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Psychosomatics 49:115-122, March-April
doi: 10.1176/appi.psy.49.2.115
© 2008 Academy of Psychosomatic Medicine
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Parental Bonding and Alexithymia in Adults With Fibromyalgia

Francisco Pedrosa Gil, M.D., Martin Weigl, M.D., M.P.H., Tina Wessels, Ph.D., Dominik Irnich, M.D., Eva Baumüller, M.D., and Andreas Winkelmann, M.D.

Received December 18, 2006; revised March 30, 2007; accepted April 10, 2007. From the Psychosomatic Outpatient Clinic, Dept. of Internal Medicine, Ludwig-Maximilian-University, Pettenkoferstr. 10, 80336 Munich, Germany; the Dept. of Physical Medicine and Rehabilitation, Ludwig-Maximilian-University, Ziemssenstrasse 1, 80336 Munich, Germany; and the Dept. of Anesthesiology, Ludwig-Maximilian-University, Pettenkoferstr. 8a, 80336 Munich, Germany. Send correspondence and reprint requests to Francisco Pedrosa Gil, M.D., Psychosomatic Outpatient Clinic, Dept. of Internal Medicine; Ludwig-Maximilian-University; Pettenkoferstrasse 10; D-80336 Munich, Germany. e-mail: Francisco.Pedrosa.Gil{at}med.uni-muenchen.de
© 2008 The Academy of Psychosomatic Medicine


  ABSTRACT

 
TOP
 ABSTRACT
INTRODUCTION
 METHOD
 RESULTS
 DISCUSSION
 REFERENCES
 
In a cross-sectional study, the authors investigated 40 female patients with fibromyalgia syndrome (FS) for the degree of alexithymia and parental bonding style. Alexithymia was assessed by the Toronto Alexithymia Scale–26; parental style by the FDEB (a German version of the Measure of Parental Style). In 15% of patients with FS, clinically significant alexithymia was found. Also, there was a positive association between the alexithymia scores (TAS total score) and "maternal abuse" and higher values in "paternal indifference," which predicted higher scores on "Difficulties identifying feelings" (TAS). The results of this study suggest that parental styles are associated with higher alexithymia scores.


  INTRODUCTION

 
TOP
 ABSTRACT
 INTRODUCTION
METHOD
 RESULTS
 DISCUSSION
 REFERENCES
 
Fibromyalgia syndrome (FS) is a common chronic pain condition that affects, where it has been studied, at least 2%–4% of the adult population worldwide.1,2 Chronic, widespread pain is the defining feature of FS.3 This common form of nonarticular rheumatism is also associated with chronic generalized musculoskeletal pain, fatigue, and a long list of other complaints, including, for example, sleep disturbance, irritable bowel syndrome, headache, and mood disorders. Although the etiology of FS is not completely understood, the syndrome is thought to arise from factors such as stress, medical illness, pain conditions, and a variety of neurotransmitter and neuroendocrine disturbances.2

Interestingly, recent studies have found an association between FS and a possible localization of a primary disorder in the central nervous system.4–6 Psychopathological variables such as depressive symptoms may adversely affect perception of disease severity,7 functional ability,8 and pain threshold and tolerance.9 This may explain the cascade of subsequent illnesses, such as psychiatric disorders, autonomic dysfunction,10,11 and painful, tense musculature with certain morphological aspects; among them, type II fiber atrophy.12,13 Also, some studies have reported elevated frequency of depressive disorders in FS,14 elevated levels of alexithymia as psychopathological features,15 and, of special importance, the occurrence of childhood traumatic events.16,17

The concept of alexithymia has been examined in a variety of different medical, psychosomatic, and psychiatric disorders (cardiac disease, hypertension, obesity, depressive disorder, alcohol abuse, and panic disorder, among others).18–21 Alexithymia, literally meaning "absence of words for emotion," is a concept developed by Sifneos;18 it is characterized by an inability to describe and identify feelings, an absence of fantasies, and the tendency to utilize an externally-focused, analytical cognitive style. Several studies have shown that alexithymia is common in FS.15,22–24

