Incidence of Alexithymia in the Symptomatic Exacerbation of Primary Tension-Type Headache

Incidence of Alexithymia in the Symptomatic Exacerbation of Primary Tension-Type Headache | Authorea try { document.documentElement.classList.add('js'); } catch (e) { } var _gaq = _gaq || []; _gaq.push(['_setAccount', 'G-8VDV14Y67G']); _gaq.push(['_trackPageview']); (function() { var ga = document.createElement('script'); ga.type = 'text/javascript'; ga.async = true; ga.src = ('https:' == document.location.protocol ? 'https://ssl' : 'http://www') + '.google-analytics.com/ga.js'; var s = document.getElementsByTagName('script')[0]; s.parentNode.insertBefore(ga, s); })(); Skip to main content Preprints Collections Wiley Open Research IET Open Research Ecological Society of Japan All Collections About About Authorea FAQs Contact Us Quick Search anywhere Search for preprint articles, keywords, etc. Search Search ADVANCED SEARCH SCROLL This is a preprint and has not been peer reviewed. Data may be preliminary. 17 July 2025 V1 Latest version Share on Incidence of Alexithymia in the Symptomatic Exacerbation of Primary Tension-Type Headache Authors : Rapisarda F. [email protected] , Stefano Boca , and Concetta Mezzatesta Authors Info & Affiliations https://doi.org/10.22541/au.175275194.42711068/v1 214 views 121 downloads Contents Abstract Introduction Methods Results Discussion Conclusions Supplementary Material Information & Authors Metrics & Citations View Options References Figures Tables Media Share Abstract Background: Tension-type headache (TTH) is a prevalent primary headache disorder with notable psychosomatic components. Alexithymia may exacerbate symptoms and impair quality of life in TTH patients. Objective: To investigate the relationship between alexithymia and symptom severity in TTH patients, examining associations with defence mechanisms, attachment styles, personality traits, psychiatric symptoms, and quality of life. Methods: 103 participants (50 TTH patients, 53 controls) completed the TAS-20, REM-71, ASQ, EPI, SCL-90, and SF-36. ANOVA and correlational analyses were used. Results: TTH patients had significantly higher difficulty identifying feelings (TAS-20 Factor 1) and used more immature defences. Factor 2 (Difficulty Describing Feelings) correlated with repression and avoidant attachment. Alexithymia was linked to psychiatric symptoms and reduced quality of life across several domains. Conclusions: Alexithymia contributes significantly to symptom exacerbation in TTH and may underlie chronic somatization and psychological vulnerability. Integrating emotional regulation interventions is recommended. Title: Incidence of Alexithymia in the Symptomatic Exacerbation of Primary Tension-Type Headache Funding Source: This research did not receive any specific grant from any funding agency in the public, commercial or not-for-profit sector. Financial Disclosure: The authors have no financial relationships relevant to this article to disclose. Conflict of Interest: The authors have no conflicts of interest to disclose that could be perceived as prejudicing the impartiality of the research reported. Ethical Standards: All procedures contributing to this work comply with the ethical standards of the relevant national and institutional committees on human experimentation and with the Helsinki Declaration of 1975, as revised in 2008. Data Availability Statement: Data available from the corresponding author on reasonable request due to privacy/ethical restrictions. Abstract : Background: Tension-type headache (TTH) is a prevalent primary headache disorder with notable psychosomatic components. Alexithymia may exacerbate symptoms and impair quality of life in TTH patients. Objective: To investigate the relationship between alexithymia and symptom severity in TTH patients, examining associations with defence mechanisms, attachment styles, personality traits, psychiatric symptoms, and quality of life. Methods: 103 participants (50 TTH patients, 53 controls) completed the TAS-20, REM-71, ASQ, EPI, SCL-90, and SF-36. ANOVA and correlational analyses were used. Results: TTH patients had significantly higher difficulty identifying feelings (TAS-20 Factor 1) and used more immature defences. Factor 2 (Difficulty Describing Feelings) correlated with repression and avoidant attachment. Alexithymia was linked to psychiatric symptoms and reduced quality of life across several domains. Conclusions: Alexithymia contributes significantly to symptom exacerbation in TTH and may underlie chronic somatization and psychological vulnerability. Integrating emotional regulation interventions is recommended. Keywords: alexithymia; defence mechanisms; adult attachment; headache Introduction Tension-Type Headache (TTH) is the most prevalent form of primary headache worldwide and is characterized by bilateral, pressing, or