- Email: [email protected]
Alexithymia moderates effects of psychotherapeutic treatment expectations on depression outcome in interdisciplinary chronic pain treatment
Journal of Psychosomatic Research xxx (xxxx) xxx–xxx
Contents lists available at ScienceDirect
Journal of Psychosomatic Research journal homepage: www.elsevier.com/locate/jpsychores
Short communication
Alexithymia moderates effects of psychotherapeutic treatment expectations on depression outcome in interdisciplinary chronic pain treatment Larissa T. Blaettlera,b, , Julian A. Stewarta,b, Danièle A. Gublera,b, Niklaus Egloffa, Roland von Känelc, Martin grosse Holtfortha,b ⁎
a
Division of Psychosomatic Medicine, Department of Neurology, Inselspital, Bern University Hospital, Bern, Switzerland Department of Psychology, University of Bern, Bern, Switzerland c Department of Consultation-Liaison Psychiatry and Psychosomatic Medicine, University Hospital Zurich, University of Zurich, Zurich, Switzerland b
ARTICLE INFO
ABSTRACT
Keywords: Alexithymia Chronic pain Expectation Interdisciplinary treatment Moderator
Objective: Previous research has shown that patient's treatment expectations predict outcome in the multimodal therapy for chronic pain. Alexithymia, defined as the difficulty to identify, describe and express one's own feelings, may moderate treatment expectations and thereby effect treatment outcome. Accordingly, the aim of the current study is to examine the moderating role of alexithymia on the association of psychotherapeutic treatment expectation on depression outcome. Method: 213 chronic pain inpatients completed a set of standardized self-report questionnaires, assessing alexithymia, psychotherapeutic treatment motivation and depression. A hierarchical linear regression model tested the moderating effect of alexithymia on the relationship of psychotherapeutic treatment expectations with depression as outcome variable. Results: Both, alexithymia and psychotherapeutic treatment expectations predicted treatment outcome independently, and alexithymia moderated the effect of psychotherapeutic treatment expectations on outcome, above and beyond the effects of control variables. Discussion: This study supports the beneficial role of positive psychotherapeutic treatment expectations in an interdisciplinary chronic pain treatment, and suggest to consider difficulties in identifying and describing feelings (alexithymia) in clinical decisions.
1. Introduction Chronic pain defined as pain that persists for > 3 to 6 months [1], is a prevalent and debilitating condition [2] for which findings on determinants of treatment outcomes and related change mechanisms continue to emerge, and psychotherapeutic interventions are central components of an interdisciplinary treatment for chronic pain. As psychotherapy mostly consists of verbal exchanges, high levels of alexithymia being defined as difficulties to identify, describe and express one's own feelings [3] may obstruct the process and outcome of psychotherapeutic interventions. Another psychological construct potentially affecting treatment outcome is psychotherapeutic treatment expectations (PTE). PTE can be defined as a cognitive component of psychotherapeutic treatment motivation (PTM) and more specifically as a particular type of psychotherapy-related expectations. In contrast to outcome expectations, PTE are beliefs about the process and functional value of psychotherapy [4,5]. Clinically, patients who believe that an
⁎
upcoming treatment will be functional regarding their condition are more likely to engage in therapeutic procedures and consequently experience better outcomes. In addition, alexithymia and PTE may interact in predicting treatment outcome. Due to stronger difficulties in differentiating, verbalizing and discussing subjective experiences and emotions, highly alexithymic patients may also expect little from psychotherapy. Empirically, both alexithymia and PTE have been shown to relate to treatment outcome. Chronic pain patients have shown elevated alexithymia levels compared to the normal population [6] and in patients with multisomatoform disorders alexithymia moderated treatment outcome [7,8]. PTE predicted outcome in a sample of chronic pain patients [9] as well as in inpatients with somatoform disorders [10]. Considering that alexithymia and PTE are theoretically distinct constructs, i.e. emotion-related skills vs. motivation-related cognitions and that both constructs are related to treatment outcome, they can be expected to predict treatment outcome separately and conjointly.
Corresponding author at: Division of Psychosomatic Medicine, Department of Neurology, Inselspital, Bern University Hospital, Bern, Switzerland. E-mail address: [email protected] (L.T. Blaettler).
https://doi.org/10.1016/j.jpsychores.2019.04.010 Received 9 January 2019; Received in revised form 10 April 2019; Accepted 11 April 2019 0022-3999/ © 2019 Elsevier Inc. All rights reserved.
Please cite this article as: Larissa T. Blaettler, et al., Journal of Psychosomatic Research, https://doi.org/10.1016/j.jpsychores.2019.04.010
Journal of Psychosomatic Research xxx (xxxx) xxx–xxx
L.T. Blaettler, et al.
Whereas a conjoint effect of alexithymia and PTE on treatment outcome has been shown in a psychiatric sample [11], it has not been examined in chronic pain patients, yet. According to the IMMPACT recommendations (Initiative on Methods, Measurement, and Pain Assessment in Clinical Trials) [12], the assessment of depression symptoms is a central element in pain treatment research. As 12.1% to 72% of chronic pain patients experience clinical depression [13] and the reduction of psychological distress is a central target of psychotherapeutic interventions also in patients with chronic pain, we chose the reduction of depression symptoms as the primary outcome in the present study. The aim of this study was to investigate the conjoint and separate prediction of depression outcome by alexithymia and PTE in an interdisciplinary chronic pain treatment. We hypothesized that, (1) both alexithymia and PTE negatively predict therapy outcome and that (2) in this setting, patients with high levels of alexithymia and low levels of psychotherapeutic expectations profit less from treatment.
