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. Author manuscript; available in PMC: 2020 Nov 1.
Published in final edited form as: Rehabil Psychol. 2019 Aug 8;64(4):469–474. doi: 10.1037/rep0000287

Alexithymia in adolescents with and without chronic pain

Rachel V Aaron 1,2,*, Emma A Fisher 1, Tonya M Palermo 1,2
PMCID: PMC6803044  NIHMSID: NIHMS1042386  PMID: 31393153

Abstract

Purpose/Objective:

Alexithymia refers to reduced emotional awareness, and is associated with higher levels of burden and disability in adults with chronic pain. Limited research has examined alexithymia in adolescents with chronic pain. The current study aimed to (a) determine whether alexithymia was higher in adolescents with (versus without) chronic pain, and (b) examine the relationship between alexithymia and pain experiences in youth.

Research Method/Design:

We assessed alexithymia in 22 adolescents with chronic pain and in 22 adolescents without chronic pain (otherwise healthy), and its relation to pain experiences (i.e., self-reported pain intensity, pain bothersomeness, and pain interference), while controlling for the concomitant effects of psychological distress (i.e., depressive and anxiety symptoms).

Results:

After controlling for psychological distress, adolescents with versus without chronic pain had higher total alexithymia scores (p = .042;η2 = .10), and specifically, greater difficulty identifying feelings (p = .001; η2 = 23). Difficulty identifying feelings was related to worse pain interference (r = .55; p = .015) and pain bothersomeness (r = .55; p = .015).

Conclusions/Implications:

These preliminary findings suggest that adolescents with chronic pain may have greater difficulty identifying their emotions, and that this might be related to increased pain interference and pain bothersomeness.

Keywords: Alexithymia, Chronic Pain, Psychological Distress

Pediatric chronic pain is prevalent in youth (Huguet & Miró, 2008) and constitutes a significant public health problem, costing an estimated $19.5 billion annually in the United States (Groenewald, Essner, Wright, Fesinmeyer, & Palermo, 2014). Chronic pain impacts a youth’s physical, psychological, social and academic functioning (Palermo, 2000), with 5–8% of children and adolescents experiencing severe and disabling pain (Huguet & Miró, 2008). Understanding factors that relate to the experience of chronic pain in youth is important for clarifying its impact and ultimately tailoring pediatric chronic pain interventions.

Emotional factors are key in the experience of chronic pain (Lumley et al., 2011). For example, ample research shows that alexithymia, which refers to difficulty identifying, describing and introspecting on one’s own emotions (Keefer, Taylor, Parker, & Bagby, 2017), is elevated in adults with chronic pain (Di Tella et al., 2017) and associated with greater pain intensity (Porcelli, De Carne, & Leandro, 2014) and pain interference (Atagun et al., 2012). Longitudinal research suggests alexithymia increases risk for the onset or persistence of chronic pain in adults (Baudic et al., 2016; Porcelli, De Carne, & Leandro, 2017). Fortunately, alexithymia can be targeted and improved in psychological intervention. For example, Burger et al. (2016) tested a novel emotional awareness and expression therapy for adults with musculoskeletal pain finding decreased alexithymia and pain intensity post-treatment. Thus, in adults, alexithymia constitutes a modifiable psychosocial factor that relates to chronic pain.

A recent meta-analysis showed that while dozens of studies have examined alexithymia in adults with chronic pain, very few (k = 4) have examined alexithymia in youth with chronic pain (Aaron, Fisher, de la Vega, Lumley, & Palermo, 2019). These studies focused largely on youth with headache relative to comparison samples (Cerutti et al., 2016; Gatta et al., 2011) and did not characterize relationships between alexithymia and pain experiences (e.g., pain intensity, pain interference) in youth. Limited research has examined how psychological distress (e.g., depression, anxiety) relates to the relationship between alexithymia and chronic pain in youth; in adults, accounting for psychological distress can attenuate relationships between alexithymia and pain (Lumley, Smith, & Longo, 2002b) and thus is important to consider.

There are unique developmental considerations to studying alexithymia in youth. Emotional awareness is a developmental construct that increases adolescence (Parker, Eastabrook, Keefer, & Wood, 2010). New research is emerging to better characterize these developmental trends. For example, emotion language comprehension (i.e., providing accurate definitions of emotion words) increases through childhood, plateauing in pre-adolescence. Throughout adolescence, these definitions evolve into increasingly complex, abstract, and mature concepts of emotional constructs (Nook et al., 2019). From adolescence into early adulthood, youth become more precise in their description of their emotional states (Nook, Sasse, Lambert, McLaughlin, & Somerville, 2018). From a methodological perspective, this research suggests that when examining alexithymia in youth with chronic pain, it is essential to examine narrow age ranges to account for developmental trajectories. A limitation of existing studies in this domain is utilization of broad age ranges, often combining children, adolescent and young adult samples.

