In collaboration with Payame Noor University and Iranian Health Psychology Association

Document Type : Scientific Research

Authors

1 Associate Professor in Psychology, University of Kashan, Kashan, Iran.

2 Ph.D in Psychology, Kashan, Iran.

3 M.A. Student in Psychology, Kashan,Iran.

Abstract

Objective: Chronic pain as a common problem may effect on the physical health, well-being and quality of life in patients. The aim of this study was to examine the mediating role of alexithymia and moderating resilience in the relationship between insecure attachment styles and the quality of life in chronic pain patients. Method: This study is a structural equation modeling. Among the chronic patients referred to Kashan therapeutic clinics in 2022, 188 patients were recruited through convenience sampling. In order to collect information, Revised Adult Attachment Scale (Collins & Reid, 1989), Toronto Alexithymia Scale (1992), Connor-Davidson Resilience Scale (2003) and  Quality of Life Scale (WHOQOL- BREF) were used. Data were analyzed using SPSS and AMOS 24 software. Results: The results of correlation coefficients showed that there are significant negative correlation between the quality of life with anxious insecure attachment, dependency insecure attachment and alexithymia, while there are significant positive correlation between resilience and quality of life (P<0.01). The results showed that the proposed model of the present study has a good fit (x2/df=2.748, p<0.001, CFI= 0.91, RMSEA=0.06). In addition, the results showed that the direct effect of anxious attachment on alexithymia (β= 0.549, P<0.05) and the direct effect of alexithymia on quality of life is significant (β= -0.632, P<0.01). When alexithymia are included as mediator in the relationship between anxious attachment and quality of life, the indirect effect of anxious attachment on quality of life is -0.347, and this indirect effect is significant (P<0.01). Also, the direct effect of dependency attachment on alexithymia is significant (β= 0.297, P<0.05). When alexithymia are included as mediator in the relationship between dependency attachment and quality of life, the indirect effect of dependency attachment on quality of life is -0.188, and this indirect effect is significant (P<0.05). Therefore, The results showed that alexithymia mediates the relationship between anxious insecure attachment and quality of life (β=-0.347, p<0.01) and dependency insecure attachment and quality of life (β=-0.188, p<0.05) in chronic pain patients. Resilience also moderates the relationship between alexithymia and quality of life (β=-0.121, p<0.05). Conclusion: The insecure attachment may effect on quality of life through alexithymia and resilience can be a protective factor against the negative impact of this effect in chronic pain patients. These results have important implications for clinicians and researcher in the field of health psychology. Psycho-educational interventions to identify emotions and describe them and reduce alexithymia can help patients manage their emotions better and improve different aspects of their quality of life. Also, interventions based on resilience can lead to improving the quality of life in chronic pain patients.

