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Alexithymia and emotional awareness in females with Painful Rheumatic Conditions
Journal of Psychosomatic Research 73 (2012) 398–400
Contents lists available at SciVerse ScienceDirect
Journal of Psychosomatic Research
Short communication
Alexithymia and emotional awareness in females with Painful Rheumatic Conditions Carolina Baeza-Velasco a,⁎, Solange Carton a, b, Caroline Almohsen b, Francis Blotman c, Marie Christine Gély-Nargeot a, b a b c
Epsylon, Laboratory Dynamic of Human Abilities and Health Behaviors, Montpellier, France University Paul Valéry Montpellier 3, France Rheumatology service of the University Hospital of Lapeyronie, CHRU Montpellier, France
a r t i c l e
i n f o
Article history: Received 12 June 2012 Received in revised form 9 August 2012 Accepted 10 August 2012 Keywords: Alexithymia Emotional awareness Painful Rheumatic Conditions Depression Anxiety
a b s t r a c t Objective: Research about the deficit of emotional regulation in Painful Rheumatic Conditions (PRC) indicates that these patients have alexithymic characteristics, as revealed by the Toronto Alexithymia Scale (TAS-20). However, the use of a unique measure to assess alexithymic trends has been questioned. The aim of the present study is twofold: to compare the levels of alexithymia and emotional awareness in females with and without PRC; and to test the predictive validity of alexithymia measures beyond negative emotions. Method: Thirty-nine women with PRC of diverse etiology and twenty-two healthy females responded to the TAS-20, the Levels of Emotional Awareness Scale (LEAS) and questionnaires of anxiety and depression. Results: The total score, factor 1 (difficulty identifying feelings) and factor 2 (difficulty describing feelings) scores of TAS-20 were significantly higher among women with PRC than controls. Females with PRC had lower scores in the subscale “self” of the LEAS (capacity to describe their own emotional experience) than the control group. Only the LEAS significantly predicted the status group after adjusting for anxiety and depression. Conclusion: Our results highlighted the impairment of emotion processing in patients with PRC and the importance of using a multimodal assessment of emotional regulation in future research. © 2012 Elsevier Inc. All rights reserved.
Introduction Research about pain and emotion carried out over the last decade, observed that greater pain is related to emotional stress and limited emotional awareness (EA), expression, and processing [1]. The most elaborated and well-researched construct for describing personalityrelated difficulties in the processing and regulation of emotion is alexithymia [2], which has been associated with physiological hyperarousal that can lead to pain-inducing changes such as prolonged muscle tension [1]. Prevalence of alexithymia is significantly higher in patients with Painful Rheumatic Conditions (PRC), such as fibromyalgia (FM) [3,4] and rheumatoid arthritis (RA) [5] than in controls. These studies explored alexithymia using the Toronto Alexithymia Scale (TAS-20) [6], which is the most widely used measure of this construct. However, some criticisms have been made towards TAS-20: it is difficult to replicate its factor structure and it is associated with negative affectivity [7,8]. For some authors, the TAS-20 reflects general distress rather than alexithymia. Futhermore, the use of explicit self-reports as a unique measure to assess alexithymia has been questioned. Explicit self-reports paradoxically require that the respondents, are aware of their lack of EA and diminished capacity to describe feelings [9]. In
