Effects of symbolic function on pain experience and vocational outcome in patients with chronic neck pain referred to the evaluation of surgical intervention: 6-year follow-up

Hannu Heikkilä; Rolf Asp; Eva Holmlund; Aet Ristmägi

doi:10.1515/sjpain-2024-0002

Article Open Access

Effects of symbolic function on pain experience and vocational outcome in patients with chronic neck pain referred to the evaluation of surgical intervention: 6-year follow-up

Hannu Heikkilä , Rolf Asp , Eva Holmlund and Aet Ristmägi

Published/Copyright: March 17, 2025

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From the journal Scandinavian Journal of Pain Volume 25 Issue 1

Abstract

Objectives

This study examined the relationship between symbolic function, coping, pain, and long-term outcomes in patients with chronic cervical pain.

Methods

The study population consisted of 104 subjects who could be candidates for cervical spinal surgery at the Department of Neurosurgery. We followed patients for 2 and 6 years, focusing on pain experience, vocational outcome, and sick leave.

Results

The SAT9 test revealed that 28% of the patients had poor symbolic function. The group classified as having poor symbolic function reported using more coping strategies and coping resources but had more of an external locus of control. They showed less objective neurophysiological findings but rated more pain on the VAS scale. The group with poor symbolic function had more sick leave days 2 years after consultation, and the vocational outcome was very poor for persons with impaired symbolic function at the 6-year follow-up. At the 6-year follow-up, patients with poor symbolic function still experienced higher pain levels and had more of an external locus of control.

Conclusions

The SAT9 results indicate that pain could also serve as an expression of distress or discomfort, and the expression of pain can be a way for individuals to communicate their need for rest, recovery, or relief from stressors. In this context, taking sick leave becomes a symbolic action addressing broader well-being concerns. Understanding the symbolic function of stress and pain concerns can be valuable for health professionals and individuals themselves. Open communication, recognizing, and reorganizing the symbolic nature of pain can contribute to a more compassionate understanding of stress-related challenges and pain.

Keywords: symbolic function; cervical pain; coping strategies; locus of control; vocational outcome; normopathy; sick leave

1 Introduction

Symbolic function is a key concept within Jean Piaget’s theory of cognitive development [1]. It refers to a stage during which children develop the ability to represent objects, events, and ideas through symbols. This stage occurs during Piaget’s preoperational phase, typically between the ages of 2 and 7 years. During this period, children use language, mental imagery, and symbolic play to understand and express concepts that are not directly observable in their immediate environment. The emergence of symbolic function marks a critical milestone in cognitive development, enabling children to engage in more complex thought processes and imaginative activities.

Psychoanalytic practitioners working with psychosomatic patients have frequently observed deficits in emotion processing. These patients often struggle to “describe their feelings or to differentiate among them” and exhibit “an absence of the capacity to produce fantasies, resulting in thought content that is restricted to a preoccupation with external objects, people, and environmental events” [2]. Sifneos and Nemiah coined the term alexithymia to describe this phenomenon [2,3,4,5,6,7]. Marty and de M’Uzan [8] suggested that this inability stems from disturbances in the early child–mother relationship, which disrupt the developmental processes necessary for experiencing feelings or using fantasy as a means of satisfying instinctual drives.

There remains ongoing debate regarding the definition, measurement, and theoretical foundations of alexithymia [9,10,11]. Classification is typically based on self-reported questionnaires, such as the Toronto Alexithymia Scale (TAS-20) [12]. In 1982, the AT9 and SAT9 tests were introduced to explore symbolic function as a central trait in alexithymia [13,14,15]. However, later revisions of the TAS-20 [16] excluded the “difficulty with fantasizing” dimension, following experimental findings that showed no significant differences in imaginal efficiency [17] or the vividness of visual imagery [18,19,20,21,22] between individuals with high or low alexithymia levels, as determined by TAS-20 scores. These empirical findings have led some researchers to question whether difficulty with fantasizing should be considered a defining feature of alexithymia [18,23,24].

Several researchers have proposed that chronic pain patients may express their emotions through various somatic pain disorders [13,25–29]. Among this population, the prevalence of alexithymia appears to be relatively high [30–33], yet few studies have specifically examined the relationship between symbolic function and pain perception. The inability to experience feelings through symbols has been hypothesized to occur in psychologically immature individuals who rely on somatization as a means of affective expression [34]. Awareness of inner feelings and fantasies, along with the ability to articulate emotions, are crucial for coping with stress. A lack of these capacities can heighten tension and suppress the expression of arousal, leading to somatic manifestations of distress [35,36]. Individuals with impaired capacity to fantasize may struggle to defend against anxiety and integrate the meaning and imagery associated with symbols [14].

Toskala et al. [36] studied the ability to symbolize in two groups of patients and controls matched for demographic characteristics and educational level. There were 18 patients (aged 31–58 years) suffering from primary fibromyalgia syndrome (PFS), 11 patients (aged 33–83 years) suffering from various non-painful muscular diseases, and 18 physically healthy (PH) subjects. All patients completed the projective SAT9 test [14,15,37]. Symbolization was poorest in the PFS group and most advanced in the PH group. The patients, as a whole, exhibited poorer symbolization than the controls. When individual measures of the SAT9 test were analyzed, the PFS group failed significantly more often than the other groups to describe the monster as dynamic, implying a lessened ability to cope with destructive feelings. There was also an inverse correlation between pain intensity and monster drawing.

Models of stress and coping may be useful in explaining adjustment differences among chronic pain populations [38]. Coping is the general plan we have at our disposal for dealing with pain [39]. Coping is proposed to be critical for understanding patients’ behavior and serves as an important part of any treatment to be offered [39]. Coping strategies have been described as behaviors that people exert in reaction to specific stressors [40]. Coping strategies may be an important factor in determining how patients adjust to chronic pain [41]. The belief that outcomes are under the control of one’s behavior is described as reflecting an internal locus of control, whereas the belief that important outcomes are controlled by factors such as chance, luck, or other people is supposed to reflect an external locus of control [42]. Pain patients with an internal locus of control orientation have been hypothesized to be more likely to use active coping strategies [43]. In their meta-analysis of the treatment of chronic pain, Jensen et al. [43] proposed that patients who believe they can control their pain, who avoid catastrophizing about their condition, and who consider themselves not severely disabled appear to function better than those who do not.

In clinical practice, it is often difficult to identify the psychogenic components of a complex, multi-cause pain syndrome. Identifying individuals with impaired symbolic function who are at higher risk for long-term disability and suffering is crucial. Many non-pharmacological treatments have been shown to be effective in managing chronic pain. Psychotherapies such as mindfulness-based interventions (MBIs), cognitive behavioral therapy (CBT), acceptance and commitment therapy (ACT), and hypnosis help reduce the perception of pain. These approaches work by enhancing awareness of internal feelings and fantasies, as well as improving emotional expression. For individuals at higher risk of developing chronic, therapy-resistant pain, integrating MBIs and other psychotherapeutic interventions within a multidisciplinary pain management plan could enhance treatment outcomes and reduce the reliance on pain-related medications.

The present study examined the relationship between symbolic function, estimated by the projective SAT 9 test, and long-term outcomes in terms of pain and working ability at 2- and 6-year follow-ups. We also looked at how inhibition of symbolic function is related to other psychological and demographic factors, such as life satisfaction and quality of life, personality (temperament and character), sociodemographic factors, locus of control, coping resources, and strategies.