Keywords

Main Subjects

Aaron, R. V., Fisher, E. A., De La Vega, R., Lumley, M. A., & Palermo, T. M. (2019). Alexithymia in individuals with chronic pain and its relation to pain intensity, physical interference, depression, and anxiety: a systematic review and meta-analysis. Pain, 160(5), 994.
Ahangarzadeh Rezaei S., & Rasoli, M. (2015). Pychometric properties of the persian of the persian version of "Conner-Davidson resilience scale" in adolescents with cancer. Nursing and Midwifery Journal, 13 (9) :739-747. (in persian)
Akbarian, M., Habibi, M., Ghanbari Jolfaee, A.,  & Taheri, A. (2021). Prediction of chronic pain components based on insecure attachment style, Mentalization and alexithymia in patients with musculoskeletal pain in 2020. Journal of Anesthesiology and Pain,13(1):14-27. (in persian)
Alschuler, K.N., Kratz, A.L., & Ehde, D.M. (2016). Resilience and vulnerability in individuals with chronic pain and physical disability. Rehabiliation Psychology, 61(1),7-18.
Arabi, E., & Bagheri, M. (2017). The mediating role of emotion regulation strategies on the relationship between pain intensity and quality of life in patients with chronic pain disorder. Health Psychology, 6(22), 72-87. (in persian)
Bagby, R. M., Parker, J. D. A., & Taylor, G. J. (1994). The twenty-item Toronto Alexithymia Scale-I. Item selection and cross-validation of the factor structure. Journal of Psychosomatic Research, 38, 23-32.
Banaeian, A., & Jabalameli, S. (2021). Evaluation the Contribution of Cognitive Emotion Regulation Strategies and Alexithymia in Prediction of Pain Indices in Patients with Migraine. Journal of Anesthesiology and Pain, 12 (3) :1-15. (in persian)
Behfar, Z., Kraskian, A., Fata, L., & Fathi, M. (2018). The Role of Attachment Styles in Quality of Life among Patients with Chronic Pain . Journal of Anesthesiology and Pain, 9 (2) :37-46. (in persian)
Besharat, M. A. (2013). Toronto Alexithymia Scale: Questionnaire, Instruction and Scoring (Persian Version). Journal of Developmental of Psychology (Iranian Psychologists), 10(37), 90-92. (in persian)
Besharat, M. A., & Shahidi, V. (2014). Mediating role of cognitive emotion regulation strategies on the relationship between attachment styles and alexithymia. Europe’s Journal of Psychology, 10(2), 352–362.
Bruce, J., Thornton, A. J., Powell, R., Johnston, M., Wells, M., Heys, S. D., . . . Recovery Study, G. (2014). Psychological, surgical, and sociodemographic predictors of pain outcomes after breast cancer surgery: a population-based cohort study. Pain, 155(2), 232-243.
Bucci, W. (2002). From subsymbolic to symbolic--and back: Therapeutic impact of the referential process. In I. R. Lasky (Ed.), Symbolization and desymbolization: Essays in honor of Norbert Freedman (pp. 50–74).
Canney, M., McNicholas, T., Scarlett, S., & Briggs, B. (2017). Prevalence and impact of chronic debilitating disorders. Health and Wellbeing: Active Ageing for Older Adults in Ireland: Evidence from the Irish Longitudinal Study on Ageing. Trinity College Dublin, Dublin.[Google Scholar].
Castelli, L., Tesio, V., Colonna, F., Molinaro, S., Leombruni, P., Bruzzone, M., et al. (2012). Alexithymia and psychological distress in fibromyalgia: prevalence and relation with quality of life. Clin. Exp. Rheumatol. 30(6 Suppl. 74), 70–77.
Collins, N. L., & Read, S. J. (1990). Adult attachment, working models, and relationship quality in dating couples. Journal of personality and social psychology, 58(4), 644.
Connor, K. M., & Davidson, J. R. (2003). Development of a new resilience scale: The Connor‐Davidson resilience scale (CD‐RISC). Depression and anxiety, 18(2), 76-82.
Cousins, L. A., Cohen, L. L., & Venable, C. (2015a). Risk and resilience in pediatric chronic pain: Exploring the protective role of optimism. Journal of Pediatric Psychology, 40, 934–942.
Cousins, L. A., Kalapurakkel, S., Cohen, L. L., & Simons, L. E. (2015b). Topical review: Resilience resources and mechanisms in pediatric chronic pain. Journal of pediatric psychology, 40(9), 840-845.
Craparo, G., Magnano, P., Zapparrata, M.V., Gori, A., Costanzo, G., Pace, U., & Pellerone, M. (2018). Coping, attachment style and resilience: the mediating role of alexithymia. Mediterranean Journal of Clinical Psychology, 6.
DIN, P. C. B. (2001). International classification of functioning, disability and health.
Ebrahimi, Z., Asadi majareh, S., Akbari, B., & Naderi Nabi, B. (2017). The relationship between Alexithymia and Emotion Dysregulation with quality of life in Patients with chronic pain. Journal of Anesthesiology and Pain, 8 (3) :1-11. (in persian)
Failo, A., Giannotti, M., & Venuti, P. (2019). Associations between attachment and pain: From infant to adolescent. SAGE open medicine, 7, 2050312119877771.
Ferraro, I. K., & Taylor, A. M. (2021). Adult attachment styles and emotional regulation: The role of interoceptive awareness and alexithymia. Personality and Individual Differences, 173, 1–7.