that sense, Lundh et al. [10] stated that subjects’ beliefs about their ability might be reported rather than alexithymia. A remedy for these potential measurement errors is the concurrent use of a performance-based instrument [9], such as the Levels of Emotional Awareness Scale (LEAS) [11]. The LEAS is a performance-based, indirect measure of alexithymia, in which examinees do not have to assess their own abilities regarding EA; their descriptions are rated by examiners who place them into the appropriate levels of EA [12]. A low level of EA can be compared to alexithymia, both signalling a deficit of emotional regulation [13]. In constrast, higher levels of EA are associated with greater physical and mental health [14]. It has been demonstrated that both instruments, TAS-20 and LEAS, can be successfully used to obtain two complementary, non-interchangeable measures of emotion processing [15]. Despite this, the number of studies in which the LEAS is used to measure alexithymia is still small [16]. The aims of this study were to examine the differences between women with PRC and healthy controls in alexithymia and EA, and to test the predictive validity of the alexithymia measures beyond anxiety and depression. Method Participants and procedure
⁎ Corresponding author at: Laboratoire Epsylon, 4 boulevard Henri IV, 34000 Montpellier, France. Tel.: + 33 672690178. E-mail address: [email protected] (C. Baeza-Velasco). 0022-3999/$ – see front matter © 2012 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jpsychores.2012.08.008
The case group included 39 women (mean age: 52.2 ± 8.9) with a confirmed rheumatological diagnosis (FM = 20; RA = 19). All of them
C. Baeza-Velasco et al. / Journal of Psychosomatic Research 73 (2012) 398–400
were outpatients of the rheumatology service of the University Hospital of Lapeyronie (Montpellier — France). The control group was composed of 22 females (mean age: 54 ± 8.2) recruited from the community. An informed consent was obtained from all participants before entering the study. Instruments The Toronto Alexithymia Scale (TAS-20) [6] The TAS-20 consists of 20 self-descriptive statements grouped into three factors: (F1) difficulty identifying feelings, (F2) difficulty describing feelings, (F3) externally oriented thinking. The Levels of Emotional Awareness Scale (LEAS) [11] The LEAS is a performance measure of the ability to put feelings into words. Twenty vignettes are posed that elicit emotional responses from the self and others. The responses are scored using specific structural criteria ranging from 0 to 4, based on a theory of cognitive–emotional development proposed by their authors. The State-Trait Anxiety Inventory (STAI) [17] This scale evaluates state anxiety, which refers to an emotional state at a specific moment in time, and trait anxiety (subscale used in this study), which refers to anxiety as an enduring personality characteristic. The Beck Depression Inventory, Second Edition (BDI-II) [18] The BDI-II is a 21-item self-report instrument to assess the existence and severity of symptoms of depression according to the DSM-IV-TR [19]. Analysis Statistical treatment included a descriptive analysis of the data, non-parametric tests and binary logistic regression. The significance level was taken as .05 for all statistical tests. Results Sociodemographic variables The groups did not differ in terms of age and years of education (Table 1). Alexithymia and EA Factors 1, 2 and the total score of the TAS-20 were significantly higher in the case group. The healthy group had a significantly higher LEAS “self” score than the PRC group (Table 1). Negative emotions The depression and the trait anxiety scores were significantly higher among females with PRC than controls (Table 1). Logistic regression We first examined whether the TAS-20 predicted group status beyond depression and anxiety. We introduced in the model the TAS-20 (total score and the three factors), trait anxiety and the BDI-II scores as covariables. Only the BDI-II score was a significant variable in this model (OR = 1.18; 95% = 1.07–1.29). Secondly, we examined whether the LEAS predicted group status beyond negative emotions. We introduced in the model the LEAS (“self”, “other” and total scores), the trait anxiety and the BDI-II scores as covariables. The The BDI-II (OR = 1.19; 95% = 1.06–1.33), the subscale “self” (OR = .71; 95% = .57–.90) and the total score of the LEAS (OR = 1.27; 95% = 1.01–1.61) were significant variables in the model. Finally, we introduced in the model the TAS-20 (total and the three factors), and the LEAS (“self”, “other” and total scores) simultaneously, without adjusting for depression and anxiety. The total score of the TAS-20 (OR = 1.06; 95% = 1.01–1.12), the “self” (OR = .72; 95% = .59–.88) and the total score of the LEAS (OR = 1.31; 95% = 1.06–1.61) significantly predicted the status group.
