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. Author manuscript; available in PMC: 2025 Apr 1.
Published in final edited form as: Psychol Trauma. 2022 Jul 11;16(Suppl 1):S2–S9. doi: 10.1037/tra0001315

Childhood Maltreatment and Somatic Symptoms: Examining the Role of Specific Types of Childhood Maltreatment and Alexithymia

Jenna L Adamowicz 1, Zoe Sirotiak 1,2, Emily B K Thomas 1
PMCID: PMC9832170  NIHMSID: NIHMS1843821  PMID: 35816585

Abstract

Objective:

Given the strong association between a history of childhood maltreatment and somatic symptoms, identification of therapeutically modifiable intervention targets is warranted. Alexithymia, or difficulty identifying and describing emotions, may be playing an important role. The present study examined contributions of alexithymia and childhood maltreatment as related to somatic symptoms.

Method:

447 individuals completed measures of childhood maltreatment, alexithymia, and somatic symptoms. Two three-step hierarchical linear regressions were conducted to examine the unique contribution of alexithymia after accounting for demographic characteristics, and childhood maltreatment. The first regression utilized total scores, and the second explored 5 domains of childhood maltreatment, a trauma validity index, and 3 domains of alexithymia.

Results:

In the first linear regression, childhood maltreatment and alexithymia were significantly associated with higher somatic symptoms. In the second linear regression, childhood maltreatment and alexithymia both significantly added to the model; however, only emotional abuse was significantly associated with somatic symptoms.

Conclusions:

In line with previous research, childhood maltreatment and alexithymia are associated with somatic symptoms. Given specific domains of alexithymia were non-significant in this relationship, it appears no one aspect of alexithymia is of greater importance. Future research should examine these associations longitudinally, as improving alexithymia may help improve outcomes in individuals with childhood maltreatment history experiencing somatic symptoms.

Keywords: alexithymia, childhood maltreatment, childhood trauma, medically unexplained symptoms, somatic symptoms

Introduction

Childhood maltreatment refers to a wide range of traumatic experiences that occur during childhood, or prior to age 18 (Bernstein, Ahluvalia, Pogge, & Handelsman, 1997; Bernstein et al., 2003). Childhood maltreatment includes physical and emotional abuse, physical and emotional neglect, and sexual abuse (Bernstein et al., 1997; Bernstein et al., 2003). Global prevalence rates of reported maltreatment range from 17.7-22.6% for physical abuse (Stoltenborgh, Bakermans-Kranenburg, Van Ijzendoorn, & Alink, 2013; Stoltenborgh, Bakermans-Kranenburg, Alink, & van IJzendoorn, 2015), 26.7-36.3% for emotional abuse (Stoltenborgh, Bakermans-Kranenburg, Alink, & Van Ijzendoorn, 2012; Stoltenborgh et al., 2015), 16.3% for physical neglect (Stoltenborgh et al., 2015), 18.4% for emotional neglect (Stoltenborgh et al., 2015), and 3-31% for sexual abuse (Barth, Bermetz, Heim, Trelle, & Tonia, 2013; Pereda, Guilera, Forns, & Gómez-Benito, 2009; Stoltenborgh, Van Ijzendoorn, Euser, & Bakermans-Kranenburg, 2011). Indeed, childhood maltreatment is not a rare occurrence.

A common physical experience among those with a history of childhood maltreatment is referred to as somatic symptoms, or the experience of physical complaints without a known cause (Shipko, 1982). The specific manifestations of somatic symptoms can vary, but common complaints that tend to cluster together include gastrointestinal problems, unexplained chronic fatigue, cardiopulmonary symptoms, cold-like symptoms, and pain (Deary, 1999; Tsai, 2010; Witthöft, Fischer, Jasper, Rist, & Nater, 2016). Relatedly, a systematic review found some of the most frequently reported somatic symptoms in adults generally to include back pain, heart palpitations, dizziness, chest pain, abdominal pain, and excess gas or bloating (Creed & Barsky, 2004).