Girme, Y. U., Jones, R. E., Fleck, C., Simpson, J. A., & Overall, N. C. (2021). Infants’ attachment insecurity predicts attachment-relevant emotion regulation strategies in adulthood. Emotion, 21(2), 260-302.
Gouin, J.-P., Caldwell, W., Woods, R., & Malarkey, W. B. (2017). Resilience resources moderate the association of adverse childhood experiences with adulthood inflammation. Annals of Behavioral Medicine: A Publication of the Society of Behavioral Medicine,51, 782–786.
Greenberg, E. N. (2012). The consequences of chronic pain. Journal of pain & palliative care pharmacotherapy, 26(1), 64-67.
Hadi, M. A., McHugh, G. A., & Closs, S. J. (2019). Impact of chronic pain on patients’ quality of life: a comparative mixed-methods study. Journal of patient experience, 6(2), 133-141.
Hatami, M., GHasemi, M., & Hasani, J. (2016). The effectiveness of combination of Cognitive Behavior Therapy and Cognitive Emotion Regulation Strategies on mindfulness, resiliency and quality of life in patients with chronic pain. Health Psychology, 5(18), 69-86. (in persian)
Helmes, E., McNeill, P. D., Holden, R. R., & Jackson, C. (2008). The construct of alexithymia: Associations with defense mechanisms. Journal of clinical psychology, 64(3), 318-331.
Hnatešen, D., Pavić, R., Radoš, I., Dimitrijević, I., Budrovac, D., Čebohin, M., & Gusar, I. (2022). Quality of Life and Mental Distress in Patients with Chronic Low Back Pain: A Cross-Sectional Study. International Journal of Environmental Research and Public Health, 19(17), 10657.
IASP. Classification of Chronic Pain. Available online: https://www.iasp-pain.org/publications/ free-ebooks/classification-ofchronic-pain-second-edition-revised/ (accessed on 25 January 2022).
Jensen, M. P., Moore, M. R., Bockow, T. B., Ehde, D. M., & Engel, J. M. (2011). Psychosocial factors and adjustment to chronic pain in persons with physical disabilities: a systematic review. Archives of physical medicine and rehabilitation, 92(1), 146-160.
Karoly, P., & Ruehlman, L. S. (2006). Psychological “resilience” and its correlates in chronic pain: findings from a national community sample. Pain, 123(1-2), 90-97.
Kirchner, K., Brauer, H., Van der Auwera, S., & Grabe, H. J. (2022). The impact of resilience, alexithymia and subjectively perceived helplessness of myocardial infarction on the risk of posttraumatic stress. Journal of Clinical Psychology in Medical Settings, 29(4), 954-962.
Kowal, J., McWilliams, L. A., Péloquin, K., Wilson, K. G., Henderson, P. R., & Fergusson, D. A. (2015). Attachment insecurity predicts responses to an interdisciplinary chronic pain rehabilitation program. Journal of Behavioral Medicine, 38, 518-526.
Kratz, A. L., Hirsh, A. T., Ehde, D. M., & Jensen, M. P. (2013). Acceptance of pain in neurological disorders: associations with functioning and psychosocial well-being. Rehabiliation Psychology, 58(1), 1-9.
Kural, A. I., & Kovacs, M. (2021). Attachment anxiety and resilience: The mediating role of coping. Acta psychologica, 221, 103447.
Lanzara, R., Conti, C., Camelio, M., Cannizzaro, P., Lalli, V., Bellomo, R. G., Saggini, R., & Porcelli, P. (2020). Alexithymia and somatization in chronic pain patients: a sequential mediation model. Frontiers in Psychology, 11, 545881.
Lee, J. W., Lee, K. E., Park, D. J., Kim, S. H., Nah, S. S., Lee, J. H., ... & Lee, S. S. (2017). Determinants of quality of life in patients with fibromyalgia: A structural equation modeling approach. Plos one, 12(2), e0171186.
Lee, J., & Hur, M. H. (2022). The Effects of Aroma Essential Oil Inhalation on Stress, Pain, and Sleep Quality in Laparoscopic Cholecystectomy Patients: A Randomized Controlled Trial. Asian Nursing Research, 16(1), 1-8.
Lyvers, M., Ryan, N., & Thorberg, F. A. (2022). Alexithymia, attachment security and negative mood. Australian Psychologist, 57(2), 86–94.
Martínez, M. P., Sánchez, A. I., Miró, E., Lami, M. J., Prados, G., & Morales, A. (2015). Relationships between physical symptoms, emotional distress, and pain appraisal in fibromyalgia: the moderator effect of alexithymia. J. Psychol. 149, 115–140.
Meredith, P.J. (2016). Attachment theory and pain. In: Hunter J and R. Maunder R (eds) Improving Patient Treatment with Attachment Theory: A Guide for Primary Care Practitioners
and Specialists
. Cham: Springer, pp. 55–73.
Mikulincer, M., & Shaver, P. R. (2015). The psychological effects of the contextual activation of security-enhancing mental representations in adulthood. Current Opinion in Psychology, 1, 18–21.
Mikulincer, M., & Shaver, P. R. (2019). Attachment orientations and emotion regulation. Current Opinion in Psychology, 25, 6–10.
Moseley, G. L., & Vlaeyen, J. W. (2015). Beyond nociception: the imprecision hypothesis of chronic pain. Pain, 156(1), 35-38.
Nejat, S., Montazeri, A., Holakouie Naieni, K., Mohammad, K., & Majdzadeh, S. (2006). The World Health Organization quality of Life (WHOQOL-BREF) questionnaire: Translation and validation study of the Iranian version. Journal of School of Public Health and Institute of Public Health Research, 4(4): 1-12.