399
Table 1 Comparison of sociodemographic variables and scores in questionnaires STAI, BDI-II, TAS-20 and LEAS of females with and without PRC Variable
Age Years of education BDI-II STAI trait TAS-20 factor 1 Factor 2 Factor 3 Total LEAS Self Other Total
Pa
Healthy group (n = 22)
PRC group (n = 39)
M
SD
M
SD
54.05 12 7.59 38.55 15.36 10.41 13.95 39.73 49.59 41.77 54.82
8.23 2.44 8.80 11.73 6.74 4.15 4.79 12.66 6.33 7.36 6.23
52.21 11.03 20.51 48.44 19.56 12.72 16.41 48.69 42.82 40.36 53.38
8.98 2.94 10.91 13.12 6.17 4.67 3.07 11.45 8.62 7.74 7.14
.408 .107 .000 .005 .009 .024 .057 .012 .002 .332 .456
PRC: Painful Rheumatic Condition, BDI-II: Beck Depression Inventory, STAI: State-Trait Anxiety Inventory, TAS-20: Toronto Alexithymia Scale, Factor 1: difficulty identifying feelings. Factor 2: difficulty describing feelings; Factor 3: externally-oriented thinking; LEAS: Levels of Emotional Awareness Scale. a Mann–Whitney test. Statistically significant p value (b .05)
Discussion In the present study, we observed on the basis of the LEAS results, that PRC women had a lower capacity to describe the own emotional experience than healthy women. Compared to the control group, females with PRC had more difficulties in describing and identifying feelings according to the TAS-20. Our results confirm earlier findings, demonstrating impairments in emotional functioning in patients with PRC measured with the TAS-20 [3,5,20]. However, to our knowledge this is the first time that TAS-20 and LEAS have been applied together to a chronic rheumatic pain sample, so there are no previous data to facilitate a comparison about the LEAS assessment in this population. The interest of providing two measures of deficit of emotional regulation arises from the critiques made on the use of explicit self-reports (such as TAS-20) as a unique measure. Indeed, it is paradoxal to ask alexithymic people, who are characterised by a low degree of affective insight, to accurately estimate their emotional disabilities [14,21]. In this regard, our findings suggest that when an indirect method is used to evaluate deficit in emotional regulation, examinees do not have to assess their own abilities regarding EA, unlike in self-reported measurements. Differences in emotional processing between people with and without PRC are also found. The logistic regression analyses revealed that the LEAS and the TAS-20 have a simultaneous predictive validity. However, the LEAS predicts the group status better than the TAS-20, once anxiety and depression are controlled for. These results are in line with those of Subic-Wrana et al. [16]. They compared TAS-20 and LEAS in inpatients of a psychosomatic ward, expecting that the LEAS, which focuses on the distinction between implicit/unconscious and explicit/conscious levels of EA, would be able to differentiate between groups more precisely than TAS-20, and the results obtained confirmed their hypothesis. A limitation of the present study is that the PRC group contains patients with RA and FM which are two different conditions. The current study did not have a large enough sample to test these groups separately. In this regards, further studies are needed on larger samples and differentiating rheumatic diseases, in order to acquire further knowledge about emotional regulation in these patients. Despite limitations, our results add to the weight of evidence that compared to healthy people, those with PRC present more difficulties in emotion regulation, as the assessment confirmed via implicit and explicit measurements, and that the TAS-20 as a self-report measure, is limited in its possibility to evaluate alexithymia. The LEAS in contrast, as a performance measure, may highlight new and important
400
C. Baeza-Velasco et al. / Journal of Psychosomatic Research 73 (2012) 398–400
aspects in the assessment of emotion regulation processes in somatic and psychosomatic diseases. Considering that feelings and emotional processing play an important role in the modulation of the intensity of sensory and emotional aspects of pain [22], it is important to include interventions targeting emotional abilities as part of the overall management of PRC. They may help to improve with the management of negative emotions associated with chronic illness, and promote a positive adjustment to symptoms and the burden of the disease in these patients. Conflict of interest F. Blotman; fees for conferences from Laboratory Pierre Fabre and “Chaine Thermale du Soleil”. The other authors declare no conflict of interest. Acknowledgments We thank all participants, Professor J-P. Boulenger, V. Macioce and S. Raffard for their valuable collaboration. References [1] Lumley M, Cohen J, Borszcz G, Cano A, Radcliffe A, Porter L, et al. Pain and emotion. Journal of Clinical Psychology 2011;67:942-68. [2] Taylor GJ, Bagby RM, Parker JDA. Disorders of affect regulation: alexithymia in medical and psychiatric illness. Cambridge: Cambridge University Press; 1997. [3] Huber A, Suman AL, Biasi G, Carli G. Alexithymia in fibromyalgia syndrome: Associations with ongoing pain. Journal of Psychosomatic Research 2009;66:425-33. [4] Steinweg DL, Dallas AP, Rea WS. Fibromyalgia: Unspeakable Suffering, A prevalence study of alexithymia. Psychosomtics 2011;52:255-62. [5] Fernandez A, Sriram TG, Rajkumar S, Chandrasekar AN. Alexithymic characteristics in rheumatoid arthritis: a controlled study. Psychotherapy and Psychosomatics 1989;51:45-50. [6] Bagby RM, Parker JDA, Taylor GJ. The Twenty-Item Toronto Alexithymia Scale: I. Item selection and cross-validation of the factor structure. Journal of Psychosomatic Research 1994;38:23-32. [7] Baiardini I, Abbà S, Ballauri M, Vuillermoz G, Braido F. Alexithymia and chronic deseases : the state of the art. Giornale Italiano di Medicina del Lavoro ed Ergonomia 2011;33:1Suppl. A, Psicol.