TAS-20 is a self-assessment questionnaire which comprises 20 items and contains three subscales (Difficulty Describing Feelings, Difficulty Identifying Feeling, Externally-Oriented Thinking). Items are rated on a 5-point Likert-scale from 1 = strongly disagree to 5 = strongly agree. For the analyses a total score was calculated by summing all the items [14]. The HADS is a self-report scale that is comprised of 14 items. For each subscale (Anxiety and Depression), 7 items are rated on a fourpoint scale ranging from 0 to 3. Thus the scores of the two subscales vary between 0 and 21 [15]. For the analyses, a total score (range: 0–42) was calculated from the 14 items as an indicator of the overall distress. All three scales are interpreted in such a way that higher values correspond to a higher expression on the respective scales. In the current study, Cronbach's alpha yielded good to excellent internal consistency for the scales used (Cronbach's alpha between 0.82 and 0.86). All analyses were conducted using SPSS version 25. Normal distribution was confirmed using the Kolmogorov-Smirnoff test. Partial correlations were calculated to analyze the relationship between alexithymia, PTE, and depression. To test the separate and conjoint prediction of HADSt1by alexithymia and PTE, a stepwise hierarchical linear regression analysis was computed. Potentially confounding variables were also included as predictors. Missing data were excluded list-wise.
2. Methods Data of 213 consecutively admitted inpatients diagnosed with chronic pain disorders according to ICD-10 (F45.41 chronic pain with somatic and psychological factors) were collected at admission and discharge of a multimodal interdisciplinary treatment program at a Swiss tertiary psychosomatic university clinic (average treatment duration was 29.3; SD = 7.4; range = 16–65). The only inclusion criterion was a minimum age of 18 years. Excluded were individuals 1) who had insufficient knowledge of German to correctly complete the questionnaires, 2) for whom there was no general consent, 3) with complaints the causes and perpetuation of which can be adequately explained by physical injury, as well as 4) persons for whom acute psychiatric illness was the main cause of current suffering. Treatment components comprised medical interventions, pharmacotherapy, psychotherapy, physical and relaxation therapy. Medical interventions included a patient-centered exploration of the main condition, a specialist anamnesis, the recording and treatment of comorbidities, as well as an individual treatment plan. Pharmacological therapy was always carried out alongside or in support of the other therapies. In almost all cases, psychotherapy followed an integrative approach with a cognitive-behavioural therapeutic and interpersonal focus. Depending on the psychotherapist's education, elements from emotionally focused (EFT), body-oriented or systemic therapy were also used. The psychotherapeutic conversations usually took place twice a week and were forstered with various group therapies (e.g. pain management group, mindfulness group, communication group). The physical therapy consisted of various individual and group offers. The group therapies included relaxation therapy in the form of progressive muscle relaxation (PMR) according to Jacobson. Further offers included training with fitness equipment, a basic body awareness group, water gymnastics or Nordic walking. In individual settings, patients could benefit from individual physiotherapy, biofeedback or massages. If indicated, relaxation could also be a smaller part of psychotherapy. All participants provided informed consent for the reuse of their anonymized health data for research purposes, and the study was in accordance with the Declaration of Helsinki and was approved by the Ethics Committee of the Canton of Bern, Switzerland (project ID 201800493). All patients completed a set of standardized self-report assessment tools. The German versions of the Questionnaire for the Measurement of Psychotherapy Motivation (FMP) [4] and the Toronto Alexithymia Scale (TAS-20) [14] were assessed at admission (t0); and the German version of the Hospital Anxiety and Depression Scale (HADS) [15] was assessed at admission (t0) and discharge (t1). The PTE subscale is part of the FMP which consists of 4 subscales (PTE, Negative Illness Consequences, Psychosocial Lay Etiology, General Openness to Psychotherapy). The 47 items are rated on a five-point scale (1–5) [4]. Only the sum score of the PTE subscale was used for the analysis. The
3. Results On average, patients were 48.4 years old (SD = 13.4, Range 18–83) and 53.5% were women. The average score of HADS at intake (t0) was 16.9 (SD = 8.1) and decreased significantly (HADSt1 = 12.7; SD = 8.2; T = 8.677, p = .001). 44.1% of the sample exceeded the clinical cut-off of 7 in both subscales at intake. PTE scores at intake were 25.9 (SD = 5.3) and TAS-20 = 48.8 (SD = 11.7), and 41.8% (N = 89) exceeded the clinical cut-off of 52 for possible alexithymia (0–51 = no alexithymia, 52–60 = possible alexithymia, > 60 high alexithymia). Partial correlation analyses controlling for age and gender revealed significant correlations between HADS at t0 and TAS-20 (r = 0.452; p = .001) and HADSt0 and PTE (r = 0.217; p = .002), whereas the correlation between TAS-20 and PTE at t0 was not significant (r = −0.002; p = .98). A hierarchical linear regression analysis with gender, age, and HADS at t0 as control variables analyzed the prediction of HADS at t1 by the FMP subscale PTE and the TAS-20 at t0 (see Table 1). After entering the control variables in the first step, the TAS-20 and the PTE were entered in the second step. TAS t0 and PTEt0 significantly predicted HADSt1, while controlling for age, gender and HADSt0, in the sense that higher levels of alexithymia and lower levels of PTE predicted higher levels of depression. To test for moderation by alexithymia, an interaction term between z-standardized PTE and TAS-20 scores was entered in the third step. A significant interaction emerged between TAS-20 and PTE, i.e., the higher patients' alexithymia score was, the stronger PTE predicted treatment outcome, controlling for age, gender and HADSt0 (see Fig. 1). 