The aim of the literature review was to elucidate and conceptualize the complex development and characteristics of alexithymia and chronic pain with their relations to depression and Early Maladaptive Schemas. The human development occurs in multiple levels which are interrelated and influence each other; e.g.
neurophysiological development is influenced by genes and environmental factors which produce different outcomes in regulation systems which in turn encode the reactions of an individual to internal or external changes.
The differentiation between body and mind as well the differentiation between
“nature and nurture” has been challenged by modern research. The early experiences modify both physiological and psychological facets of the individual.
The development of the whole personality with its individual features is a complex learning process based on neuroplasticity and influenced by genetics, epigenetics and environmental factors. The consequences are concretized and to some extent discernible in neurobiological findings, in properties of the stress regulation system and immunological alterations. Psychological outcome manifests in behavioural, cognitive and emotional responses.
The research on early adversities highlights the importance of the quality of child treatment during the early years and the longstanding effects of mistreatment.
However, there is still a long way from “bench to bed” and from statistics to the individual level. Our knowledge is collected from various research attempts and the empirical data about brain alterations or stress system adjustment is confined to small explorative studies or animal studies. Epidemiology and statistics point in the health problem direction but their results are indirect and depend on the methods used. The probability of a direct line from childhood adversities to adult health problems still has many concerns. We are inclined to consider human development as a linear time bound process from childhood to adulthood and aberrations in this process as (health) problems. It is possible that “development” is not linear, but consists of different paths, steps, stops and retrograde movements. The results of childhood adversities may also be explained as adaptive processes and/or protective strategies and in any case, as a logical outcome emerging from the given circumstances.
Science is determined by seeking the facts and the objectivity. Psychological phenomena are highly subjective in nature and their assessment according to the demands of objectivity is difficult. Questionnaires and interview based methods used to assess alexithymia, pain as well as depressiveness and EMSs face these
difficulties. The reliability and the validity of the methods depend on their chosen contents, repeatability, comparability and usefulness. Self-report questionnaires and interview based assessments have demonstrated their sufficient properties but invariably involve the very problem of response and interpretation bias. Brain scanning of psychological properties is still in its infancy.
Chronic pain has long been regarded as an extension of acute, somatic pain.
There is now mounting evidence that chronic pain is a distinct disorder, although sometimes its initial stage seems to be associated with acute pain, which probably triggers the chronic pain syndrome. Susceptibility to chronic pain, however, is multifactorial and chronic pain itself consists of various pain disorders. The onset of chronic pain depends on the life history and predisposing life events. Every chronic pain patient has his or her own subjective pain experience which represents that individual’s life trauma or adaptation to life events.
Early Maladaptive Schemas reflect early adversities and psychological adjustment to them. There is some evidence that certain EMSs may at least predispose to chronic pain through the coping styles associated with EMSs.
Connections between alexithymia and EMSs have not been widely studied but their coexistence has been noticed in some psychological problems, such as in posttraumatic stress disorders. Theoretically, alexithymia and EMSs originate from the same breeding ground and may represent different facets and outcomes of early adverse experiences.
Depression occurs frequently with chronic pain, alexithymia and EMSs and its severity and effect on them varies. In chronic pain patients, depression manifests mainly as the psychological side of chronic pain and helps to maintain the pain problem. Fear-avoidance and pain catastrophizing can be considered as working models of depression in chronic pain.
Alexithymia has been proposed as a risk factor for chronic pain but its effect on the development of chronic pain is unclear. Only a proportion of chronic pain patients are alexithymic but those who suffer from chronic pain and are alexithymic usually report more pain and have more pain exacerbating factors such as low mood and catastrophizing. In chronic pain samples, alexithymia is associated with depressiveness, and depressiveness has been shown to mediate the effect of alexithymia on the variables describing the pain situation (pain intensity, pain disability). It is also unclear if chronic pain and depressiveness jointly predispose together to alexithymia or vice versa. The involvement of emotion dysregulation in chronic pain highlights the role of alexithymia with depression as factors which exacerbate the pain situation and impede possible recovery. It is also
possible that depressive alexithymic pain patients do not actually have a pain disease but that the amplified somatic symptoms and somatization representing emotional dysregulation are misinterpreted and treated as pain disorder without proper cure.
3 AIMS OF THE STUDY
The memories of early trauma may be inaccessible but their effect may manifest in their consequences. As chronic pain, alexithymia, depression and Early Maladaptive Schemas have connections with childhood adversities, their co-occurrence in adulthood may reflect the long-term effects of childhood trauma on health status.
The aim of the present study is to increase the understanding of the role of alexithymia in the context of chronic pain phenomena by exploring the relations of experienced pain, alexithymia, depression and Early Maladaptive Schemas in a sample of chronic pain patients in cross-sectional (Study I and II) and longitudinal study (Study III and IV) designs.
The concrete aims of the study are as follows:
Study I
1. To assess the prevalence of alexithymia in a clinical sample of chronic pain patients
2. To measure differences in pain variables and depression between alexithymic and nonalexithymic patients
3. To evaluate relations of alexithymia, depression and pain disability
Study II
1. To explore alexithymia, depression and Early Maladaptive Schemas and to estimate their combined effect on pain experience
2. To ascertain if alexithymic chronic pain patients have some typical Early Maladaptive Schemas or schema domains
Study III
1. To explore in a one-year follow-up the changes in pain variables, alexithymia and depression in a sample of chronic pain patients
2. To investigate the differences in pain variables and depression between alexithymic and nonalexithymic patients at baseline and at follow-up 3. To evaluate how baseline alexithymia and depression influence treatment
choices
4. To evaluate the possible predictive value of baseline variables and the treatment selected on the outcome of the pain situation
Study IV
1. To evaluate in an eight-year follow-up the changes in the pain situation, alexithymia and depression in a sample of chronic pain patients
2. To explore the effect of basic characteristics, baseline pain variables, alexithymia and depression on the outcome of the pain situation 3. To investigate the relations between depression and alexithymia in the
chronic pain situation