Psychosomatics 39:399-404, October 1998
© 1998 The Academy of Psychiatric Medicine
Alexithymia and Somatic Amplification in Chronic Pain
Anna Kosturek, M.D.,
Robert J. Gregory, M.D.,
Anthony J. Sousou, B.A., and
Paula Trief, Ph.D.
Received November 12, 1997; February 6, 1998; accepted February 11, 1998. From the Department of Psychiatry, the State University of New York (SUNY) Health Science Center, Syracuse, New York. Address reprint requests to Dr. Gregory, Department of Psychiatry, SUNY Health Science Center, 750 East Adams St., Syracuse, NY 13210.
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ABSTRACT
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A controlled study was undertaken to assess alexithymia and somatic amplification among 50 medical outpatients with chronic pain referred for psychiatric consultation. Data were collected on demographics; DSM-IV diagnoses; and measures of anxiety, depression, and alexithymia, assessed with the Toronto Alexithymia Scale (TAS–20), as well as somatic amplification, assessed with the Somatosensory Amplificiation Scale (SAS). Data analysis revealed low scores on the TAS–20 and SAS for the pain patients, compared with a control group without pain. In this sample, depression and anxiety were the primary determinants of alexithymia and somatic amplification, rather than pain. These findings suggest that psychological markers for chronic pain may be different from those for other somatoform disorders.
Key Words: alexithymia • somatic amplification • chronic pain
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INTRODUCTION
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The concept of alexithymia was first introduced by Sifneos in 1972 to describe psychological characteristics of patients with psychosomatic diseases.1,2 The construct includes difficulties identifying and describing feelings, impoverishment of fantasy life, and excessive preoccupation with physical symptoms and external events.3 Although alexithymia was initially described in the context of psychosomatic illness, more recent studies indicate that alexithymic characteristics are also common in diverse psychiatric syndromes, including posttraumatic stress disorder, eating disorders, panic disorder, and substance use disorders.4,5
In terms of etiology, MacLean6 and Nemiah7 postulated that a disconnection between the neocortex and the limbic system occurs that may limit fantasy and cause difficulty verbalizing feelings and regulating affect. Reported prevalence rates for alexithymia range from 6.7% to 18.8% in community samples.8–11
There have been many attempts to develop standardized measures for alexithymia. These include both observer-rated scales, such as the Beth Israel Questionnaire,2 and self-reported questionnaires, such as the Schalling-Sifneos Personality Scale12 and the Minnesota Multiphasic Personality Inventory (MMPI) alexithymia scale.13 Currently, the most commonly used and best-researched measure is the Toronto Alexithymia Scale (TAS) and its two modified versions, the TAS–R and TAS–20.14–18
A more recent construct that has been used to conceptualize psychosomatic illness is somatic amplification. As originally conceived by Barsky et al.19 in 1988, somatic amplification refers to a tendency in hypochondriacal patients to scrutinize their bodies for somatosensory input and then to amplify and misinterpret the sensation as representing a pathological process. The Somatosensory Amplification Scale (SAS) was designed and validated to measure this phenomenon.19 SAS scores have also been noted to be elevated in patients with somatization disorder.19,20
The concepts of alexithymia and somatic amplification have been less well studied in chronic pain patients. Postone21 compared alexithymic traits in 18 patients with chronic pain with 19 psychotherapy patients by using the Beth Israel Questionnaire and the MMPI. The study demostrated higher alexithymia scores in the pain patients but did not control for degree of psychopathology. Mendelson,22 in an open study of 60 patients with chronic pain, also found high rates of alexithymia (measured by the MMPI alexithymia scale), and there were no differences between the alexithymic and nonalexithymic patients on measures of anxiety, depression, and hostility. Another uncontrolled study was done by Cox et al.23 that used the TAS–20 to measure alexithymia among 55 survivors of motor-vehicle accidents who met DSM-III-R criteria for somatoform pain disorder. Although the researchers found a high rate of alexithymia, substance use and other possibly confounding psychopathology were not measured.
Given the small number of patients used in the aforementioned studies and their uncontrolled nature, further research is needed in this area. In addition, to our knowledge, no studies have examined somatic amplification in chronic pain. There has been some research done, however, employing a related construct—the MMPI hypochondriasis subscale (Hs). This scale consists of a checklist of somatic symptoms. A high Hs score in conjunction with a low depression score and high hysteria score (called the Conversion "V" profile) has been reported in patients having functional pain syndromes,24,25 as well as those with well-documented physical etiologies.26 Studies attempting to correlate the Conversion "V" with pain treatment outcomes have been mixed.27 Attempts were not made in those studies to correlate MMPI profiles with other measures of psychopathology.
The present study investigated alexithymia and somatic amplification in chronic pain patients while taking into account comorbid psychopathology and substance use. Based on prior research, we hypothesized that we would find high rates of alexithymia and somatic amplification in our subjects with chronic pain.
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METHODS
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Subjects
The study population included 50 consecutive patients referred from the Pain Treatment Center of the State University of New York Health Science Center to the Outpatient Psychiatry Consultation Program. Our study was conducted in 1997. Most of the patients (n=38) were referred as part of a routine presurgical evaluation before placement of a dorsal-column stimulator. The remainder were referred for evaluation of depression. Inclusion criteria included chronic pain (duration longer than 1 year). Exclusion criteria included cognitive impairment, a primary psychotic disorder, or a somatoform disorder other than pain disorder (by DSM-IV criteria).
Most patients (n=30) were privately insured through worker's compensation. Almost all the patients (n=43) had pain in the back or extremities, rather than other sites. The most common medical diagnoses were lumbar disk disease and reflex sympathetic dystrophy.