4. Discussion The current study aimed at investigating the conjoint and separate prediction of depression outcome by alexithymia and psychotherapeutic treatment expectations (PTE) of patients in an interdisciplinary treatment for chronic pain. As hypothesized, the results showed that (1) each factor alone, i.e., having a lower ability to interpret emotions in a meaningful way (i.e., being highly alexithymic) and seeing little value in psychotherapeutic interventions (i.e., low PTE) predicted a worse outcome regarding depression change of a multimodal treatment for chronic pain, and (2) particularly patients with both, high alexithymia and low PTE demonstrated worse prospects of depression change. Underscoring the relevance of alexithymia for chronic pain patients and confirming previous evidence [6], a high proportion of chronic pain patients in our sample demonstrated elevated levels of 2
Journal of Psychosomatic Research xxx (xxxx) xxx–xxx
L.T. Blaettler, et al.
Table 1 Hierarchical regression analyses predicting psychological distress (HADSt1) outcomes at posttreatment. HADSt1
Step 1: control variables Age Gender HADSt0 Step 2: Alexithymia and psychotherapy motivation TAS PTE Step 3: Interaction effect TAS × PTE
B
SEb
β
t
−0.075 0.482 0.598
0.033 0.888 0.055
−0.123 0.030 0.596
−2.262⁎,⁎⁎ 0.543 10.911⁎⁎⁎
0.081 −0.326
0.041 0.082
0.117 −0.213
1.985⁎ −3.967⁎⁎⁎
−0.013
0.007
−0.667
−2.000⁎
R2
Δ R2
0.388
0.388
0.446
0.058
0.456
0.010
SE = standard error; ΔR2 = Change in R2; PTE = Psychotherapeutic treatment expectations, TAS = Toronto Alexithymia Scale. ⁎ p < .05. ⁎⁎ p < .01. ⁎⁎⁎ p < .001.
alexithymia. Also as in earlier studies, both alexithymia and PTE predicted depression outcome [9]. However, for the first time in chronic pain patients our results demonstrate the conjoint effects of alexithymia and PTE on treatment outcome, with alexithymia moderating the prediction of depression outcome by treatment expectations. As psychotherapeutic interventions are central components of an interdisciplinary treatment for chronic pain, and as psychotherapy mostly consists of verbal exchanges, it seems reasonable to expect that high levels of alexithymia obstruct beneficial treatment outcomes in terms of depression relief. Whereas worse outcomes can be expected for patients who expect little for an upcoming treatment due to potentially less engagement in therapeutic procedures, the combination of bad expectations and high levels of alexithymia seems to put pain patients at particular risk of worse outcomes that goes beyond the mere addition of effects. As one potential explanation, patients with high levels of alexithymia might have had previous experiences of failed therapeutic interventions that may render them generally skeptic or even resistant toward psychotherapeutic interventions. Future research may study the causal and or temporal relationship of alexithymia and treatment expectations. As our results show, the combination of a high level of alexithymia and low levels of treatment expectations seems to be a particular challenge for therapists who wish to reach beneficial outcomes despite unfavorable conditions. When considering the short-term nature of our treatment it seems advisable to target relatively amenable patient characteristics in the setting. Whereas the level of alexithymia seems to depend on the circumstances and may even be changed by interventions of longer duration, it is generally considered to be a rather stable
patient characteristic as compared to treatment expectations [16]. On this background the strengthening of treatment expectations may be a more feasible short-term treatment goal for pain patients with high levels of alexithymia. How could treatment expectations as well as treatment outcome be enhanced in patients with chronic pain who present with reduced emotional skills? Therapists may choose other than verbal “channels” to motivate and involve the patients in treatment to attain targeted changes and improve patient mood. Of the various interventions within a multimodal therapy, e.g. physiotherapy and/or ergotherapy may be more appealing options for highly alexithymic patients. This is not to say that physiotherapy or ergotherapy do not involve emotionally charged processes or do not lead to changes at the emotional level. Instead, these therapies may offer a wider range of interventions, for which the conscious identification and processing of emotions may be less central. Generally, clinicians may try to choose therapeutic interventions that capitalize on the patients' resources without mainly focusing on emotion processing [17]. A few limitations of this study need to be mentioned. As measurements were self-report questionnaires, the potential for socially desirable esponse-tendencies should be considered. Follow-up assessments were not long-term, warranting future research on the persistence of the observed effects beyond hospitalization. Future research is needed to empirically identify suitable interventions for fostering psychotherapeutic treatment motivation in general and particularly in alexithymic patients to further improve outcomes in the multimodal inpatient treatment of chronic pain patients.