Many studies have established a relationship between psychological trauma broadly and somatic symptoms. For example, those with a trauma history were 3.7 times more likely to have endorsed four or more somatic symptoms (Andreski, Chilcoat, & Breslau, 1998) and 2.7 times more likely to have a functional somatic syndrome (Afari et al., 2014). Somatic symptoms have also been extensively linked to childhood maltreatment in particular (Katon, Sullivan, & Walker, 2001; Spertus, Yehuda, Wong, Halligan, & Seremetis, 2003; Waldinger, Schulz, Barsky, & Ahern, 2006; Walker et al., 1999). For example, emotional abuse, physical abuse, and emotional neglect in childhood have predicted somatic symptoms in adulthood (Sansone, Wiederman, Tahir, & Buckner, 2009; Spertus et al., 2003). Further, a large study of women from a health maintenance organization found that a history of childhood maltreatment was related to greater reports of somatic symptoms (Walker et al., 1999). Taken together, these findings highlight that many individuals with a history of childhood maltreatment experience somatic symptoms; this association is cause for concern, as persistent somatic symptoms can impair and impact many domains of living, such as quality of life and well-being.

Given the strong association between childhood maltreatment and somatic symptoms, identification of mechanisms for targeted interventions for individuals with a history of childhood maltreatment experiencing somatic symptoms is warranted. One factor that may play an important role in the relationship between childhood maltreatment and somatic symptoms is alexithymia. Alexithymia is conceptualized as a multifaceted construct involving several components: difficulty identifying one’s own feelings, difficulty describing one’s own feelings, and externally oriented thinking (Preece, Becerra, Robinson, Dandy, & Allan, 2018). Difficulty identifying feelings refers to the inability to recognize emotions that arise, such as happiness or anger, whereas difficulty describing feelings refers to the inability to put to words how one is feeling. Externally oriented thinking refers to a thinking style where one’s focus is on stimuli in the external environment, rather than one’s emotional state. The inability to recognize and/or describe one’s emotions can become particularly problematic when individuals have unwanted, or distressing, internal experiences. For example, an individual with a high level of alexithymia may be unable to identify or describe the emotion of anxiety, and instead attribute the physical sensations to a somatic complaint, such as a stomachache or nausea. Alexithymia may be an important factor for mental health providers (i.e., psychologists, psychiatrists) to consider, as greater alexithymia is associated with poor outcomes for both psychotherapy (Ogrodniczuk, Piper, & Joyce, 2011) and pharmacological treatments (Özsahin, Uzun, Cansever, & Gulcat, 2003). Difficulty identifying feelings in particular has been found to be related to poor treatment results (Terock et al., 2015). Fortunately, alexithymia appears to be therapeutically modifiable with clinical intervention (Cameron, Ogrodniczuk, & Hadjipavlou, 2014; Norman, Marzano, Coulson, & Oskis, 2019).

A growing body of research supports the assertion that alexithymia is related to childhood maltreatment (Brown, Fite, Stone, Richey, & Bortolato, 2018; Güleç et al., 2013; Kooiman et al., 2004; Zlotnick, Mattia, & Zimmerman, 2001). Emotional abuse has been shown to be associated with externally oriented thinking and difficulty describing feelings, whereas emotional neglect has been associated with difficulty identifying feelings (Brown et al., 2018). Emotional abuse, emotional neglect, and physical neglect were related to alexithymia (Güleç et al., 2013; Zlotnick et al., 2001). Alexithymia was related to greater somatic symptoms (Taycan, Özdemir, & Taycan, 2017) and one review found the difficulty identifying feelings dimension to be most highly related (De Gucht & Heiser, 2003).

There is also preliminary empirical support identifying childhood emotional maltreatment (emotional abuse and emotional neglect) as particularly important in the relationship with both alexithymia and somatic symptoms. Smith and Flannery-Schroeder (2013) examined the association between childhood emotional maltreatment, somatic symptoms, and alexithymia. Findings indicated that childhood emotional maltreatment was moderately associated with both somatic symptoms and alexithymia. Moreover, the authors found that after controlling for sex and other forms of childhood maltreatment (physical abuse, sexual abuse, and physical neglect), only childhood emotional maltreatment was significantly associated with these outcomes.

