Alexithymia and Pain in Three Chronic Pain Samples: Comparing Caucasians and African Americans

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.

The Role of Neuro-Immune Interaction in Chronic Pain Conditions; Functional Somatic Syndrome, Neurogenic Inflammation, and Peripheral Neuropathy

Functional somatic syndromes are increasingly diagnosed in chronically ill patients presenting with an array of symptoms not attributed to physical ailments. Conditions such as chronic fatigue syndrome, fibromyalgia syndrome, or irritable bowel syndrome are common disorders that belong in this broad category. Such syndromes are characterised by the presence of one or multiple chronic symptoms including widespread musculoskeletal pain, fatigue, sleep disorders, and abdominal pain, amongst other issues. Symptoms are believed to relate to a complex interaction of biological and psychosocial factors, where a definite aetiology has not been established. Theories suggest causative pathways between the immune and nervous systems of affected individuals with several risk factors identified in patients presenting with one or more functional syndromes. Risk factors including stress and childhood trauma are now recognised as important contributors to chronic pain conditions. Emotional, physical, and sexual abuse during childhood is considered a severe stressor having a high prevalence in functional somatic syndrome suffers. Such trauma permanently alters the biological stress response of the suffers leading to neuroexcitatory and other nerve issues associated with chronic pain in adults. Traumatic and chronic stress results in epigenetic changes in stress response genes, which ultimately leads to dysregulation of the hypothalamic-pituitary axis, the autonomic nervous system, and the immune system manifesting in a broad array of symptoms. Importantly, these systems are known to be dysregulated in patients suffering from functional somatic syndrome. Functional somatic syndromes are also highly prevalent co-morbidities of psychiatric conditions, mood disorders, and anxiety. Consequently, this review aims to provide insight into the role of the nervous system and immune system in chronic pain disorders associated with the musculoskeletal system, and central and peripheral nervous systems.

Chronic Pain Severity and Sociodemographics: An Evaluation of the Neurobiological Interface

Chronic pain is variably associated with brain structure. Phenotyping based on pain severity may address inconsistencies. Sociodemographic groups also differ in the experience of chronic pain severity. Whether differences by chronic pain severity and/or sociodemographic groups are indicated in pain-related areas of the brain is unknown. Relations between 2 measures of chronic pain severity and brain structure via T1-weighted MRI were investigated and sociodemographic group differences explored. The observational study included 142 community-dwelling (68 non-Hispanic Black [NHB] and 74 non-Hispanic White [NHW]) adults with/at risk for knee osteoarthritis. Relationships between chronic pain severity, sociodemographic groups, and a priori selected brain structures (postcentral gyrus, insula, medial orbitofrontal, anterior cingulate, rostral middle frontal gyrus, hippocampus, amygdala, thalamus) were explored. Chronic pain severity associated with cortical thickness. NHB participants reported lower sociodemographic protective factors and greater clinical pain compared to NHWs who reported higher sociodemographic protective factors and lower clinical pain. Greater chronic pain severity was associated with smaller amygdala volumes in the NHB group and larger amygdala volumes in the NHW group. Brain structure by chronic pain stage differed between and within sociodemographic groups. Overall, chronic pain severity and sociodemographic factors are associated with pain-related brain structures. Our findings highlight the importance of further investigating social and environmental contributions in the experience of chronic pain to unravel the complex array of factors contributing to disparities. PERSPECTIVE: The study presents data demonstrating structural brain relationships with clinical pain severity, characteristic pain intensity and chronic pain stage, differ by sociodemographic groups. Findings yield insights into potential sources of previous inconsistent pain-brain relationships and highlights the need for future investigations to address social and environmental factors in chronic pain disparities research.

Applying the NIA Health Disparities Research Framework to Identify Needs and Opportunities in Chronic Musculoskeletal Pain Research

Disparities in the experience of chronic musculoskeletal pain in the United States stem from a confluence of a broad array of factors. Organized within the National Institute on Aging Health Disparity Research Framework, a literature review was completed to evaluate what is known and what is needed to move chronic musculoskeletal pain research forward specific to disproportionately affected populations. Peer-reviewed studies published in English, on human adults, from 2000 to 2019, and conducted in the United States were extracted from PubMed and Web of Science. Articles were reviewed for key words that focused on underrepresented ethnic/race groups with chronic musculoskeletal pain applying health factor terms identified in the NIAHealth Disparity Research Framework four levels of analysis: 1) environmental, 2) sociocultural, 3) behavioral, and 4) biological. A total of 52 articles met inclusion criteria. There were limited publications specific to underrepresented ethnic/race groups with chronic musculoskeletal pain across all levels with particular research gaps under sociocultural and biological categories. Current limitations in evidence may be supplemented by a foundation of findings specific to the broader topic of "chronic pain" which provides guidance for future investigations. Study designs including a focus on protective factors and multiple levels of analyses would be particularly meritorious. PERSPECTIVE: Chronic musculoskeletal pain unequally burdens underrepresented ethnic/race groups. In order to move research forward and to systematically investigate the complex array of factors contributing toward health disparities, an organized approach is necessary. Applying the NIA Health Disparities Research Framework, an overview of the current state of evidence specific to chronic musculoskeletal pain and underrepresented ethnic/race groups is provided with future directions identified.

Beyond Neuropsychiatric Manifestations of Systemic Lupus Erythematosus: Focus on Post-traumatic Stress Disorder and Alexithymia

PURPOSE OF REVIEW

To deepen the comprehension of the role of specific psychological conditions in the pathogenesis and in the treatment of systemic lupus erythematosus (SLE). Specifically, the present comprehensive review aims at examining the association between SLE, alexithymia (AT)-a personality construct referring to the inability to identify, describe, and express sensations, emotions, and physical state-and post-traumatic stress disorder (PTSD), to infer potential biological relationships between these psychopathological issues and disease course, and to draw up a research agenda on gray areas of these topics.