To address these limitations, the current study examined levels of alexithymia in adolescents with and without chronic pain using a narrow developmental range (i.e., older adolescents aged 14–17). First, we aimed to determine whether alexithymia is higher in adolescents with (versus without) chronic pain. Next, we examined associations between alexithymia and pain experiences (i.e., self-reported pain intensity, pain bothersomeness, and pain interference). We considered depressive and anxiety symptoms as covariates in these analyses. We hypothesized alexithymia would be higher in youth with pain, and related to worse pain experiences.

Methods

These data were part of a pilot experimental study investigating parent-adolescent interactions. This is the first paper from this study. This study was approved by the Institution’s Institutional Review Board.

Participants

We recruited 44 adolescents with and without chronic pain, and their primary caregivers, from the Pacific Northwest of the United States. Participants with chronic pain were recruited from a tertiary children’s hospital. Participants without chronic pain were recruited through online advertisements (e.g., various forums for interested research participants), flyers in the community, and contact with participants who had previously participated in studies in our lab and consented to be contacted about future studies. Adolescents in the chronic pain group experienced the presence of pain for longer than three months. Adolescents in the healthy group did not have a current chronic pain condition. Before consenting families, we first screened for inclusion and exclusion criteria in a short telephone interview with the participating caregiver. Inclusion criteria for both groups included being aged 14–17, having internet access, and having English language proficiency. Exclusion criteria for both groups included cognitive impairment and presence of a chronic health condition such as cancer (both of which were yes/no questions with follow-up as needed). If families were eligible and willing to take part in the study, adolescents and their caregivers provided verbal and electronic consent, and then completed an online questionnaire battery. We contacted 96 families and ultimately enrolled 22 youth with chronic pain (60 declined participation; 14 were ineligible). We recruited a healthy sample from the community: we contacted 50 families and ultimately enrolled 22 healthy adolescents (20 declined; 8 were ineligible).

Sample Size.

As these data were collected as part of an internal pilot project, this study was not specifically powered for the current analyses. However, we conducted a post hoc power analysis using estimates from Gatta et al. (2010) who report large effect sizes in group comparisons in alexithymia in youth with and without tension-type headache (Cohen’s d = .86). Thus, to achieve 90% power to detect a large effect in our current sample, 48 participants were required. With our sample of 44 participants, we were adequately powered to detect large effects only.

Questionnaires

Demographics.

Caregivers completed a demographic questionnaire including items related to household income, caregiver education, and race and ethnicity.

Alexithymia.

The Toronto Alexithymia Scale-20 (TAS-20) is a widely used assessment of alexithymia, and the most frequent tool for assessing alexithymia in individuals with chronic pain (Aaron et al., 2019). It is comprised of three subscales; difficulty identifying feelings, difficulty describing feelings, and externally oriented thinking. Example items include “I have feelings that I can’t quite identify. ” Responses are made on a five-point Likert scale from strongly disagree to strongly agree. Scores are summed to create subscale and total scores with higher scores indicating higher levels of alexithymia. This measure has been used widely in adolescent populations, as well as in the few studies conducted in youth with chronic pain (e.g., Cerutti et al., 2016, Gatta et al., 2015). The TAS-20 has adequate psychometric properties among older adolescents (α = 0.75 in adolescents aged 15–16; Parker et al., 2010), though caution has been advised in interpreting externally oriented thinking scores in youth, as the psychometric properties are not as strong for this particularl TAS-20 subscale. In the current study, Cronbach’s alpha was: 0.89 (TAS-20 Total), 0.79 (difficulty identifying feelings), 0.86 (difficulty describing feelings) and 0.66 (externally oriented thinking).

Pain experiences.

Adolescents in the chronic pain group responded to questions about their pain over the past 7 days. Average pain intensity was assessed with an 11-point Numerical Rating Scale (0 indicates “no pain;” 10 indicates “worst pain possible”), a well-validated approach for assessing pain in youth (von Baeyer et al., 2009). We used a validated self-report questionnaire (Tonya M Palermo, Valenzuela, & Stork, 2004) to obtain assessments of pain bothersomeness and pain interference. Specifically, youth rated the degree to which pain is bothersome or upsetting on a 5-point Likert scale (1 indicates “not at all,” 5 indicates “very much”) and rated pain interference (“how much do aches or pain limit or stop you from doing your usual activities” on a 100-point visual analog scale (0 indicates “does not limit any activities”, 100 = “limits all activities”).