2 Methods

2.1 Subjects

The Research Ethics Committee at the University Hospital of Northern Sweden (1186/1995) approved the study, and written informed consent was obtained from all participants in the intervention study. Consecutive patients under 65 years of age with cervical pain, cervical disc herniation, or symptomatic spondylosis who were admitted to or treated at the Department of Neurosurgery at the University Hospital of Northern Sweden between October 1995 and September 1996 were asked to participate in this study. Ninety-four patients (90%) of the total 104 patients, 45 women and 49 men, 21–65 years old (mean = 46.4), answered the follow-up questionnaire. Seventy-four (71%) of the total 104 patients completed the SAT9 questionnaire. The mean symptom duration was 30 months. Seventy percentage was employed when entering the study. Among the subjects, 49% had received elementary or comprehensive education (4–9 years of study) and 51% senior secondary education (approx. 12 years of study). The distribution of marital status was 66% married, 18% living together, 10% single, and 6% divorced. Forty-four patients underwent surgical intervention (38%), and nine patients underwent reoperation. Twenty patients (61%) reported no major change in symptoms at postoperative follow-up, 27% reported slight improvement, and 12% reported a good result.

2.2 Symbolic function

A semi-structured interview [44] was conducted with each patient to evaluate affect differentiation and assess symbolic function. Following the interview, each patient completed the SAT9 test [14,15], a quantitative scoring system derived from the AT9 test developed by Cohen et al. The inter-rater reliability of this scoring system has been reported as satisfactory [14,15,32]. For the chronic pain patient group, the inter-rater reliability coefficient was excellent, with a value of 0.931, which was statistically significant based on the total scale and all subsections [14,15].

The SAT9 measures the capacity for symbolization and fantasizing [14,15]. It is grounded in the theory of the anthropological structures of images developed by Durand [45], which posits that the basic processes of imagery – such as controlling time and death – serve to mitigate existential anxiety [14,15]. The test includes nine items: a fall, a sword, a refuge, a devouring monster, something cyclical, a character, water, an animal, and fire. Patients were required to incorporate these elements into a drawing and compose a story around them. Additionally, patients were provided a form to explain the meanings they attributed to each item.

Based on SAT9 results, two psychotherapists (HH and EH) categorized patients into three groups: those with good symbolic function, moderately impaired symbolic function, and poor symbolic function. Cut-off scores were defined as follows: >65 for good symbolic function, 34–65 for moderately impaired symbolic function, and <33 for poor symbolic function [14,15] (Figure 1).

Figure 1

Based on SAT9, two psychotherapists divided patients into three groups: good symbolic function (1), moderately impaired symbolic function (2), and poor symbolic function (3).

The inter-rater reliability of the SAT9 test was assessed using Pearson product-moment correlations and weighted kappa. The total scale showed a Pearson correlation of r = 0.936 (p < 0.001), while subgroup classifications yielded r = 0.967 (p < 0.001). Cohen’s weighted kappa for subgroup classifications was 0.947 (p < 0.001, CI 0.89–1.0), confirming good agreement between raters.

2.3 Pain intensity

The questionnaire [46] contains items on localization, intensity, and duration of complaints in the musculoskeletal system of nine anatomical regions of the body, i.e., the 7-day prevalence of complaints from the neck, shoulders, upper back, lower back, elbows, hands, hips, knees, and feet. Subjects who indicated such complaints rated the intensity of the complaints usually perceived throughout the previous 7-day period and the maximal intensity during the 7-day period using a 100-mm-horizontal visual analog scale (VAS), ranging from “no pain” to “maximal pain.” The subjects also reported the duration of the complaints over the past 7 days.

2.4 Sociodemographic variables

This questionnaire [46] was designed to yield information on sociodemographic variables such as age, time of employment, and number of children, among others. The subject’s experienced health (Life Satisfaction) was assessed using a checklist comprising 1 item for reporting satisfaction with life as a whole and 10 domain-specific life satisfaction items [47]. Each item had to be rated according to a 6-grade scale ranging from very dissatisfied (scale grade 1) to very satisfied (grade 6). We calculated total life satisfaction as the sum of all the ten items. The McGill Quality of Life questionnaire [48] was used to access physical, existential, social, environmental, and healthcare aspects of life.

2.5 Locus of control

The construct “locus of control” stems from Rotter’s learning theory [41], which explains a tendency to attribute causes of one’s behavior to internal as opposed to external forces. In other words, the construct refers to the extent to which an individual perceives events and actions in his life as being a consequence of his behavior, ability, or characteristics (so-called internal control) or fate, luck, chance, or powerful others (so-called external control). The questionnaire [49] consists of 40 items referring to the locus of control orientation with an equal distribution between the internal and external direction. In addition, it includes a 10-item desirability scale, which was adapted from the KSP, a personality inventory elaborated by the Karolinska Institute in Stockholm [50]. A four-point forced-choice scale of Likert type with the following alternatives and their corresponding weights is applied: (1) strongly disagree, (2) disagree, (3) agree, and (4) strongly agree. The scale is scored in the external direction, which means the higher the score, the more the external locus of control.

2.6 Pain coping strategies

Patients’ use of pain coping strategies was measured using the Coping Strategies Questionnaire (CSQ) [40]. The CSQ is a 44-item questionnaire, yielding scores for seven coping strategies: diverting attention, reinterpreting pain sensations, ignoring pain sensations, coping self-statements, praying or hoping, catastrophizing, and increasing activity level. Each item is rated on a 7-point scale to indicate how often that strategy is used to cope with pain (0 = never, 3 = sometimes, and 6 = always). The CSQ also includes two measures of the overall effectiveness of the strategies used. Using a 7-point scale, patients rate how much control they have over their pain and how much they are able to decrease it. Research has shown the CSQ to be a reliable and valid instrument among various pain populations [36,40,51,52].

2.7 Coping Resources Inventory (CRI)

The CRI is a 60-item instrument measuring coping resources according to five domains: cognitive, social, emotional, spiritual/philosophical, and physical. Its internal consistency and reliability using Cronbach’s alpha have been shown to be satisfactory (the range of alpha is 0.71–0.91 for the subscales). The cognitive domain describes the extent to which individuals maintain a positive sense of self-worth, a positive outlook toward others, and optimism about life in general. The social domain characterizes the degree to which individuals are embedded in social networks and able to provide social support in times of stress. The emotional domain deals with the degree to which individuals are able to accept and express a range of effects, based on the premise that a range of emotional responses ameliorates the negative long-term consequences of stress. The spiritual/philosophical domain characterizes the degree to which the actions of individuals are guided by stable and consistent values derived from religious, familiar, or cultural traditions or a personal philosophy. The physical domain assesses the degree to which individuals enact health-promoting behaviors that are supposed to contribute to increased physical well-being. The CRI total resources score was found to be a significant incremental predictor of stress symptoms over time, and it was found to be negatively related to depression, grief, physical symptoms, psychological symptoms, and morbidity. Coping resources were also found to be a determinant of outcome after a multidisciplinary pain rehabilitation program [53].

2.8 Temperament and Character Inventory (TCI)

The TCI [54,55] is a self-report personality questionnaire based on Cloninger’s psychobiological model of personality, which accounts for both normal and abnormal variation in the two major components of personality: temperament and character. The TCI assesses four dimensions of temperament, including novelty seeking (NS), harm avoidance (HA), reward dependence (RD), and persistence, and three dimensions of character, including self-directedness (SD), cooperativeness (C), and self-transcendence (ST). The normative data for the Swedish TCI based on a representative Swedish sample of 1,300 adults have been shown to replicate the American version well for the means, distribution of scores, and relationships within the scales and subscales.