Fig. 1. Graphical illustration of the moderation model between PTE and alexithymia in relation to depression outcome.
3
Journal of Psychosomatic Research xxx (xxxx) xxx–xxx
L.T. Blaettler, et al.
Declarations of interest None.
[9]
Competing interest statement [10]
The authors have no competing interests to report.
[11]
References [1] IASP Taxonomy Working Group, [Internet]: Classification of Chronic Pain, Second edition, (2011) [Accessed 05/04/2019]. Available from: http://www.iasp-pain. org/PublicationsNews/Content.aspx?ItemNumber=1673&navItemNumber=677. [2] H.J. Grabe, C. Meyer, U. Hapke, H.J. Rumpf, H.J. Freyberger, H. Dilling, U. John, Somatoform pain disorder in the general population, Psychother. Psychosom. 72 (2003) 88–94, https://doi.org/10.1159/000068681. [3] G.J. Taylor, Alexithymia: concept, measurement, and implications for treatment, Am. J. Psychiatry 141 (1984) 725–732, https://doi.org/10.1176/ajp.141.6.725. [4] W. Schneider, H.D. Basler, B. Beisenherz, FMP, Fragebogen zur Messung der Psychotherapiemotivation [Questionnaire for the Measurement of Psychotherapy Motivation] (In German). Weinheim, Beltz, (1989). [5] M.J. Constantino, Believing is seeing: an evolving research program on patients' psychotherapy expectations, Psychother. Res. 22 (2012) 127–138, https://doi.org/ 10.1080/10503307.2012.663512. [6] M. Di Tella, L. Castelli, Alexithymia in chronic pain disorders, Curr. Rheumatol. Rep. 18 (41) (2016), https://doi.org/10.1007/s11926-016-0592-x. [7] T. Probst, H. Sattel, P. Henningsen, H. Gündel, C. Lahmann, Alexithymia as a moderator of treatment outcomes in a randomized controlled trial on brief psychodynamic interpersonal psychotherapy for patients with multisomatoform disorder, Psychother. Psychosom. 86 (2017) 57–59, https://doi.org/10.1159/ 000448287. [8] T. Probst, H. Sattel, H. Gündel, P. Henningsen, J. Kruse, G. Schneider, C. Lahmann, Moderating effects of alexithymia on associations between the therapeutic alliance
[12]
[13]
[14] [15] [16]
[17]
4
and the outcome of brief psychodynamic-interpersonal psychotherapy for multisomatoform disorder, Front. Psychiatry 8 (261) (2017), https://doi.org/10.3389/ fpsyt.2017.00261. J.A. Stewart, N. Egloff, R. von Känel, J. Grolimund, M. Studer, M. grosse Holtforth, Motivation for psychological treatment predicts favorable outcomes in multimodal interdisciplinary treatment for chronic somatoform pain, Psychother. Psychosom. 86 (2016) 60–61, https://doi.org/10.1159/000449471. B. Timmer, G. Bleichhardt, W. Rief, Importance of psychotherapy motivation in patients with somatization syndrome, Psychother. Res. 16 (2006) 348–356, https:// doi.org/10.1080/10503300500485292. J. Terock, D. Janowitz, H.J. Grabe, H.J. Freyberger, W. Schneider, T. Klauer, Alexithymia and psychotherapeutic treatment motivation: main and interactional effects on treatment outcome, Psychother. Psychosom. 86 (2017) 185–186, https:// doi.org/10.1159/000457961. D.C. Turk, R.H. Dworkin, R.R. Allen, N. Bellamy, N. Brandenburg, D.B. Carr, ... D.J. Hewitt, Core outcome domains for chronic pain clinical trials: IMMPACT recommendations, Pain 106 (2003) 337–345, https://doi.org/10.1016/j.pain.2003. 08.001. L. Rayner, M. Hotopf, H. Petkova, F. Matcham, A. Simpson, L.M. McCracken, Depression in patients with chronic pain attending a specialized pain treatment centre: prevalence and impact on health care costs, Pain 157 (2016) 1472, https:// doi.org/10.1097/j.pain.0000000000000542. M. Bach, D. Bach, M. de Zwaan, M. Serim, F. Böhmer, Validation of the German version of the 20-item Toronto Alexithymia Scale in normal persons and psychiatric patients (in German), Psychother. Psychosom. Med. Psychol. 46 (1996) 23–28. A.T. Beck, C.H. Ward, M. Mendelson, J. Mock, J. Erbaugh, An inventory for measuring depression, Arch. Gen. Psychiatry 4 (1961) 561–571, https://doi.org/10. 1001/archpsyc.1961.01710120031004. A. Hiirola, S. Pirkola, M. Karukivi, N. Markkula, R.M. Bagby, M. Joukamaa, ... J. Suvisaari, An evaluation of the absolute and relative stability of alexithymia over 11 years in a Finnish general population, J. Psychosom. Res. 95 (2017) 81–87, https://doi.org/10.1016/j.jpsychores.2017.02.007. C. Flückiger, F. Caspar, M. grosse Holtforth, U. Willutzki, Working with patients' strengths: a microprocess approach, Psychother. Res. 19 (2009) 213–223, https:// doi.org/10.1080/10503300902755300.