In rheumatoid arthritis, there is evidence that patients with greater functional impairment showed significantly higher alexithymia scores.25,26 In low-back pain, some results also support a positive association with alexithymia,27 but it is of interest that a recent study15 could demonstrate that FS patients were more alexithymic than rheumatoid arthritis patients. The literature on the role of family and arthritis regarding psychosocial impact is inconsistent.28 A recent study29 found that parent–child interaction patterns influence patients’ adaptation to pain, and a previous survey30 indicated that mothers of children with juvenile rheumatoid arthritis are at risk for psychological distress. To-date, there has not been direct measurement by use of parental-bonding assessment instruments in arthritis patients.

Only a few studies have investigated the association between alexithymia and parental style. However, there are signs indicating that the degree of alexithymia is negatively associated with the degree to which positive feelings are expressed in the family of origin31–33 and positively associated with higher pathological family interaction.34 Other studies using the Parental Bonding Instrument suggest that mothers’ perceived low care is related to adults’ scores on alexithymia; in particular, the construct "Difficulty Describing Feelings" on the Toronto Alexithymia Scale (TAS)35,36 in patients with panic disorder, social phobia, and also in healthy college students. A study including psychiatric outpatients37 found that maternal care and paternal overprotection were moderately associated with difficulties in identifying feelings. A more recent study in a similar setting confirmed the relevance of parenting for development of alexithymia.38 These results support the hypothesis39,40 that serious interferences in early life, such as the lack of empathic and responsive parents, may cause disturbances in emotional development, possibly leading to alexithymia in later life.

In general, empirical and clinical studies suggest that inadequate parenting is associated with alexithymic features in adulthood. However, the data and number of studies are still too small to draw firm conclusions. In a recent study of alcoholic inpatients, it was found that alexithymia was predicted by a lack of warmth perceived in the relationship with the father.41 In patients with FS, investigators found a higher lifetime prevalence rate for psychosocial victimization during childhood and adolescence,42 even though the details about sexual abuse and physical maltreatment by parents varied widely.16,43,44 Although both perceived parenting and alexithymia have shown a certain relationship, their interrelationship in patients with FS has not yet been investigated. The goal of this cross-sectional study is to determine the degree of alexithymia in patients with FS and to evaluate a possible association with parental bonding style. We hypothesize that negatively-perceived parental bonding is associated with a higher degree of alexithymic features.


  METHOD

 
TOP
 ABSTRACT
 INTRODUCTION
 METHOD
RESULTS
 DISCUSSION
 REFERENCES
 
Study Design, Patients, and Recruitment
We conducted a cross-sectional study with 40 consecutively-enrolled patients (all women; mean age: 55.7; standard deviation [SD]: 6.5) meeting the American College of Rheumatology 1990 criteria for the diagnosis of FS45 at the Department of Physical Medicine and Rehabilitation, Munich University, between May 2005 and August 2006. The department is a well-known inter- and multidisciplinary center of competence in fibromyalgia that offers a day clinic with a 4-week multidisciplinary treatment program for patients with FS. This treatment program is conducted in groups of 10 patients and consists of mild endurance training, proprioceptive training, hydrotherapy, Qigong, cognitive-behavioral therapy, relaxation therapy, and information and education about pathophysiology and chronic disabling pain. The costs are covered by all compulsory health insurance plans according to a specific contract between the clinic and the plans, but only by some private health insurance plans, depending on individual contracts.