RECENT FINDINGS

Whereas several studies document the presence of neuropsychiatric symptoms in patients with SLE, psychological distress, alexithymia, and post-traumatic manifestations are usually neglected by healthcare professionals and poorly investigated in research contexts. However, the interplay of these aspects, which affect physiologic stress coping mechanisms, potentially plays an important role in SLE pathogenesis. In particular, research documents that cytokine repertoire pattern alteration and hypothalamic-pituitary-adrenal axis impairment leading to inflammation and pain represent the main links between emotional health and immunity. AT and PTSD seem to be common in patients with SLE and account for multiple aspects of SLE-related morbidity. Furthermore, abnormal processing of stressful stimuli as hallmarks of PTSD and AT might promote neuroendocrine dysfunction and dysregulated immunity, thus contributing to the pathogenesis of SLE. A comprehensive, multidisciplinary clinical approach, based on a cooperation between immunologists, rheumatologists, neurologists, and mental health professionals, is crucial to promote patients' global health.

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.

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.

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.

Genito-Pelvic Pain Through a Dyadic Lens: Moving Toward an Interpersonal Emotion Regulation Model of Women's Sexual Dysfunction

Researchers and clinicians alike widely acknowledge the inherently interpersonal nature of women's sexual dysfunctions given that both partners impact and are impacted by these difficulties. Yet theoretical models for understanding the role of interpersonal factors in women's sexual dysfunctions are severely lacking and have the potential to guide future research and inform more effective interventions. The most widely studied sexual dysfunction in women that has espoused a dyadic approach by including both members of affected couples is genito-pelvic pain/penetration disorder (GPPPD). In this article we use the example of GPPPD to introduce a novel interpersonal emotion regulation model of women's sexual dysfunction. We first review current knowledge regarding distal and proximal interpersonal factors in GPPPD. Then, we describe our theoretical model and consider relevant pain and sex-related research on emotion regulation processes-emotional awareness, expression, and experience-in the context of GPPPD, including sexual function, satisfaction, and distress. Next, we review how existing theories from the fields of chronic pain and sex and relationships research have informed our model and how our model further builds on them. Finally, we discuss the implications of our model and its applications, including to other sexual dysfunctions in women.

Emotional Dysregulation as a Factor of Psychosomatic Disturbances in Depression and Cardiovascular Pathology (Analytical Review of Foreign Literature)

The review presents data on cognitive processes of emotional regulation, which are the result of the interaction of the activity of the prefrontal cortex and emotional centers, as the most important pathogenetic link in the psychosomatic relations of depressive and cardiovascular diseases. The neuroanatomical substrate of emotional regulation is the connection between emotional and cognitive processes, which are carried out through bidirectional neuronal interactions between the neocortex and emotional centers. This connection allows emotional centers to modulate cortical activity, and cognitive centers, through descending cortical influences, to modulate the processing of emotions. At present, direct and indirect connections of the frontal cortex with the centers of the autonomic nervous system and its stimulating sympathetic and inhibitory parasympathetic influences have been confirmed. Pathogenetic links of emotional dysregulation include neurobiological and cognitive (rumination, fixation on negative information) processes. The pathophysiological mechanisms of depression and cardiovascular diseases have common links - the dysregulation of the metabolic, immunological and hypothalamus-pituitary-adrenal systems. The tendency to negative emotional response, the prevalence of negative emotions and alexithymia (low awareness of emotions) stand out as predictors of the development of both cardiovascular diseases and depression. Studies aimed at studying the typology and meaning of emotional dysregulation in various forms of psychopathological disorders in the aspect of comorbidity and psychosomatic relationships with somatic diseases can be fruitful in terms of finding new approaches to diagnosis and therapy.

Body talk: Sex differences in the influence of alexithymia on physical complaints among psychiatric outpatients

This study investigated the relationship between alexithymia and physical complaints among psychiatric outpatients, and whether sex moderated this relationship. Participants (N = 185) completed measures of physical complaints (bodily symptom burden, pain severity, pain interference), alexithymia, current symptom (depression, anxiety) distress, and somatosensory amplification (i.e., a person's tendency to be bothered by physical sensations). Hierarchical regression analyses were conducted, controlling for the influence of current psychiatric symptom distress and somatosensory amplification. Findings revealed differential relationships between alexithymia and physical complaints (pain interference) for women and men, in addition to main effects for sex and alexithymia. The findings suggest that the negative influence of alexithymia on bodily-related problems may not be universal.

Alexithymia, not fibromyalgia, predicts the attribution of pain to anger-related facial expressions

BACKGROUND

Fibromyalgia (FM) is a syndrome characterized by chronic, widespread musculoskeletal pain, occurring predominantly in women. Previous studies have shown that patients with FM display a pattern of selective processing or cognitive bias which fosters the encoding of pain-related information. The present study tested the hypothesis of an increased attribution of pain to facial expressions of emotions (FEE), in patients with FM. As previous studies have shown that alexithymia influences the processing of facial expressions, independent of specific clinical conditions, we also investigated whether alexithymia, rather than FM per se, influenced attribution of pain to FEE.

METHODS

One hundred and twenty-three women (41 with FM, 82 healthy controls, HC) were enrolled in this cross-sectional case-control study. We adopted two pain-attribution tasks, the Emotional Pain Estimation and the Emotional Pain Ascription, both using a modified version of the Ekman 60 Faces Test. Psychological distress was assessed using the Hospital Anxiety and Depression Scale, and alexithymia was assessed using the Toronto Alexithymia Scale.

RESULTS

Patients with FM did not report increased attribution of pain to FEE. Alexithymic individuals demonstrated no specific problem in the recognition of basic emotions, but attributed significantly more pain to angry facial expression.

LIMITATIONS

Our study involved a relatively small sample size. The use of self-reported instruments might have led to underestimation of the presence of frank alexithymia in individuals having borderline cut-off scores.

CONCLUSIONS

Alexithymia, rather than FM per se, plays a key role in explaining the observed differences in pain attribution to anger-related facial expressions.

Positive and negative affect mediate the bidirectional relationship between emotional processing and symptom severity and impact in irritable bowel syndrome

INTRODUCTION

Individuals with IBS report higher levels of psychological distress compared to healthy controls. Distress has been associated with emotional processing difficulties but studies have not explored how the relationship between distress and emotional processing affects IBS. There is little research on the role of positive affect (PA) in IBS.

AIMS

(a) If difficulties in self-reported emotional processing are associated with affect and IBS measures (i.e., symptom severity, interference in life roles) (b1) If affect mediates the relationship between emotional processing and IBS measures (b2) Alternative model: if affect mediates the relationship between IBS and emotional processing (c) If PA moderates the relationship between distress and IBS.