Contents lists available at ScienceDirect
Journal of Psychosomatic Research journal homepage: www.elsevier.com/locate/jpsychores
Short communication
Alexithymia moderates effects of psychotherapeutic treatment expectations on depression outcome in interdisciplinary chronic pain treatment Larissa T. Blaettlera,b, , Julian A. Stewarta,b, Danièle A. Gublera,b, Niklaus Egloffa, Roland von Känelc, Martin grosse Holtfortha,b ⁎
a
Division of Psychosomatic Medicine, Department of Neurology, Inselspital, Bern University Hospital, Bern, Switzerland Department of Psychology, University of Bern, Bern, Switzerland c Department of Consultation-Liaison Psychiatry and Psychosomatic Medicine, University Hospital Zurich, University of Zurich, Zurich, Switzerland b
ARTICLE INFO
ABSTRACT
Keywords: Alexithymia Chronic pain Expectation Interdisciplinary treatment Moderator
Objective: Previous research has shown that patient's treatment expectations predict outcome in the multimodal therapy for chronic pain. Alexithymia, defined as the difficulty to identify, describe and express one's own feelings, may moderate treatment expectations and thereby effect treatment outcome. Accordingly, the aim of the current study is to examine the moderating role of alexithymia on the association of psychotherapeutic treatment expectation on depression outcome. Method: 213 chronic pain inpatients completed a set of standardized self-report questionnaires, assessing alexithymia, psychotherapeutic treatment motivation and depression. A hierarchical linear regression model tested the moderating effect of alexithymia on the relationship of psychotherapeutic treatment expectations with depression as outcome variable. Results: Both, alexithymia and psychotherapeutic treatment expectations predicted treatment outcome independently, and alexithymia moderated the effect of psychotherapeutic treatment expectations on outcome, above and beyond the effects of control variables. Discussion: This study supports the beneficial role of positive psychotherapeutic treatment expectations in an interdisciplinary chronic pain treatment, and suggest to consider difficulties in identifying and describing feelings (alexithymia) in clinical decisions.
1. Introduction Chronic pain defined as pain that persists for > 3 to 6 months [1], is a prevalent and debilitating condition [2] for which findings on determinants of treatment outcomes and related change mechanisms continue to emerge, and psychotherapeutic interventions are central components of an interdisciplinary treatment for chronic pain. As psychotherapy mostly consists of verbal exchanges, high levels of alexithymia being defined as difficulties to identify, describe and express one's own feelings [3] may obstruct the process and outcome of psychotherapeutic interventions. Another psychological construct potentially affecting treatment outcome is psychotherapeutic treatment expectations (PTE). PTE can be defined as a cognitive component of psychotherapeutic treatment motivation (PTM) and more specifically as a particular type of psychotherapy-related expectations. In contrast to outcome expectations, PTE are beliefs about the process and functional value of psychotherapy [4,5]. Clinically, patients who believe that an
⁎
upcoming treatment will be functional regarding their condition are more likely to engage in therapeutic procedures and consequently experience better outcomes. In addition, alexithymia and PTE may interact in predicting treatment outcome. Due to stronger difficulties in differentiating, verbalizing and discussing subjective experiences and emotions, highly alexithymic patients may also expect little from psychotherapy. Empirically, both alexithymia and PTE have been shown to relate to treatment outcome. Chronic pain patients have shown elevated alexithymia levels compared to the normal population [6] and in patients with multisomatoform disorders alexithymia moderated treatment outcome [7,8]. PTE predicted outcome in a sample of chronic pain patients [9] as well as in inpatients with somatoform disorders [10]. Considering that alexithymia and PTE are theoretically distinct constructs, i.e. emotion-related skills vs. motivation-related cognitions and that both constructs are related to treatment outcome, they can be expected to predict treatment outcome separately and conjointly.
Corresponding author at: Division of Psychosomatic Medicine, Department of Neurology, Inselspital, Bern University Hospital, Bern, Switzerland. E-mail address: [email protected] (L.T. Blaettler).
https://doi.org/10.1016/j.jpsychores.2019.04.010 Received 9 January 2019; Received in revised form 10 April 2019; Accepted 11 April 2019 0022-3999/ © 2019 Elsevier Inc. All rights reserved.
Please cite this article as: Larissa T. Blaettler, et al., Journal of Psychosomatic Research, https://doi.org/10.1016/j.jpsychores.2019.04.010
Journal of Psychosomatic Research xxx (xxxx) xxx–xxx
L.T. Blaettler, et al.
Whereas a conjoint effect of alexithymia and PTE on treatment outcome has been shown in a psychiatric sample [11], it has not been examined in chronic pain patients, yet. According to the IMMPACT recommendations (Initiative on Methods, Measurement, and Pain Assessment in Clinical Trials) [12], the assessment of depression symptoms is a central element in pain treatment research. As 12.1% to 72% of chronic pain patients experience clinical depression [13] and the reduction of psychological distress is a central target of psychotherapeutic interventions also in patients with chronic pain, we chose the reduction of depression symptoms as the primary outcome in the present study. The aim of this study was to investigate the conjoint and separate prediction of depression outcome by alexithymia and PTE in an interdisciplinary chronic pain treatment. We hypothesized that, (1) both alexithymia and PTE negatively predict therapy outcome and that (2) in this setting, patients with high levels of alexithymia and low levels of psychotherapeutic expectations profit less from treatment.