tightening pain of mild to moderate intensity. Unlike migraine, TTH is not aggravated by physical activity and is less frequently associated with nausea or photophobia. However, its chronic and recurrent nature often leads to significant discomfort, reduced quality of life, and psychosocial impairment. Despite the absence of identifiable organic lesions, TTH presents a strong psychogenic component, with substantial evidence suggesting that psychological variables such as stress, anxiety, and affective dysregulation may play crucial roles in its manifestation and maintenance. One construct that has drawn increasing attention in psychosomatic research is alexithymia, which refers to a subclinical inability to identify and describe emotions. Originally described by Sifneos (1973), alexithymia encompasses three core dimensions: difficulty identifying feelings (DIF), difficulty describing feelings (DDF), and externally oriented thinking (EOT). The presence of alexithymic traits has been associated with a range of somatic and psychosomatic disorders, including irritable bowel syndrome, fibromyalgia, and chronic pain syndromes. Several studies have highlighted the relevance of alexithymia in patients with primary headaches, particularly TTH. Alexithymic individuals may experience heightened autonomic arousal due to unprocessed emotional stress, which could exacerbate physical symptoms and hinder effective coping mechanisms. Furthermore, dysfunctional defence mechanisms, insecure attachment styles, and certain personality traits may compound the difficulty these individuals face in managing emotional and somatic distress. The present study investigates the incidence and impact of alexithymia in patients diagnosed with symptomatic exacerbation of primary TTH. It aims to explore correlations between alexithymia, defence mechanisms, attachment styles, personality profiles, psychiatric symptoms, and health-related quality of life. We hypothesize that TTH patients with higher levels of alexithymia will demonstrate more maladaptive psychological features and reduced well-being, thus warranting integrative treatment approaches that include emotional awareness and regulation strategies. Methods Participants The study sample consisted of 103 individuals, comprising 50 patients diagnosed with chronic or episodic Tension-Type Headache (TTH) and 53 healthy control subjects. The TTH group included patients recruited from neurological and psychological outpatient clinics, with a confirmed diagnosis based on the International Classification of Headache Disorders (ICHD-3) criteria. Inclusion criteria for the clinical group included age between 18 and 65 years and a minimum of six months’ history of TTH episodes. Exclusion criteria included diagnosis of migraine, cluster headache, current major neurological disorders, or severe psychiatric conditions. Control participants were matched for age and sex and reported no history of primary headache disorders or significant psychiatric conditions. All participants provided written informed consent and the study received ethical approval in accordance with the Helsinki Declaration and institutional standards. Instruments Toronto Alexithymia Scale (TAS-20) The TAS-20 is a widely used self-report instrument for assessing alexithymia, composed of three factors: Difficulty Identifying Feelings (Factor 1), Difficulty Describing Feelings (Factor 2), and Externally Oriented Thinking (Factor 3). REM-71 The Response Evaluation Measure assesses 21 defence mechanisms, classifiable as mature, neurotic, or immature. Higher scores on immature defences are associated with lower emotional resilience. Adult Attachment Style Questionnaire (ASQ) The ASQ evaluates adult attachment across five dimensions: Confidence, Discomfort with Closeness, Need for Approval, Preoccupation with Relationships, and Relationships as Secondary. Eysenck Personality Inventory (EPI) This inventory measures two broad personality dimensions: Neuroticism and Extraversion, along with a Lie scale. Symptom Checklist-90 (SCL-90-R) The SCL-90-R is a self-report symptom inventory designed to reflect psychological symptom patterns, including anxiety, depression, somatization, and psychoticism. SF-36 Health Survey The SF-36 evaluates health-related quality of life across eight domains, including physical functioning, bodily pain, general health, vitality, social functioning, emotional roles, and mental health. Procedure All participants completed the full battery of psychometric instruments in a single session, either in person or via a secure online platform. Demographic information was collected along with clinical history in the case of TTH patients. Statistical analyses were performed using SPSS v.26. Between-group comparisons were conducted using one-way ANOVA. Correlational analyses (Pearson’s r) were