Depressive and Anxiety Symptoms.

Depressive and anxiety symptoms were assessed using respective PROMIS Pediatric Short Forms (version 1.1; Varni et al., 2014). Each measure consists of eight items, and adolescents report on symptoms over the previous seven days on a five-point scale (0 indicates “never”, 4 indicates “almost always”). For each form, item responses are summed, such that higher scores indicate greater depressive symptoms. Total scores are then converted to t-scores (Mean = 50, SD = 10). Internal consistency of both measures were high in this study, with α =.95 for depressive and α =.94 for anxiety symptoms.

Statistical approach

Sample characteristics were summarized by group (pain vs healthy) using descriptive statistics and differences by group were examined using t-tests (age) and chi square (sex, race, household income, parent education) analyses. To test our first aim, we assessed group differences in TAS-20 total and subscale scores using a series of one-way analyses of variance (ANOVA). We then applied analyses of covariance (ANCOVA) to significant findings, to determine whether group differences were accounted for by differences in psychological distress. We report partial eta-squared coefficients to characterize effect sizes of these analyses which can be interpreted as small (η2 = 01), medium (η2 = .06), and large (η2 = .14) effect size. To address our second aim, we examined partial correlations between TAS-20 total and subscale scores and pain experiences, controlling for depressive and anxiety symptoms, among the chronic pain sample only. Statistical significance was set at p<.05.

Results

Table 1 describes demographic characteristics of the sample. The mean age of the overall sample was 15.97 (SD = 1.36) with 67% female participants. The sample was predominantly Caucasian (80%) and middle to upper class (43% of participants had household income above $150K). There were no statistically significant group differences by age, sex, race, household income or parent education (p’s > .05). Depressive and anxiety symptoms are presented in Table 1, as well as test of group differences. In general, both groups reported average levels of depressive and anxiety symptoms, with no significant group differences (ps > .69).

Table 1.

Demographic and psychosocial characteristics of chronic pain and healthy samples.

Chronic Pain
n=22		 Healthy
n=22		 Test of Group Difference
Sex (% female) 74% 59% X2= 3.45, p = .063
Race (%) X2= 5.00, p = .172
      Caucasian 78% 82%
      African-American 5% 14%
      Pacific Islander 0% 5%
      Other 13% 0%
Household Income (%) X2= 1.52, p = .911
      $10,000 - $29,000 4% 0%
      $30,000 - $49,999 13% 9%
      $50,000 - $79,999 4% 5%
      $80,000 - $119,000 13% 18%
      $120,000 - $149,000 13% 18%
      > $150,000 39% 46%
Parent Education (%) X2= 4.99, p = .172
      High School or Less 0% 5%
      Less than College Degree 9% 0%
      College Degree 52% 36%
      Graduate Degree 35% 59%
Psychosocial Factors (M, SD)
      Depressive Symptoms 51.47 (9.79) 50.54 (10.38) t = .170, p = .866, d = .09
      Anxiety Symptoms 52.46 (11.52) 53.06 (11.19) t = −.294, p = .770, d = .09
Pain Location (%)
      Head 44%
      Musculoskeletal 30%
      Stomach 9%
      Chest 4%
      Other 9%
Pain Experiences (M, SD)
      Pain Intensity 4.90 (1.41)
      Pain Bothersomeness 3.20 (0.77)
      Pain Interference 52.40 (26.47)
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Table 1 describes pain characteristics of the chronic pain sample. The primary pain location was head (44%) followed by musculoskeletal (30%). Among adolescents with chronic pain, mean pain intensity was 4.90 (SD = 1.41); pain bothersomeness was 3.20 (SD = 0.77); and pain interference was 52.40 (SD = 26.47).For our first aim, we examined group differences in alexithymia total and subscale scores in teens with and without chronic pain. Means, SD, and results of ANOVA groups differences tests are reported in Table 2. Teens with chronic pain had significantly higher total alexithymia scores compared to teens without chronic pain, with a moderate effect size (F (1, 43) = 4.54, p = .039, η2 = .10). With regards to subscales, teens with chronic pain had higher levels of difficulty identifying feelings, an effect that was large in magnitude (F (1, 43) = 12.33, p = .001, η2 = .23). There were no significant group differences for difficulty describing feelings or externally oriented thinking. In ANCOVAs controlling for both depressive and anxiety symptoms, group differences in total alexithymia (F(1, 40) = 4.40 , p = .042, η2 = 10) and the difficulty identifying feelings subscale (F(1, 40) = 12.17 , p = .001, η2 = .23) remained significant and with similar effect sizes.