As such, the present study aims to further examine the roles of alexithymia and childhood maltreatment in somatic symptoms. Notably, the present study will contribute to the extant literature by examining specific domains of childhood maltreatment and alexithymia to determine whether a particular type of childhood maltreatment or alexithymia associate with greater somatic symptoms. The present study will examine all forms of childhood maltreatment (emotional abuse, physical abuse, sexual abuse, emotional neglect, physical neglect) in relationship to somatic symptoms. By including all forms of maltreatment, the present study can help to replicate the Smith and Flannery-Schroeder (2013) findings that emotional neglect and emotional abuse account for all of the variance in somatic symptoms, beyond the contributions of physical abuse, sexual abuse, and physical neglect. Further, the present study will examine the contributions of the unique components of alexithymia. Better understanding which components of alexithymia impact somatic symptoms can aid in the development of specific types of targeted preventive interventions for those who have experienced childhood maltreatment. It was hypothesized that childhood maltreatment and alexithymia would significantly and positively relate to greater somatic symptoms. It was also expected that alexithymia would significantly and uniquely contribute to the variance in somatic symptoms, even with the contribution of childhood maltreatment in the model. Based on prior work (Güleç et al., 2013; Smith & Flannery-Schroeder, 2013), both emotional abuse and emotional neglect were expected to be associated with greater somatic symptoms. The examinations of specific components of alexithymia were exploratory.

Materials and Methods

Participants and procedures

A total of 447 undergraduates from a large university in the Midwestern United States participated in the current study. This study was approved by the Institutional Review Board, and informed consent was obtained from all participants. Students were recruited from a study pool that provided partial course credit for participation. Eligibility criteria included enrollment in a psychology course, ability to read English, and aged 18-26 years old. The average age was 18.66 (SD = 1.02). The majority identified as female (76.5%), white (81.9%), non-Hispanic (89.5%), and heterosexual (87.9%). Most participants were in the first year of college (68.5%), unemployed (61.1%), and single (61.1%). Descriptive characteristics of the sample are provided in Table 1.

Table 1.

Descriptive statistics of the sample (n = 447).

Characteristics
Age, M years ± SD 18.66 ± 1.02
Gender identity, N(%)
 Male 101 (22.6%)
 Female 342 (76.5%)
 Transgender 2 (.4%)
 Other 2 (.4%)
Race, N(%)
 White 366 (81.9%)
 Asian 43 (9.6%)
 African American or Black 10 (2.2%)
 American Indian or Alaska Native 1 (.2%)
 Native Hawaiian or Pacific Islander 1 (.2%)
 Biracial or multiracial 25 (5.6%)
 Missing 1 (.2%)
Ethnicity, N(%)
 Hispanic or Latinx 45 (10.1%)
 Non-Hispanic or Latinx 400 (89.5%)
 Missing 2 (.4%)
Year in school, N(%)
 First year 306 (68.5%)
 Second year 99 (22.1%)
 Third year 31 (6.9%)
 Fourth year 5 (1.1%)
 Fifth year+ 5 (1.1%)
 Missing 1 (.2%)
Employment status, N(%)
 Full-time 13 (2.9%)
 Part-time 158 (35.3%)
 Unemployed 273 (61.1%)
 Missing 3 (.7%)
Sexual orientation, N(%)
 Heterosexual 393 (87.9%)
 Homosexual 13 (2.9%)
 Bisexual 36 (8.1%)
 Other 4 (.9%)
 Prefer not to disclose 1 (.2%)
Relationship status, N(%)
 In a relationship 174 (38.9%)
 Single 273 (61.1%)
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Measures

Demographics.

Age, gender identity, race, ethnicity, year in school, employment status, sexual orientation, and relationship status were assessed. Due to an auto-selection feature of the survey platform wherein age 18 was auto-filled, age was missing among the surveys of participants who otherwise completed the questionnaires (n = 79). Importantly, age was an inclusion criterion for the study, and most of the missing data corresponded with first or second-year student status (87.4%).

Childhood maltreatment.