METHODS

Participants with a confirmed diagnosis of IBS (n=558) completed a questionnaire including measures of emotional processing (i.e., unhelpful beliefs about negative emotions, impoverished emotional experience), distress, PA, and IBS symptoms/interference. Mediation and moderation analyses were conducted with Maximum Likelihood Estimation.

RESULTS

Distress and PA mediated or partly mediated the relationship between unhelpful beliefs about negative emotions/impoverished emotional experience and both IBS measures. The alternative models were also valid, suggesting a two-way relationship between emotional processing and IBS through affect. PA did not moderate the relationship between distress and IBS.

CONCLUSION

Future interventions in IBS may benefit from not only targeting the management of physical symptoms and their daily impact but also aspects related to the experience of both negative and positive affect, and the acceptance and expression of negative emotions. Longitudinal studies are needed to confirm causal relationships within the explored models.

Emotion dysregulation in hypochondriasis and depression

BACKGROUND

The aim of this study was to explore whether certain aspects of emotion dysregulation (i.e., facets of alexithymia and rumination) are more closely linked to hypochondriasis than to depression and vice versa.

METHODS

Nineteen patients with hypochondriasis (HYP), 33 patients with depression, and 52 healthy control participants completed the Toronto Alexithymia Scale, the Response Styles Questionnaire, and additional symptom and illness behaviour scales. A clinical interview was used to establish DSM-IV diagnoses and to exclude all cases with more than one axis I diagnosis.

RESULTS

Depression patients reported more difficulties describing feelings and more symptom- and self-focused rumination than both HYP patients and healthy individuals, whereas HYP patients differed only from healthy individuals in regard to more difficulties in identifying feelings and more symptom-focused rumination. Multiple regression analyses, including all assessed facets of emotion dysregulation, showed that the degree of somatoform features (somatic symptoms, health anxiety, and illness behaviour) was specifically predicted by higher difficulties in identifying feelings scores, whereas depressive symptom levels were specifically predicted by higher rumination scores.

CONCLUSIONS

Specific associations were found between difficulties in identifying feelings and key features of HYP, whereas depression was linked to a more generalized pattern of emotion regulation deficits.

KEY PRACTITIONER MESSAGE

Emotion dysregulation can be found in hypochondriasis and depression Difficulties in identifying own feelings are specifically linked to somatic symptoms, health anxiety, and illness behaviour, whereas a more generalized pattern of emotion dysregulation is found in relation to depression Further research is needed to investigate whether the effectiveness of current treatments for depression, hypochondriasis, health anxiety, and related disorders could be improved by additional emotion regulation interventions.

Pain experience in Fibromyalgia Syndrome: The role of alexithymia and psychological distress

BACKGROUND

Fibromyalgia (FM) is a chronic pain syndrome with a high prevalence of alexithymia, a personality disposition that affects emotional self-awareness. The present study aimed to investigate the relationship between alexithymia and pain, differentiating between the sensory and affective components of pain experience, in a sample of FM patients.

METHODS

One hundred and fifty-nine FM patients completed a battery of tests assessing pain experience, pain intensity, alexithymia and psychological distress. In order to characterize the clinical profile of alexithymic FM patients, alexithymic and non-alexithymic groups were compared on the different measures. Two regression analyses were performed on the total sample, in order to investigate the relationship between alexithymia and pain, controlling for psychological distress.

RESULTS

Alexithymic FM patients presented higher scores on all the clinical measures compared to non-alexithymic ones. Positive correlations were found between alexithymia and the affective, but not the sensory, dimension of pain experience variables. Regression analyses showed that alexithymia (difficulty identifying feelings factor) ceased to uniquely predict affective pain, after controlling for psychological distress, particularly anxiety. In addition, none of the alexithymia variables significantly explained pain intensity variance. Finally, a significant effect of anxiety in mediating the relationship between alexithymia and affective pain was found.

LIMITATIONS

No longitudinal data were included.

CONCLUSIONS

These findings show the presence of higher levels of pain and psychological distress in alexithymic vs. non-alexithymic FM patients, and a relevant association between alexithymia and the affective dimension of pain experience. Specifically, this relationship appears to be significantly mediated by anxiety.

I too, am America: a review of research on systemic lupus erythematosus in African-Americans

Systemic lupus erythematosus (SLE) is a multi-organ autoimmune disorder that can cause significant morbidity and mortality. A large body of evidence has shown that African-Americans experience the disease more severely than other racial-ethnic groups. Relevant literature for the years 2000 to August 2015 were obtained from systematic searches of PubMed, Scopus, and the EBSCOHost platform that includes MEDLINE, CINAHL, etc. to evaluate research focused on SLE in African-Americans. Thirty-six of the 1502 articles were classified according to their level of evidence. The systematic review of the literature reported a wide range of adverse outcomes in African-American SLE patients and risk factors observed in other mono and multi-ethnic investigations. Studies limited to African-Americans with SLE identified novel methods for more precise ascertainment of risk and observed novel findings that hadn't been previously reported in African-Americans with SLE. Both environmental and genetic studies included in this review have highlighted unique African-American populations in an attempt to isolate risk attributable to African ancestry and observed increased genetic influence on overall disease in this cohort. The review also revealed emerging research in areas of quality of life, race-tailored interventions, and self-management. This review reemphasizes the importance of additional studies to better elucidate the natural history of SLE in African-Americans and optimize therapeutic strategies for those who are identified as being at high risk.

Links among emotional awareness, somatic awareness and autonomic homeostatic processing

Emotional awareness and somatic interoceptive awareness are essential processes for human psychosomatic health. A typical trait of lacking emotional awareness related to psychosomatic symptoms is alexithymia. In contrast, alexisomia refers to the trait of lacking somatic awareness. Links between emotional and somatic awareness and homeostatic processing are also significant for the psychosomatic health. The purpose of the present paper is to review the links among emotional awareness, somatic interoceptive awareness and autonomic homeostatic processing. On the basis of the collected evidence, the following arguments were presented¹: (1) The main subcortical neural substrates for these processes are limbic-related systems, which are also responsible for autonomic functions for optimization of homeostatic efficiency. (2) Considerable studies have shown that autonomic activity and/or reactivity to stress correlate with both emotional and interoceptive awareness. A hypothesis was advocated about the links between the two types of awareness and autonomic function: Autonomic dysfunction, especially high sympathetic tone at baseline and/or attenuated reactivity or variability to stress, appears to be involved in disturbance of emotional and interoceptive awareness. (3) Several studies suggest that a link or a cooperative relationship exists between emotional and somatic awareness, and that somatic awareness is the more fundamental of the two types of awareness. Emotional awareness, somatic awareness and autonomic homeostatic processing generally occur in parallel or concurrently. However, some complex features of pathologies include coexistence of reduced interoceptive awareness and somatosensory amplification. The autonomic homeostatic process is fundamentally involved in emotional and somatic awareness. Investigation of these types of awareness with both neuroimaging evaluations and estimation of peripheral autonomic function are required as next steps for exploration of the relationship between awareness and human somatic states including somatic symptoms as well as general psychosomatic health.

