Alexithymia, Depression, Inflammation, and Pain in Patients With Rheumatoid Arthritis

Abstract

Objective. We previously reported that depression and inflammation have independent effects on pain severity in patients with rheumatoid arthritis (RA). Alexithymia is a personality trait characterized by deficits in cognitive processing and regulation of emotions. A broad association between alexithymia and various health problems has been suggested, including depression, inflammation, and pain. The objective of this study was to examine the independent influence of alexithymia on pain perception and its relationship to depression and inflammation. Methods. We evaluated 213 RA outpatients who completed self-administered questionnaires, including the Beck Depression Inventory-II (BDI-II) to measure depression severity, the 20-item Toronto Alexithymia Scale (TAS-20) to measure degree of alexithymia, and a visual analog scale to quantify perceived pain. Serum C-reactive protein (CRP) levels were measured to quantify inflammation severity.Results. An initial significant positive association between the TAS-20 score and pain severity (P ‫؍‬ 0.01) lost significance after controlling for BDI-II score and CRP level using regression analysis. An interaction was observed among alexithymia, depression, and inflammation with regard to perceived pain. Among those without alexithymia, pain severity increased linearly with the CRP tertile levels regardless of the presence of depression (P < 0.001 for trend). No linear association between pain severity and CRP level was observed among those with alexithymia. Moreover, depressed patients with alexithymia (BDI-II score >14 and TAS-20 score >61) reported severe pain even at low CRP levels. Conclusion. Alexithymia might have a substantial role in pain perception as well as depression in patients with RA. A biopsychosocial approach is essential to achieve better pain control. INTRODUCTIONRheumatoid arthritis (RA) is a chronic disease in which an autoimmune disorder causes inflammation of the joints and surrounding tissues. Patients with RA experience persistent pain, arising from inflammation. This pain is also known to possess a strong emotional component and is affected by mood and psychosocial factors (1). We previously reported the independent influences of depression severity and inflammation on perceived pain in patients with RA (2). Both the depression score and the serum levels of C-reactive protein (CRP), a biomarker of inflammation, were significantly associated with pain, even after controlling for each other and for clinical covariates by regression analysis. Alexithymia is defined as a personality construct with difficulties in affective self-regulation (3). It has been proposed to be a cluster of cognitive and affective characteristics that are commonly observed among classic psychosomatic patients for whom therapy has been unsuccessful (4). Individuals with alexithymia tend to experience difficulties in identifying and describing their inner feelings and have a limited imaginary capacity and a preference for externally oriented thinking rather than introspection (3)....

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