2.9 Neurophysiological investigation and MRI findings

Fifty consecutive patients were investigated with electromyography (EMG) and dermatomal sensory evoked potentials (SEP) at the Department of Clinical Neurophysiology at the University Hospital of Northern Sweden in order to estimate neurophysiological dysfunction due to injuries to the nervous tissue [56,57]. The patients had a heterogeneity of acute or chronic symptoms and signs indicating involvement of one or more cervical nerve roots [55,56]. All MRIs were interpreted and scored by an experienced specialist in neuroradiology, both independently and prior to the EMG examination. For each cervical spine level and side, the degree of narrowing of the spinal canal (anterior part) and intervertebral foramen (“root channel”) was assessed as no compression (0), 10–30% compression (1), 30–60% (2), and more than 60% (3) compared to the adjacent or contralateral level defined as normal. Routinely, abnormal findings on the symptomatic side also initiated an EMG examination of the corresponding contralateral muscles.

2.10 Sick leave

Sick leave data were collected from the National Insurance Board 2 years before, 2 years after consultation, and at a 6-year follow-up.

2.11 Statistical analysis

Group outcomes were analyzed using Chi-Square tests to evaluate categorical data. One-way analyses of variance (ANOVA) were conducted to compare mean values across multiple groups. Post-hoc comparisons were performed using the least significant difference (LSD) test to identify specific group differences.

For comparisons between two groups, the independent-samples t-test procedure was employed, which also automated the computation of effect sizes for the t-tests. Levene’s test for equality of variances was used to assess the homogeneity of variance assumption. Depending on the outcome of Levene’s test, either the pooled-variances t-test (equal-variance assumption) or the separate-variances t-test (unequal-variance assumption) was applied to ensure accurate mean comparisons.

All statistical calculations were performed by means of SPSS 28.0.0. 2021.

3 Results

3.1 Symbolic function and sociodemographic variables

Based on the SAT9 test results, 28 patients (41%) were classified in the good symbolic function group, 21 (31%) in the moderately impaired symbolic function group, and 19 (28%) in the poor symbolic function group. Among patients with poor symbolic function, 13 (65%) reported the onset of cervical pain following a stressful life event, such as the separation from a partner or the death of a relative. Similarly, 57% of the patients with moderately impaired symbolic function reported such events compared to only 17 patients (39%) in the good symbolic function group, yielding a significant difference (χ² = 4.0, p = 0.04).

Patients with poor symbolic function showed a tendency to more often reside in the countryside compared to the control group (χ² = 3.5, p = 0.12) and were more likely to have children living at home (χ² = 4.11, p = 0.11). However, these findings were not statistically significant. Vocational motivation was significantly lower in patients with poor symbolic function compared to the control group (95% CI: −4.4 to −0.48, p = 0.008), while no significant differences were observed for job satisfaction, belief in job return, or job stimulation across the three groups.

Educational attainment showed a non-significant tendency for lower levels in the poor symbolic function group (χ² = 1.4, p = 0.23). Among patients with poor symbolic function, 33% reported higher education, compared to 50% in the moderately impaired symbolic function group and 48% in the good symbolic function group. No significant differences in reported income were identified between the groups.

Other sociodemographic variables showed no significant differences across groups. The mean age for the good symbolic function group was 47 years (SD = 6.5), 46 years (SD = 11.5) for the moderately impaired symbolic function group, and 43 years (SD = 6.9) for the poor symbolic function group.

3.2 Life satisfaction and quality of life

A non-significant tendency (F = 2.5, p = 0.12) to report lower life satisfaction was observed in the group with poor symbolic function. This group rated their total life satisfaction at 40.8 (SD = 7.5), compared to 43.4 (SD = 10.5) for patients with moderately impaired or good symbolic function. Quality of life results are summarized in Table 1.

Table 1

McGill Quality of Life questionnaire was used to access physical, existential, social, psychological, and healthcare aspects of life

	Symbolic function	N	Mean	SD	P sign./95% CI
Physical	Good-moderate	49	29.0	6.4	0.18
Physical	Poor symbolic	18	27.2	3.9	−4.4 to 0.8
Social	Good-moderate	49	37.0	6.6	0.52
Social	Poor symbolic	18	35.9	5.9	−4.7 to 2.4
ADL	Good-moderate	49	31.7	6.8	0.14
ADL	Poor symbolic	18	29.1	5.3	−6.2 to 0.9
Joy	Good-moderate	49	10.7	2.8	0.22
Joy	Poor symbolic	18	11.6	2.6	−0.6 to 2.4
Health care	Good-moderate	49	10.6	3.0	0.42
Health care	Poor symbolic	18	11.2	2.8	−1.0 to 2.3
Psychological	Good-moderate	49	32.5	6.5	0.30
Psychological	Poor symbolic	18	30.7	5.7	−5.3 to 1.6
Total quality of life	Good-moderate	49	157.6	53.9	0.19
Total quality of life	Poor symbolic	18	145.7	120.6	−30.1 to 6.3
Physical	Poor symbolic	18	27.2	5.7	0.17
Physical	moderate	21	29.5	5.0	−1.1 to 5.7
Social	Poor symbolic	18	35.9	5.9	0.33
Social	moderate	21	37.7	5.3	−1.9 to 5.4
ADL	Poor symbolic	18	29.1	5.3	0.009
ADL	moderate	21	33.4	4.4	1.2 to 7.5
Joy	Poor symbolic	18	11.6	2.6	0.91
Joy	moderate	21	11.5	2.1	−1.6 to 1.4
Health care	Poor symbolic	18	11.2	2.8	0.85
Health care	moderate	21	11.0	3.0	−2.0 to 1.7
Psychological	Poor symbolic	18	30.7	5.7	0.09
Psychological	moderate	21	33.8	5.7	−0.5 to 6.9
Total quality of life	Poor symbolic	18	145.7	20.6	0.08
Total quality of life	moderate	21	171.3	73.6	−10.8 to 62.0
Physical	Good	49	28.6	6.6	0.62
Physical	moderate symbolic	18	29.5	6.3	−4.6 to 2.8
Social	Good	49	36.6	7.5	0.57
Social	moderate symbolic	18	37.7	5.3	−4.9 to 2.8
ADL	Good	49	30.5	8.0	0.11
ADL	Moderate symbolic	18	33.4	4.4	−6.5 to 0.9
Joy	Good	49	10.0	3.1	0.05
Joy	Moderate symbolic	18	11.5	2.1	−2.9 to 0.0
Health care	Good	49	10.2	2.9	0.33
Health care	Moderate symbolic	18	11.0	3.0	−2.5 to 0.9
Psychological	Good	49	31.4	6.9	0.20
Psychological	Moderate symbolic	18	33.8	5.7	−6.1 to 1.3
Total quality of life	Good	49	147.3	30.1	0.12
Total quality of life	moderate symbolic	18	171.3	73.6	−54.8 to 6.9

Ratings are shown for the group with poor symbolic function and compared to the combined group with good or moderately impaired symbolic function. Ratings are also compared between the groups with poor symbolic function and moderately impaired symbolic function.

Bold values indicate significance.

