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.     

Severity of illness and illness behaviour: a comparative study of coronary care patients.

Patients entering a coronary care unit (CCU) usually fall into one of two groups; those with an unequivocal diagnosis of myocardial infarction (MI) who remain to be monitored in CCU for some days before discharge to a general medical ward, and those who fail to attract a diagnosis of MI or other serious illness and are rapidly discharged to a general ward. It was hypothesized that the former group would perceive the severity of their illness as being greater than that of the latter group, and would exhibit patterns of illness behaviour in accord with this perception. In particular, it was expected that patients with MI would exhibit a greater recognition of the presence of serious illness, a greater acceptance of the sick role and a more intense affective response to illness than patients without MI.These expectations were examined by comparing illness behaviour profiles of 120 survivors of MI, with identically obtained profiles of 40 persons admitted to a CCU with chest pain but rapidly discharged with neither a diagnosis of MI or other serious illness. Only the first, relating to the recognition of the presence of serious illness, was confirmed. In all other respects, patterns of illness behaviour among survivors of MI was no different from that among patients without MI.It would seem then that patterns of illness behaviour were more influenced by the element of experience common to the two groups, admission to a CCU, than by differences either in the actual severity of the illness or the degree to which this was recognized. This suggests in turn that patients discharged from a CCU without a diagnosis of MI, are none the less concerned about the integrity of their cardiovascular systems, and if psychological intervention has been shown to benefit patients with MI, it may also be indicated for those patients with the less serious illness.     

Menstrual problems in women with primary affective illness

Reports in the literature on the relationship between manifestations or exacerbations of symptoms of affective psychiatric illness and menstruation are often conflicting and confusing. For example, McClure et al.,¹ in a study investigating premenstrual symptoms of women calling a suicide prevention center, suggest that hypomanic premenstrual symptoms may be an indicator of a tendency to an affective illness. However, Coppen² reports that women suffering from affective disturbance have a normal prevalence of menstrual disorders and that two-thirds of these patients report that affective symptoms are unchanged or improved at menstruation. In contrast, Mandell and Mandell³ found that an increased number of women called the Los Angeles Suicide Prevention Center in the late luteal and menstrual phase of their cycle, and MacKinnon and MacKinnon⁴ report that women who died from accident or suicide did so very much more frequently in the premenstrual phase than at other times. Correlations have also been reported between premenstrual or menstrual phases of cycle and admission to a hospital for acute psychiatric illness.⁵In view of the seemingly conflicting reports in the literature, the present study was undertaken to determine the extent of premenstrual and menstrual somatic and affective disturbances in a carefully selected, well-defined group of women with primary affective illness. The possible relationship between hormonal changes and affective menstrual symptoms is discussed.     

Evidence for a possibly X-linked trait related to affective illness

OBJECTIVE: The present report attempts to replicate on the probands' brothers, a previously reported (1992) negative relationship between maternal grandfather longevity (MGFL) and affective illness in grandsons. Hitherto this finding had not been replicated. To provide further evidence that the association may be recessive and X-linked, we also examined the association between MGFL and affective illness in the probands' mothers. Finally, in order to examine why MGFL might be a predictor of affective illness, the report examines the association of the probands' affective illness and their own mortality. METHOD: A 60-year prospective study of men selected in 1940 and followed until the present day provided good information on depressive illness in relatives and longevity of ancestors. To overcome the uncertainty of depressive diagnoses, we assessed affective illness in the probands categorically, dimensionally, operationally and with the Lazare Personality Inventory. RESULTS: Presence of affective illness in brothers was negatively associated with MGFL (p = 0.003) but maternal affective illness was independent of MGFL. Test items suggesting emotional lability in the probands were significantly and negatively associated with MGFL. Consistent with the association of increased MGFL with low affective distress in the probands, the 70 probands showing the least evidence of affective distress before age 50 had twofold (p < 0.001) lower mortality at 80 than the rest of the sample. The 31 probands manifesting the greatest affective distress manifested twofold higher mortality before age 65 (p < 0.001) than the rest of the sample. CONCLUSION: The strong negative association of proband affective distress -- and equally important -- the positive association of proband mental health with MGFL and the lack of association of maternal longevity and depression with MGFL points to the possibility of a recessive X-gene or genes playing a role in depressive illness.     

Analgesia to painful stimuli in affective illness.

Patients with bipolar and unipolar affective illness (N = 76) were compared with 48 control subjects on a psychophysical pain rating procedure using both threshold and signal detection analysis. Affectively ill patients were more analgesic than controls, and depressed men were significantly more analgesic than depressed women or control subjects. Bipolar men showed a different pattern of analgesia than unipolar patients. Pain appreciation in depressed patients may be related to endogenous opiate-like substances; this could be assessed in narcotic antagonist studies of pain-tolerant depressed subjects.     

