Complex regional pain syndrome, alexithymia, and psychological distress

https://doi.org/10.1016/j.jpsychores.2014.07.005Get rights and content

Highlights

  • Persons with CRPS are characterized with high levels of alexithymia.

  • Non-physical pain processing avenues may benefit persons with CRPS.

  • Difficulty identifying feelings may predict pain, beyond psychological distress.

Abstract

Objective

This study aims to elucidate the relationships between alexithymia, psychological distress, and pain in persons with complex regional pain syndrome (CRPS).

Methods

Participants were 60 Israeli adults ages 19–65. This is a cross sectional study with a comparison group. Alexithymia, psychological distress, and pain were assessed in 30 individuals with CRPS in comparison to 30 gender- and age-matched persons with lower back pain (LBP). Assessments included the Toronto Alexithymia Scale, Hospital Anxiety and Depression Scale, and two subscales of the McGill Pain Questionnaire.

Results

Persons with CRPS had significantly higher ratings of psychological distress and of alexithymia when compared to LBP controls. Pain severity was significantly associated with higher levels of alexithymia and psychological distress among persons with CRPS, but not among controls. Alexithymia and pain severity correlations were significantly different between the two groups. In persons with CRPS, the relationships between alexithymia and pain severity and between difficulty identifying feelings and pain were not confounded by psychological distress.

Conclusions

To our knowledge, this is the first cross sectional study providing empirical evidence on the relationship between alexithymia and CRPS. From the perspective of conceptualizing alexithymia as an outcome of CRPS, findings highlight the importance of early CRPS diagnosis and support the provision of care that addresses pain-related psychological distress and alexithymia among CRPS patients. Also, findings underscore the need to generate alternative, non-physical avenues, such as learning to identify feelings for processing pain, in order to reduce pain among persons with CRPS.

Introduction

Complex regional pain syndrome (CRPS) is a chronic pain condition characterized by a continuing (spontaneous and/or evoked) regional pain that is seemingly disproportionate in length of time or degree of pain after trauma or other lesions. The pain usually has a distal predominance of abnormal sensory, motor, sudomotor, vasomotor edema, and/or trophic findings [1]. The evolution of CRPS varies, but it typically results in functional impairment in the affected limb, which adversely affects one's quality of life [2], [3]. While the etiology of CRPS is still unclear, several underlying patho-physiological mechanisms have been identified. These include aberrant changes in vasomotor function, abnormalities in regulating inflammatory responses on a local, regional and/or central level, and problems with regulation of neuroplasticity [4], [5].

Psychological factors such as stressful life events and psychological states such as anxiety, depression, and anger may alter catecholamine activity. Thus, they may directly affect pain intensity and in this way impact patho-physiological mechanisms of CRPS and contribute to its perpetuation [6], [7]. Therefore, pain in persons with CRPS may be affected by factors relating to emotional regulation. The findings on the relationships between psychological distress, emotional regulation, and pain in persons with CRPS are inconclusive. Understanding these relationships may elucidate effective coping styles and beneficial rehabilitation efforts for persons with CRPS [8].

One indicator of emotional regulation is alexithymia, a multidimensional psychological structure that includes difficulty identifying, verbalizing, or describing feelings and an externally-oriented thinking style [9]. High levels of alexithymia have been reported among persons with various types of pain, including lower back pain (LBP) [10], fibromyalgia [11], and myofascial pain [12], [13]. Conversely, others have found no association between alexithymia and pain among chronic pain patients [e.g., [14]]. The relationship between alexithymia and CRPS has been scantly examined. In a psychiatric evaluation of 34 persons with CRPS it was found that 88% met the clinical criteria of alexithymia [15]. On the other hand, in a prospective study of patients with a fracture in the distal radius, no differences in alexithymia scores were found among patients who subsequently developed CRPS when compared to patients who did not develop CRPS [16].

The relationship between CRPS, anxiety, and depression is inconclusive [see review by 6]. With regards to depression, higher [17], [18], comparable [19], [20], and lower [21], [22] levels of depression have been found in persons with CRPS when compared to other groups. In a similar manner, findings on anxiety and CRPS diverge, with reports of higher [18], comparable [19], and lower [23] anxiety levels in persons with CRPS in comparison to other groups.

Psychological distress may confound the association between pain and alexithymia in persons with CRPS. It has been suggested that alexithymia hinders a successful regulation of negative feelings, which in turn leads to increased negative affect or distress, chronic over-activation of the sympathetic system, and decreased capacity of the immune system. These psychological and physical outcomes may contribute to CRPS exacerbation and increased pain [24], [25]. Accordingly, distress has been associated with pain, demonstrating a more potent association among persons with CRPS in comparison to persons with other chronic pain [17]. In addition, alexithymia has been associated with psychological distress [26], depression [27], anxiety, and higher internalized anger expression [13]. Studies of persons with non-CRPS chronic pain have shown that when controlling for distress factors, the association found between alexithymia and pain did not reach significance [28] or was significant for affective pain but not sensory pain [12].