Patients with poor symbolic function reported lower satisfaction with environmental factors and physical health compared to the group with moderately impaired symbolic function. A significant difference was identified for environmental factors between the poor symbolic function group and the combined group of patients with good or moderately impaired symbolic function (p < 0.05).

3.3 Pain

Table 2 shows the differences in pain ratings across the three groups, based on the complaints typically experienced over a 7-day period. Subjects with poor symbolic function reported higher pain levels across nearly all pain regions compared to the control group with moderately impaired or good symbolic function. The largest differences were observed in shoulder pain (p = 0.05, 95% CI: −29.3 to 0.0), neck pain (p = 0.05, 95% CI: −26.1 to −0.3), and hip pain (p = 0.06, 95% CI: −28.1 to 0.7). At the 6-year follow-up, patients with poor symbolic function continued to report higher pain levels compared to the combined group of patients with good or moderately impaired symbolic function (Table 3).

Table 2

Pain ratings for the intensity of the complaints usually perceived throughout the 7-day period using a 100 mm VAS for different loci for patients with good symbolic function, with moderately impaired symbolic function, and with poor symbolic function. Subjects with poor symbolic function rated higher for almost all pain regions compared to the control group with moderately impaired or good symbolic function

Pain area	Good symbolic function		Moderately impaired		Poor symbolic function
	(n = 28)		(N = 21)		(N = 18)
	Mean (SD)		Mean (SD)		Mean (SD)
Arm	21.9	(25.1)	23.9	(28.8)	28.1	(32.3)
Shoulder	42.9	(30.4)	46.3	(23.3)	59.1	(24.9)
Lower back	16.8	(23.4)	16.3	(21.1)	27.4	(32.9)
Hand	25.7	(23.9)	35.4	(29.8)	41.1	(31.6)
Hip	8.8	(18.6)	20.0	(25.6)	27.3	(34.8)
Neck	52.0	(23.0)	46.1	(21.5)	62.7	(24.7)
Back (thorax)	24.6	(28.8)	29.4	(28.8)	37.4	(37.7)
Number of pain loci	7.7	(4.7)	8.3	(5.2)	8.9	(4.5)
Number of loci with paresthesia	3.1	(2.3)	3.1	(2.2)	3.3	(2.0)

Table 3

Pain ratings for pain intensity for the group with poor symbolic function compared to the combined group with good or moderately impaired symbolic function

VAS scale pain	Symbolic function	N	Mean	SD	P sign./95% CI
Neck pain	Poor	17	62.7	24.7	0.04
Neck pain	Control	49	49.5	22.3	0.3 to 26.0
Neck pain 6 years	Poor	11	62.7	15.5	0.004
Neck pain 6 years	Control	35	43.1	24.0	6.8 to 32.3
Shoulder pain	Poor	17	59.1	24.9	0.05
Shoulder pain	Control	49	44.4	27.3	−0.00 to29.4
Shoulder pain 6 years	Poor	11	50.9	28.8	0.1
Shoulder pain 6 years	Control	34	35.0	26.8	−3.1 to 35.0
Elbow pain	Poor	18	28.1	32.3	0.49
Elbow pain	Control	49	22.8	26.5	−10.1 to 20.8
Elbow pain 6 years	Poor	10	6.0	19.0	0.15
Elbow pain 6 years	Control	35	16.9	24.5	−26.1 to 4.4
Pain in hands	Poor	18	41.1	31.6	0.15
Pain in hands	Control	48	29.7	26.6	−4.0 to 26.8
Pain in hands 6 years	Poor	11	37.3	34.4	0.27
Pain in hands 6 years	Control	34	26.8	24.1	−8.0 to 29.3
Thorax pain	Poor	18	37.4	37.7	0.28
Thorax pain	Control	49	26.7	28.6	−6.4 to 28.0
Thorax pain 6 years	Poor	10	42.0	30.5	0.06
Thorax pain 6 years	Control	35	24.3	24.5	−1.0 to 36.4
Low back pain	Poor	17	27.3	32.9	0.22
Low back pain	Control	49	16.6	22.2	−7.1 to 28.6
Low back pain for 6 years	Poor	11	39.1	32.7	0.12
Low back pain for 6 years	Control	35	23.4	26.9	−4.1 to 35.4
Hip pain	Poor	18	27.3	34.8	0.06
Hip pain	Control	49	13.6	22.3	−0.7 to 28.1
Hip pain for 6 years	Poor	11	40.0	39.0	0.05
Hip pain for 6 years	Control	35	12.9	21.5	0.3 to 54.0
Knee pain	Poor	17	16.2	27.4	0.33
Knee pain	Control	47	9.0	19.1	−7.8 to 22.2
Knee pain for 6 years	Poor	11	9.1	20.7	0.93
Knee pain for 6 years	Control	34	9.7	18.7	−14 to 12.8
Foot pain	Poor	18	10.4	24.2	0.70
Foot pain	Control	48	12.9	23.6	−16 to 10.6
Foot pain for 6 years	Poor	10	21.0	29.2	0.84
Foot pain for 6 years	Control	34	18.8	30.5	−20 to 24.8

Pain ratings at first consultation and 6-year follow-up are shown using a 100 mm VAS for different loci. Subjects with poor symbolic function rated higher for almost all pain regions compared to the control group with moderately impaired or good symbolic function.

Significant differences are indicated with bold.

3.4 Neurophysiological findings and MRI

Fifty percentage of the patients with poor symbolic function exhibited pathological neurophysiological findings, compared to 92% of the patients in the good or moderately impaired symbolic function groups (χ² = 4.0, p = 0.04). Additionally, 52% of the patients with poor symbolic function had significant nerve root or spinal-cord entrapment on MRI, compared to 65% in the good or moderately impaired symbolic function group (χ² = 0.99, p = 0.32). However, among the combined group of non-responders to the SAT9 test with poor symbolic function, 44% showed significant neuro-radicular findings compared to 65% in the group with good or moderately impaired symbolic function (χ² = 4.9, p = 0.03).

3.5 Coping resources, strategies, and locus of control

Patients with poor symbolic function scored higher on the CSQ subscales and reported significantly more coping strategies overall (Table 4). These patients also scored higher on the CRI total scores compared to those with good or moderately impaired symbolic function (Table 5). However, there were no significant differences in the ratings of pain strategy efficiency across the three groups. A non-significant tendency was observed in the group with poor or impaired symbolic function, showing a trend toward lower pain control efficiency (p = 0.19). The group with impaired symbolic function also rated significantly higher (p = 0.007) on the locus of control compared to the control group (Table 6). At the 6-year follow-up, the locus of control score for the poor symbolic function group was 86.3 (SD = 8.2), compared to 82.1 (SD = 6.6) for the group with good or moderately impaired symbolic function (p = 0.09, 95% CI: −9.3 to 0.7). Additionally, the entire neck pain group reported higher locus of control scores (m = 84.5, SD = 9.1) compared to the healthy control group (m = 76.7, SD = 8.7), as described by Eisemann et al. [49].