Well-being in patients with chronic fatigue syndrome: the role of acceptance

OBJECTIVE: Research in chronic pain patients has shown that accepting the chronic nature of their illness is positively related to quality of life. The aim of this study was to investigate whether acceptance is also associated with better well-being in patients suffering from chronic fatigue syndrome (CFS). METHODS: Ninety-seven patients completed a battery of questionnaires measuring fatigue, functional impairment, psychological distress, and acceptance. RESULTS: Results indicated that acceptance has a positive effect upon fatigue and psychological aspects of well-being. More specifically, acceptance was related to more emotional stability and less psychological distress, beyond the effects of demographic variables, and fatigue severity. CONCLUSION: We suggest that promoting acceptance in patients with CFS may often be more beneficial than trying to control largely uncontrollable symptoms.     

Illness behavior in children of chronic pain patients.

OBJECTIVE: Recent studies on pain behavior have pointed to a relationship between expression of illness in patients with chronic pain and reports of physical complaints in other family members. This article includes two related studies. The aim of the first study was to determine whether, among pain patient families, parents who exhibited higher levels of illness behavior and emotional distress were more likely to report that their children had frequent pain complaints. The aim of the second study was to assess whether children of patients with chronic pain were perceived by their parents to have more pain and illness behavior than children of non-pain parents. METHOD: In the first study, forty-two primary caregivers in families with a parent with chronic pain completed questionnaires regarding their children's pain and illness behavior. In the second study, report of somatic complaints in children of chronic pain parents was compared to complaints in fifty-five children of parents without chronic pain. RESULTS: Results of the first study showed that frequently reported pain in the child was associated with significantly higher levels of parent disability, pain behavior and emotional distress. Results of the second study showed that children of patients with chronic pain were reported to have more frequent abdominal pain and to use more medication than children of parents without pain. CONCLUSIONS: The findings of these studies suggest that children of parents with chronic pain may be at risk for illness behavior, especially when the parents exhibit emotional reactions to their pain.     

Psychiatric illness in diabetes mellitus. Relationship to symptoms and glucose control

The lifetime prevalence of psychiatric illness was determined in 114 patients with diabetes mellitus (types I and II) who were selected randomly from patients undergoing diabetes evaluations at a large medical center. The relationship of psychiatric illness to diabetic control was studied using glycosylated hemoglobin (HbA1) and self-report measures of metabolic symptoms. Seventy-one percent of the patients had a lifetime history of at least one criteria-defined psychiatric illness; affective and anxiety disorders were the most common diagnoses. A significant difference (p = .02) in mean glycosylated hemoglobin levels was observed comparing patients with a recent psychiatric illness (mean = 10.8%) to those never psychiatrically ill (mean = 9.6%). These psychiatrically ill patients also reported more symptoms of poor metabolic control and more distress associated with these symptoms than did patients never psychiatrically ill (p less than .0001 for both). The overall report of diabetes symptoms was unrelated to HbA1 (p = .25) and was influenced primarily by the recent presence of psychiatric disorder (p less than .0001). We conclude that emotional illness is associated with both poorer metabolic control and the increased report of clinical symptoms of diabetes.     

The measurement of abnormal illness behavior: toward a new research agenda for the Illness Behavior Questionnaire

Abnormal illness behavior (AIB) refers to a maladaptive manner of experiencing, evaluating, or acting in response to health and illness that is disproportionate to evident pathology. The construct was originally informed by the sociological notions of the sick role and illness behavior. The present article provides a comprehensive review of the conceptual and empirical development of AIB with a detailed insight into the variety of illness contexts to which it has been applied using the Illness Behavior Questionnaire (IBQ). While the relevance of AIB continues to be demonstrated within the prescribed contexts of the chronic pain and psychiatric literatures, criticisms of AIB and its measurement have arisen when researchers have attempted to move beyond these contexts. In recognition of these criticisms, this article presents a new research agenda to address key limitations that currently impede the broader development and application of AIB. Most importantly, it is proposed that greater consideration needs to be given to the definition of AIB according to type of illness and for general community members without a current illness. The article concludes with comment on the potential practical implications of any future reconceptualization of AIB, including the need to reconsider the manner in which IBQ scores are derived and interpreted, and the need for caution when applying the label "abnormal" in specific illness contexts.     

Affect and vigilance performance in depressive illness

The relationships between the affective states of depression and anxiety on the one hand, and vigilance performance on the other, were examined for 10 neurotic depressive patients, 10 psychotic depressive patients and 10 normal controls. Affect did not consistently and systematically influence vigilance performance for individual subject groups.Combination of all 3 groups did however produce some significant relationships in the hypothesized directions. A significant negative relationship between severity of depressive affect and signal detection performance and a significant curvilinear (inverted U) relationship between anxiety and signal detection performance allowed confirmation of the hypotheses.The results were discussed in terms of a cognitive deficit among patients with depressive illness.     