Patients with undiagnosed chronic widespread pain, suspected FS, or established FS were referred for diagnosis and treatment by general practitioners or resident physicians with specialties in orthopedic surgery or rheumatology. Forty consecutive patients from the waiting list for participation in the 4-week multidisciplinary treatment program were asked to participate in this study. According to the recruitment procedure, the inclusion and exclusion criteria for this study were identical to the criteria for participation in the multidisciplinary treatment program. Inclusion criteria were the following: FS according to the American College of Rheumatology (ACR) 1990 criteria,45 a history of widespread pain for at least 3 months, and pain in 11 of 18 tender point-sites on digital palpation. The sensitivity of these criteria is 88.4%; the specificity is 81.1%.

The clinical diagnosis of FS was made by a specialist in physical and rehabilitation medicine from the Department of Physical Medicine and Rehabilitation, Munich University. The clinical diagnosis of FS asked, in addition to the ACR criteria, for differentiation of pain on palpation (i.e., high level of pain at muscle insertion, low level of pain at joint spaces) and any additional symptoms, such as sleep disorder, fatigue, or attention deficits. Although the ACR classification criteria are validated for clinical studies and widely used in research, there is no generally agreed-upon definition as to how FS should be diagnosed in clinical encounters.46 Exclusion criteria were severe medical disorders (e.g., autoimmune, neoplastic, cardiac, pulmonary, or endocrine diseases) and severe mental illnesses, such as schizophrenia, schizoaffective disorder, bipolar disorder, substance-abuse disorders, or major depression (severe depressive episode). Also, patients with pending disability claims were excluded.

Study Procedures
All patients who were interested in participation underwent a second examination by AW (specialist in physical and rehabilitation medicine, senior physician in the FS day clinic) to confirm the FS classification criteria of the ACR.45,46 FS was confirmed for all 40 patients. All of them agreed to participate. Afterwards, the psychiatric diagnoses were established in a clinical interview by a trained psychiatrist (FPG), as well as by additional psychological measures according to the diagnostic criteria and guidelines suggested by the ICD–10.47 The psychological measures did not include the somatoform-disorder module because the investigators did not believe that a distinction between FS with somatization and FS without somatization could reliably be made.48,49 The study protocol was approved by the ethics committee of the University of Munich. Written informed consent was obtained from each patient before their inclusion.

Measures
The set of measures included a standard set that is used in the FS day clinic and additional measures for alexithymia and parental bonding that were added for this study, as follows:

The Toronto Alexithymia Scale (TAS–26) The TAS–26 was developed to measure alexithymia, a trait that can be characterized as the inability to identify and describe one’s own emotions and those of others. The original version was developed by Taylor et al.50 To assess the presence and severity of alexithymia in these participants, the validated German version of the TAS–26 was used.51 This version consists of 26 items, rated on a 5-point Likert scale. A three-factor structure has been replicated in clinical and non-clinical groups. This measure includes 26 items that generate scores on three dimensions: 1) "difficulty identifying feelings;" 2) "difficulty describing feelings;" and 3) "externally-oriented thinking." The German version was validated with a representative population sample (N=2,084), and it shows adequate internal consistencies, ranging between 0.67 and 0.84. The overall TAS–26 scores range from 18 to 90, because only 18 of the 26 scales were then entered in the evaluation. Scores over raw value 54 (T-score: 61) on the TAS–26 were taken to indicate significant alexithymia. This cut-off point is used to distinguish between alexithymic and non-alexithymic individuals.

Measure of Parental Style (MOPS) The MOPS52 represents an internationally-accepted self-assessment instrument for dysfunctional parenting. The MOPS is the "refined" form of the PBI (Parental Bonding Instrument). It includes 30 statements, which refer to parental "indifference," "overprotection," and "abuse" that subjects recall having received from either mother (maternal form) or father (paternal form) during their first 16 years of life. The items are scored on a 4-point Likert-scale that indicates the degree of the subject’s agreement with the item statement. Higher scores indicate less care and more indifference, respectively, or more overprotection and more abuse. The German version, the FDEB Scale ("Fragebogen Dysfunktionaler Elterlicher Beziehungsstile"), has shown good validity and reliability.53 Since it has not been used in patients with FS before, we assessed the reliability of the FDEB scale in our population.