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.

Practice recommendations for pain assessment by self-report with African American older adults

Despite decades of education and clinical practice guidelines underscoring disparities in pain management, pain continues to be inadequately managed in older African American adults as a result of patient, provider, and systems factors. Critical factors influencing pain assessment in older African American adults has not been extensively examined, contributing to a lack of data to inform health care providers' knowledge on culturally-responsive pain assessment in older African Americans. Assessing pain in older African Americans is unique because differences in language, cultural beliefs, and practices moderate how they report and express pain. This paper presents an overview of patient-provider factors that affect pain assessment in older African Americans with a focus on this population's unique cultural beliefs and practices. Recommendations for best practices for performance of a culturally-responsive pain assessment with older African Americans are provided.

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.

[Changes in basic emotion recognition in patients with chronic low back pain. A cross-sectional study analyzing emotion recognition and alexithymia]

BACKGROUND

Persistent chronic pain leads to cortical changes in areas involved in the recognition of emotions. Wand et al. suggest a close correlation between the affective pain component and the extent to which these changes occur. As a consequence, the emotion profile may be influenced and difficulties in emotional communication may arise.

MATERIALS AND METHODS

A total of 49 patients with chronic low back pain (CLBP) were classified as grade 1 + 2 or 3 + 4 using the Graded Chronic Pain Scale (GCPS) questionnaire. In all patients, the ability to recognize basic emotions coded through facial expression was assessed using the Facially Expressed Emotion Labeling (FEEL) test. Furthermore, the Toronto Alexithymia Scale-26 (TAS-26) was used to assess if the patients showed signs of alexithymia. Data of the GCPS grade 3 + 4 (n = 35) group were analyzed.

RESULTS

Findings of the FEEL test indicate that the GCPS grade 3 + 4 group recognized the basic emotion 'surprise' significantly more often (p = 0.001) and showed a higher level of currently perceived anger than unaffected subjects. The TAS-26 showed that 28.5 % of the patients with CLBP were alexithym.

CONCLUSION

The results suggest changes in the recognition of emotions and that patients with CLBP show signs of alexithymia. Further studies with larger sample sizes are required to confirm the detected trends.

Alexithymia is associated with greater risk of chronic pain and negative affect and with lower life satisfaction in a general population: the Hisayama Study

INTRODUCTION

Chronic pain is a significant health problem worldwide, with a prevalence in the general population of approximately 40%. Alexithymia -- the personality trait of having difficulties with emotional awareness and self-regulation -- has been reported to contribute to an increased risk of several chronic diseases and health conditions, and limited research indicates a potential role for alexithymia in the development and maintenance of chronic pain. However, no study has yet examined the associations between alexithymia and chronic pain in the general population.

METHODS

We administered measures assessing alexithymia, pain, disability, anxiety, depression, and life satisfaction to 927 adults in Hisayama, Japan. We classified the participants into four groups (low-normal alexithymia, middle-normal alexithymia, high-normal alexithymia, and alexithymic) based on their responses to the alexithymia measure. We calculated the risk estimates for the criterion measures by a logistic regression analysis.

RESULTS

Controlling for demographic variables, the odds ratio (OR) for having chronic pain was significantly higher in the high-normal (OR: 1.49, 95% CI: 1.07-2.09) and alexithymic groups (OR: 2.56, 95% CI: 1.47-4.45) compared to the low-normal group. Approximately 40% of the participants belonged to these two high-risk groups. In the subanalyses of the 439 participants with chronic pain, the levels of pain intensity, disability, depression, and anxiety were significantly increased and the degree of life satisfaction was decreased with elevating alexithymia categories.

CONCLUSIONS

The findings demonstrate that, in the general population, higher levels of alexithymia are associated with a higher risk of having chronic pain. The early identification and treatment of alexithymia and negative affect may be beneficial in preventing chronic pain and reducing the clinical and economic burdens of chronic pain. Further research is needed to determine if this association is due to a causal effect of alexithymia on the prevalence and severity of chronic pain.

Alexithymia and chronic pain: the role of negative affectivity

OBJECTIVES

Alexithymia has been shown to be associated with key pain-related variables in persons with chronic pain from western countries, but the generalizability of these findings across cultures has not been examined adequately. Also, there remain questions regarding the importance of alexithymia to patient functioning over and above the effects of the general negative affectivity.

METHODS

Alexithymia, pain intensity, pain interference, depression, anxiety, and pain catastrophizing were measured in 128 Japanese patients with chronic pain. Because of the low internal consistency coefficients for 2 of the alexithymia scales (measuring difficulty describing feelings and externally oriented feelings) in our sample, we limited our analyses to a scale assessing difficulty identifying feelings and the total alexithymia scale score.

RESULTS

Although the 20-item Toronto Alexithymia Scale total and the Difficulty Identifying Feelings scale scores were not significantly associated with pain intensity, these scales were associated with pain interference, catastrophizing, and negative affectivity in our sample. However, these associations became nonsignificant when measures of negative affectivity were controlled.

DISCUSSION

The findings support the cross-cultural generalizability of significant associations between alexithymia and both pain interference and catastrophizing. However, whether (1) alexithymia influences patient functioning indirectly by its effects on negative affect or (2) the univariate associations found between alexithymia and measures of patient functioning are a byproduct of both being influenced by negative affect needs to be tested using longitudinal and experimental research.

Alexithymia and its impact on quality of life in a group of Brazilian women with migraine without aura

Background

Migraine is a type of primary headache widely known for its impact on quality of life of patients. Although the psychological aspects of the disease are receiving increasing attention in current research, some of them, as alexithymia, are still seldom explored. This study aimed to provide evidence on the relationships between markers of depression, anxiety, alexithymia, self-reflection, insight and quality of life in migraine.

