Temporal pathways between alexithymia, psychological distress, and pain: An autoregressive mediation analysis

Alexithymia-a cluster of emotional deficits, including difficulties identifying and describing one's feelings-is elevated in chronic pain and is cross-sectionally related to worse pain-related outcomes. However, the temporal relationships between alexithymia and pain-related outcomes are unclear. The current study aimed to test the direct and indirect effects of alexithymia on pain-related outcomes (i.e., pain severity and pain interference), via psychological distress (i.e., elevated symptoms of depression and anxiety), using longitudinal data.

This 2-year prospective cohort study (N = 1,453) included participants with mixed chronic pain conditions from around the United States, who completed self-report measures of alexithymia, psychological distress, pain severity, and pain interference. We conducted two three-wave autoregressive mediation models, allowing for cross-lagged relationships, to test the hypothesized mediation pathway from alexithymia (baseline) to psychological distress (12 months) to (a) pain severity and (b) pain interference (24 months).

Alexithymia had a significant indirect effect on pain interference through psychological distress. The opposite pattern was not observed as pain interference did not directly or indirectly predict alexithymia, increasing confidence in alexithymia as a risk factor for pain interference. Psychological distress did not mediate the relationship between alexithymia and pain severity.

Although cross-sectional associations between alexithymia and chronic pain have been well established, their temporal relationship and underlying mechanisms have been unclear. The current findings demonstrate that alexithymia is indirectly related to worse pain interference via heightened psychological distress, pointing to alexithymia and psychological distress as targets of psychological intervention to improve physical function. (PsycInfo Database Record (c) 2026 APA, all rights reserved).