TAS-20 is a self-assessment questionnaire which comprises 20 items and contains three subscales (Difficulty Describing Feelings, Difficulty Identifying Feeling, Externally-Oriented Thinking). Items are rated on a 5-point Likert-scale from 1 = strongly disagree to 5 = strongly agree. For the analyses a total score was calculated by summing all the items [14]. The HADS is a self-report scale that is comprised of 14 items. For each subscale (Anxiety and Depression), 7 items are rated on a fourpoint scale ranging from 0 to 3. Thus the scores of the two subscales vary between 0 and 21 [15]. For the analyses, a total score (range: 0–42) was calculated from the 14 items as an indicator of the overall distress. All three scales are interpreted in such a way that higher values correspond to a higher expression on the respective scales. In the current study, Cronbach's alpha yielded good to excellent internal consistency for the scales used (Cronbach's alpha between 0.82 and 0.86). All analyses were conducted using SPSS version 25. Normal distribution was confirmed using the Kolmogorov-Smirnoff test. Partial correlations were calculated to analyze the relationship between alexithymia, PTE, and depression. To test the separate and conjoint prediction of HADSt1by alexithymia and PTE, a stepwise hierarchical linear regression analysis was computed. Potentially confounding variables were also included as predictors. Missing data were excluded list-wise.
2. Methods Data of 213 consecutively admitted inpatients diagnosed with chronic pain disorders according to ICD-10 (F45.41 chronic pain with somatic and psychological factors) were collected at admission and discharge of a multimodal interdisciplinary treatment program at a Swiss tertiary psychosomatic university clinic (average treatment duration was 29.3; SD = 7.4; range = 16–65). The only inclusion criterion was a minimum age of 18 years. Excluded were individuals 1) who had insufficient knowledge of German to correctly complete the questionnaires, 2) for whom there was no general consent, 3) with complaints the causes and perpetuation of which can be adequately explained by physical injury, as well as 4) persons for whom acute psychiatric illness was the main cause of current suffering. Treatment components comprised medical interventions, pharmacotherapy, psychotherapy, physical and relaxation therapy. Medical interventions included a patient-centered exploration of the main condition, a specialist anamnesis, the recording and treatment of comorbidities, as well as an individual treatment plan. Pharmacological therapy was always carried out alongside or in support of the other therapies. In almost all cases, psychotherapy followed an integrative approach with a cognitive-behavioural therapeutic and interpersonal focus. Depending on the psychotherapist's education, elements from emotionally focused (EFT), body-oriented or systemic therapy were also used. The psychotherapeutic conversations usually took place twice a week and were forstered with various group therapies (e.g. pain management group, mindfulness group, communication group). The physical therapy consisted of various individual and group offers. The group therapies included relaxation therapy in the form of progressive muscle relaxation (PMR) according to Jacobson. Further offers included training with fitness equipment, a basic body awareness group, water gymnastics or Nordic walking. In individual settings, patients could benefit from individual physiotherapy, biofeedback or massages. If indicated, relaxation could also be a smaller part of psychotherapy. All participants provided informed consent for the reuse of their anonymized health data for research purposes, and the study was in accordance with the Declaration of Helsinki and was approved by the Ethics Committee of the Canton of Bern, Switzerland (project ID 201800493). All patients completed a set of standardized self-report assessment tools. The German versions of the Questionnaire for the Measurement of Psychotherapy Motivation (FMP) [4] and the Toronto Alexithymia Scale (TAS-20) [14] were assessed at admission (t0); and the German version of the Hospital Anxiety and Depression Scale (HADS) [15] was assessed at admission (t0) and discharge (t1). The PTE subscale is part of the FMP which consists of 4 subscales (PTE, Negative Illness Consequences, Psychosocial Lay Etiology, General Openness to Psychotherapy). The 47 items are rated on a five-point scale (1–5) [4]. Only the sum score of the PTE subscale was used for the analysis. The
3. Results On average, patients were 48.4 years old (SD = 13.4, Range 18–83) and 53.5% were women. The average score of HADS at intake (t0) was 16.9 (SD = 8.1) and decreased significantly (HADSt1 = 12.7; SD = 8.2; T = 8.677, p = .001). 44.1% of the sample exceeded the clinical cut-off of 7 in both subscales at intake. PTE scores at intake were 25.9 (SD = 5.3) and TAS-20 = 48.8 (SD = 11.7), and 41.8% (N = 89) exceeded the clinical cut-off of 52 for possible alexithymia (0–51 = no alexithymia, 52–60 = possible alexithymia, > 60 high alexithymia). Partial correlation analyses controlling for age and gender revealed significant correlations between HADS at t0 and TAS-20 (r = 0.452; p = .001) and HADSt0 and PTE (r = 0.217; p = .002), whereas the correlation between TAS-20 and PTE at t0 was not significant (r = −0.002; p = .98). A hierarchical linear regression analysis with gender, age, and HADS at t0 as control variables analyzed the prediction of HADS at t1 by the FMP subscale PTE and the TAS-20 at t0 (see Table 1). After entering the control variables in the first step, the TAS-20 and the PTE were entered in the second step. TAS t0 and PTEt0 significantly predicted HADSt1, while controlling for age, gender and HADSt0, in the sense that higher levels of alexithymia and lower levels of PTE predicted higher levels of depression. To test for moderation by alexithymia, an interaction term between z-standardized PTE and TAS-20 scores was entered in the third step. A significant interaction emerged between TAS-20 and PTE, i.e., the higher patients' alexithymia score was, the stronger PTE predicted treatment outcome, controlling for age, gender and HADSt0 (see Fig. 1). 4. Discussion The current study aimed at investigating the conjoint and separate prediction of depression outcome by alexithymia and psychotherapeutic treatment expectations (PTE) of patients in an interdisciplinary treatment for chronic pain. As hypothesized, the results showed that (1) each factor alone, i.e., having a lower ability to interpret emotions in a meaningful way (i.e., being highly alexithymic) and seeing little value in psychotherapeutic interventions (i.e., low PTE) predicted a worse outcome regarding depression change of a multimodal treatment for chronic pain, and (2) particularly patients with both, high alexithymia and low PTE demonstrated worse prospects of depression change. Underscoring the relevance of alexithymia for chronic pain patients and confirming previous evidence [6], a high proportion of chronic pain patients in our sample demonstrated elevated levels of 2
Journal of Psychosomatic Research xxx (xxxx) xxx–xxx
L.T. Blaettler, et al.