A control group was randomly selected from patients referred to the Outpatient Psychiatry Consultation Program from our general medical clinic or from the practices of private internists in the community. Exclusion criteria included having a pain syndrome, cognitive impairment, a primary psychotic disorder, or a somatoform disorder.
The control group was largely unemployed and Medicaid recipients. As shown in in Table 1, there were no significant differences between the groups in age, gender, or marital status. There was more racial heterogeneity, however, in the control group.
Measures
Patients referred to the Outpatient Psychiatry Consultation Program are evaluated in a clinical interview with a board-certified psychiatrist (RG). Diagnoses are assigned according to DSM-IV criteria. Patients referred to the program are also routinely administered several self-rated psychological measures, including the TAS–20, the SAS, and the Brief Symptom Inventory (BSI) for anxiety and depression. The BSI is a symptom checklist derived from the Hopkins Symptom Checklist and has been shown to have good validity and reliability.28
Retrospective reviews were performed on the charts of the patients selected for this study. The study was considered "exempt" research by our Institutional Review Board.
Data Analysis
Data were collected on demographics, psychiatric diagnoses, and scores on the TAS–20, SAS, and BSI. Between-group differences for these variables were assessed by two-tailed unpaired t-tests, two-tailed Pearson chi-square tests (for categorical variables), and analyses of covariance (ANCOVA) with the software program "Statistica." Linear regression analyses were performed to assess the determinants of TAS–20 scores and SAS scores in our sample.
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RESULTS
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As shown in Table 2, the most common psychiatric disorders seen in both groups were mood disorders, primarily major depressive disorder. All forms of psychopathology were higher in the group without chronic pain (control group). This difference was significant for substance use disorders ( 2=6.25, df=1, P=0.01) and personality disorders (2=3.84, df=1, P=0.05). Among the patients with chronic pain, 46% (n=23) were diagnosed as having a DSM-IV pain disorder.
Consistent with the diagnostic findings on interview, Table 3 illustrates that psychological measures of anxiety and depression were higher in the control group. Contrary to our hypotheses, scores on the SAS (t=-3.24, df=94, P=0.002) and the TAS–20 (t=-2.19, df=93, P=0.03) were also higher in the control group. These differences did not reach statistical significance, however, in ANCOVA analyses, adjusting for between-group differences on BSI scores. This suggests that low levels of anxiety and depression in the chronic pain group accounts for their relatively low SAS and TAS–20 scores. Only 22% (n=11) of the patients with chronic pain scored in the alexithymic range on the TAS–20.
A separate analysis was then done of subjects within the chronic pain study group (n=50) to see whether the patients who were diagnosed with a DSM-IV pain disorder (n=23) differed on psychological measures from those without a pain disorder (n=27). Results of the analysis indicated that there were no significant differences on any of the psychological measures between these two groups.
Since neither chronic pain nor pain disorder were major determinants of alexithymia or somatic amplification in our sample, we performed linear regression analyses to find the determinants. Separate analyses were done, using the TAS–20 and SAS scores as dependent variables, and age, gender, race, chronic pain, psychological measures, and psychiatric diagnoses as independent variables (total 11 independent variables, n=100). The analyses indicated that significant determinants of SAS scores at a Bonferroni-corrected P<0.05 included BSI depression scores (R2=0.28), BSI anxiety scores (R2=0.28), and TAS–20 scores (R2=0.19). Significant determinants of TAS–20 scores included BSI depression scores (R2=0.26), BSI anxiety scores (R2=0.23), SAS scores (R2=0.19), and major depression (R2=0.16). Demographic variables and the presence or absence of chronic pain were not significant predictors of SAS or TAS–20 scores.
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DISCUSSION
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Our principal finding was the low rates of somatic amplification and alexithymia in our chronic pain patients (including those with a DSM-IV pain disorder), contrary to our expections based on results from prior studies. The major limitation of our study is that our control group came from a different clinic, had higher rates of psychopathology, and had greater racial heterogeneity than our study group. On the other hand, the two groups were closely matched in age, gender, and marital status. Moreover, even excluding consideration of a control group, our rates of somatic amplification and alexithymia were lower than those reported in samples of general medical outpatients.9,29,30
One explanation for these discrepancies, compared with other studies, includes the use of different scales for psychological measures. This is especially so for the SAS, which has not been previously reported in pain populations. This is an insufficient explanation, however, for the discrepancies in the rates of alexithymia from prior studies, some of which used the TAS or TAS–20.23,31,32
We believe that the primary reason for the discrepancies between our study and prior ones is attributable to our study population. We excluded somatoform disorders other than pain disorder, and our pain patients were generally high functioning and had low rates of comorbid psychopathology. Prior studies failed to adequately take into account comorbid depression, anxiety, or substance use, all of which have been shown to be associated with alexithymia.20
It may be that comorbid mood and anxiety disorders, rather than pain, accounted for the high rates of alexithymia reported in past studies. For example, Millard and Kinsler31 and Zayfert et al.32 reported that while 34%–36% of consecutive referrals to pain clinics scored above the cutoff for alexithymia on the TAS, high scores were associated with measures of affective distress but were unrelated to pain intensity. This explanation is also supported by the finding that in our pain population, anxiety and depression were the principal determinants of SAS and TAS–20 scores in the regression analyses.
Based on our findings, we hypothesize that chronic pain patients may have different psychological characteristics than patients with hypochondriasis or somatization disorder, a plausible conclusion that dovetails with DSM-IV's differentiation of pain disorder from other somatoform disorders. Further research is needed to explore the psychological characteristics of patients with chronic pain.
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ABSTRACT
INTRODUCTION