Symptom Checklist-90 Revised (SCL-90–R) The SCL-90–R54 reveals different aspects of psychopathology. It assesses patients’ current symptoms within a specified and optimal point in time (i.e., the past 7 days). The symptom scales include the Somatization, Obsessive-Compulsive, Interpersonal Sensitivity, Depression, Anxiety, Hostility, Phobic Anxiety, Paranoid Ideation, and Psychoticism scales. The SCL-90–R index scales include the Positive Symptom Total (PST), Positive Symptom Distress Index (PSDI), and Global Severity Index (GSI), as three global index scales. The SCL-90–R index and symptom scale scores are represented as T-scores, with a mean of 50 and SD of 10. Higher T-scores reflect a greater number and/or severity of patient self-reported symptoms. On the basis of testers’ recommendations,54 we defined a "clinically significant" or "elevated" scale score to be a T-score of 60 or higher.

The 21-item Beck Depression Inventory (BDI) The BDI55 was utilized in the present study to provide an index of self-rated depression severity. Individuals are asked to rate themselves on a spectrum of 0–3 (0: least; 3: most), with a score range of 0–63. The total score is the sum of all items.

Analyses
Descriptive statistics were derived for sociodemographic and clinical baseline characteristics. Control variables, independent variables, and dependent variables were tested for normal distribution and linearity. Unadjusted associations between control variables (BDI score, GSI from the SCL–90) and the TAS scales, and between the MOPS scales and the TAS scales were examined by Pearson correlation coefficients. To determine whether different parental styles predicted different levels of the four TAS scales of alexithymia, four multiple stepwise linear-regression analyses were performed. First, in each regression analysis, control variables were included stepwise to control for the amount of variance in alexithymia already explained by these variables. Second, the six subscales of the MOPS were included stepwise to determine which parental style predicted levels of alexithymia.


  RESULTS

 
TOP
 ABSTRACT
 INTRODUCTION
 METHOD
 RESULTS
DISCUSSION
 REFERENCES
 
Sociodemographic and Clinical Patient Characteristics
The total sample of 40 female patients (mean age: 55.7; SD: 6.5), with their demographic and clinical characteristics, is presented in Table 1; 27.5% had the equivalent of high school graduation or more; 62.5% of the patients were employed; 50% (20 patients of the sample of 40) were receiving antidepressants, 18 of whom received tricyclic antidepressants, and 3 of whom received an SSRI. None of them were receiving benzodiazepines or neuroleptics.


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TABLE 1. Sociodemographic and Clinical Characteristics of Patients With Fibromyalgia Syndrome (N=40)



The analysis of the participants’ subjective general psychiatric symptomatology (indexed by the participants’ scores on the SCL) revealed that the patients exhibited an elevated GSI score (mean: 64.0; SD: 12.1). Our patients exceeded the mean value50 on all scales of SCL for somatization, obsessive-compulsiveness, social insecurity, depression, anxiety, aggression, phobic anxiety, paranoid ideation, and psychoticism. The mean BDI score of 15.5 (7.6) in the sample indicated only a mild-to-moderate degree of depression.

In 38 of 40 patients, the psychiatric examination showed a psychiatric comorbidity, primarily affective disorders: dysthymia (F=34.1; N=21), recurrent depressive disorder, moderate (F=33.1; N=11), recurrent depressive disorder, mild (F=33.0; N=5), depressive reaction (F=43.2; N=1), panic disorder (F=41.0; N=3), phobia (F=40.2; N=3), agoraphobia (F=40.0; N=1), and posttraumatic stress disorder (N=1).