Table 1 Hierarchical regression analyses predicting psychological distress (HADSt1) outcomes at posttreatment. HADSt1
Step 1: control variables Age Gender HADSt0 Step 2: Alexithymia and psychotherapy motivation TAS PTE Step 3: Interaction effect TAS × PTE
B
SEb
β
t
−0.075 0.482 0.598
0.033 0.888 0.055
−0.123 0.030 0.596
−2.262⁎,⁎⁎ 0.543 10.911⁎⁎⁎
0.081 −0.326
0.041 0.082
0.117 −0.213
1.985⁎ −3.967⁎⁎⁎
−0.013
0.007
−0.667
−2.000⁎
R2
Δ R2
0.388
0.388
0.446
0.058
0.456
0.010
SE = standard error; ΔR2 = Change in R2; PTE = Psychotherapeutic treatment expectations, TAS = Toronto Alexithymia Scale. ⁎ p < .05. ⁎⁎ p < .01. ⁎⁎⁎ p < .001.
alexithymia. Also as in earlier studies, both alexithymia and PTE predicted depression outcome [9]. However, for the first time in chronic pain patients our results demonstrate the conjoint effects of alexithymia and PTE on treatment outcome, with alexithymia moderating the prediction of depression outcome by treatment expectations. As psychotherapeutic interventions are central components of an interdisciplinary treatment for chronic pain, and as psychotherapy mostly consists of verbal exchanges, it seems reasonable to expect that high levels of alexithymia obstruct beneficial treatment outcomes in terms of depression relief. Whereas worse outcomes can be expected for patients who expect little for an upcoming treatment due to potentially less engagement in therapeutic procedures, the combination of bad expectations and high levels of alexithymia seems to put pain patients at particular risk of worse outcomes that goes beyond the mere addition of effects. As one potential explanation, patients with high levels of alexithymia might have had previous experiences of failed therapeutic interventions that may render them generally skeptic or even resistant toward psychotherapeutic interventions. Future research may study the causal and or temporal relationship of alexithymia and treatment expectations. As our results show, the combination of a high level of alexithymia and low levels of treatment expectations seems to be a particular challenge for therapists who wish to reach beneficial outcomes despite unfavorable conditions. When considering the short-term nature of our treatment it seems advisable to target relatively amenable patient characteristics in the setting. Whereas the level of alexithymia seems to depend on the circumstances and may even be changed by interventions of longer duration, it is generally considered to be a rather stable
patient characteristic as compared to treatment expectations [16]. On this background the strengthening of treatment expectations may be a more feasible short-term treatment goal for pain patients with high levels of alexithymia. How could treatment expectations as well as treatment outcome be enhanced in patients with chronic pain who present with reduced emotional skills? Therapists may choose other than verbal “channels” to motivate and involve the patients in treatment to attain targeted changes and improve patient mood. Of the various interventions within a multimodal therapy, e.g. physiotherapy and/or ergotherapy may be more appealing options for highly alexithymic patients. This is not to say that physiotherapy or ergotherapy do not involve emotionally charged processes or do not lead to changes at the emotional level. Instead, these therapies may offer a wider range of interventions, for which the conscious identification and processing of emotions may be less central. Generally, clinicians may try to choose therapeutic interventions that capitalize on the patients' resources without mainly focusing on emotion processing [17]. A few limitations of this study need to be mentioned. As measurements were self-report questionnaires, the potential for socially desirable esponse-tendencies should be considered. Follow-up assessments were not long-term, warranting future research on the persistence of the observed effects beyond hospitalization. Future research is needed to empirically identify suitable interventions for fostering psychotherapeutic treatment motivation in general and particularly in alexithymic patients to further improve outcomes in the multimodal inpatient treatment of chronic pain patients.