Table 4

Differences in coping strategies (CSQ) between the group classified as poor symbolic function and the group with good or moderately impaired symbolic function (combined)

	Symbolic function	N	Mean	SD	P sign./95% CI
Catastrophizing	Good or moderate	44	12.3	6.8	0.59
Catastrophizing	Poor	18	11.3	6.4	−2.7 to 4.8
Pain behavior	Good or moderate	44	16.1	4.4	0.28
Pain behavior	Poor	18	17.7	6.1	−4.3 to 1.2
Div attention	Good or moderate	44	12.7	6.1	0.12
Div attention	Poor	18	15.6	7.7	−6.6 to 0.8
Pain sensation	Good or moderate	44	5.3	6.3	0.07
Pain sensation	Poor	18	9.0	8.8	−7.6 to 1.3
Coping self-statements	Good or moderate	44	18.1	6.6	0.07
Coping self-statements	Poor	18	21.7	7.7	−7.5 to 0.2
Ignoring sensation	Good or moderate	44	14.3	7.6	0.05
Ignoring sensation	Poor	18	18.4	6.7	−8.2 to 0.03
Praying hoping	Good or moderate	44	14.0	6.9	0.19
Praying hoping	Poor	18	16.6	6.5	−6.3 to 1.3
Increasing behavior	Good or moderate	44	13.8	6.0	0.14
Increasing behavior	Poor	18	16.6	8.0	−6.4 to 0.9
Pain behavior	Good or moderate	44	16.1	4.4	0.28
Pain behavior	Poor	18	17.7	6.1	−4.3 to 1.2
Sum of subscales	Good or moderate	44	106.7	30.7	0.03
Sum of subscales	Poor	18	126.8	37.9	−38.5 to −1.7

Significant differences are indicated with bold.

Table 5

Patients with poor symbolic function rated higher on the CRI total scores compared to the group with good or moderately impaired symbolic function

CRI
	Symbolic function	N	Mean	SD	P sign./95% CI
CRI cognitive	Poor	20	27.5	3.7	0.1
	Symbolic function	20	27.5	3.7	0.1
	Good or moderate	42	25.7	4.3	−0.4 to 4.1
	Symbolic function	42	25.7	4.3	−0.4 to 4.1
CRI social	Poor	20	39.0	5.3	0.07
	Symbolic function	20	39.0	5.3	0.07
	Good or moderate	42	36.2	5.5	−2.5 to 5.6
	Symbolic function	42	36.2	5.5	−2.5 to 5.6
CRI emotional	Poor	20	44.4	6.3	0.22
	Symbolic function	20	44.4	6.3	0.22
	Good or moderate	42	42.1	7.3	−1.5 to 6.1
	Symbolic function	42	42.1	7.3	−1.5 to 6.1
CRI spiritual	Poor	20	27.6	4.8	0.13
	Symbolic function	20	27.6	4.8	0.13
	Good or moderate	42	25.6	5.0	−0.6 to 4.7
	Symbolic function	42	25.6	5.0	−0.6 to 4.7
CRI physical	Poor	20	26.1500	5.3	0.19
	Symbolic function	20	26.1500	5.3	0.19
	Good or moderate	42	25.0	4.2	−1.4 to 3.6
	Symbolic function	42	25.0	4.2	−1.4 to 3.6
CRI total	Poor	20	166.0	18.6	0.04
	Symbolic function	20	166.0	18.6	0.04
	Good or moderate	42	155.2	19.2	0.38 to 21.0
	Symbolic function	42	155.2	19.2	0.38 to 21.0

Significant differences are indicated with bold.

Table 6

Locus of control ratings, social desirability scale ratings, ratings of mean efficiency of pain control efforts, and the mean control of pain for patients with good symbolic function, moderately impaired, and poor symbolic function

	Good symbolic function		Moderately impaired		Poor symbolic function
	(n = 28)		(n = 19)		(n = 17)
	Mean (SD)		Mean (SD)		Mean (SD)
Locus of control	80.7	(8.2)	81.0	(8.9)	87.3	(8.9)
6-year follow-up	81.1	(7.9)	83.6	(8.6)	86.4	(6.6)
Social desirability	26.4	(4.3)	27.6	(3.6)	28.3	(4.3)
6-year follow-up	28.3	(3.8)	27.0	(2.8)	29.1	(3.3)
Pain strategy efficiency (CSQ)	2.5	(1.2)	2.7	(1.0)	2.3	(1.4)
Pain control efficiency (CSQ)	3.0	(1.5)	3.1	(1.2)	2.5	(1.2)

The group with impaired symbolic function rated higher external locus of control compared to the controls when entering the study, and after 6 years, the group with poor symbolic function still showed more external locus of control (p = 0.05, 95%CI 2,6 - - 0,0).

Significant differences are indicated with bold.

There was a non-significant tendency for higher ratings on the social desirability scale in the groups with poor or moderately impaired symbolic function. Compared to healthy controls (m = 26.2, SD = 4.6), pain patients (m = 27.7, SD = 4.1) did not show a significant difference in social desirability ratings. At the 6-year follow-up, the group with poor symbolic function rated 29.1 (SD = 3.3) on the social desirability scale compared to 27.8 (SD = 3.5) for the group with good or moderately impaired symbolic function (p = 0.28, 95% CI: −3.5 to 1.1).

3.6 Personality

Patients with poor symbolic function reported higher scores on the TCI (Table 7). There was a significant difference in subscale ST. ST is one of the aspects of human character in Cloninger’s biopsychosociospiritual model [55] of personality (the concept of our participation in the world as a whole).

Table 7

Patients with poor symbolic function reported higher scores on TCI

TCI
	Symbolic function	N	Mean	SD	P sign./95% CI
Harm avoidance	Poor	14	13.0	5.2	0.31
	Symbolic function	14	13.0	5.2	0.31
	Good or moderate	30	14.8	7.0	−0.18 to 0.52
	Symbolic function	30	14.8	7.0	−0.18 to 0.52
Reward dependency	Poor	14	14.6	3.1	0.39
	Symbolic function	14	14.6	3.1	0.39
	Good or moderate	30	14.0	3.9	−6.1 to 2.4
	Symbolic function	30	14.0	3.9	−6.1 to 2.4
Persistence	Poor	14	4.6	1.4	0.10
	Symbolic function	14	4.6	1.4	0.10
	Good or moderate	30	3.7	1.8	−1.8 to 3.0
	Symbolic function	30	3.7	1.8	−1.8 to 3.0
Self-directedness	Poor	14	34.6	5.8	0.26
	Symbolic function	14	34.6	5.8	0.26
	Good or moderate	30	32.1	7.2	−1.9 to 7.0
	Symbolic function	30	32.1	7.2	−1.9 to 7.0
Cooperativeness	Poor	14	34.4	4.2	0.19
	Symbolic function	14	34.4	4.2	0.19
	Good or moderate	30	32.4	5.8	−1.1 to 5.2
	Symbolic function	30	32.4	5.8	−1.1 to 5.2
Self-transcendence (ST)	Poor	14	14.2	5.0	0.05
	Symbolic function	14	14.2	5.0	0.05
	Good or moderate	30	11.0	4.9	0.01 to 6.5
	Symbolic function	30	11.0	4.9	0.01 to 6.5

Significant differences are indicated with bold.

3.7 Non-responding group for SAT9

Thirty patients (12 women and 18 men) failed to complete the SAT9 test. One person was unable to write due to neurological dysfunction. The remaining non-responders were not prepared to complete the SAT9 questionnaire, mainly due to their inability to draw the items as stipulated. These patients were older than the responding group (47 years compared to 46, p = 0.58). They rated higher on several CSQ scales (Table 8). Furthermore, they scored higher on the locus of control (88.4 vs 83.1, p = 0.01). Table 9 displays the results at the 6-year follow-up for the combined group with poor symbolic function or failure to complete the SAT9 test in comparison to the group with good or moderately impaired symbolic function. Patients with good or moderately impaired symbolic ability had more of an internal locus of control (p = 0.002) and rated less satisfaction with medical care (p = 0.005).

