A large, two-year study led by researchers at Johns Hopkins Medicine and consisting of more than 1,400 adults living with chronic pain across the United States found that people who struggle to identify and describe their emotions experience greater disruption to daily life from pain over time due to increased psychological distress.
The study examined how alexithymia — a trait marked by difficulty recognizing and expressing emotions — affects pain outcomes. While previous research has linked alexithymia to worse pain, this study is among the first to show how and when that effect unfolds over time.
The study's findings were published March 26 in the journal American Psychological Association.
Chronic pain is typically defined as pain that persists for greater than three months. According to the Centers for Disease Control and Prevention, 24.3% of adults experience chronic pain, and 8.3% have chronic pain severe enough to limit the amount of physical labor they can do in a day. When alexithymia, a subclinical trait, is elevated in patients with chronic pain, patients have worse pain severity, physical interference, depression and anxiety. Though underexplored, there has been evidence suggesting alexithymia can be targeted and reduced in chronic pain treatment. For the purposes of psychological intervention for chronic pain, this study aimed to explore the temporal relationships between alexithymia and pain outcomes.
Senior author Rachel Aaron Ph.D., associate professor of physical medicine and rehabilitation at the Johns Hopkins University School of Medicine says, "Prior studies have shown that alexithymia tends to be higher in people who have chronic pain. However, we did not know whether alexithymia leads to worse pain, or whether worse pain leads to alexithymia. We also have not had a good understanding of why these two distinct processes were related."
To conduct this study, over a two-year span, researchers monitored and surveyed a cohort of 1,453 patients with mixed chronic pain conditions across the U.S. Participating patients were measured for alexithymia via the Toronto Alexithymia Scale and were prompted to fill out a 20-item questionnaire consisting of three subscales: Difficulty Identifying Feelings, Difficulty Describing Feelings and Externally Oriented Thinking.
Patients' pain severity and pain interference were also measured by two subscales of the Brief Pain Inventory, and the Patient-Reported Outcomes Measures Information System was used to measure anxiety and depression and were used to assess patient participants' level of psychological distress.
Using these advanced statistical modeling methods, study investigators tested whether emotional difficulties predicted later pain outcomes — and whether psychological distress played a mediating role.
Results of the study found that patients with higher levels of alexithymia at the start of the study developed greater psychological distress one year later. It was also found that increased distress predicted greater pain interference at two years, meaning pain had a larger impact on daily functioning and quality of life. Alternatively, results showed that alexithymia and distress did not significantly increase how intense pain felt for study participants. Pain interference also did not predict later alexithymia, which supported evidence that emotional processing difficulties are a risk factor, not a consequence, of worsening pain outcomes.
"Greater difficulties identifying one's own feelings can lead to greater symptoms of psychological distress, including symptoms of depression and anxiety," says Aaron. "This in turn can lead to greater difficulties managing chronic pain. These findings highlight the role of considering alexithymia in psychological treatment for chronic pain, and how it might lead to psychological distress, to improve pain outcomes."
The study highlights psychological distress—especially anxiety and depression—as a key intervention target, particularly for people who have difficulty identifying and expressing emotions. Furthermore, this study provides new evidence that how people experience and process their emotions plays a crucial role in how chronic pain shapes their lives over time and addressing psychological distress may be one of the most effective ways to improve long-term outcomes.
Funding for this research was provided by the Johns Hopkins Clinician Scientist Award (R.V.A), National Institutes of Health K23HD104934, F32DA049393, R01MD009063, 3K12NS130673, K12TR005467.
None of the authors of the study have conflicts of interest to disclose.