Fig. 1. Graphical illustration of the moderation model between PTE and alexithymia in relation to depression outcome.
3
Journal of Psychosomatic Research xxx (xxxx) xxx–xxx
L.T. Blaettler, et al.
Declarations of interest None.
[9]
Competing interest statement [10]
The authors have no competing interests to report.
[11]
References [1] IASP Taxonomy Working Group, [Internet]: Classification of Chronic Pain, Second edition, (2011) [Accessed 05/04/2019]. Available from: http://www.iasp-pain. org/PublicationsNews/Content.aspx?ItemNumber=1673&navItemNumber=677. [2] H.J. Grabe, C. Meyer, U. Hapke, H.J. Rumpf, H.J. Freyberger, H. Dilling, U. John, Somatoform pain disorder in the general population, Psychother. Psychosom. 72 (2003) 88–94, https://doi.org/10.1159/000068681. [3] G.J. Taylor, Alexithymia: concept, measurement, and implications for treatment, Am. J. Psychiatry 141 (1984) 725–732, https://doi.org/10.1176/ajp.141.6.725. [4] W. Schneider, H.D. Basler, B. Beisenherz, FMP, Fragebogen zur Messung der Psychotherapiemotivation [Questionnaire for the Measurement of Psychotherapy Motivation] (In German). Weinheim, Beltz, (1989). [5] M.J. Constantino, Believing is seeing: an evolving research program on patients' psychotherapy expectations, Psychother. Res. 22 (2012) 127–138, https://doi.org/ 10.1080/10503307.2012.663512. [6] M. Di Tella, L. Castelli, Alexithymia in chronic pain disorders, Curr. Rheumatol. Rep. 18 (41) (2016), https://doi.org/10.1007/s11926-016-0592-x. [7] T. Probst, H. Sattel, P. Henningsen, H. Gündel, C. Lahmann, Alexithymia as a moderator of treatment outcomes in a randomized controlled trial on brief psychodynamic interpersonal psychotherapy for patients with multisomatoform disorder, Psychother. Psychosom. 86 (2017) 57–59, https://doi.org/10.1159/ 000448287. [8] T. Probst, H. Sattel, H. Gündel, P. Henningsen, J. Kruse, G. Schneider, C. Lahmann, Moderating effects of alexithymia on associations between the therapeutic alliance
[12]
[13]
[14] [15] [16]
[17]
4
and the outcome of brief psychodynamic-interpersonal psychotherapy for multisomatoform disorder, Front. Psychiatry 8 (261) (2017), https://doi.org/10.3389/ fpsyt.2017.00261. J.A. Stewart, N. Egloff, R. von Känel, J. Grolimund, M. Studer, M. grosse Holtforth, Motivation for psychological treatment predicts favorable outcomes in multimodal interdisciplinary treatment for chronic somatoform pain, Psychother. Psychosom. 86 (2016) 60–61, https://doi.org/10.1159/000449471. B. Timmer, G. Bleichhardt, W. Rief, Importance of psychotherapy motivation in patients with somatization syndrome, Psychother. Res. 16 (2006) 348–356, https:// doi.org/10.1080/10503300500485292. J. Terock, D. Janowitz, H.J. Grabe, H.J. Freyberger, W. Schneider, T. Klauer, Alexithymia and psychotherapeutic treatment motivation: main and interactional effects on treatment outcome, Psychother. Psychosom. 86 (2017) 185–186, https:// doi.org/10.1159/000457961. D.C. Turk, R.H. Dworkin, R.R. Allen, N. Bellamy, N. Brandenburg, D.B. Carr, ... D.J. Hewitt, Core outcome domains for chronic pain clinical trials: IMMPACT recommendations, Pain 106 (2003) 337–345, https://doi.org/10.1016/j.pain.2003. 08.001. L. Rayner, M. Hotopf, H. Petkova, F. Matcham, A. Simpson, L.M. McCracken, Depression in patients with chronic pain attending a specialized pain treatment centre: prevalence and impact on health care costs, Pain 157 (2016) 1472, https:// doi.org/10.1097/j.pain.0000000000000542. M. Bach, D. Bach, M. de Zwaan, M. Serim, F. Böhmer, Validation of the German version of the 20-item Toronto Alexithymia Scale in normal persons and psychiatric patients (in German), Psychother. Psychosom. Med. Psychol. 46 (1996) 23–28. A.T. Beck, C.H. Ward, M. Mendelson, J. Mock, J. Erbaugh, An inventory for measuring depression, Arch. Gen. Psychiatry 4 (1961) 561–571, https://doi.org/10. 1001/archpsyc.1961.01710120031004. A. Hiirola, S. Pirkola, M. Karukivi, N. Markkula, R.M. Bagby, M. Joukamaa, ... J. Suvisaari, An evaluation of the absolute and relative stability of alexithymia over 11 years in a Finnish general population, J. Psychosom. Res. 95 (2017) 81–87, https://doi.org/10.1016/j.jpsychores.2017.02.007. C. Flückiger, F. Caspar, M. grosse Holtforth, U. Willutzki, Working with patients' strengths: a microprocess approach, Psychother. Res. 19 (2009) 213–223, https:// doi.org/10.1080/10503300902755300.