Childhood maltreatment was measured with the Childhood Trauma Questionnaire (CTQ-SF-SR)(Bernstein et al., 2003). Items related to experiences before the age of 18 are rated on a 5-point Likert scale ranging from never true to very often true. Higher scores indicate greater childhood adversity (range: 25-125). Items make up five subscales of five items each: emotional abuse, physical abuse, sexual abuse, emotional neglect, and physical neglect. Sample items include: “When I was growing up, people in my family said hurtful or insulting things to me” (emotional abuse); “When I was growing up, people in my family hit me so hard that it left me with bruises or marks” (physical abuse); “When I was growing up, someone tried to touch me in a sexual way, or make me touch them” (sexual abuse); “When I was growing up, people in my family felt close to each other” (emotional neglect – reverse scored); “When I was growing up, I didn't have enough to eat” (physical neglect); and “When I was growing up, I had the perfect childhood” (minimization and denial). The three-item minimization and denial validity scale examines underreporting (range: 5 – 15) and has been strongly recommended for inclusion in analyses (MacDonald et al., 2016). Reliability in the current sample was adequate (total α = .92; emotional abuse α = .89; physical abuse α = .77; sexual abuse α = .94; emotional neglect α = .88, physical neglect α = .67; minimization/denial α = .89).

Alexithymia.

Alexithymia was measured with the Perth Alexithymia Questionnaire (PAQ)(Preece et al., 2018). Items are rated on a 7-point Likert scale ranging from strongly disagree to strongly agree. Responses are based on how individuals perceive and experience personal bad (or unpleasant) and good (or pleasant) emotions. Higher scores indicate greater alexithymia (range: 24-168). The 24 items make up three unique component subscales: difficulty identifying own feelings, difficulty describing own feelings, and externally oriented thinking. A fourth component scale (difficulty appraising own feelings) was not used as it includes only items from difficulty identifying and describing feelings component subscales. Sample items include: “When I'm feeling bad, I can't tell whether I'm sad, angry, or scared” (difficulty identifying feelings); “When I'm feeling good, I can't talk about those feelings in much depth or detail” (difficulty describing feelings); “I prefer to just let my feelings happen in the background, rather than focus on them” (externally oriented thinking). Reliability in the current sample was adequate (total α = .96; difficulty identifying feelings α = .91; difficulty describing feelings α = .90; externally oriented thinking α = .76).

Somatic symptoms.

Somatic symptoms were measured with the Patient Health Questionnaire (PHQ-15)(Kroenke, Spitzer, & Williams, 2002). Items are rated on a 3-point Likert scale, ranging from not at all to bothered a lot, regarding experiences over the past four weeks (e.g., stomach, back, or joint pain). Higher scores on the 15-item scale indicate greater somatic symptoms (range: 0-30). Reliability in the current sample was adequate (α = .80).

Statistical analyses

Analyses were conducted in SPSS, version 27.0 (IBM, 2020). Data were examined for normality, outliers, skewness, and kurtosis. Then, item-level missingness was assessed. If ≤20% of items were missing from a scale, items were imputed by subscale with person mean imputation. If >20% of items were missing from a scale, the score was identified as missing and excluded from the analyses (Hawthorne, Hawthorne, & Elliott, 2005). Missing data were rare; the number (and percentage) of imputed items on each of the scales were: CTQ: 17 (.14%), PAQ: 5 (.05%), PHQ-15: 0 (0%). Next, demographic variables were examined for inclusion as covariates if the predictor was associated with the somatic symptoms. Continuous variables were examined with bivariate correlation, and dichotomous variables were examined with independent sample t-tests.

For the primary analysis, a three-step hierarchical linear regression analysis was conducted to examine the unique contribution of alexithymia in accounting for variance in somatic symptoms (Step 3) after accounting for demographic characteristics (Step 1) and childhood trauma (Step 2). If significant, a second three-step hierarchical regression analysis was conducted to examine the unique contributions of three components of alexithymia (difficulty identifying feelings, difficulty describing feelings, and external oriented thinking; Step 3) in accounting for variance in somatic symptoms, after demographic characteristics (Step 1) and the five components of childhood trauma and the validity subscale (emotional abuse, physical abuse, sexual abuse, emotional neglect, physical neglect, and minimization/denial; Step 2). The minimization and denial subscale of the CTQ was included given findings indicating that failure to include this subscale may result in underestimation of the impact of childhood maltreatment on outcomes (MacDonald et al., 2016). Multicollinearity was examined in each model using variance inflation factors (VIFs), using a cutoff of 10 (Kleinbaum, Kupper, Nizam, & Rosenberg, 2013).

Results

Preliminary analyses.