Assessment of Alexithymia
Table 1 shows that the patients had a total TAS score of 51.0 (SD: 9.7), with 15% of the patients (N=6) over the cut-off T-value of 6150 representing clinically significant alexithymia.51 Results show sub-score T-values of 52.4 (SD: 9.5) on the subscale "Difficulty Identifying Feelings;" 50.3 (SD: 9.8) on the subscale "Difficulty Describing Feelings;" and 48.7 (SD: 8.7) on the subscale "Externally-Oriented Thinking."

Reliability of the MOPS in Our Sample of FS Patients
The Cronbach {alpha} for the Indifference and Abuse scales were good-to-excellent. Cronbach {alpha} for the scales Indifference: Father and Mother were 0.68 and 0.93, and values for Abuse: Father and Mother were 0.78 and 0.87, respectively. In our sample of FS patients, the reliability of the Overprotection scales could not be confirmed (Overprotection: Father: {alpha}=0.29; Overprotection: Mother: {alpha}=0.01). We therefore omitted them from further analyses.

Unadjusted Associations Among Control Variables, Parental Style, and Alexithymia
The results of the correlation analyses between control variables, MOPS scales, and the TAS are displayed in Table 2. The control variables GSI and BDI (sum) and most scales of the MOPS showed statistically significant correlations with TAS Scale 1 (Difficulty Identifying Feelings). Only GSI and BDI sums had significant correlations with TAS Scale 2 (Difficulty Describing Feelings). None of the control variables and none of the MOPS scales were significantly correlated with TAS Scale 3 (Externally-Oriented Thinking). Besides the control variables, only two scales of the MOPS (Indifference: Mother and Abuse: Mother) showed a significant correlation with the TAS total score.


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TABLE 2. Unadjusted Correlation Coefficients Among Control Variables, Independent Variables (MOPS Scales), and the Toronto Alexithymia Scale (TAS)



Linear-Regression Analyses
Regression models explaining the TAS scales (Table 3): A total of 72.9% of the variance in "Difficulty Identifying Feelings" could be explained with the final regression model. Of the control variables, the BDI and the GSI were included in the final regression model and accounted together for 58.1% of the variance in TAS Scale 1. After adjusting for the BDI and the GSI, "Indifference: Father" counted for an additional 14.8% of the variance on this TAS scale. The beta weight indicates that higher values on "Indifference: Father" predict higher scores on "Difficulty Identifying Feelings." The GSI is the only control variable significantly associated with the TAS scale "Describing Feelings," and it explains 39.9% of the variance. None of the parental-style scales significantly contributed to the variance on the TAS scale "Difficulty Describing Feelings." For the regression analysis with the dependent variable "Externally-Oriented Thinking," neither control variables nor any parental-style variables were predictive. Accordingly, no regression model is presented. A total of 69.1% of the variance could be explained in the total TAS score. Of the control variables, the GSI (SCL-90–R) could explain 55.4% of the variance in the total TAS score. After adjusting for the GSI, "Abuse: Mother" counted for 5.6% of the variance in the total TAS score. Beta weights indicate that the higher the "Abuse: Mother" score, the higher the alexithymia value.


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TABLE 3. Final Regression Models With Toronto Alexithymia Scales (TAS) as Dependent Variables and MOPS Scales as Independent Variables




  DISCUSSION

 
TOP
 ABSTRACT
 INTRODUCTION
 METHOD
 RESULTS
 DISCUSSION
REFERENCES
 
The results of this cross-sectional study in patients with FS suggest that some parental styles are associated with higher alexithymia values. The "Indifference: Father" factor was a predictor for a higher score on the TAS subscale "Difficulty Identifying Feelings." There are indications that the "Abuse: Mother" is also associated with higher alexithymia values. Moreover, we found a high prevalence of alexithymia in our patients with FS; namely, 15%, reaching clinically significant alexithymia—clearly higher values than in non-clinical populations. Kokkonen et al.56 found alexithymia values of 9.4% in male and 5.2% in female subjects, and Posse et al.57 found a prevalence of 7.9% in a non-clinical female population.