Table 8

Differences in coping strategies subgroups (CSQ) and coping resources (CRI) between the group, not being able or failing to complete the SAT9 test compared to the group with good or moderately impaired symbolic function (Control)

		N	Mean	SD	P sign./95% CI
CSQ – div attention	Non-responders	30	17.4	6.8	0.01
CSQ – div attention	Control	62	13.5	6.7	0.8 to 6.7
CSQ – pain sensation	Non-responders	30	10.6	8.5	0.02
CSQ – pain sensation	Control	62	6.4	7.2	0.9 to 7.6
CSQ – coping self-statements	Non-responders	30	21.9	5.9	0.07
CSQ – coping self-statements	Control	62	19.1	7.1	−0.2 to 5.7
CSQ – praying hoping	Non-responders	30	16.5	6.8	0.25
CSQ – praying hoping	Control	62	14.8	6.8	−1.3 to 4.8
CSQ – ignoring sensation	Non-responders	30	17.5	6.0	0.22
CSQ – ignoring sensation	Control	62	15.5	7.5	−1.2 to 5.0
CSQ – catastrophizing	Non-responders	30	15.5	7.0	0.02
CSQ – catastrophizing	Control	62	12.0	6.7	0.5 to 6.4
CSQ – increasing behavior	Non-responders	30	18.4	7.0	0.01
CSQ – increasing behavior	Control	62	14.6	6.7	0.8 to 6.8
CSQ – pain behavior	Non-responders	30	19.5	5.0	0.01
CSQ – pain behavior	Control	62	16.6	5.0	0.7 to 5.1
CSQ – sum of subscales	Non-responders	30	137.3	33.8	0.001
CSQ – sum of subscales	Control	62	112.5	33.9	9.8 to 39.7
CRI total	Non-responders	33	163.2	19.6	0.29
CRI total	Control	62	158.7	19.5	−4.7 to 3.0

Significant differences are indicated with bold.

Table 9

Quality of life, life satisfaction, and locus of control for patients with poor symbolic function or inability/not willing to perform the SAT 9 test compared to controls with good or moderate symbolic function (Control) at 6 years follow-up

	Symbolic function	N	Mean	SD	P sign./95% CI
Satisfaction with life as a whole	Poor /unable	38	42.0	10.3	0.29
Satisfaction with life as a whole	Control	35	44.9	11.3	−7.9 to 2.2
Total quality of life	Poor/ unable	38	152.9	26.9	0.67
Total quality of life	Control	35	155.6	25.8	−14.9 to 9.7
Psychological	Poor/unable	38	34.1	5.9	0.34
Psychological	Control	35	35.4	5.8	−1.1 to 1.4
Somatic	Poor/ unable	38	29.6	6.1	0.69
Somatic	Control	35	30.1	6.9	−3.6 to 2.4
Social	Poor /unable	38	35.2	7.4	0.58
Social	Control	35	36.1	7.0	−4.3 to 2.4
ADL	Poor/unable	38	32.8	6.7	0.15
ADL	Control	35	35.1	6.6	−5.4 to 0.8
Joy of life	Poor/ unable	38	11.1	2.3	0.70
Joy of life	Control	35	11.3	2.8	−1.4 to 1.0
Satisfaction with medical care	Poor/unable	38	10.2	3.8	0.005
Satisfaction with medical care	Control	35	7.5	4.2	0.8 to 4.6
Locus of control	Poor/unable	38	88.0	7.9	0.002
Locus of control	Control	35	81.8	8.1	2.4 to 9.9
Social desirability	Poor/unable	38	29.0	4.1	0.20
Social desirability	Control	35	27.9	3.5	−0.7 to 2.8

Significant differences are indicated with bold.

3.8 Vocational situation

Seventy percent were employed when entering the study, and at the 6-year follow-up, 37% were still working. Forty-eight percentage of the patients with good or slightly impaired symbolic function were working, while only 5% of the patients with poor symbolic function were working (Chi-Square 9.6, p = 0.002) after 6 years. Days on sick leave for patients with poor symbolic function 2 years before entering the study was 276 (SD = 240) compared to 206 (SD = 211) for controls with good or slightly impaired symbolic function (F = 1.5, p = 0.22). Use of sick leave days 2 years after consultation was 605 (SD = 202) for the group with poor symbolic function compared to 328 (SD = 282) for the control group (F = 15.6, p < 0.001). For the group with moderately impaired symbolic function, the use of sick leave days 2 years later was 335 (SD = 265) compared to 344 (SD = 304) for the group with good symbolic function. Forty-four percentage of the patients with impaired symbolic function were working 6 years later compared to 52% of the group with good symbolic function.

The use of sick leave days before entering the study for the combined group of non-responders and poor symbolic function (n = 57) was 224 (SD = 243) compared to 204 (SD = 211) for the group with moderately impaired symbolic function (n = 49). Two years later, use of sick leave days was 493 (SD = 268) for the combined group (non-responders and poor symbolic function) and 328 (SD = 283) for controls with good or moderately impaired symbolic function (F = 8.8, p = 0.004). Eighteen percentage of the non-responders and the group with poor symbolic function were still working, compared to 48% of the control group with good or moderately impaired symbolic function.

4 Discussion

In clinical practice, it is often difficult to identify the psychogenic components of a complex, multi-cause pain syndrome. Our results indicate that the neck-pain patient group is not homogeneous with respect to the degree of symbolic function. Furthermore, our results indicate that poor symbolic function, as defined by the inhibition of symbolic function, correlates with pain and the ability to work. Patients with poor symbolic function reported significantly more often the onset of symptoms after a stressful life event, such as separation from their partner or the death of a relative. The group classified as having poor symbolic function reported more frequent use of coping strategies and resources and had more of an external locus of control compared to the group with moderately impaired symbolic function. Patients with poor symbolic function also reported higher scores on the TCI. Thus, the questionnaires seem to move in a completely different direction compared to the symbolic function estimated by the projective SAT9 test. However, patients with poor symbolic function showed less objective neurophysiological findings but rated more pain on a VAS scale. After 6 years, they still reported significantly higher levels of pain, more external locus of control, and an inability to work. We also tried, through a semi-structured interview, to ascertain affect differentiation and assess normopathy traits in this group of pain patients. McDougall [58] introduced the term “normopathy” meaning a fear of individuality. Identifying normopathy traits can be challenging, as these individuals often strive to blend in and emulate their peers. This kind of person yearns for social approval and validation at the expense of individual expression and creativity. The concept of normopathy resonates with D. W. Winnicott’s idea [59] of the false self, which is developed in response to the demands of the external environment rather than from impulses and desires from within. We classified 31% of the patients with good or moderately impaired symbolic function as exhibiting normopathy traits and 48% of the patients with poor symbolic function as belonging to the normopathy group (Chi Square 3.9, p = 0.05). By reporting higher coping resources, higher use of coping strategies, and personality traits as higher ST, the group with poor symbolic function seems to enable the normopathic state of mind [60]. “The normopathic state of mind has lost this vital connection between feeling and speech.”