Methods

Forty female outpatients from a Brazilian specialized headache hospital service and a paired control group were compared.

Results

The results revealed that women with migraine had higher levels of depression, anxiety and alexithymia, and lower levels of quality of life, self-reflection and insight, compared to controls. Quality of life in women with migraine was predicted by levels of depression and one alexithymia factor (ability to express emotions and fantasies). A binary regression analysis between clinical and control groups revealed the migraine group to comprise individuals with high anxiety, low quality of life in the physical domain and the presence of a concrete thinking style.

Conclusions

The results highlight the relevance of considering psychological variables in the routine healthcare practices for migraine patients in general, while keeping steady attention to individual case features.

The alexithymic brain: the neural pathways linking alexithymia to physical disorders

Alexithymia is a personality trait characterized by difficulties in identifying and describing feelings and is associated with psychiatric and psychosomatic disorders. The mechanisms underlying the link between emotional dysregulation and psychosomatic disorders are unclear. Recent progress in neuroimaging has provided important information regarding emotional experience in alexithymia. We have conducted three brain imaging studies on alexithymia, which we describe herein. This article considers the role of emotion in the development of physical symptoms and discusses a possible pathway that we have identified in our neuroimaging studies linking alexithymia with psychosomatic disorders. In terms of socio-affective processing, alexithymics demonstrate lower reactivity in brain regions associated with emotion. Many studies have reported reduced activation in limbic areas (e.g., cingulate cortex, anterior insula, amygdala) and the prefrontal cortex when alexithymics attempt to feel other people's feelings or retrieve their own emotional episodes, compared to nonalexithymics. With respect to primitive emotional reactions such as the response to pain, alexithymics show amplified activity in areas considered to be involved in physical sensation. In addition to greater hormonal arousal responses in alexithymics during visceral pain, increased activity has been reported in the insula, anterior cingulate cortex, and midbrain. Moreover, in complex social situations, alexithymics may not be able to use feelings to guide their behavior appropriately. The Iowa gambling task (IGT) was developed to assess decision-making processes based on emotion-guided evaluation. When alexithymics perform the IGT, they fail to learn an advantageous decision-making strategy and show reduced activity in the medial prefrontal cortex, a key area for successful performance of the IGT, and increased activity in the caudate, a region associated with impulsive choice. The neural machinery in alexithymia is therefore activated more on the physiologic, motor-expressive level and less in the cognitive-experiential domains of the emotional response system. Affects may play an important role in alleviating intrinsic physiologic reactions and adapting to the environment. Deficient development of emotional neural structures may lead to hypersensitivity to bodily sensations and unhealthy behaviors, a possible mechanism linking alexithymia to psychosomatic disorders.

Altered insula activation during pain anticipation in individuals recovered from anorexia nervosa: evidence of interoceptive dysregulation

OBJECTIVE

Recent evidence raises the possibility that symptoms of anorexia nervosa (AN) could be related to impaired interoception. Pain is an interoceptive process with well-characterized neuroanatomical pathways that may overlap to a large degree with neural systems that may be dysregulated in individuals with AN, such as the insula.

METHOD

Functional magnetic resonance imaging (fMRI) was used to assess neural substrates of pain anticipation and processing in 10 healthy control women (CW) and 12 individuals recovered from AN (REC AN) in order to avoid the confounding effects of malnutrition. Painful heat stimuli were applied while different colors signaled the intensity of the upcoming stimuli.

RESULTS

REC AN compared with CW showed greater activation within right anterior insula (rAI), dorsolateral prefrontal cortex (dlPFC) and cingulate during pain anticipation, and greater activation within dlPFC and decreased activation within posterior insula during painful stimulation. Greater anticipatory rAI activation correlated positively with alexithymic feelings in REC AN participants.

DISCUSSION

REC AN showed a mismatch between anticipation and objective responses, suggesting altered integration and, possibly, disconnection between reported and actual interoceptive state. Alexithymia assessment provided additional evidence of an altered ability to accurately perceive bodily signals in women recovered from AN.

Are emotion regulation skills related to adjustment among people with chronic pain, independent of pain coping?

Although emotion regulation capacities have been linked to adjustment among people with chronic pain, researchers have yet to determine whether these capacities are related to functioning independent of established facets of pain coping. The present study was designed to address this gap. A sample 128 Australian adults with chronic pain (44 men, 84 women) completed self-report measures of adjustment (quality of life, negative affect, and pain-related disability), pain coping, and features of emotion regulation (emotion appraisal, perceived efficacy in emotion regulation, emotion utilization). Hierarchical multiple regression analyses indicated that efficacy in emotion regulation was related to quality of life and reduced negative affect even after statistically controlling for effects of other measures of adjustment, pain coping efficacy, and pain coping. Conversely, features of emotion regulation did not improve the prediction model for pain-related disability. Findings suggest emotion regulation capacities may have a unique role in the prediction of specific facets of adjustment among people with chronic pain.

Migraine prevalence, alexithymia, and post-traumatic stress disorder among medical students in Turkey

The aim of this study was to investigate the prevalence of migraine, alexithymia, and post-traumatic stress disorder among medical students at Cumhuriyet University of Sivas in Turkey. A total of 250 medical students participated in this study and answered the questionnaires. The study was conducted in three stages: the self-questionnaire, the neurological evaluation, and the psychiatric evaluation. In the first stage, the subjects completed a questionnaire to assess migraine symptoms and completed the three-item Identification of Migraine Questionnaire, the Toronto Alexithymia Scale, and the Post-Traumatic Stress Disorder Checklist-Civilian Version Scale. The subjects who reported having a migraine underwent a detailed neurological evaluation conducted by a neurologist to confirm the diagnosis. In the final stage, the subjects with a migraine completed a psychiatric examination using the structured clinical interview for DSM-IV-R Axis I. The actual prevalence of migraine among these medical students was 12.6 %. The students with a migraine were diagnosed with alexithymia and post-traumatic stress disorder more frequently than those without migraine. The Migraine Disability Assessment Scale scores correlated with the post-traumatic stress disorder scores. The results of this study indicate that migraine was highly prevalent among medical students in Turkey and was associated with the alexithymic personality trait and comorbid psychiatric disorders including post-traumatic stress disorder. Treatment strategies must be developed to manage these comorbidities.