The objective of the current study is to elucidate the relationships between alexithymia, psychological distress, and pain in persons with CRPS in order to promote accurate assessment of pain and effective rehabilitation initiatives for this population. Accordingly, we examined levels of alexithymia, psychological distress, and pain in persons with CRPS in comparison to gender- and age-matched persons with chronic LBP. A measurement of psychological distress, a multidimensional assessment of pain, and an empirical assessment of alexithymia were utilized.

Section snippets

Participants

Ninety-three Israeli adults aged 19–65 were approached, of whom 46.2% had a diagnosis of CRPS, and 53.7% reported chronic LBP. Inclusion criteria were: 1. aged 18 or older; 2. experiencing pain for duration of at least 3 months; and 3. Hebrew proficiency. Exclusion criteria were: 1. pain intensity lower than 3/10 on the Visual Analogue Scale; 2. suffering simultaneously from CRPS and LBP; 3. history of CRPS in persons with LBP; and 4. history of mental illness or brain injury. CRPS was diagnosed

A comparison of pain, psychological distress and alexithymia

Alexithymia total scores as well as sub-scale scores (identifying feelings, describing feelings, externally-oriented thinking) were significantly higher in persons with CRPS when compared to controls, t (58) = 5.23, 4.85, 4.93, 3.62, p = 0.01, respectively. Persons with CRPS had significantly higher ratings of psychological distress when compared to those with chronic LBP, t (58) = 4.35, p = 0.01. No statistically significant differences in pain indicators (PRIS, VAS) were found between persons with

Discussion

This study examined the relationships between alexithymia, psychological distress, and pain in 30 persons with CRPS in comparison to 30 gender- and age-matched persons with chronic LBP. Persons with CRPS showed higher levels of alexithymia when compared to persons with chronic LBP. To our knowledge, this is the first cross sectional study with a comparison group providing empirical evidence on the relationship between alexithymia and CRPS. In addition, persons with CRPS had higher levels of

Conflict of interests

The authors have no competing interests to report.

Acknowledgments

There are no funding sources.

References (56)

  • A Kosturek et al.

    Alexithymia and somatic amplification in chronic pain

    Psychosomatics

    (1998)
  • RM Bagby et al.

    The twenty-item Toronto Alexithymia Scale—I. Item selection and cross-validation of the factor structure

    J Psychosom Res

    (1994)
  • I Bjelland et al.

    The validity of the Hospital Anxiety and Depression Scale: an updated literature review

    J Psychosom Res

    (2002)
  • C Herrmann

    International experiences with the Hospital Anxiety and Depression Scale—a review of validation data and clinical results

    J Psychosom Res

    (1997)
  • R Melzack

    The McGill Pain Questionnaire: major properties and scoring methods

    Pain

    (1975)
  • C Spitzer et al.

    Gender-specific association of alexithymia and norepinephrine/cortisol ratios. A preliminary report

    J Psychosom Res

    (2005)
  • A Huber et al.

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

    J Psychosom Res

    (2009)
  • MA Lumley et al.

    The relationship of alexithymia to subjective and biomedical measures of disease

    Psychosomatics

    (1997)
  • V de Gucht et al.

    Alexithymia and somatisation: a quantitative review of the literature

    J Psychosom Res

    (2003)
  • W Rief et al.

    Explaining medically unexplained symptoms—models and mechanisms

    Clin Psychol Rev

    (2007)
  • M Hosoi et al.

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

    Pain

    (2010)
  • M de Mos et al.

    The incidence of complex regional pain syndrome: a population-based study

    Pain

    (2007)
  • KM Hettne et al.

    Applied information retrieval and multidisciplinary research: new mechanistic hypotheses in complex regional pain syndrome

    J Biomed Discov Collab

    (2007)
  • P Low et al.

    Clinical characteristics of patients with reflex sympathetic dystrophy (sympathetically maintained pain) in the USA

  • M de Mos et al.

    Current understandings on complex regional pain syndrome

    Pain Pract

    (2009)
  • A Goebel

    Complex regional pain syndrome in adults

    Rheumatology

    (2011)
  • S Bruehl

    An update on the pathophysiology of complex regional pain syndrome

    Anesthesiology

    (2010)
  • S Bruehl et al.

    Psychological and behavioral aspects of complex regional pain syndrome management

    Clin J Pain

    (2006)
  • Cited by (0)

    View full text