Normality data from the measures were acceptable, and no outliers were identified. Demographic variables were examined for inclusion as covariates. Age was not significantly correlated with somatic symptoms (r(368) = −.07, p = .22). Between-group comparisons were conducted for gender identity, race, ethnicity, year in school, employment status, sexual orientation, and relationship status. Given the low sample size within categories of gender identity, race, year in school, employment status, and sexual orientation, categories were collapsed to examine group differences. Males and females differed significantly in somatic symptoms (male M(SD) = 4.98(3.55) vs. female M(SD) = 8.26(4.77); t(209.54) = 7.40, p <.001.) The Hispanic versus non-Hispanic groups differed significantly on somatic symptoms (Hispanic M(SD) = 9.59(4.71) vs. non-Hispanic M(SD) = 7.33(4.72), t(432) = 3.01, p = .003). There was a significant difference in somatic symptoms for those who identified as heterosexual versus non-heterosexual (heterosexual M(SD) = 7.26(4.56) vs. non-heterosexual M(SD) = 9.66(5.57), t(434) = −3.49, p = .001), as well as for those working versus not working (working M(SD) = 8.20(4.50) vs. not working M(SD) = 7.18(4.87), t(432) = 2.20, p = .028.) Significant differences in somatic symptoms were not reported in White versus non-White groups (t(433) = −1.33, p = .186), first-year students versus non-first-year students (t(433) = −.70, p = .485) or those single vs in a romantic relationship (t(434) = .22, p = .828). Thus, gender identity, ethnicity, sexual orientation, and employment status were included as covariates.

Correlations and descriptive statistics are in Table 2. Briefly, somatic symptom scores were significantly and positively correlated with all childhood maltreatment types and each subscale of alexithymia. Somatic symptom scores were significantly and negatively correlated with the minimization and denial of childhood maltreatment. Regarding correlations between types of maltreatment, emotional abuse was significantly correlated with physical abuse, sexual abuse, emotional neglect, and physical neglect. Individuals reporting greater emotional abuse were also less likely to minimize the extent of their childhood maltreatment. Moreover, physical abuse was significantly correlated with sexual abuse, emotional neglect, and physical neglect, and sexual abuse was significantly correlated with emotional neglect and physical neglect. Emotional neglect and physical neglect were all negatively associated with minimization/denial of childhood maltreatment.

Table 2.

Descriptive statistics and correlations among primary outcome measures.

CTQ-
total1 		CTQ-
EA2 		CTQ-
PA3 		CTQ-
SA4 		CTQ-
EN5 		CTQ-
PN6 		CTQ-
MD7 		PAQ-
total8 		PAQ-
DIF9 		PAQ-
DDF10 		PAQ-
EOT11 		PHQ-
1512
2 .89** -
3 .71** .60** -
4 .54** .33** .28** -
5 .86** .73** .46** .26** -
6 .73** .53** .41** .21** .65** -
7 −.77** −.72** −.47** −.26** −.78** −.55** -
8 .35** .35** .21** .13** .32** .28** −.36** -
9 .32** .32** .18** .10* .29** .28** −.34** .93** -
10 .35** .34** .19** .19** .33** .28** −.36** .95** .88** -
11 .29** .31** .20** .12* .27** .19** −.30** .89** .71** .74** -
12 .36** .39** .24** .14** .27** .24** −.30** .35** .36** .36** .24** -
M 36.53 9.04 6.26 5.92 8.69 6.68 10.27 76.76 23.34 26.70 26.93 7.55
SD 12.97 4.72 2.54 3.07 4.01 2.65 3.41 31.10 10.78 11.32 11.68 4.76
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*

p <.05

**

p <.01; CTQ = childhood trauma questionnaire; EA = emotional abuse subscale; PA = physical abuse subscale; SA = sexual abuse subscale; EN = emotional neglect subscale; PN = physical neglect subscale; MD = minimization/denial subscale; PAQ = perth alexithymia questionnaire; DIF = difficulty identifying feelings subscale; DDF = difficulty describing feelings subscale; EOT = externally oriented thinking subscale; PHQ-15 = patient health questionnaire 15.

Primary analyses.