Pain and illness behaviour: a comparative study.

A 52-item Illness Behaviour Questionnaire (I.B.Q.) was administered to 100 patients referred for the management of pain that had not responded adequately to conventional treatment. A comparison group of 40 patients attending rheumatology, radiotherapy, pulmonary, and physiotherapy clinics, that reported pain as a prominent symptom, also completed the I.B.Q. Responses of the two groups were scored on the seven scales of the I.B.Q. measuring general hypochondriasis, disease conviction, somatic versus psychological perception of illness, affective inhibition, affective disturbance, denial, and irritability. A significant difference emerged on the second scale indicating that patients with intractable pain were more convinced as to the presence of disease, were somatically preoccupied, and could not seem to accept reassurance from a doctor. These attitudes were unrelated to degree of organic pathology. It was suggested that this response pattern may be most usefully conceptualised as a form of “abnormal illness behaviour”.     

The relationship of cognitive styles and affective status to post-operative analgesic utilization

The relationship of post-operative analgesic utilization to field dependence, locus of control and psychologic status was studied in 37 post-cholecystectomy patients. The results show a positive correlation between psychological disturbance and increased medication. External locus and field dependence were also correlated with depression, but not more medication. The findings reject a linear relationship between these two personality variables and pain response, but suggest an interaction between cognitive styles and affective status that augments narcotic utilization.     

The relationship of alexithymia to pain severity and impairment among patients with chronic myofascial pain: comparisons with self-efficacy,catastrophizing, and depression

OBJECTIVE: Alexithymia is elevated among patients with chronic pain, but the relationship of alexithymia to the severity of pain among chronic pain patients is unclear. Also, studies have rarely examined whether alexithymia is unique from other, more widely studied constructs in the chronic pain literature (i.e., self-efficacy, catastrophizing, and depression), and research has not examined how alexithymia relates to the sensory versus affective dimensions of pain. METHODS: Among 80 patients with chronic myofascial pain, we tested how alexithymia (Toronto Alexithymia Scale-20) was related to three competing constructs--self-efficacy, catastrophizing, and depression--and to the sensory and affective dimensions of pain as well as physical impairment. We then determined whether alexithymia remained correlated with pain and impairment when tested simultaneously with each of the three competing constructs. RESULTS: Analyses controlled for patients' sex, age, marital status, and duration of pain. Alexithymia was moderately correlated with less self-efficacy and greater catastrophizing, and substantially correlated with greater depression. Alexithymia was positively related to both affective pain and physical impairment, but was unrelated to sensory pain, whereas all three of the competing constructs were related to both types of pain as well as physical impairment. Regression analyses indicated that alexithymia remained a significant and independent correlate of affective pain severity while controlling for either self-efficacy or catastrophizing, but depression accounted for alexithymia's relationship with affective pain. Also, alexithymia was no longer related to physical impairment, after controlling for any of the other three constructs. CONCLUSION: Although alexithymia is not related to the sensory component of pain, it is correlated positively with the affective or unpleasantness component of pain, independent of self-efficacy or catastrophizing. The emotional regulation deficits of alexithymia may lead to depression, which appears to mediate alexithymia's relationship to affective pain. Alexithymia's relationship with physical impairment appears to be better accounted for by self-efficacy or catastrophizing.     

Health attitudes and psychological distress in patients attending a lithium clinic

ABSTRACT– Health attitudes and psychological distress were investigated in 50 patients attending a lithium clinic and in 50 normal controls. Patients receiving lithium treatment did not report more worry about illness, hypochondriacal attitudes, concern about pain, disease phobia and bodily preoccupations than normals, even though they took fewer precautions about their health and exhibited more self-rated psychological distress. Since most of the psychiatric patients were found to display more fears about illness and death than controls in other studies, this preliminary report may suggest that normal health attitudes are associated with lithium compliance in affective illness.     

Factors affecting anxiety and depression in psychiatric consultation patients

Factors that contribute to dysphoric affects in patients seen on a consultation-liaison service were investigated. Eighty-five subjects were studied to assess the role of character style, locus of control and seriousness of medical illness upon the magnitude of depression and anxiety each patient experienced. Results indicated that the obsessoid individual as well as individuals in pain reported significantly more depression and anxiety than their hysteroid counterparts. The severity of illness did not correlate with greater dysphoria. Those individuals who were more externally located were found to be in greater subjective pain. Furthermore, psychiatric consultants significantly tended to ignore the issue of the pain more often than anxiety and depression. The implications of these findings are discussed as they relate to a patient's personality style and the experience of illness and hospitalization.     

