Association between Alexithymia and Medically Unexplained Symptoms in Children: A Review, Exercises of Psychiatry

Download Association between Alexithymia and Medically Unexplained Symptoms in Children: A Review and more Exercises Psychiatry in PDF only on Docsity! Alexithymia in children with Medically Unexplained Symptoms: A systematic review Maria Hadji-Michael DClinPsych1,2* Eve McAllister DClinPsych1,2 Colin Reilly PhD1,3 Isobel Heyman FRCPsych1,2 Sophie Bennett PhD 1,2 *Corresponding author Affiliations 1UCL Great Ormond Street Institute of Child Health (ICH), 30 Guilford Street London WC1N 1EH UK. 2Great Ormond Street Hospital for Children NHS Trust, Great Ormond Street, London WC1N 3JH, UK. 3Research Department, Young Epilepsy, Lingfield, Surrey, RH7 6PW, UK. Short Title: Alexithymia and Medically Unexplained Symptoms in children Corresponding Author: Maria.Hadji-Michael@gosh.nhs.uk Keywords: Alexithymia, Functional somatic illness, medically unexplained symptoms, children. Declarations of interest: none Highlights  Children with MUS have higher levels of Alexithymia than controls on survey measures  Higher rates of alexithymia were however, not found on task based measures  Children with MUS and alexithymia are at significant risk for anxiety significant positive correlation between somatisation and alexithymia in adults and a significant increase in the prevalence of alexithymia in those with MUS compared to healthy controls [29]. In summary, research has demonstrated a possible association between high levels of alexithymia and increased medically unexplained symptoms in adults. There is also some evidence to suggest that alexithymia is associated with poorer treatment outcome for both MUS and commonly co-occurring mental health disorders in adults. However, despite the high prevalence of MUS in children and young people, there have been no systematic reviews which have examined the relationship between alexithymia and MUS in this age group. The aim of this review was therefore to investigate associations between MUS and alexithymia in children and young people. Specific objectives were to determine how the relationship between MUS and alexithymia has been studied to date in the paediatric population, establish whether there is a consistent relationship between alexithymia and MUS in this group and to investigate the association between alexithymia and measures of psychological functioning. Method Systematic review methods were used in accordance with Cochrane guidelines [30]. Electronic searches EMBASE, MEDLINE, PsycINFO and CINAHL databases were searched from inception to 25th April 2018. Independent literature searches were conducted by MHM & EM. Broadly, the search terms were categorized into three primary areas; (1) Medically Unexplained Symptoms (2) Alexithymia (3) Children. See Appendix A for full list of search terms. Search terms were derived from those used in previous studies exploring the association between medically unexplained symptoms and alexithymia in the adult systematic review [29]. Other search resources Reference lists and citations of identified papers were also searched for relevant papers Inclusion criteria Studies were included where the focus was on the association between alexithymia and MUS in paediatric populations. Studies were included irrespective of whether MUS/alexithymia were defined categorically (i.e. the presence/absence of a disorder) or dimensionally (i.e. number/severity of symptoms). Papers had to be published in English and all participants in the studies were aged between 0–17 years. With respect to alexithymia studies were included if the scales or tasks referred directly to alexithymia or alternatively emotion awareness. Exclusion criteria Papers were excluded where a mixed somatoform-organic group (e.g. epilepsy together with non-epileptic seizures) was present or where it was not clear whether the sample was a mixed organic-somatoform group, which was the case for the majority of studies on chronic pain. Data extraction A data extraction form was developed (Appendix B) which focussed on extracting the main study characteristics such as sample characteristic, alexithymia measures, MUS measures/ diagnosis, measures of psychosocial functioning & main findings and results. Data was independently extracted by two reviewers (MHM & EM). Methodological quality assessment Study quality was independently assessed by two reviewers (MHM and EM) using the Effective Public Health Practice Project Quality Assessment Tool (EPHPP – 31,32]. This tool was chosen for its suitability in assessing a range of study designs within the area of public health research. Studies are rated as strong, moderate or weak, using predefined criteria, on a range of areas: selection bias, study design, confounders, blinding, data collection methods, withdrawals and dropouts. Total sample size is not considered. An overall total for study quality is also calculated by assessing the number of areas rated weakly (strong studies have no weak ratings, moderate ones have one weak rating and weak studies have two or more weak ratings). Results The initial search identified 52 unique papers (see Figure 1 for search process). After screening, a total of 10 papers were found to meet eligibility criteria (see Table 1). Figure 1: Search process for studies focussing on alexithymia in children with medically unexplained symptoms (MUS) 10 that children with more somatic complaints reported significantly more negative and less positive moods than those who reported less somatic complaints on a MOOD Questionnaire. Jellesma et al. [36] found that Children