The final models from the primary analyses are in Table 3. Gender identity (β = .28, t(410) = 6.66, p <.001) and ethnicity (β = .13, t(410) = 2.95, p = .003) significantly associated with somatic symptoms. Neither sexual orientation nor employment status significantly associated with somatic symptoms (ps > .05). Childhood maltreatment significantly associated with somatic symptoms (β = .26, t(410) = 5.58, p < .001), as did alexithymia (β = .23, t(410) = 5.17, p < .001). Demographic variables (Step 1) accounted for 12% of the variance in somatic symptoms (R2 = .12). Childhood maltreatment (Step 2) significantly added to the model (ΔR2 = .10, F-change (1, 411) = 55.21, p < .001.) Alexithymia (Step 3) also added significantly to the model (ΔR2 = .05, F-change (1, 410) = 26.74, p < .001.) All VIFs were deemed acceptable (<2.)

Table 3.

Role of childhood maltreatment and alexithymia in somatic symptoms.

Variable B SE β t p
Overall Model R2 = .28**
 Gender identity 3.16 0.47 0.28 6.66 <0.001
 Ethnicity 1.92 0.65 0.13 2.95 0.003
 Sexual orientation −0.05 0.66 0.00 −0.08 0.94
 Employment status 0.68 0.41 0.07 1.66 0.10
 Childhood maltreatment 0.10 0.02 0.26 5.58 <0.001
 Alexithymia 0.04 0.01 0.23 5.17 <0.001
Expanded Model R2 = .29**
 Gender identity 2.92 0.49 0.26 5.94 <0.001
 Ethnicity 1.89 0.67 0.12 2.82 0.005
 Sexual orientation −0.14 0.68 −0.01 −0.21 0.84
 Employment status 0.61 0.41 0.06 1.49 0.14
 Emotional abuse 0.27 0.07 0.27 3.69 <0.001
 Physical abuse 0.07 0.11 0.04 0.67 0.50
 Sexual abuse −0.01 0.07 −0.01 −0.17 0.86
 Emotional neglect 0.00 0.09 0.00 −0.04 0.97
 Physical neglect 0.01 0.10 0.00 0.06 0.95
 Minimization/denial 0.01 0.10 0.01 0.07 0.94
 Difficulty identifying feelings 0.05 0.04 0.12 1.35 0.18
 Difficulty describing feelings 0.07 0.04 0.16 1.64 0.10
 Externally oriented thinking −0.02 0.03 −0.05 −0.77 0.44
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Note:

**

p < .01. Final models reported with all steps. Emotional abuse, physical abuse, sexual abuse, emotional neglect, physical neglect, and minimization/denial are subscales of the Childhood Trauma Questionnaire (CTQ). Difficulty identifying feelings, difficulty describing feelings, and externally oriented thinking are subscales of the Perth Alexithymia Questionnaire (PAQ).

Given that both childhood maltreatment and alexithymia were significantly associated with somatic symptoms after controlling for relevant demographic variables, a second model examined how demographic variables (Step 1), specific domains of childhood maltreatment (including minimization and denial validity index) (Step 2), and specific domains of alexithymia (Step 3) associated with somatic symptoms. The final model indicated that gender identity (β = .26, t(398) = 5.94, p <.001) and ethnicity (β = .12, t(398) = 2.82, p = .005) were significantly associated with somatic symptoms, whereas sexual orientation and working status were not (p > .05). Together, the demographic variables (Step 1) accounted for 13% of the variance in somatic symptoms (R2 = .13.) Regarding childhood maltreatment, only emotional abuse was significantly associated with somatic symptoms (β = .27, t(398) = 3.69, p < .001.) The domains of childhood maltreatment (Step 2) accounted for additional variance (ΔR2 = .12, F-change (6, 401) = 10.70, p < .001.) No domains of alexithymia (difficulty identifying feelings, difficulty describing feelings, or externally oriented thinking) were significantly associated with somatic symptoms (ps > .05). However, the alexithymia domains (Step 3) added significantly to the model (ΔR2 = .05, F-change (3, 398) = 9.13, p < .001.) All VIFs were deemed acceptable (<6).