used to examine relationships among alexithymia scores, defence mechanisms, attachment styles, personality traits, psychiatric symptoms, and quality of life indicators. Excellent. Here is the Results section, structured per academic journal standards: Results Alexithymia Profiles Analysis of TAS-20 scores revealed that TTH patients scored significantly higher than controls on Factor 1 – Difficulty Identifying Feelings (p < .01). No statistically significant differences emerged for Factor 2 – Difficulty Describing Feelings or Factor 3 – Externally Oriented Thinking . These findings suggest that the core alexithymic feature differentiating TTH patients from controls is the impaired capacity to recognize emotional states. Defence Mechanisms Data from the REM-71 indicated a statistically significant increase in the use of immature defence mechanisms among TTH patients, particularly conversion , projection , and displacement (p < .05). These defences are commonly associated with low levels of insight and emotional regulation. Correlation analyses showed that TAS-20 Factor 1 positively correlated with these immature defences, suggesting that difficulty identifying emotions is associated with maladaptive coping strategies. Additionally, Factor 2 was significantly correlated with repression , indicating a pattern of suppressing rather than articulating affective content. Attachment Style and Personality Traits Analysis of ASQ scores revealed that TAS-20 Factor 2 was significantly associated with Discomfort with Closeness (p < .05), indicative of an avoidant attachment style . No significant correlations were found between alexithymia scores and other attachment dimensions. Regarding personality traits, TTH patients showed elevated psychoticism scores on the EPI scale compared to controls (p < .05), although these did not strongly correlate with alexithymia dimensions. Psychiatric Symptomatology TAS-20 total scores showed positive correlations with multiple dimensions of the SCL-90 , including somatization , anxiety , and interpersonal sensitivity (p < .01). This supports the hypothesis that alexithymic traits are associated with broader psychological distress in the TTH population. Quality of Life Impairments Significant correlations were observed between TAS-20 Factor 1 and reduced scores on multiple domains of the SF-36, particularly in Physical Functioning , Emotional Role Functioning , Social Functioning , and Mental Health (p < .01). These findings indicate that alexithymia is linked to impaired overall functioning and diminished quality of life in patients with TTH. Discussion The present study demonstrates a significant association between alexithymia—particularly difficulty identifying emotions—and the symptomatic exacerbation of primary tension-type headache (TTH). Patients with TTH exhibited higher levels of alexithymia compared to healthy controls, with Factor 1 of the TAS-20 emerging as the most discriminative dimension. This supports existing literature suggesting that emotional dysregulation plays a pivotal role in the expression and chronicity of somatic symptoms, especially in disorders like TTH, where structural neurological damage is absent or minimal. One of the central findings is the strong correlation between alexithymia and immature defence mechanisms such as conversion and projection. These mechanisms may reflect a reliance on somatic expression as a substitute for emotional articulation—a phenomenon consistent with the somatization hypothesis and the alexithymia construct itself. Patients who struggle to cognitively process their affective experiences may instead express psychological distress through physical symptoms such as head pain, thereby reinforcing a self-perpetuating cycle of emotional repression and somatic amplification. The correlation between alexithymia and avoidant attachment patterns aligns with developmental theories that link early relational insecurity to impaired affect regulation in adulthood. Individuals with avoidant styles may be predisposed to disconnect from internal emotional states as a strategy to minimize interpersonal vulnerability, a process that may manifest in increased somatic focus and reduced psychological insight. Moreover, the association between alexithymia and diminished quality of life, as reflected in SF-36 domains, underscores the functional impairment that accompanies emotional processing deficits. These patients reported greater limitations in social and emotional functioning, reinforcing the clinical relevance of assessing and addressing emotional awareness in headache management protocols. These results can also be interpreted in light of theoretical frameworks such as the Polyvagal Theory (Porges, 2007), which highlights the role of autonomic regulation in social engagement and stress response. In alexithymic