[8] Kooiman CG, Spinhoven P, Trijsburg RW. The assessment of alexithymia — a critical review of the literature and a psychometric study of the Toronto Alexithymia Scale-20. Journal of Psychosomatic Research 2002;53:1083-90. [9] Parling T, Mortazavi M, Ghaderi A. Alexithymia and emotional awareness in anorexia nervosa: time for a shift in the measurement of the concept? Eating Behaviors 2010;11:205-10. [10] Lundh LG, Johnsson A, Sundqvist K, Olsson H. Alexithymia, memory of emotion, emotional awareness, and perfectionism. Emotion 2002;2:361-79. [11] Lane RD, Quinlan DM, Schwartz GE, Walker PA, Zeitlin SB. The Levels of Emotional Awareness Scale: a cognitive-developmental measure of emotion. Journal of Personality Assessment 1990;55:124-34. [12] Igarashi T, Komaki G, Lane R, Moriguchi Y, Nishimura H, Arakawa H, et al. The reliability and validity of the Japanese version of the Levels of Emotional Awareness Scale (LEAS-J). BioPsychoSocial Medicine 2011;5:2, doi:10.1186/1751-0759-5-2. [13] Berthoz S, Ouhayoun B, Parage N, Kirzenbaum M, Bourgey M, Allilaire JF. Etude préliminaire de validation française de léchelle de niveaux de conscience émotionnelle chez des patients déprimés et des contrôles. Annales MédicoPsychologiques 2000;158:665-72. [14] Waller E, Scheidt C. Somatoform disorders as disorders of affect regulation. A study comparing the TAS-20 with non-self-report measures of alexithymia. Journal of Psychosomatic Research 2004;57:239-47. [15] Carton S, Bayard S, Jouanne C, Lagrue G. Emotional awareness and alexithymia in smokers seeking help for cessation: a clinical analysis. Journal of Smoking Cessation 2008;3:81-91. [16] Subic-Wrana C, Bruder S, Thomas W, Lane RD, Kohle K. Emotional awareness deficits in inpatients of a psychosomatic ward: a comparison of two different measures of alexithymia. Psychosomatic Medicine 2005;67:483-9. [17] Spielberger CD, Gorsuch RL, Lushene RE. The stait-trait anxiety inventory. Palo Alto, CA: Consulting Psychologist; 1970. [18] Beck AT, Steer RA, Brown GK. Inventaire de Dépression de Beck — 2ème édition (BDI-II). Paris: Editions du Centre de Psychologie Appliquée (ECPA); 1998. [19] American Psychiatric Association. Diagnostic and statistical manual of mental disorders, 4th edition, text revision (DSM-IV-TR). Washington, DC: American Psychiatric Publishing; 2000. [20] Mehling W, Krause N. Are difficulties perceiving and expressing emotions associated with low-back pain?: the relationship between lack of emotional awareness (alexithymia) and 12-month prevalence of low-back pain in 1180 urban public transit operators. Journal of Psychosomatic Research 2005;58:73-81. [21] Carton S, Bayard S, Paget V, Jouanne C, Varescon I, Edel Y, et al. Emotional awareness in substance-dependent patients. Journal of Clinical Psychology 2010;66: 1–12. [22] Elbeze Rimasson D, Gay MC. Emotional processing in chronic pain: the state of the art. Annales Médico-Psychologiques 2012;170:163-8.