Our findings that 28% of the patients with chronic cervical pain at the unit of neurosurgery had poor symbolic function, according to the SAT9, are somewhat lower than the incidence of alexithymia (33%) Postone [30] found among chronic pain patients. However, it is evident that the non-responding group (n = 30, 29%), who did not complete the SAT9 questionnaire, exhibited characteristics such as a greater external locus of control, lower education, pain behavior, and pain sensation on the CSQ-scales, were more similar to the group with poor symbolic function than the other two groups. Two years after the consultation, patients who didn’t respond (29%) and patients whose symbolic function was poor (20%) took significantly more sick days, and only 18% of them were still working after 6 years, while 48% of the patients who completed the symbolic function test with good or moderate results were still working. Patients with poor symbolic function reported higher pain levels and more of an external locus of control at the first appointment and still at a 6-year follow-up. At the same time, the prognosis for pain experience and working ability after treatment seem to be poor for this group of patients. The SAT9 gives, with its unique properties compared to questionnaires, an understanding of an individual’s inner resource for self-care [14,37,45]. The SAT9, based on our description, appears to focus on assessing the ability for imagination, verbalization, and perhaps other cognitive functions. The test provides a qualitative sample of the existing ability for imagination and the ability to verbalize the same [14,45]. The questionnaires in this study move in a completely different dimension, but it feels interesting to clarify, not least neurologically/cognitively, how they interact and differ. It seems very important to consider these traits among patients suffering from chronic pain disorders and consider them as indicators of the outcome of treatment. Almost all of our patients were thought to have a neurological disease, making them a potential candidate for cervical spinal surgery. Therefore, it seems more rational to identify those patients who are characterized by traits that make them susceptible and prone to developing a chronic pain syndrome, regardless of the presence of a somatic injury or neurological disease.

Pain can serve as a symbolic communication tool to express underlying concerns, stress, or dissatisfaction with the work environment or interpersonal relationships [13,25–29]. Expressing pain can be a symbolic way of seeking support, understanding, or empathy from others as a non-verbal request for help and acknowledgement of one’s struggles. Understanding the function of pain in the workplace requires considering the cultural, psychological, and social dynamics. Pain can symbolize deeper issues, whether they are physical health problems, emotional struggles, or stressors in one’s life. Psychological factors, such as an individual’s coping mechanisms and resilience, influence how they interpret and manage pain [38,41–43]. Our results suggest that good symbolic function, rather than questionnaire-estimated coping strategies and resources, is an important factor of resilience.

External locus of control and symbolic function are two concepts that can influence how individuals perceive and respond to various situations [13,42,49]. External locus of control refers to the belief that external factors, such as fate, luck, or powerful others, control one’s life [41]. Therefore, individuals with a strong external locus of control tend to attribute outcomes to external forces rather than their actions, including stressors or challenges beyond their personal control. The symbolic function of pain may serve as a way to express a personal lack of control over external stressors. External locus of control may lead to a tendency to seek external solutions [41,42,49] or symbolic expressions such as taking sick leave. The relationship between locus of control and symbolic function can have an effect on well-being. Patients who use symbolic expressions of pain may experience a sense of relief or control through these actions, even if they believe broader circumstances are beyond their influence [41]. Understanding an individual´s locus of control and their symbolic functions can provide insights into how they interpret and respond to pain or stress. Additionally, fostering a sense of internal locus of control can empower individuals to take more active roles in managing stressors and addressing their emotional needs [41]. For people with chronic pain whose symbolic function is impaired, rehabilitation could include learning how to talk about their feelings using mindfulness techniques like ACT [61], as well as doing activities or rituals that can help them deal with their pain. Several authors [9,61–64] have previously described psychotherapy techniques that are compatible with this approach. There is also a growing body of work supporting the role of emotion schemas and experiential avoidance [65–72].

Engaging in activities like deep breathing, meditation, or other symbolic rituals can provide individuals with a sense of control and relief from stressors. Different cultures may have specific symbols or practices to symbolically address their stress by engaging in activities that symbolize resilience. Narratives, stories, or metaphors can also serve as symbolic representations of stress.

The SAT9 seems to have the property of enabling us to make an important distinction within the pain population, namely that between good or moderately impaired symbolic function and poor symbolic function. Moderately impaired symbolic function has been regarded as resulting from a primary medical illness or other stress [13,14,15]. Krystal’s work [73] on the consequences of massive trauma supports this distinction. Our results indicate that there is an important difference between the groups with poor and moderately impaired symbolic function. The group with moderately impaired symbolic function reported lower pain levels and better vocational outcomes at 2- and 6-year follow-ups.

These results support the idea that symbolic function is neither a cause nor a result of a physical disorder or state. Instead, it is part of a pattern of responses to stress and pain as a stressor, a pattern that shows how people tend to report physical signs and symptoms instead of their true feelings [13,14,15].

Understanding the symbolic function of stress can be valuable for health professionals and individuals themselves. Encouraging open communication, recognizing, and reorganizing the symbolic nature of stress can contribute to a more compassionate and understanding approach to addressing stress-related challenges and pain.

In conclusion, the significant presentation of poor symbolic function or inability to produce the SAT9 test in chronic cervical pain patients has important implications for the theoretical understanding of the relationship between pain and physical illness, working ability, and the treatment of cervical pain.

† Deceased.

Acknowledgments

No.

Research ethics: Data collection is carried out according to the European data protection law. Research involving human subjects complied with all relevant national regulations and institutional policies and was in accordance with the tenets of the Helsinki Declaration (as amended in 2013). The study was approved by the Research Ethics Committee at the University Hospital of Northern Sweden (1186/1995).
Informed consent: Informed consent was obtained from all individuals included in this study who participated voluntarily.
Author contributions: The authors have accepted responsibility for the entire content of this manuscript and approved its submission. All authors contributed equally to the manuscript, read it, and approved the final version.
Competing interest: The authors state no conflict of interest.
Research funding: None declared.
Data availability: The raw data can be obtained on request from the corresponding author.
Artificial intelligence/Machine learning tools: Not applicable.

References

[1] Piaget J, Inhelder B. La psychologie de l’enfant. Paris: Presses universitaires de France; 1966.Search in Google Scholar

[2] Nemiah JC, Sifneos PE. Psychosomatic illness: A problem in communication. Psychother Psychosom. 1970;18(1):154–60. 10.1159/000286074.Search in Google Scholar PubMed

[3] Nemiah JC, Sifneus PE. Affect and fantasy in patients with psychosomatic disorders. In: Hill DW, editor. Modern trends in psychosomatic medicine. Vol 2, London: Butterworths; 1976. p. 26–34.Search in Google Scholar

[4] Nemiah JC, Sifneos PE. Alexithymia and psychosomatic illness. J Cont Educ Psychiatry. 1970;25–37.Search in Google Scholar

[5] Nemiah JC. Alexithymia: Theoretical considerations. Psychother Psychosom. 1977;28:199–206. 10.1159/000287064.Search in Google Scholar PubMed

[6] Nemiah JC. The psychodynamic view of anxiety. In: Pasnau RO, editor. Diagnosis and treatment of anxiety disorders. Washington, DC: American Psychiatric Press; 1984. p. 117–37.Search in Google Scholar

[7] Sifneos PE. The prevalence of ‘alexithymic’characteristics in psychosomatic patients. Psychother Psychosom. 1973;22(2):255–62. 10.1159/000286529.Search in Google Scholar PubMed