The relationship between alexithymia and psychological factors in systemic lupus erythematosus

BACKGROUND

Alexithymia has been described as an important dimension in several medical diseases. Systemic lupus erythematosus (SLE) is a chronic condition characterized by unpredictable clinical manifestations. Our aim is to reveal which factors (psychological factors and quality of life dimensions) are associated with alexithymia in SLE patients.

METHODS

Fifty-three sequential SLE patients (ACR criteria) and 41 asthma patients were studied by means of validated scales for alexithymia (Toronto Alexithymia Scale), psychopathology (Brief Symptom Inventory, Hospital Anxiety and Depression Scale), personality dimensions (NEO-FFI), and quality of life (Short Form-36 Health Survey). Systemic lupus erythematosus patient's clinical and laboratorial evaluation was performed by indicators of activity (Systemic Lupus Erythematosus Disease Activity Index) of accumulated damage (Systemic Lupus International Collaborating Clinics/ACR Damage Index), length of disease, and therapy.

RESULTS

An association between alexithymia and psychopathological symptoms, and personality and quality of life dimensions was found. By means of multiple regression analysis, openness and depression were the 2 predictors for alexithymia in SLE patients. We found a high prevalence rate of alexithymia in SLE patients; however, when controlling for depression symptoms (Hospital Anxiety and Depression Scale-Depression, <7), we found a lower percentage of alexithymic traits than that of the total sample of SLE.

CONCLUSION

Alexithymia was associated with psychological distress and with quality of life impairment. Understanding the role of psychological factors in SLE patients may contribute to a more comprehensive perspective of the disease, its impact on patient's daily routine, and how patients adapt emotionally to a chronic disease.

Pain and emotion: a biopsychosocial review of recent research

OBJECTIVE AND METHOD

Research on emotion and pain has burgeoned. We review the last decade's literature, focusing on links between emotional processes and persistent pain.

RESULTS

Neurobiological research documents the neural processes that distinguish affective from sensory pain dimensions, link emotion and pain, and generate central nervous system pain sensitization. Psychological research demonstrates that greater pain is related to emotional stress and limited emotional awareness, expression, and processing. Social research shows the potential importance of emotional communication, empathy, attachment, and rejection.

CONCLUSIONS

Emotions are integral to the conceptualization, assessment, and treatment of persistent pain. Research should clarify when to eliminate or attenuate negative emotions, and when to access, experience, and express them. Theory and practice should integrate emotion into cognitive-behavioral models of persistent pain.

Causal attributions and alexithymia in female patients with fibromyalgia or chronic low back pain

AIMS

Our general objective was to assess the psychological symptoms and the types of causal attributions linked to the symptoms among women chronic pain.

METHODS

70 fibromyalgia (FM) patients, 56 chronic low back pain (CLBP) patients and 72 healthy controls were assessed within a general hospital setting, using the Toronto Alexithymia Scale, Brief Symptom Inventory and Symptom Interpretation Questionnaire. Three-way analysis of variance and chi-square tests were used for inter-group comparisons, followed by multivariate correlation, covariate analysis and linear regression.

RESULTS

Alexithymia, somatization, depression, anxiety and hostility scores were significantly higher in FM patients relative to CLBP patients and healthy controls (P < 0.05). Alexithymia was linked to psychological attributions in FM patients and to somatic attributions in CLBP patients. Psychological attributions, the number of symptoms and difficulty in describing emotions were related to increased anxiety in FM patients. Depression, anxiety and somatization were significantly increased in subjects with high alexithymia scores in the FM group. There was no difference between groups regarding causal attributions.

CONCLUSIONS

Causal attributions do not seem to have distinctive features between functional somatic syndromes like FM and CLBP, though differences might exist between groups as to the effects of coexisting psychological distress symptoms like anxiety and depression.

Correlations between alexithymia and pain severity, depression, and anxiety among patients with chronic and episodic migraine

AIMS

Some studies have found elevated alexithymia among patients with chronic pain, but the correlations between alexithymia and the severity of pain, depression, and anxiety among migraine patients are unclear. The aims of the present study were to investigate whether individuals suffering from episodic migraine (EM) differ from those with chronic migraine (CM) in regards to depression, anxiety, and alexithymia measures and to investigate the association of alexithymia with the results of depression and anxiety test inventories and illness characteristics.

METHODS

A total of 165 subjects with EM and 135 subjects with CM were studied. The Beck Depression Inventory (BDI), State-Trait Anxiety Inventory (STAI), and Toronto Alexithymia Scale (TAS) were administered to all subjects. The correlation between alexithymia and sociodemographic variables, family history of migraine and illness characteristics (pain severity, frequency of episode, duration of illness) were evaluated.

RESULTS

Compared with EM patients, the CM patients had significantly higher scores on measures of depression but not alexithymia and anxiety. There was a positive correlation between TAS scores and age and education in both migraine groups, but there was no correlation between TAS scores and other demographic variables. Depression and anxiety were significantly correlated with alexithymia in both migraine groups.

CONCLUSION

Our results indicate that CM patients are considerably more depressive than EM patients. In this study, depression and anxiety were significantly correlated with alexithymia in both migraine groups. Our results demonstrate a positive association between depression, anxiety, and alexithymia in migraine patients.

Relationships among alexithymia and pain intensity, pain interference, and vitality in persons with neuromuscular disease: Considering the effect of negative affectivity

Alexithymia, the inability to identify or label emotions, has been shown to be associated with pain in patients with a number of chronic pain conditions. We sought to: (1) replicate this association in samples of persons with chronic pain secondary to neuromuscular disease, (2) extend this finding to other important pain-related measures, and (3) to determine whether relationships among alexithymia and study variables existed after controlling for negative affect. One hundred and twenty-nine individuals with muscular dystrophy and chronic pain were administered measures of alexithymia (Toronto Alexithymia Scale, TAS-20), pain intensity (0-10 NRS), pain interference (Brief Pain Inventory Interference scale), mental health (SF-36 Mental Health scale; as a proxy measure of negative affect) and vitality (SF-36 Vitality scale). Higher TAS scores were associated significantly with higher pain intensity and interference, and less vitality. Although the strengths of these associations were reduced when mental health was used as a control, the associations between the Difficulty Identifying Feelings scale and vitality, and the Externally Oriented Thinking and Total TAS scales and pain intensity remained statistically significant. The findings replicate and extend previous findings concerning the associations between alexithymia and important pain-related variables in a sample of persons with chronic pain and neuromuscular disease. Future research is needed to determine the extent to which the associations are due to (1) a possible causal effect of alexithymia on patient functioning that is mediated via its effects on negative affect or (2) the possibility that alexithymia/outcome relationships reflect response bias caused by general negative affectivity.