Contents lists available at SciVerse ScienceDirect
Journal of Psychosomatic Research
Short communication
Alexithymia and emotional awareness in females with Painful Rheumatic Conditions Carolina Baeza-Velasco a,⁎, Solange Carton a, b, Caroline Almohsen b, Francis Blotman c, Marie Christine Gély-Nargeot a, b a b c
Epsylon, Laboratory Dynamic of Human Abilities and Health Behaviors, Montpellier, France University Paul Valéry Montpellier 3, France Rheumatology service of the University Hospital of Lapeyronie, CHRU Montpellier, France
a r t i c l e
i n f o
Article history: Received 12 June 2012 Received in revised form 9 August 2012 Accepted 10 August 2012 Keywords: Alexithymia Emotional awareness Painful Rheumatic Conditions Depression Anxiety
a b s t r a c t Objective: Research about the deficit of emotional regulation in Painful Rheumatic Conditions (PRC) indicates that these patients have alexithymic characteristics, as revealed by the Toronto Alexithymia Scale (TAS-20). However, the use of a unique measure to assess alexithymic trends has been questioned. The aim of the present study is twofold: to compare the levels of alexithymia and emotional awareness in females with and without PRC; and to test the predictive validity of alexithymia measures beyond negative emotions. Method: Thirty-nine women with PRC of diverse etiology and twenty-two healthy females responded to the TAS-20, the Levels of Emotional Awareness Scale (LEAS) and questionnaires of anxiety and depression. Results: The total score, factor 1 (difficulty identifying feelings) and factor 2 (difficulty describing feelings) scores of TAS-20 were significantly higher among women with PRC than controls. Females with PRC had lower scores in the subscale “self” of the LEAS (capacity to describe their own emotional experience) than the control group. Only the LEAS significantly predicted the status group after adjusting for anxiety and depression. Conclusion: Our results highlighted the impairment of emotion processing in patients with PRC and the importance of using a multimodal assessment of emotional regulation in future research. © 2012 Elsevier Inc. All rights reserved.
Introduction Research about pain and emotion carried out over the last decade, observed that greater pain is related to emotional stress and limited emotional awareness (EA), expression, and processing [1]. The most elaborated and well-researched construct for describing personalityrelated difficulties in the processing and regulation of emotion is alexithymia [2], which has been associated with physiological hyperarousal that can lead to pain-inducing changes such as prolonged muscle tension [1]. Prevalence of alexithymia is significantly higher in patients with Painful Rheumatic Conditions (PRC), such as fibromyalgia (FM) [3,4] and rheumatoid arthritis (RA) [5] than in controls. These studies explored alexithymia using the Toronto Alexithymia Scale (TAS-20) [6], which is the most widely used measure of this construct. However, some criticisms have been made towards TAS-20: it is difficult to replicate its factor structure and it is associated with negative affectivity [7,8]. For some authors, the TAS-20 reflects general distress rather than alexithymia. Futhermore, the use of explicit self-reports as a unique measure to assess alexithymia has been questioned. Explicit self-reports paradoxically require that the respondents, are aware of their lack of EA and diminished capacity to describe feelings [9]. In
that sense, Lundh et al. [10] stated that subjects’ beliefs about their ability might be reported rather than alexithymia. A remedy for these potential measurement errors is the concurrent use of a performance-based instrument [9], such as the Levels of Emotional Awareness Scale (LEAS) [11]. The LEAS is a performance-based, indirect measure of alexithymia, in which examinees do not have to assess their own abilities regarding EA; their descriptions are rated by examiners who place them into the appropriate levels of EA [12]. A low level of EA can be compared to alexithymia, both signalling a deficit of emotional regulation [13]. In constrast, higher levels of EA are associated with greater physical and mental health [14]. It has been demonstrated that both instruments, TAS-20 and LEAS, can be successfully used to obtain two complementary, non-interchangeable measures of emotion processing [15]. Despite this, the number of studies in which the LEAS is used to measure alexithymia is still small [16]. The aims of this study were to examine the differences between women with PRC and healthy controls in alexithymia and EA, and to test the predictive validity of the alexithymia measures beyond anxiety and depression. Method Participants and procedure