Discussion

The current study sought to examine the roles of childhood maltreatment and alexithymia in somatic symptoms. Given the known association between childhood maltreatment and somatic symptoms, it is important to investigate processes that may be malleable to psychological intervention. When such processes are identified, further work to evaluate the mechanistic role of the process is necessary. The present study investigated alexithymia as one such process. The findings indicated that both childhood maltreatment and alexithymia accounted for unique variance in somatic symptoms. Subsequently, analyses examined whether specific types of childhood maltreatment (e.g., physical abuse, emotional neglect) and specific domains of alexithymia (e.g., difficulty identifying feelings) were associated with somatic symptoms. Only emotional abuse was significantly associated with somatic symptoms. None of the specific domains of alexithymia (difficulty identifying feelings, difficulty describing feelings, and externally oriented thinking) were significantly associated with somatic symptoms when the components were included individually. Thus, although alexithymia as a whole was related to somatic symptoms, none of the specific components of alexithymia emerged as most associated with somatic symptoms when in a model with the subtypes of trauma. In summary, childhood maltreatment, specifically emotional abuse, and alexithymia were associated with greater somatic symptoms.

These findings align with previous reports, which have found that alexithymia and childhood maltreatment are related to greater somatic symptoms (Katon et al., 2001; Spertus et al., 2003; Taycan et al., 2017; Waldinger et al., 2006). The current study also builds upon extant literature examining the role of alexithymia on the relationship between childhood maltreatment and somatic symptoms by examining different domains of both childhood maltreatment and alexithymia. Smith and colleagues (2013) previously found childhood emotional maltreatment was related to alexithymia and somatic symptoms. The investigation used two hierarchical multiple regressions to examine the role of childhood emotional maltreatment in alexithymia and somatic symptoms separately. The current study builds upon these findings, using a larger sample of undergraduate students, and by including alexithymia in the hierarchical regression model with childhood maltreatment. Including alexithymia in the model allowed the authors to measure the separate and unique contribution of alexithymia as related to somatic symptoms, beyond the contribution of types of childhood maltreatment.

Similarly, among a sample of individuals with major depressive disorder, Güleç et al. (2013) found that alexithymia was significantly and positively correlated with childhood maltreatment, and a history of emotional abuse and emotional neglect both predicted greater alexithymia. Further, the association between childhood maltreatment (i.e., emotional, physical, and sexual abuse) and somatic symptoms was no longer significant when alexithymia was added as a covariate. Both of these investigations (Güleç et al., 2013; Smith & Flannery-Schroeder, 2013) examined alexithymia unidimensionally rather than examining specific facets or skills. Therefore, the current study builds upon extant literature by examining the unique contributions of the different components of alexithymia.

Though overall childhood maltreatment accounted for unique variance in the experience of somatic symptoms in the current study, only emotional abuse remained significant when each domain of childhood trauma, and the minimization and denial scale, were included. It is possible that experiencing emotional abuse as a child leads people to question their internal experiences, such as emotions and physical sensations. For example, if someone is called ‘stupid’ or ‘lazy,’ this may hurt their self-efficacy in trusting internal experiences, like physical pain or sadness. Spertus et al. (2003) also suggested that emotional abuse may promote poor self-care or reduced self-worth. As a consequence of having trouble identifying or describing these experiences, these individuals may experience wear and tear on their bodies, which presents as somatic symptoms. Future research should continue to investigate the reasons behind the relation between emotional abuse and somatic symptoms by further examining the mediating contextual, intrapersonal, and interpersonal factors that impact an individual’s trajectory following childhood maltreatment.

Though the current findings indicates that emotional abuse may be particularly important, it is equally important to consider that emotional abuse likely does not occur in isolation. Experiencing multiple types of maltreatment has been shown to be more common than experiencing a single type of maltreatment (Arata, Langhinrichsen-Rohling, Bowers, & O'Farrill-Swails, 2005; Higgins & McCabe, 2000). In the current sample, emotional abuse was positively associated with physical abuse, sexual abuse, emotional neglect, and physical neglect, and negatively associated with minimization/denial, meaning individuals reporting greater emotional abuse were also less likely to minimize the extent of their childhood maltreatment. Thus, individuals who have experienced emotional abuse are also likely to have experienced other forms of abuse as well. The findings suggest that when controlling for the shared variance between the types of childhood maltreatment, emotional abuse appears to be most associated with greater somatic symptoms.

Alexithymia also accounted for unique variance in somatic symptom severity, beyond the role of childhood maltreatment. However, when three domains of alexithymia were examined (i.e., difficulty identifying emotions, difficulty describing emotions, and externally oriented thinking), none of the specific domains were significantly associated with somatic symptoms. This suggests that while alexithymia is contributing to somatic symptoms, no one component of alexithymia is more associated than the others. This study used the Perth Alexithymia Questionnaire, which allows for the examination of several facets of this construct. One possible explanation as to why the individual domains were non-significant may be because of the high intercorrelations among subscales. For example, difficulty identifying emotions was strongly related to difficulty describing emotions in the current sample. Thus, the domains may be overlapping constructs that are not necessarily distinct from one another.

