The Association Between Alexithymia, Interoception, and Pain in Pediatric Chronic Pain: A Systematic Review

Objectives: Pediatric chronic pain negatively affects emotional, psychological, and social function. This may be due to differences in interoception, the ability to notice and contextualize sensations arising inside the body, and alexithymia, the inability to identify and communicate emotions, as has been shown in adults. In children with chronic pain, interoceptive impairment include difficulties perceiving, interpreting, or responding to physical symptoms such as hunger or pain. Alexithymia symptoms include limited emotional vocabulary or reliance on complaining about physical symptoms to communicate emotional distress. Both alexithymia and interoceptive impairment could contribute to the development or maintenance of chronic pain and lead to issues with pain management. However, whether these are altered in pediatric chronic pain has not been investigated. Methods: The protocol was written prospectively and indexed online in the International Prospective Register of Systematic Reviews (PROSPERO; #42023439236). The literature search included the Cumulative Index to Nursing and Allied Health (CINAHL), PsycINFO, PubMed/MEDLINE, Scopus, and Google Scholar databases. Eligible studies included participants aged ≤18 years old with chronic pain conditions, assessed for symptoms of alexithymia or interoception. Study screening and data extraction were completed independently in duplicate. PRISMA guidelines were followed; the Newcastle-Ottawa Scale assessed risk of bias. Results: Fourteen studies assessing alexithymia in children/adolescents with/without chronic pain were identified. Of eight studies that reported mean alexithymia symptoms between groups, six reported significantly higher symptoms in the pain group. Alexithymia symptoms were associated with "pain bother" and "interference" but not "intensity." Two studies also assessed interoception; one compared pain/non-pain groups, finding a significant association between decreased self-reported interoception and higher chronic pain. Conclusions: Alexithymia symptoms may be increased in children/adolescents with chronic pain. Our review was limited by incomplete reporting and inconsistent measures across studies, decreasing certainty in the overall strength of the evidence. There is a need to understand the role of interoception and alexithymia in pediatric pain to better mitigate and treat pediatric pain. More research is warranted.