Alexithymia is associated with increased cardiovascular mortality in middle-aged Finnish men

OBJECTIVE

To explore the associations between alexithymia and increased somatic morbidity. The mechanisms underlying these associations, however, are still unclear. Furthermore, data on the association between alexithymia and mortality are scarce.

METHODS

A total of 2321 Finnish men, aged 46 to 61 years, were followed up for an average of 20 years. Mortality rates were obtained from the national register. The associations between baseline alexithymia and cardiovascular disease (CVD), all-cause, injury, and cancer deaths were examined with adjustments for age and several behavioral (smoking, alcohol consumption, physical activity), physiological (low- and high-density lipoprotein cholesterol, body mass index, systolic blood pressure, history of CVD), and psychosocial (marital status, education, depression) factors.

RESULTS

After all adjustments, the risk of CVD death was increased by 1.2% for each 1-point increase in Toronto Alexithymia Scale-26 scores.

CONCLUSIONS

Alexithymia is associated with increased cardiovascular mortality.

Alexithymia in fibromyalgia syndrome: associations with ongoing pain, experimental pain sensitivity and illness behavior

OBJECTIVE

Alexithymia, a lack of emotional awareness, is common in chronic pain patients. The aim of the study was to investigate the relationship of alexithymia to ongoing pain, experimental pain sensitivity, and illness behavior in patients with chronic musculoskeletal pain.

METHODS

Sixty-eight women with fibromyalgia (age: average, 43.4 years; range, 19-72 years) completed self-report measures on alexithymia (20-Item Toronto Alexithymia Scale), ongoing pain [Visual Analogue Scale, Questionario Italiano del Dolore (QUID), Margolis], psychological distress (Center for Epidemiology Studies-Depression Scale, State-Trait Anxiety Inventory Form Y), and illness behavior (Illness Behavior Questionnaire). Psychophysical tests were performed to assess experimental pain sensitivity, including pain thresholds for mechanical (von Frey, tender point count) and thermal (heat, cold) stimuli, and cold pressor pain threshold and tolerance.

RESULTS

Alexithymia "difficulty identifying feelings" (DIF) was related to higher ratings of the affective-but not the sensory-dimensions of ongoing pain (QUID) and to a lower cold pressor pain tolerance, while alexithymia scores were independent of all pain thresholds. Multiple regression demonstrated that alexithymia DIF ceased to uniquely predict affective ongoing pain when psychological distress or illness behavior was separately controlled for. Higher alexithymia DIF scores were predictive of hypochondriacal illness behavior, over and above what was explained by psychological distress and affective pain.

CONCLUSION

Alexithymia is associated with increased affective pain and hypochondriacal illness behavior. The former relationship is better explained, and possibly mediated, by psychological distress and illness behavior. The hypothesis of a generally increased sensitivity to unpleasant stimuli in alexithymic chronic pain patients is not supported by the data.

Pain intensity and severe pain in young immigrant patients with long-standing back pain

The aim of this study was to explore if self-rated pain intensity and severe pain differed significantly between immigrants from different regions, and if other socio-economic, or clinical, characteristics could predict severe pain. A total of 129 men and 217 women at a primary health centre in Stockholm, Sweden, 27-45 years, on long-term sick leave, were recruited in consecutive order and grouped into a Turkish (n = 122), Southern European (n = 52), Middle East (n = 69) and one Mixed (n = 173) group of immigrants. All were employed in service jobs. Somatic status, depression and level of psychosocial stressors, including pain anxiety, were established by standardized procedures. All reported long-standing disabling back pain. Patients rated intensity of pain "right now" on a 0-100 mm visual analogue scale (VAS) as a last part of the consultation with two doctors. Severe pain was defined as VAS 75-100. Median values (md) with inter-quartile ranges (IQR) were calculated for interval and ordinal data. Non-parametric statistics were used to calculate significant differences between groups. Crude and age-standardized odds ratios (OR) with 95% confidence intervals (95% CI) as rating severe pain were calculated by binary and forward conditional logistic regression. Men and women were analyzed separately. Women had more tender points, (P < 0.001), and reported pain anxiety more often (P < 0.01). Frequency of depression did not differ between the immigrant groups. The VAS-values varied, but not significantly, between the immigrant groups of men and women. Men had lower VAS values than women (md 50, IQR 36-69 vs. md 72, IQR 51-85), (P < 0.001). Women had a three-fold risk to rate severe pain (OR 2.9, 95% CI 1.8-4.7). By sex, no immigrant group had significantly elevated OR to rate severe pain. Being 40-45 year old doubled the OR as rating severe pain. Men with depression, or little education, had high risks as rating severe pain (age-standardized ORs 4.1; 95% CI 1.7-10.0 and 2.7; 95% CI 1.1-6.8, respectively), and so had depressed women (age-standardized OR 1.9; 95% CI 1.1-3.4). Women with pain anxiety had a doubled, not statistically significant, elevated risk (age-standardized OR 2.0, 95% CI 0.95-4.3). The groups did not differ significantly in pain intensity or severe pain. Severe pain was predicted by depressed mood and probably linked to gender, age and sick roles.

Alexithymia and 7.5-year incidence of compensated low back pain in 1207 urban public transit operators

OBJECTIVE

Alexithymia, a lack of emotional awareness, was positively associated with self-reported low back pain (LBP) in cross-sectional studies. We assessed the association of alexithymia with 7.5-year incidence of LBP prospectively in a cohort study of 1207 San Francisco transit operators.

METHODS

Alexithymia was measured by the 20-item Toronto Alexithymia Scale (TAS-20). LBP was assessed by physician-confirmed diagnoses from administrative workers' compensation data. Cox proportional hazards analyses controlled for demographic, behavioral, and physical and psychosocial job factors measured by questionnaire and interview.