Clinical significance

Identifying potentially modifiable therapeutic processes related to childhood maltreatment and somatic symptoms can help with the development of targeted preventive interventions. Based on the current findings, it is hypothesized that someone with a history of emotional abuse experiencing somatic symptoms may benefit from a clinical intervention that specifically focuses on identifying and describing one’s emotional experiences. Identifying such modifiable targets is imperative, given the significant health care use and cost of somatic symptoms and related disorders. Individuals with somatic symptoms have been shown to utilize more primary, specialty, and emergency healthcare visits and hospital admissions (Barsky, Orav, & Bates, 2005). Interventions aimed to improve somatic symptoms may be particularly important to prevent chronicity and impairment.

Limitations

Several limitations should be considered when interpreting the results of the current analyses. First, data were cross-sectional, and causality cannot be inferred. Given that this study was cross-sectional in nature, temporal mediation could not be conducted, which is an assumption of mediation analyses. In order to address this limitation, future studies should continue to study these associations longitudinally and investigate the mediating role of alexithymia. Secondly, data were collected from a homogenous sample of college students who identified as majority White and non-Hispanic, limiting generalizability beyond a White and non-Hispanic college student sample. This limitation could be addressed in future research with more diverse samples, such as among samples with a wider age range, or with racial and ethnic backgrounds other than White and non-Hispanic. Moreover, as the current study was conducted in a relatively healthy sample of college students, future investigations with patients with comorbid health conditions may be prudent.

Conclusions

The association between childhood maltreatment and somatic symptoms have long been established. As somatic symptoms can increase health care utilization and costs, it is important to identify modifiable therapeutic processes that may account for variance in somatic symptoms. Alexithymia, or difficulty in identifying and describing one’s emotions, has been shown to be associated with both childhood maltreatment and somatic symptoms and are modifiable through clinical intervention. The current study examined childhood maltreatment and alexithymia simultaneously as related to somatic symptoms, using two, three-step hierarchical linear regressions. Findings suggest that while both childhood maltreatment and alexithymia are associated with somatic symptoms, only emotional abuse remained significant when examining different domains of childhood maltreatment and alexithymia. Thus, although it appears that alexithymia is related to somatic symptoms significantly and uniquely, and beyond the contributions of childhood maltreatment, no one domain of alexithymia was especially important. Future work should continue to examine these associations longitudinally, as identifying therapeutically modifiable intervention targets (such as alexithymia) could contribute to improved outcomes for individuals with a history of childhood maltreatment (and emotional abuse, in particular) experiencing somatic symptoms.

Clinical Impact Statement.

Many individuals who have experienced childhood maltreatment report somatic symptoms. Both have been associated with alexithymia, the inability to identify or describe emotions. Understanding which types of maltreatment or alexithymia contribute most to somatic symptoms is less clear. This study examined how specific types of childhood maltreatment and alexithymia relate to somatic symptoms. Overall childhood maltreatment and alexithymia were related to greater somatic symptoms and when specific types were examined, only emotional abuse was associated with somatic symptoms. These findings indicate individuals with a history of emotional abuse in particular experience increased somatic symptoms, as do those with alexithymia.

Acknowledgements:

We would like to acknowledge Manny Stegall and Justin Rhode, as well as the rest of the Thrive Lab at the University of Iowa, for their help in this study.

Funding:

This work was supported in part by the National Institute of Health T32 pre-doctoral training grant: T32GM108540 (J.L.A). Neither the NIH nor the University of Iowa had any role in the study design, collection, analysis, or interpretation of the data, writing of the manuscript, or the decision to submit the paper for publication.

Footnotes

Declarations of Interest: The authors declare to conflicts of interest.

Data Accessibility Statement:

In congruence with the IRB approved protocol, we will share de-identified and aggregated data with researchers upon reasonable request.

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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Data Availability Statement

In congruence with the IRB approved protocol, we will share de-identified and aggregated data with researchers upon reasonable request.

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