This is in accordance with Fukunishi et al.,36 who suggests that maternal attachment in infancy and/or childhood may play an important role in the development of alexithymic characteristics. In a recent study of a large sample of students, alexithymia was also linked to perceptions of a lack of maternal care.58 Furthermore, our findings suggest that "Indifference: Father" is associated with "Difficulty Identifying Feelings." This in accordance with the results of De Rick et al.,41 showing that in inpatients treated for alcohol abuse, a lack of warmth perceived in the relationship with the father is associated with alexithymic features. Obviously, in FS patients, both father and mother figures are associated with alexithymic features. Likewise, a recent study,59 found that patients with FS had a poorer emotional relationship with both parents. Our results do not correspond with those from Reid et al.,60 who found no significant group differences in the children’s or parents’ psychological adjustment or ratings of family functioning in juvenile fibromyalgia, as compared with pain-free control subjects. To our knowledge, there are no other studies investigating alexithymia in relation to parental bonding in FS patients.

The results of our study support theories originating from psychoanalytic backgrounds61 claiming that problems in regulating affects, such as alexithymia, have an origin in a problematic early relationship in the parental bonding process. Likewise, developmental and clinical psychology and neurobiology research focus increasingly on periods of childhood and later adult disorders.62,63

They also correspond with clinical observations that traumatic experiences may lead to alexithymic features.64,65 According to the trauma hypothesis, Ciccone et al.66 found that posttraumatic stress disorder was more prevalent in the FS group. Moreover, women with FS are more likely to report a history of sexual and/or physical abuse than women without FS. Regrettably, our study did not investigate severe extensive hospitalizations or sexual abuse in childhood.

Our results demonstrated also that a majority of our patients with FS show psychiatric symptoms, especially affective disorders. This is in agreement with recent research showing that depression is associated with alexithymia, anger, and somatization.67–69 But it is not possible to determine the etiology of FS symptoms. Alternatively, mood and anxiety problems could be seen as "symptoms" of FS. Prospective cohort studies could shed light on this question. Some questions remain unanswered. The influence of gender could not be evaluated because all patients were women. The comparatively small sample size reduces the precision of the results. Another potential limitation is a selection bias because of the sample size and because of the implementation of the study in one highly specialized study center in a university hospital. However, an over-representation of patients with high socioeconomic status is unlikely because a contract with compulsory insurance plans guarantees the coverage of the prestigious 4-week multidisciplinary rehabilitation program at this institution. As in all cross-sectional studies, one should be cautious with causal conclusions; that is, it is possible that a disturbed regulation of affect in a child may lead to a parenting style that is perceived as less adequate. The MOPS is a validated German instrument for measuring parental style, but it has not yet been used for patients with FS. The reliability was good-to-excellent for the scales Indifference: Father/Mother and Abuse: Father/Mother, but poor for the Overprotection scales. Therefore, results for Overprotection: Father/Mother are not presented, and we cannot draw conclusions about the relevance of overprotectiveness in the development of alexithymia in patients with FS. We suggest further validation of the MOPS in patients with FS.

Further studies would be valuable to replicate our results. In our opinion, the results of this study have relevant implications for therapeutic interventions in patients with FS, especially if psychotherapeutic interventions are included in the treatment concept. In patients with FS who show the alexithymic trait, attention should be given to the establishment of a secure therapeutic alliance. Capacities for regulating emotions on a verbal level can only be acquired within an environment based on trust and perceived by the patient as safe. Substitution of physicians should be avoided. The high comorbidity of psychiatric disorders underscores the importance of psychiatric interventions in patients with FS.


  ACKNOWLEDGMENTS

 
We are grateful to Robin Hieblinger, Ph.D., for editing this article.


  REFERENCES

 
TOP
 ABSTRACT
 INTRODUCTION
 METHOD
 RESULTS
 DISCUSSION
 REFERENCES
 

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