⁎ Corresponding author at: Laboratoire Epsylon, 4 boulevard Henri IV, 34000 Montpellier, France. Tel.: + 33 672690178. E-mail address: [email protected] (C. Baeza-Velasco). 0022-3999/$ – see front matter © 2012 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jpsychores.2012.08.008
The case group included 39 women (mean age: 52.2 ± 8.9) with a confirmed rheumatological diagnosis (FM = 20; RA = 19). All of them
C. Baeza-Velasco et al. / Journal of Psychosomatic Research 73 (2012) 398–400
were outpatients of the rheumatology service of the University Hospital of Lapeyronie (Montpellier — France). The control group was composed of 22 females (mean age: 54 ± 8.2) recruited from the community. An informed consent was obtained from all participants before entering the study. Instruments The Toronto Alexithymia Scale (TAS-20) [6] The TAS-20 consists of 20 self-descriptive statements grouped into three factors: (F1) difficulty identifying feelings, (F2) difficulty describing feelings, (F3) externally oriented thinking. The Levels of Emotional Awareness Scale (LEAS) [11] The LEAS is a performance measure of the ability to put feelings into words. Twenty vignettes are posed that elicit emotional responses from the self and others. The responses are scored using specific structural criteria ranging from 0 to 4, based on a theory of cognitive–emotional development proposed by their authors. The State-Trait Anxiety Inventory (STAI) [17] This scale evaluates state anxiety, which refers to an emotional state at a specific moment in time, and trait anxiety (subscale used in this study), which refers to anxiety as an enduring personality characteristic. The Beck Depression Inventory, Second Edition (BDI-II) [18] The BDI-II is a 21-item self-report instrument to assess the existence and severity of symptoms of depression according to the DSM-IV-TR [19]. Analysis Statistical treatment included a descriptive analysis of the data, non-parametric tests and binary logistic regression. The significance level was taken as .05 for all statistical tests. Results Sociodemographic variables The groups did not differ in terms of age and years of education (Table 1). Alexithymia and EA Factors 1, 2 and the total score of the TAS-20 were significantly higher in the case group. The healthy group had a significantly higher LEAS “self” score than the PRC group (Table 1). Negative emotions The depression and the trait anxiety scores were significantly higher among females with PRC than controls (Table 1). Logistic regression We first examined whether the TAS-20 predicted group status beyond depression and anxiety. We introduced in the model the TAS-20 (total score and the three factors), trait anxiety and the BDI-II scores as covariables. Only the BDI-II score was a significant variable in this model (OR = 1.18; 95% = 1.07–1.29). Secondly, we examined whether the LEAS predicted group status beyond negative emotions. We introduced in the model the LEAS (“self”, “other” and total scores), the trait anxiety and the BDI-II scores as covariables. The The BDI-II (OR = 1.19; 95% = 1.06–1.33), the subscale “self” (OR = .71; 95% = .57–.90) and the total score of the LEAS (OR = 1.27; 95% = 1.01–1.61) were significant variables in the model. Finally, we introduced in the model the TAS-20 (total and the three factors), and the LEAS (“self”, “other” and total scores) simultaneously, without adjusting for depression and anxiety. The total score of the TAS-20 (OR = 1.06; 95% = 1.01–1.12), the “self” (OR = .72; 95% = .59–.88) and the total score of the LEAS (OR = 1.31; 95% = 1.06–1.61) significantly predicted the status group.
399
Table 1 Comparison of sociodemographic variables and scores in questionnaires STAI, BDI-II, TAS-20 and LEAS of females with and without PRC Variable
Age Years of education BDI-II STAI trait TAS-20 factor 1 Factor 2 Factor 3 Total LEAS Self Other Total
Pa
Healthy group (n = 22)
PRC group (n = 39)
M
SD
M
SD
54.05 12 7.59 38.55 15.36 10.41 13.95 39.73 49.59 41.77 54.82
8.23 2.44 8.80 11.73 6.74 4.15 4.79 12.66 6.33 7.36 6.23
52.21 11.03 20.51 48.44 19.56 12.72 16.41 48.69 42.82 40.36 53.38
8.98 2.94 10.91 13.12 6.17 4.67 3.07 11.45 8.62 7.74 7.14
.408 .107 .000 .005 .009 .024 .057 .012 .002 .332 .456
PRC: Painful Rheumatic Condition, BDI-II: Beck Depression Inventory, STAI: State-Trait Anxiety Inventory, TAS-20: Toronto Alexithymia Scale, Factor 1: difficulty identifying feelings. Factor 2: difficulty describing feelings; Factor 3: externally-oriented thinking; LEAS: Levels of Emotional Awareness Scale. a Mann–Whitney test. Statistically significant p value (b .05)