with FAP and children with more somatic complaints reported more negative moods on Anger, Sadness and Fear scale of the MQ and on the CDI compared to the control group with few somatic complaints. There was not a significant difference between the groups with respect to happiness. Discussion MUS in the pediatric population are distressing and impairing for children and their families, and represent a significant challenge to health service providers. Both patients and supporting health professionals often express frustration regarding diagnosis and treatment. Understanding more about the association between alexithymia and the development and maintenance of MUS and co-occurring conditions may help improve the assessment and treatment of children experiencing these difficulties. In this systematic review, we synthesized evidence from studies examining the relationship between alexithymia and medically unexplained symptoms in children. Higher levels of self-reported alexithymia in the children with MUS compared to healthy controls were found in the majority of studies but this finding was not replicated in studies where objective tasks measuring alexithymia were used. Results of studies comparing alexithymia in children with MUS and children with with medical/psychiatric controls were inconsistent. There is thus some evidence of increased emotional symptoms in children with MUS and alexithymia compared to controls but studies have employed a diverse range of methods of measuring alexithymia and emotional functioning making comparisons across studies difficulty. The current limited evidence does not allow firm conclusions to be drawn about the relationship between MUS and alexithymia in children and young people. The difference in results regarding the relationship between MUS and alexithymia between self- reported measures and task-based approaches noted in this review is important. The efficiency of self-report measures and the long-standing belief that self-report provided optimal access to one’s own psychological processes has kept self- report measures at the forefront in research on psychological functioning. Yet, self-report may be limiting particularly with respect to assessing alexithymia. There is the conceptual difficulty regarding the reporting of characteristics that by definition involve limited or impaired introspection, thus raising questions about the validity of this approach [52,53]. Studies adopting task based methodology have not found a consistent association between MUS and difficulty in understanding one’s own emotions and these studies suggest that it is not a difficulty in understanding emotions per se that might be different between children with MUS and controls, but differences in emotion processing. It is possible that children have learned what emotional experience they or another person would/should have in a specific circumstance (emotional empathy), but not spontaneously recognise when they are feeling bodily symptoms associated with the specific emotion. Children with alexithymia would appear to be at significant risk of mental health symptoms in particular symptoms of anxiety based on results of the current review and several other studies previously conducted [54]. However, in the current review, not all studies included measure of emotional symptoms and measures varied across studies. Another factor not considered in the 11 studies concerns the validity of measures of self-reported mental health symptoms in this population. These measures may not be useful in detecting mental health problems in children with MUS [55] and thus professional clinical diagnoses are likely to be the gold standard in the MUS population. Future research and clinical implications The higher rates of alexithymia in children with MUS compared to healthy controls based on questionnaire measures found in this review may mean that evidence based psychological interventions to treat both the MUS and comorbid mental health difficulties may need to be adapted. Children with alexithymia may benefit from specific interventions such as body awareness training/ interoceptive training [56] to enhance engagement with, and response to, cognitive behavioural therapy, but studies are needed to examine this. Given that individuals with alexithymia may have difficulty recognising and reporting on their own emotions the use of experimental tasks for assessing alexithymia should be a priority in future research studies. Additionally as well as self and parent report of behavioural-emotional functioning the need for professional clinical assessment and diagnoses of mental health conditions should be a priority in research. All studies to date are cross-sectional and there is a need for longitudinal data to better understand the relationship between alexithymia and MUS over time. Studies of psychological interventions for MUS in children need to include measures of alexithymia to better understand factors which might contribute to outcome in this group. It will be important to assess whether levels of alexithymia change after treatment and what this might mean for prognosis. In adults there is evidence in patients with eating disorders that alexithymia improved following treatment [56] and it may be that psychological interventions change core symptoms but also impact on alexithymia. To date studies that have included measures of behavioural and emotional functioning have included only measures of depression and anxiety. There is also a need for future studies to include measures of autism spectrum disorder [57], attention deficit hyperactivity disorder and also neuropsychological assessment data which may be related to alexithymia. Finally, little is known about the developmental course of MUS and alexithymia; this requires more research to establish whether difficulties in childhood also play out in adulthood. Conclusion There is some evidence that children with MUS have significantly higher levels of alexithymia than healthy controls based on self-report measures however, this finding was not replicated in objective tests of alexithymia and measures have varied significantly across studies. Children with alexithymia have elevated rates of anxiety. Future studies which employ both self-report and task based measures of alexithymia and include measures of comorbid psychiatric and neuropsychological functioning are needed to better understand the possible role of alexithymia in paediatric MUS. 