Table 2.

Group differences in alexithymia total and subscale scores among teens with and without chronic pain.

Chronic Pain Healthy Comparison ANOVA Results and
Effect Size
n=22 n=22 F p η 2
Difficulty Identifying Feelings 18.5 (5.25) 13.64 (3.82) 12.33 0.001 0.23
Difficulty Describing Feelings 14.73 (5.05) 12.55 (4.48) 2.30 0.137 0.05
Externally Oriented Thinking 19.55 (3.89) 19.00 (4.70) 3.27 0.677 0.00
Total Alexithymia Score 52.77 (12.22) 45.18 (11.41) 4.54 0.039 0.10
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Note. Statistically significant (p < .05) values bolded.

To investigate our second aim, we conducted partial correlations examining associations between TAS-20 total and subscale scores with pain intensity, pain bothersomeness, and pain interference, controlling for depressive and anxiety symptoms, in the chronic pain sample only (Table 3). Greater difficulty identifying feelings was associated with greater pain bothersomeness and interference with moderate effect sizes (rs = 0.55, ps = .015). Relationships between pain intensity and alexithymia were not significant. There were no significant relationships between difficulty describing feelings and externally oriented thinking with pain experiences.

Table 3.

Partial correlations between TAS-20 total and subscale scores and pain characteristics

Pain Experience Variable
Intensity Bothersomeness Interference
r (p) r (p) r (p)
Difficulty Identifying Feelings −0.02 (.942) 0.55 (.015) 0.55 (.015)
Difficulty Describing Feelings −0.12(.639) 0.23 (.349) 0.31 (.190)
Externally-Oriented Thinking 0.06 (.800) 0.08 (.757) 0.07 (.785)
Total −0.04 (.885) 0.35 (.141) 0.38 (.106)
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Note. Statistically significant (p < .05) values bolded.

Discussion

We examined alexithymia in adolescents with and without chronic pain. Alexithymia was elevated in adolescents with versus without chronic pain; in particular, these youth had greater difficulty identifying feelings, an effect that was large in magnitude. Furthermore, greater difficulty identifying feelings was associated with worse pain interference and pain bothersomeness in youth with chronic pain, with large effect sizes. Other aspects of alexithymia (i.e., difficulty describing feelings, externally oriented thinking) were not statistically significantly different in adolescents with versus without chronic pain, and were not associated with pain experiences among those with chronic pain.

The current findings are consistent with previous literature demonstrating elevated alexithymia in youth with chronic pain (Cerutti et al., 2016; Gatta et al., 2011). We extend previous literature by controlling for developmental (i.e., age) and psychological (i.e., depressive and anxiety symptoms) factors that may confound the relationship between alexithymia and chronic pain. Only the alexithymia subscale difficulty identifying feelings was elevated in adolescents with chronic pain, similar to a recent study examining youth with headache (Gatta et al., 2011). Even after accounting for depressive and anxiety symptoms, this group difference was large in effect. Meta-analysis findings of alexithymia in adults suggest difficulty identifying feelings is also most robustly associated with chronic pain, with large effect sizes; though other domains are elevated as well, with weaker effect sizes (Aaron et al., 2019). A limitation of the large body of literature examining alexithymia in chronic pain is its reliance on cross-sectional, self-report studies (Aaron et al., 2019). Future studies are needed to test and derive empirically-driven models explaining the relationship between alexithymia and chronic pain, which could help explain specific subscale findings (e.g., why difficulty identifying feelings is most robustly associated with chronic pain). For example, individuals with chronic pain have reduced ability to accurately discern interoceptive cues (Di Lernia, Serino, & Riva, 2016); modern emotion theory argues that awareness of such cues is essential for generating subjective emotional experiences (Barrett, 2006). Pain may increase the challenge of discerning specific affective cues, which may limit one’s ability to identify specific emotion states; this may be particularly true for youth, who are still learning new emotion words and concepts (Nook et al., 2019). This is one of many possible models that warrants further study.