Discussion In the present study, we observed on the basis of the LEAS results, that PRC women had a lower capacity to describe the own emotional experience than healthy women. Compared to the control group, females with PRC had more difficulties in describing and identifying feelings according to the TAS-20. Our results confirm earlier findings, demonstrating impairments in emotional functioning in patients with PRC measured with the TAS-20 [3,5,20]. However, to our knowledge this is the first time that TAS-20 and LEAS have been applied together to a chronic rheumatic pain sample, so there are no previous data to facilitate a comparison about the LEAS assessment in this population. The interest of providing two measures of deficit of emotional regulation arises from the critiques made on the use of explicit self-reports (such as TAS-20) as a unique measure. Indeed, it is paradoxal to ask alexithymic people, who are characterised by a low degree of affective insight, to accurately estimate their emotional disabilities [14,21]. In this regard, our findings suggest that when an indirect method is used to evaluate deficit in emotional regulation, examinees do not have to assess their own abilities regarding EA, unlike in self-reported measurements. Differences in emotional processing between people with and without PRC are also found. The logistic regression analyses revealed that the LEAS and the TAS-20 have a simultaneous predictive validity. However, the LEAS predicts the group status better than the TAS-20, once anxiety and depression are controlled for. These results are in line with those of Subic-Wrana et al. [16]. They compared TAS-20 and LEAS in inpatients of a psychosomatic ward, expecting that the LEAS, which focuses on the distinction between implicit/unconscious and explicit/conscious levels of EA, would be able to differentiate between groups more precisely than TAS-20, and the results obtained confirmed their hypothesis. A limitation of the present study is that the PRC group contains patients with RA and FM which are two different conditions. The current study did not have a large enough sample to test these groups separately. In this regards, further studies are needed on larger samples and differentiating rheumatic diseases, in order to acquire further knowledge about emotional regulation in these patients. Despite limitations, our results add to the weight of evidence that compared to healthy people, those with PRC present more difficulties in emotion regulation, as the assessment confirmed via implicit and explicit measurements, and that the TAS-20 as a self-report measure, is limited in its possibility to evaluate alexithymia. The LEAS in contrast, as a performance measure, may highlight new and important
400
C. Baeza-Velasco et al. / Journal of Psychosomatic Research 73 (2012) 398–400
aspects in the assessment of emotion regulation processes in somatic and psychosomatic diseases. Considering that feelings and emotional processing play an important role in the modulation of the intensity of sensory and emotional aspects of pain [22], it is important to include interventions targeting emotional abilities as part of the overall management of PRC. They may help to improve with the management of negative emotions associated with chronic illness, and promote a positive adjustment to symptoms and the burden of the disease in these patients. Conflict of interest F. Blotman; fees for conferences from Laboratory Pierre Fabre and “Chaine Thermale du Soleil”. The other authors declare no conflict of interest. Acknowledgments We thank all participants, Professor J-P. Boulenger, V. Macioce and S. Raffard for their valuable collaboration. References [1] Lumley M, Cohen J, Borszcz G, Cano A, Radcliffe A, Porter L, et al. Pain and emotion. Journal of Clinical Psychology 2011;67:942-68. [2] Taylor GJ, Bagby RM, Parker JDA. Disorders of affect regulation: alexithymia in medical and psychiatric illness. Cambridge: Cambridge University Press; 1997. [3] Huber A, Suman AL, Biasi G, Carli G. Alexithymia in fibromyalgia syndrome: Associations with ongoing pain. Journal of Psychosomatic Research 2009;66:425-33. [4] Steinweg DL, Dallas AP, Rea WS. Fibromyalgia: Unspeakable Suffering, A prevalence study of alexithymia. Psychosomtics 2011;52:255-62. [5] Fernandez A, Sriram TG, Rajkumar S, Chandrasekar AN. Alexithymic characteristics in rheumatoid arthritis: a controlled study. Psychotherapy and Psychosomatics 1989;51:45-50. [6] Bagby RM, Parker JDA, Taylor GJ. The Twenty-Item Toronto Alexithymia Scale: I. Item selection and cross-validation of the factor structure. Journal of Psychosomatic Research 1994;38:23-32. [7] Baiardini I, Abbà S, Ballauri M, Vuillermoz G, Braido F. Alexithymia and chronic deseases : the state of the art. Giornale Italiano di Medicina del Lavoro ed Ergonomia 2011;33:1Suppl. A, Psicol.
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