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Case control -32 (26 females, aged 8 -15 yrs.) with tension-type headache (THH). -32 healthy controls (26 females, aged 8-15 yrs.). ACQ Diagnosis for TTH based on ICHD None -Significantly Higher rates of alexithymia were observed in TTH group compared to controls on total score 2009 Jellesma et al. Case control 34 (13 females, aged 8 – 13 yrs.) with few somatic complaints # 35 (23 females, aged 8-13) children with many somatic complaints ¤ - Spontaneous attention for emotions task* - Identification of own emotions * - Emotion Identification in mixed emotion situations* - 2 Subscales EAQ Based on scores on SCL None -Compared to children with few somatic complaints, children with many somatic complaints had significantly higher self- reports of alexithymia on the differentiating emotions subscale but not verbal sharing of emotions subscale of EAQ. -Groups did not differ on a task measuring spontaneous attention for emotion -Children with many somatic complaints reported higher intensities of fear (and sadness compared to children with children with few somatic complaints. 2007 Van de Putte et al. Case Control - 40 adolescents (31 female aged 12-18 yrs.) with Chronic Fatigue Syndrome (CFS). TAS-20 Clinical diagnosis of CFS CIS-20 CIS CDI STAIC - 12 (30%) CFS adolescents fulfilled the criteria for alexithymia. - CFS adolescents scored significantly higher only on the total score and the subscale identifying feelings of the TAS-20. 21 -36 adolescent healthy controls (12 -18 yrs). - Those with CFS and alexithymia had higher scores for depression and anxiety but similar equal scores for fatigue & somatic complaints. 2007 Sayin et al. Case Control - 15 children (7 female, aged 7-17yrs) with depression - 21 patients with complaints of pain (14 female, aged 7 to 17 yrs.) -15 healthy controls. TAS-20 Clinical Complaints of pain without organic aetiology BDI STAI -Children with non-organic pain were not significantly more alexithymic than depressed patients and controls -In the non-organic pain group, alexithymia scores were significantly and positively correlated with STAI scores but not BDI scores. 2006 Burba et al. Case control -120 children (84 females aged 12- 17 yrs.) with somatoform pain disorder. -60 healthy control children aged 12-17 yrs. TAS-20 ICD-10 Somatoform pain disorder HADS -Rate of alexithymia (i.e. scores above cut off on TAS-20) in adolescents with somatoform pain disorder were significantly higher than that in healthy control subjects -Anxiety but not depression was significantly higher in somatoform pain group (62%) compared to control subjects 2006 Jellesma et al. Case control -33 children (16 females aged 8-13 yrs.) with Functional Abdominal Pain (FAP) -High SCL scores. 61 (31 females, 8- 12years) EAQ Clinical diagnosis of FAP or constipation SCL CDI MQ - Children with FAP and children with more somatic complaints reported more difficulty differentiating their emotions and communicating them (on the EAQ) and a lower sense of coherence compared to children with few complaints 22 -Low SCL scores. 59 that scored in the (26 female, 8-12 years). -These two groups also reported more negative moods on Anger, Sadness and Fear scale of the MQ and on the CDI -There was no sig difference between the groups with respect to happiness 2004 Rieffe et al. Case control - 282 children (141 female aged 8-13 yrs.) sampled. 26 with the highest SCL scores (high SCL) and 26 with no or almost no somatic complaints (low SCL) subsequently compared. Emotional Identification Task& SCL MQ -No differences between low/high SCL groups in being able to identify emotions on vignettes. -Children in the low SCL group reported more anger than in the high somatic complaints groups whereas this pattern was reversed for fear. -Children with more somatic complaints reported significantly more negative and less positive moods than those who reported less somatic complaints 2001 Meade et al., Cohort Study 92 children (49 male) aged 10-13 years. TAS-20 CSI (Child and Parent) None -Children who have higher levels of alexithymia have lower self-reported health but higher parent-reported health. *Spontaneous attention for emotions: - picture card shown to child and asked ‘tell me something about this picture’, answer rated on whether they referred to an emotion/cause of the emotion; Identification of own emotions - 4 questions regarding 4 basic emotions (Rieffe et al., 2007); Emotion identification in mixed emotion situations Story with the potential of evoking multiple emotions, after the story child asked if they would feel happy/angry/sad/afraid, why they would feel this & the intensity (Terwogt, Koops, Oosterhoff & Olthof, 1986), #scoring in the lowest 10% on the Somatic Complaint List, ¤i.e. the children scoring in the