RESULTS

Of all drivers, 27.7% (n=334) filed compensated claims for LBP injuries with workers' compensation insurance during the 7.5-year observation time. The hazard ratios from the fully adjusted model were 0.73 (0.56-0.96) for the TAS-20 scale and 0.82 (0.69-0.98) for the subscale "difficulty describing feelings." Alexithymia scores did not predict the duration of compensated work disability.

CONCLUSION

In contrast to previous cross-sectional positive associations between alexithymia and LBP, alexithymia is negatively associated with compensated LBP claims. We hypothesize that shame and reporting behavior may explain these inconsistent results.

Correlation between alexithymia and hypersensitivity to visceral stimulation in human

Empirical studies indicate that alexithymia exacerbates physical illness. However, direct evidence to explain the mechanism of this exacerbation has not been provided. One hypothesis is that alexithymics amplify unpleasant internal signals. In the present study, we investigated how alexithymia influences sensitivity to visceral stimulation in human. In 45 non-clinical healthy subjects (34 males and 11 females), brain processing of visceral sensation induced by colonic distension was examined using H(2)(15)O positron emission tomography (PET). Subjective feeling evaluated on an ordinate scale and neuroendocrine response to stimuli were also measured. The degree of alexithymia was determined using the 20-item of Toronto alexithymia scale (TAS-20), and the correlation between reaction to stimuli and the scores of TAS-20 and its three subscales [difficulty to identify feelings (DIF), difficulty to describe feelings (DDF) and external oriented thinking (EOT)] was evaluated. Greater activation was observed during colonic distension in the pregenual anterior cingulate cortex, right insula and midbrain in the 10 (out of 45) subjects that were identified as alexithymic by TAS-20 scores larger than 61. TAS-20 scores positively correlated with both activity in the right insula and orbital gyrus and adrenaline levels in the blood in response to stimulation. Subjects with high scores of DIF perceived strong pain, urgency for defecation, stress, anxiety, and slight sleepiness. The present study demonstrates that alexithymia is associated with hypersensitivity to visceral stimulation. This finding supports the somatosensory amplification hypothesized in alexithymics and is important to elucidate the influence of alexithymia on brain-gut function, particularly to understand the pathophysiology of FGIDs (functional gastrointestinal disorders).

Relationship of alexithymia to cardiovascular disease risk factors among African Americans

BACKGROUND

Alexithymia, a deficit in emotional awareness and expression, may contribute to cardiovascular disease (CVD) and other diseases. African Americans have a high prevalence of CVD, but almost nothing is known about alexithymia in this ethnic group. This study examined the relationship of alexithymia to a range of risk factors for CVD among African Americans.

METHODS

On a community sample of 162 African American adults, we assessed alexithymia (Toronto Alexithymia Scale-20) and several risk factor domains: physiological (body mass index, blood pressure), behavioral (smoking, exercise), emotional (trait anxiety, depression, and anger; forms of anger expression), racial discriminatory, and socioeconomic (income, education).

RESULTS

Alexithymia was positively correlated with all emotional risk factors (P < .01) and inversely correlated with socioeconomic status (P < .01). Alexithymia has a small, inverse relationship with responses to racism (P < .01) but was not significantly related to the experience of racism. Alexithymia was weakly related to smoking but was unrelated to physiological risk factors. These relationships were largely unchanged when only people without hypertension (n = 116) were studied.

CONCLUSIONS

This pattern of relationships is consistent with findings on ethnic majority samples and suggests that alexithymia as measured with the Toronto Alexithymia Scale-20 is a valid construct among African Americans. It correlates with socioeconomic and emotional variables in this population, but only minimally or not at all with behavioral or physiological factors. If alexithymia influences CVD and other diseases, it appears to do so through social and emotional pathways.

Gender Differences in Pain and Healthcare Utilization for Adult Sickle Cell Patients: The PiSCES Project

BACKGROUND

Many studies have found gender differences in frequency and intensity of pain. Women often report lower pain thresholds, higher pain ratings, and lower tolerance for pain. People with sickle cell disease (SCD) experience both chronic and acute pain throughout life.

OBJECTIVES

To compare adult men and women with SCD in terms of reported pain, crises, healthcare utilization, and opioid usage.

METHODS

Two hundred twenty-six adults with SCD in Virginia were enrolled in a prospective cohort study of pain and completed daily diaries for 1-6 months. Subjects reported for the previous day their maximum SCD-related pain, distress, and interference (0-9 scale), whether they were in a sickle cell crisis, had unplanned utilization (clinic, emergency room, or hospitalization), or used opioids. Episodes of pain, crisis, or utilization were defined as consecutive days of such. Men and women were compared, using analysis of covariance (ANCOVA), controlling for age, SCD genotype, depression, and education.

RESULTS

There were no significant differences between men and women in the percentage of days subjects experienced pain (men 58.6% vs. women 56.5%) or the number of pain episodes/6 months (7.7 vs. 9.6). Mean pain scores were comparable, when subjects were in crisis (5.5 vs. 5.6) or not (2.5 vs. 2.2). Distress and interference results were similar. Men with the SS genotype reported a higher percentage of days with crisis(18.5% vs. 11.6%) and utilization (5.1% vs. 2.7%) than women with the SS genotype.

CONCLUSIONS

Contrary to many studies of pain, particularly chronic pain, men and women with SCD reported generally similar pain experiences.

Alexithymia and pain in temporomandibular disorder

OBJECTIVE

To clarify the relationship of global alexithymia and its facets with pain, assessed prospectively using experience sampling methods (ESMs), in temporomandibular disorder (TMD).

METHODS

People with painful TMD (n=49), pain-free somatic controls (24 people with disk displacement), and healthy controls (n = 28) completed measures of alexithymia (Toronto Alexithymia Scale-20 [TAS-20]) and depressed mood. Patients with painful TMD used ESM to record jaw pain multiple times daily for a week.

RESULTS

The somatic and the healthy controls were equivalent on alexithymia and were combined. The painful TMD group had higher difficulty in identifying feelings but lower externally oriented thinking (EOT); only the latter effect remained after covarying depressed mood. Among patients with painful TMD, the TAS-20 total and EOT correlated positively with pain severity after controlling for depressed mood.

CONCLUSION

Findings highlight the complex relationships of alexithymia and its facets to TMD pain. Research should examine alexithymia facets separately and distinguish between methods that compare groups on alexithymia (e.g., pain patients versus controls) and those that correlate alexithymia with pain severity within a group.