Grief experiences of parents whose children suffer from mental illness

OBJECTIVE: To examine the grief experience of parents of adult children with a mental illness and its relationship to parental health and well-being and parent child attachment and affective relationship. METHODS: Participants were recruited from a variety of organizations throughout Australia that provide support services for sufferers of mental illness and/or for their families. Seventy-one participants (62 mothers and nine fathers) all of whom had a child diagnosed with mental illness volunteered to take part in the study. All completed measures of grief, health status and parent-child relationship. RESULTS: Parents reported experiencing grief in relation to their child's illness as evidenced by intrusive thoughts and feelings and avoidance of behaviour as well as difficulties adapting to and distress associated with reminders of the illness. Parental grief appears to reduce over time, but only in some aspects of grief and after an extended period. Increased parental grief was related to lowered psychological well-being and health status and associated with an anxious/ambivalent and a negative affective parent-child relationship. CONCLUSION: The study provides important insights into the grief experiences of parents following their child's diagnosis with mental illness. The significant relationship between parental grief and parental psychological well-being and health status as well as to parent-child relationship has important implications for health professionals. Foremost amongst these are the need to validate the distress and grief of parents and to better understand how to provide interventions that promote grief work and family bonds while reducing emotional distress and life disruption.     

Personality differences in patients with depressive illness and anxiety neurosis

This study explores personality in subgroups of affective illness. Self-assessment scores on Cattell's 16 Personality Factor (16 PF) Questionnaire were obtained from 87 patients comprising five groups, namely ill and recovered unipolar and bipolar depressives and chronic anxiety (CA) neurotics. It was predicted that the anxiety group would have more abnormal scores than both actively depressed groups, but the three groups had markedly similar traits. The prediction that three different types of personality profiles would be obtained from the two recovered depressive groups and the anxiety group was partly confirmed. However, the scores of the anxious patients were more similar to those of recovered unipolar depressives than either was to recovered bipolar depressives. It is suggested that the similar personalities of unipolar depressives and anxiety neurotics may be aetiologically important. Furthermore, the differences between the two recovered depressive groups supports the idea of distinguishing between sub-populations in studies of affective illness.     

Erythrocyte electrolytes in psychiatric illness

Erythrocyte sodium and potassium were measured in 71 patients with a variety of psychiatric disorders and 39 normal controls. Alterations in red cell sodium and potassium occurred in association with changes with mood state in affective illness. However, alterations in erythrocyte potassium may be a non-specific finding in all psychiatric illness. The methodological limitations of our study are discussed. Our data suggest that further study is required to clarify the role of intracellular electrolyte disturbances in psychiatric illness, particularly affective disorders.     

Family history of affective illness in schizophrenia patients: Symptoms and cognition

This study examined the relationship between having a family history of affective disorder and neuropsychological functioning and PANSS symptoms in schizophrenia patients falling into four exclusive family history groups (affective spectrum disorders, schizophrenia spectrum disorders, both, or neither). Schizophrenia patients with a family history of affective illness had the best performance on IQ tests and executive function measures. Symptoms showed fewer family history group differences. Schizophrenia patients with a family history of affective disorder may be a distinct subtype in the group of schizophrenias and may be biologically more similar to patients with serious affective disorder.     

Infectious mononucleosis: psychological symptoms during acute and subacute phases of illness

Although anecdotal reports suggest that anxiety and depressive disorders may be precipitated by acute infectious mononucleosis (AIM), there are few population-based studies measuring distress and psychiatric disorder during and after infection. The purpose of this research was to study the prevalence of psychiatric disorders and psychological distress in patients with AIM at initial infection and over the subsequent 6 months. In addition, we examined the correlation of baseline biopsychosocial factors with distress at 2 and 6 months postillness. A population-based cohort with AIM was surveyed at initial infection and at 2- and 6-month follow-up visits. Measures included physical and laboratory examinations, trait and state measures of psychological and somatic distress, locus of control, social support, and functioning. Patients also received a structured psychiatric interview during the initial infection. Although transient psychological distress was common during acute infection, few patients met criteria for DSM-III-R psychiatric illness. Greater distress at 2 months was associated with significantly lower social functioning in the month prior to diagnosis and higher aspartate aminotransferase (SGOT/AST) levels, less confidence in the physician and health care system (locus of control), and less severe physical symptoms of AIM at baseline. Greater distress at 6 months was associated with an increased number of adverse life events in the 6 months after developing AIM and more days of reduced activity in the 2 weeks prior to the onset of AIM. This population-based study suggests that few subjects develop DSM-III-R psychiatric disorders with AIM. Both biological and psychosocial factors are highly correlated with psychosocial distress at 2 months, whereas psychosocial factors are more important at 6-month follow-up.