individuals, reduced vagal tone and impaired neurovisceral integration may predispose them to heightened physiological reactivity and somatic dysregulation, including chronic pain syndromes like TTH. Taken together, the findings advocate for a reconceptualization of TTH as a biopsychosocial disorder in which psychological factors, particularly affective unawareness and maladaptive coping styles, contribute to both onset and maintenance. This view challenges a purely biomedical model and supports integrative approaches that include emotional, relational, and cognitive dimensions in both assessment and treatment. Here is the Conclusions section, aligned with academic standards and coherent with the previous sections: Conclusions This study underscores the critical role of alexithymia—especially the difficulty in identifying emotions—in the symptomatic profile of patients with primary tension-type headache (TTH). The presence of alexithymia appears to exacerbate physical symptoms, impair emotional regulation, and reduce quality of life. The data further reveal that alexithymia is linked to immature defence mechanisms and avoidant attachment styles, reinforcing its role as a transdiagnostic vulnerability factor. From a clinical perspective, these findings highlight the importance of integrating psychological assessment and treatment into standard care for TTH. Interventions aimed at enhancing emotional awareness and regulation—such as emotion-focused therapy, mindfulness-based interventions, and mentalization-based approaches—may provide substantial benefit for patients with high alexithymic traits. The chronic course of emotional dysregulation observed in this population raises the hypothesis of a potential “headache-related alexithymic syndrome,” wherein persistent affective impairment contributes to the somatization and maintenance of pain. Early identification and targeted psychotherapeutic support may help interrupt this cycle, improving both symptomatology and psychosocial functioning. Future studies should address the causal relationships between alexithymia and TTH through longitudinal designs and incorporate neurobiological correlates (e.g., vagal tone, autonomic markers) to further elucidate underlying mechanisms. A multidimensional and integrative model of care may be key to managing the complex interplay of emotional, somatic, and relational factors in chronic headache disorders. References • 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(1), 23–32. https://doi.org/10.1016/0022-3999(94)90005-1 • Bifulco, A., Moran, P. M., Ball, C., & Bernazzani, O. (2002). Adult attachment style. I: Its relationship to clinical depression. Social Psychiatry and Psychiatric Epidemiology, 37(2), 50–59. https://doi.org/10.1007/s127-002-8215-0 • Bond, M., Gardiner, D., & Sigal, J. (1983). Defense style and vulnerability to depression. Canadian Journal of Psychiatry, 28(6), 567–572. • Derogatis, L. R. (1977). SCL-90-R: Administration, scoring and procedures manual. 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Medical Care, 30(6), 473–483. https://doi.org/10.1097/00005650-199206000-00002 Supplementary Material File (tab. 1 tas-20.docx) Download 14.67 KB File (tab. 2 rem-71.docx) Download 18.91 KB File (tab. 2a- correlation tas-20 rem-71.docx) Download 22.10 KB File (tab. 3 epi.docx) Download 14.54 KB File (tab. 3a correlation tas-20 epi.docx) Download 15.29 KB File (tab. 4 asq.docx) Download 14.77 KB File (tab. 4a correlation tas-20 asq.docx) Download 16.10 KB File (tab. 5 scl-90.docx) Download 16.37 KB File (tab. 5a correlation tas-20 scl-90.docx) Download 18.02 KB File (tab. 6 sf-36.docx) Download 15.78 KB File (tab. 6a- correlation tas-20 sf-36.docx) Download 17.89 KB File (tab. a- headache medical history.docx) Download 12.97 KB File (tab. b- sample study.docx) Download 34.79 KB Information & Authors Information Version history V1 Version 1 17 July 2025 Copyright This work is licensed under a Non Exclusive No Reuse License. Keywords attachment clinical psychology emotional distress quality of life Authors Affiliations Rapisarda F. [email protected] Universita degli Studi di Palermo Dipartimento di Scienze Psicologiche Pedagogiche dell'Esercizio Fisico e della Formazione View all articles by this author Stefano Boca Universita degli Studi di Palermo Dipartimento di Scienze Psicologiche Pedagogiche dell'Esercizio Fisico e della Formazione View all articles by this author Concetta Mezzatesta no affiliation View all articles by this author Metrics & Citations Metrics Article Usage 214 views 121 downloads .FvxKWukQNSOunydq8rnd { width: 100px; } Citations Download citation Rapisarda F., Stefano Boca, Concetta Mezzatesta. Incidence of Alexithymia in the Symptomatic Exacerbation of Primary Tension-Type Headache. Authorea . 17 July 2025. 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