We also extend previous literature by examining the relationship between alexithymia and pain experiences. Our finding that alexithymia is associated with increased pain bothersomeness and pain interference, with large effect sizes, is also consistent with a number of adult studies (Atagun et al., 2012; Lumley et al., 2002). However, we found no relationship between pain intensity and alexithymia in the current study. This diverges from meta-analysis of adult findings, which show statistically significant, though small in magnitude, associations between alexithymia and pain intensity. It also diverges from laboratory-based studies that show altered pain processes in adults with elevated alexithymia (Kano, Hamaguchi, Itoh, Yanai, & Fukudo, 2007). A number of studies have demonstrated that controlling for psychological distress attenuates the relationship between alexithymia and pain intensity in adults with chronic pain (Hosoi et al., 2010; Lumley, Smith, & Longo, 2002; for exception, see Margalit, Ben Har, Brill, & Vatine, 2014). In the current study, we found average levels of depressive and anxiety symptoms for youth with and without chronic pain, with no significant group differences. If negative affect is a driver of elevated pain intensity in alexithymia, it may help explain the nonsignificant relationship between alexithymia and pain intensity observed in the current study. Other research shows that alexithymia is associated with greater affective, rather than sensory, dimensions of pain (Lumley et al., 2002), which may explain why increased pain bothersomeness and interference were found to be related, rather than pain intensity. Finally, future research is needed to investigate pain processing in youth with chronic pain.

While the lack of group differences in psychological distress differs from many adult studies, it helps tell a more straightforward story in youth. Our findings suggest that alexithymia, particularly the difficulty identifying feelings subscale, is elevated in youth with chronic pain, a magnitude that is large in effect regardless of psychological distress. Identifying and labeling one’s emotions is key in the process of emotion regulation (Gross, 2015). Elevated alexithymia might interfere with successfully coping with chronic pain, as well as the myriad emotional challenges associated with living with chronic pain in youth (e.g., maintaining friendships, keeping up with schoolwork). Longitudinal research studies are needed to examine the relationship between alexithymia and chronic pain over time. Youth with chronic pain are at heightened risk for developing mental health disorders into adulthood (Noel, Groenewald, Beals-Erickson, Gebert, & Palermo, 2016); it is possible that alexithymia in youth with pain poses risk for the eventual development of psychopathology.

In adults, alexithymia can be targeted and improved with psychosocial intervention. Improving the emotional awareness and expression of adults with pain has been shown to result in improvements in pain and mental health outcomes (Burger et al., 2016; Lumley et al., 2017). In schoolchildren, curriculum designed to promote emotional awareness and regulation in youth resulted in a number of interpersonal and academic improvements (Brackett, Rivers, Reyes, & Salovey, 2012). Additional research is needed to determine whether targeting emotional processes, such as alexithymia, in youth with chronic pain results in positive pain-related outcomes.

The current study should be considered in light of its limitations. This is a relatively small sample and findings should be considered preliminary as we were only powered to detect large effects. The assessment of alexithymia in youth is limited, as predominant assessment tools were developed for adult samples. In particular, assessing externally oriented thinking is youth has been questioned, given its low reliability (Parker et al., 2010). We chose to include it in the current study because of its acceptable (albeit poor, α = .66) reliability, and for comparison with extant literature; however, findings related to EOT should be interpreted with caution. Moving forward, it is important to investigate non self-report methods of assessing alexithymia in youth as self-report of alexithymia is subject to social desirability bias (Messina, Fogliani, & Paradiso, 2010) and may also be impacted by negative affect (Makino et al., 2013). The current sample was comprised of patients with general chronic pain conditions but was too small to examine any potential differences based on specific chronic pain condition.

In sum, we conclude that adolescents with chronic pain have greater difficulty identifying their feelings compared to healthy participants, and that this is associated with increased pain interference and pain bothersomeness. These findings are not solely explained by elevated depressive and anxiety symptoms. This adds clarity to the nature of alexithymia in adolescence with chronic pain and raises several issues to address in future research.

Impact.

  • Emerging research suggests that alexithymia can be reduced in targeted interventions for adults with chronic pain, and that changes in alexithymia are associated with improvements in pain experiences. Limited research examining the relationship between alexithymia and chronic pain in adolescents hinders the application of such research to pediatric samples. In this project, we took one step towards this larger goal by establishing preliminary findings regarding the association between alexithymia and pain in adolescents.

  • Adolescents with chronic pain may have reduced ability to identify their feelings, compared to their peers without chronic pain. This may have implications for emotion regulation and mental health. This may also impact the delivery of psychological interventions to youth with chronic pain; for example, these youth may benefit from strategies to label and identify their emotions in therapy.

Acknowledgments

This work was supported by the National Institutes of Health [T32GM086270, K24HD06006]. Rachel Aaron is now at the Johns Hopkins School of Medicine (Baltimore, MD, USA); Emma Fisher is now at the University of Bath (Bath, UK).

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