditions, the narratives were evaluated using the LEAS scoring system. Additionally, we assessed the impact of childhood trauma on affect-centered mentalization with the Childhood Trauma Questionnaire (CTQ).

Results

While the non-clinical sample displayed the same level of affect-centered mentalization in both conditions, the majority of the clinical sample reached higher scores in the attachment distress condition. There was no strong relationship between reported trauma and mentalization scores.

Discussion

Our findings lend strong empirical support to the assumption that affect-centered mentalization is modulated by attachment-related distress. Several possible explanations for the differences between and within the clinical and the non-clinical sample are discussed.

Emotion Regulation in Chronic Disease Populations: An Integrative Review

BACKGROUND AND PURPOSE

Emotion regulation, the experiencing, processing, and modulating of emotional response, is necessary to manage the emotional stressors common in patients with chronic illness. Overwhelming emotional demands deplete the resources needed for everyday self-care management of chronic disease, contributing to poor health outcomes. Emotion regulation is shown to impact behaviors in healthy individuals; yet, a review of literature examining evidence of associations in chronically ill populations is lacking. The purpose of this article is to examine the state of the science relative to the impact of emotion regulation on health outcomes in chronic illness populations.

METHODS

Articles were reviewed (N = 14) that focused on emotion regulation and outcomes of patients with chronic illness.

RESULTS

Indicate that most of the studies focused on these concepts are cross-sectional and measure emotion regulation using various surveys. Potential relationships exist with increased age, male gender, higher education, decreased stress, depressive, and anxiety symptoms being associated with more adaptive emotion regulation. Of primary importance to patients with chronic illnesses is the potential link between greater difficulties with emotion regulation and the presence of chronic disease as well as poorer physical function.

IMPLICATIONS FOR PRACTICE

Care should include attention to affective regulation as well as physiologic responses of chronic illness.

The Relationship Between Alexithymia and Emotional Awareness: A Meta-Analytic Review of the Correlation Between TAS-20 and LEAS

Background: Alexithymia and emotional awareness may be considered overlapping constructs and both have been shown to be related to psychological and emotional well-being. However, it is not clear how the constructs relate to each other empirically or if they may overlap more or less in different populations. The aim of this review was therefore to conduct a meta-analysis of correlations between the most commonly used measures of alexithymia (i.e., the self-report instrument Toronto Alexithymia Scale; TAS-20) and emotional awareness (i.e., the observer-rated instrument Level of Emotional Awareness Scale; LEAS) and to explore potential moderators of their relationship.

Methods: Electronic databases were searched for studies published until the end of February 2018. Study samples were coded as medical conditions, psychiatric disorders and/or healthy controls and sample mean age and gender distribution were extracted. Correlations between the TAS-20 and the LEAS were subjected to a random effect of meta-analysis and moderators were explored in subgroup analyses and meta-regressions. Publication bias was considered.

Results: 21 studies reporting on 28 independent samples on correlation analysis were included, encompassing a total of 2857 subjects (57% women). The aggregated correlation between TAS-20 and LEAS was r = −0.122 (95% CI [−0.180, −0.064]; Z = −4.092; p < 0.001), indicating a significant, but weak, negative relationship between the measures. Heterogeneity was moderate, but we found no indication of significant differences between patients with medical conditions, psychiatric disorders or healthy controls, nor that mean age or percentage of female subjects moderated the relationship. The overall estimate became somewhat weaker after adjusting for possible publication bias.

Conclusions: Our results indicate that TAS-20 and LEAS measure different aspects of emotional functioning. The small overlap suggests that alexithymia and emotional awareness are distinct constructs of emotional well-being. Clinicians need to assess both aspects when considering treatment options for individual patients. Moreover, from the clinical standpoint, an easy reliable and valid way of measuring emotional awareness is still needed. More research should be focus on the differences between alexithymia and emotional awareness in specific conditions, but also how to integrate self-report instrument and observed based measures in a clinical situation.

A Meta-analysis on the Association Between Emotional Awareness and Borderline Personality Pathology