Pan, F., Tian, J., Cicuttini, F., & Jones, G. (2020). Sleep disturbance and its association with pain severity and multisite pain: a prospective 10.7-year study. Pain and therapy, 9, 751-763.
Parker, J. D. A., Taylor, G. J., & Bagby, R. M. (2003). The 20-item Toronto Alexithymia Scale-III. Reliability and factorial validity in a community population. Journal of Psychosomatic Research, 55, 269-275.
Peñacoba, C., Perez‐Calvo, S., Blanco, S., & Sanroman, L. (2018). Attachment styles, pain intensity and emotional variables in women with fibromyalgia. Scandinavian Journal of Caring Sciences, 32(2), 535-544.
Pishva, N., Bayanlou, A., poursharifi, H., & Yavari, T. (2016). Relationship between Alexithymia and Quality of Life in Patients with Clinical Pain Complain and Healthy People. Health Psychology, 5(19), 57-68. (in persian)
Raja, S. N., Carr, D. B., Cohen, M., Finnerup, N. B., Flor, H., Gibson,S., et al. (2020). The revised International Association for the Study of Pain definition of pain: concepts, challenges, and compromises. Pain 161, 1976–1982.
Rezaei, Z., & Fatah, N. (2019). The mediating role of cognitive emotion regulation strategies in the relationship between alexithymia, pain perception and perceived social support in patients with chronic pain. Journal of Psychological Methods and Models, 11(40), 27-4. (in persian)
Romeo, A., Di Tella, M., Ghiggia, A., Tesio, V., Fusaro, E., Geminiani, G. C., & Castelli, L. (2020). Attachment style and parental bonding: Relationships with fibromyalgia and alexithymia. PloS one, 15(4), e0231674.
Salcuni, S., Mancinelli, E., Muneratti, A., Grillo, A., Alessi, C., Guglielmino, A., & Finos, L. (2021). Couples undergoing Assisted Reproductive Techniques: An Actor-Partner Interdependence Model of dyadic adjustment, attachment, and body-image avoidance. Health Psychology Open, 8(2), 1–12.
Sechi, C., Lucarelli, L., & Vismara, L. (2021). Depressive symptoms and quality of life in a sample of Italian women with a diagnosis of fibromyalgia: The role of attachment styles. Depression research and treatment, 1-7.
Sechi, C., Vismara, L., Brennstuhl, M. J., Tarquinio, C., & Lucarelli, L. (2020). Adult attachment styles, self-esteem, and quality of life in women with fibromyalgia. Health Psychology Open, 7(2), 1-8.
Sine, H., Achbani, A., & Filali, K. (2022). The effect of hypnosis on the intensity of pain and anxiety in cancer patients: a systematic review of controlled experimental trials. Cancer Investigation, 40(3), 235-253.
Sisto, A., Vicinanza, F., Campanozzi, L. L., Ricci, G., Tartaglini, D., & Tambone, V. (2019). Towards a transversal definition of psychological resilience: A literature review. Medicina, 55(11), 745-767.
Sturgeon, J. A. (2014). Psychological therapies for the management of chronic pain. Psychology research and behavior management, 115-124.
Taylor, G. J., & Bagby, M. (2000). An overview of the alexithymia construct. In R. Bar-On & J. D. A. Parker (Eds.), The handbook of emotional intelligence (pp. 263-276). San Francisco: Jossey-Bass.
Taylor, G. J., & Bagby, R. M. (2012). “The alexithymia personality dimension,” in The Oxford Handbook of Personality Disorders, ed. T. A. Widiger (New York, NY: Oxford University Press), 648–676.
Taylor, G. J., Bagby, R. M., & Parker, J. D. (1999). Disorders of Affect Regulation: Alexithymia in Medical and Psychiatric Illness. Cambridge: Cambridge University Press.
Tesio, V., Di Tella, M., Ghiggia, A., Romeo, A., Colonna, F., Fusaro, E., ... & Castelli, L. (2018). Alexithymia and depression affect quality of life in patients with chronic pain: A study on 205 patients with fibromyalgia. Frontiers in psychology, 9, 442.
Treede, R. D., Rief, W., Barke, A., Aziz, Q., Bennett, M. I., Benoliel, R., et al. (2019). Chronic pain as a symptom or a disease: the IASP classification of chronic pain for the international classification of diseases (ICD-11). Pain 160, 19–27.
Tuzer, V., Bulut, S. D., Bastug, B., Kayalar, G., Göka, E., & Be¸stepe, E. (2011).
Causal attributions and alexithymia in female patients with fibromyalgia or
chronic low back pain. Nord. J. Psychiatry 65, 138–144.
Winterheld, H. A. (2016). Calibrating use of emotion regulation strategies to the relationship context: An attachment perspective. Journal of Personality, 84(3), 369–380.
Zautra, A. J., Johnson, L. M., & Davis, M. C. (2005). Positive affect as a source of resilience for women in chronic pain. Journal of consulting and clinical psychology, 73(2), 212.
Zhang, J., Zhang, Y., Mao, Y., & Wang, Y. (2023). The relationship between insecure attachment and alexithymia: A meta-analysis. Current Psychology, 1-22.
Zibakerdar, M. (2012). Investigating the psychometric properties of the attachment questionnaire for adult cholinesteroids and its relationship with the five personality factors NEO-FFI-R. Master's thesis. Central Tehran Islamic Azad University. (in persian).