Theories on borderline personality pathology (BPP) suggest that characteristic emotional dysregulation is due to low levels of emotional awareness or alexithymia. This study is the first meta-analysis to systematically review and analyze the evidence. A systematic search of the literature was performed using PsycInfo, Web of Science/MEDLINE, and Scopus. The term "borderline personality disorder" was searched for in conjunction with "emotional awareness," "emotional self-awareness," "emotion recognition," "alexithymia," "emotional processing," "emotional granularity," "emotional intelligence," or "emotion regulation." All references in the included studies were reviewed for additional relevant articles. Thirty-nine studies were then evaluated in a random effects meta-analysis to assess the association between BPP and emotional awareness. An overall moderate positive association between BPP and emotional awareness was significant (r = 0.359; 95% CI [0.283, 0.431]; Z = 8.678; p < 0.001) along with high heterogeneity (Q(38) = 456.7; p < .001; I² = 91.7%). Studies comparing borderline personality disorder to healthy controls yielded a strong association (r = 0.518; 95% CI [0.411, 0.611]). No significant difference was found between studies using instruments for emotional awareness and those using alexithymia instruments. The strongest associations with regard to aspects of alexithymia were found for difficulties in identifying and describing emotions rather than externally oriented thinking. The results corroborate a moderate relationship between low emotional awareness and BPP. However, the mono-method self-report used in almost all studies is found problematic and precludes drawing definite conclusions. Since leading psychotherapeutic treatments strongly focus on increasing emotional awareness, future research should address this issue and further examine to what extent low levels of emotional awareness, particularly alexithymia, can be treated.

Effect of Alexithymia and Emotional Repression on Postsurgical Pain in Women With Breast Cancer: A Prospective Longitudinal 12-Month Study

Alexithymia, the inability to identify and express emotions, and emotional repression, a defensive mechanism used to avoid unpleasant emotional experience, have been associated with chronic pain and medical illness including breast cancer, but whether these constructs might predict pain after breast cancer surgery has not been assessed. The present study was conducted to assess the predictive value of alexithymia and emotional repression in postoperative pain. Anxiety, depression, catastrophizing, and psychological adjustment were also assessed. Data were collected before surgery, and then at 2 days and 2, 3, 6, and 12 months after surgery. We included 100 pain-free women, 96% of whom were followed for up to 12 months. Separate multivariate analyses identified anxiety as a significant predictor of postsurgical pain at 3 months, alexithymia at 3, 6, and 12 months, and body image and catastrophizing predicted acute or subacute pain at 2 months. In contrast, emotional repression was not predictive of pain. The generalized estimating equation approach was used and identified alexithymia as the only significant predictor of pain during the 12-month period after surgery. Alexithymia, but not emotional repression, predicted the development of persistent pain after breast surgery independently of anxiety and depression. Thus, alexithymia might be involved in mechanisms of pain chronicity.

PERSPECTIVE

This prospective study, conducted in women with breast cancer surgery, showed that alexithymia but not emotional repression predicted postsurgical pain. These results highlight the role of dysfunction in emotional processing in the development of postsurgical pain.

Alexithymia, mood states and pain experience in systemic lupus erythematosus and rheumatoid arthritis

This prospective study aims to examine alexithymia, mood states and pain experience in systemic lupus erythematosus (SLE) and rheumatoid arthritis (RA) patients. We enrolled 49 patients with SLE or RA. All patients were evaluated through a set of questionnaires: (1) the Toronto Alexithymia Scale-20 (TAS), (2) the Profile of Mood States (POMS) and (3) visual analogue scale (VAS) and Questionario Italiano sul Dolore, self-report measures to assess pain intensity. Alexithymia was more prevalent in RA (44 %) than in SLE (37.5 %). The mean values of VAS were significantly higher in RA than in SLE population (p < 0.05). A linear relation between TAS and VAS values has been found in SLE (R = 0.714, p < 0.0001). The mean values of POMS regarding all negative dimensions of mood were higher in SLE than in RA. There was a linear relationship between TAS and POMS values in SLE patients (R = 0.7, p < 0.001). We found a high prevalence of alexithymia in SLE and RA. The chronic pain is influenced by emotional status as documented by a linear relation between TAS and VAS values in SLE patients. The difficulty in reporting emotional responses in these patients seems to be mediated by negative mood states.

Alexithymia and fibromyalgia: clinical evidence

This review proposes a critical discussion of the latest studies investigating the presence of alexithymia in patients with fibromyalgia (FM) and its relation to other psychological disorders. The focus is on the most relevant literature exploring the relationship between FM, a chronic pain syndrome, and alexithymia, an affective dysregulation, largely observed in psychosomatic diseases. The articles were selected from the Medline/Pubmed database using the search terms “Fibromyalgia,” “Alexithymia,” and “Psychological Distress.” Of the seven studies fulfilling these criteria, one found no differences between FM patients and the control group, four found significant differences, with higher levels of alexithymia in the FM sample, while two showed unclear results. Overall, the majority of findings highlighted the high prevalence of alexithymia in FM patients. Future studies should clarify the role of alexithymia in FM, paying attention to two principal aspects: the use, as a control group, of patients with chronic pain conditions but a low psychosomatic component, and the use of other measures, in addition to the Toronto Alexithymia Scale (TAS-20), to assess alexithymia.