[8] Marty P, de M’Uzan M. La “Pensee Operatoire”. Rev Fr Psychanal. 1963;27:1345–56.Search in Google Scholar

[9] Lane RD, Weihs KL, Herring A, Hishaw A, Smith R. Affective agnosia: Expansion of the alexithymia construct and a new opportunity to integrate and extend Freud’s legacy. Neurosci Biobehav Rev. 2015;55:594–611. 10.1016/j.neubiorev.2015.06.007.Search in Google Scholar PubMed

[10] Taylor GJ, Bagby RM, Parker JD. What’s in the name ‘alexithymia’? A commentary on “Affective agnosia: Expansion of the alexithymia construct and a new opportunity to integrate and extend Freud’s legacy”. Neurosci Biobehav Rev. 2016;68:1006–20. 10.1016/j.neubiorev.2016.05.025.Search in Google Scholar PubMed

[11] Watters CA, Taylor GJ, Quilty LC, Bagby RM. An examination of the topology and measurement of the alexithymia construct using network analysis. J Pers Assess. 2016;98:649–59. 10.1080/00223891.2016.1172077.Search in Google Scholar PubMed

[12] Bagby RM, Taylor GJ, Parker JD, Dickens SE. The development of the Toronto structured interview for alexithymia: Item selection, factor structure, reliability and concurrent validity. Psychother Psychosom. 2006;75:25–39. 10.1159/000089224.Search in Google Scholar PubMed

[13] Demers-Desrosiers LA. Influence of alexithymia on symbolic function. Psychother Psychosom. 1982;38(1):103–20. 10.1159/000287619.Search in Google Scholar PubMed

[14] Cohen KR, Demers-Desrosiers LA, Catchlove RF. The SAT9. A qualitative scoring system for the AT 9 test as a measure of symbolic function. Psychother Psychosom. 1983;39(2):77–88. 10.1159/000287725.Search in Google Scholar PubMed

[15] Cohen K, Audl F, Demers L, Catchlove R. Alexithymia. The development of a valid and reliable projective measure (the objectively scored archetypal 9 test). J Nerv Ment Dis. 1985 Oct;173(10):621–7. 10.1097/00005053-198510000-00008.Search in Google Scholar PubMed

[16] Taylor GJ, Bagby RM, Parker JD. The revised Toronto alexithymia scale: Some reliability, validity, and normative data. Psychother Psychosom. 1992;57:34–41. 10.1159/000288571.Search in Google Scholar PubMed

[17] Czernecka K, Szymura B. Alexithymia–imagination–creativity. Pers Individ Dif. 2008;45:445–50. 10.1016/j.paid.2008.05.019.Search in Google Scholar

[18] Bausch S, Stingl M, Hartmann LC, Leibing E, Leichsenring F, Kruse J, et al. Alexithymia and script-driven emotional imagery in healthy female subjects: no support for deficiencies in imagination. Scand J Psychol. 2011;52:179–84. 10.1111/j.1467-9450.2010.00847.x.Search in Google Scholar PubMed

[19] Golena N. The relation between alexithymia and the vividness of memories during the recall of sad memories. Bachelor’s thesis. Enschede, Netherlands: University of Twente; 2014.Search in Google Scholar

[20] Mantani T, Okamoto Y, Shirao N, Okada G, Yamawaki S. Reduced activation of posterior cingulate cortex during imagery in subjects with high degrees of alexithymia: A functional magnetic resonance imaging study. Biol Psychiatry. 2000;57:982–90. 10.1016/j.biopsych.2005.01.047.Search in Google Scholar PubMed

[21] Campos A, Chiva M, Moreau M. Alexithymia and mental imagery. Pers Individ Differ. 2000;29:787–91. 10.1016/S0191-8869(99)00231-7.Search in Google Scholar

[22] Friedlander L, Lumley MA, Farchione T, Doyal G. Testing the alexithymia hypothesis: physiological and subjective responses during relaxation and stress. J Nerv Ment Dis. 1997;185:233–9. 10.1097/00005053-199704000-00003; Bausch S, Stingl M, Hartmann LC, Leibing E, Leichsenring F, Kruse J, et al. Alexithymia and script-driven emotional imagery in healthy female subjects: No support for deficiencies in imagination. Scand J Psychol. 2011;52:179–84. doi:10.1111/j.1467-9450.2010.00847.x.Search in Google Scholar PubMed

[23] Morera OF, Culhane SE, Watson PJ, Skewes MC. Assessing the reliability and validity of the Bermond-Vorst alexithymia questionnaire among US anglo and US hispanic samples. J Psychosom Res. 2005;58:289–98. 10.1016/j.jpsychores.2004.09.001.Search in Google Scholar PubMed

[24] Parkers CM. Factors determining the persistence of phantom pain in the amputee. J Psychosom Res. 1973 Mar;17(2):97–108. 10.1016/0022-3999(73)90010-x.Search in Google Scholar PubMed

[25] Pilowsky J, Spence ND. Pain, anger and illness behavior. J Psychosom Res. 1976;20(5):411–6. 10.1016/0022-3999(76)90003-9.Search in Google Scholar PubMed

[26] Catchlove RF, Cohen KR, Braha RE, Demers-Desrosiers LA. Incidence and implications of alexithymia in chronic pain patients. J Nerv Ment Dis. 1985 Apr;173(4):246–8. 10.1097/00005053-198504000-00007.Search in Google Scholar PubMed

[27] Kirmayer JL. Languages of suffering and healing: Alexithymia as a social and cultural process. Transcult Psych Res Rev. 1987;24:119–36.10.1177/136346158702400204Search in Google Scholar

[28] McDonald PW, Pirkachin KM. The expression and perception of facial emotion in alexithymia. A pilot study. Psychosom Med. 1990 Mar-Apr;52(2):199–210. 10.1097/00006842-199003000-00007.Search in Google Scholar PubMed

[29] Mendelson G. Alexithymia and chronic pain: Prevalence, correlates and treatment results. Psychother Psychosom. 1982;37(3):154–64. 10.1159/000287568.Search in Google Scholar PubMed

[30] Postone N. Alexithymia in chronic pain patients. Gen Hosp Psychiatry. 1986 May;8(3):163–7. 10.1016/0163-8343(86)90075-7.Search in Google Scholar PubMed

[31] Sivik T. The thematic apperception test as an aid in understanding the psychodynamics of develpment of chronic idiopathic pain syndrome. Psychother Psychosom. 1992;57(1–2):57–60. 10.1159/000288574.Search in Google Scholar PubMed

[32] Aaron RV, Fisher EA, de la Vega R, Lumley MS, Palermo TM. Alexithymia in individuals with chronic pain and its relation to pain intensity, physical interference, depression, and anxiety: A systematic review and meta-analysis. Pain. 2019;160(5):994–1006. 10.1097/j.pain.0000000000001487.Search in Google Scholar PubMed PubMed Central

[33] Taylor GJ. Psychosomatic medicine and contemporary psychoanalysis. IUP Stress and Health Series Monograph. Madison: International University Press; 1987.Search in Google Scholar

[34] Sifneus PE, Apfel-Savitz R, Frankel FH. The phenomenon of “alexithymia”, Observations in neurotic and psychosomatic patients. Psychother Psychosom. 1977;28(1–4):47–57. 10.1159/000287043.Search in Google Scholar PubMed

[35] Nemiah JC. Alexithymia and psychosomatic illness. J Cont Educ Psychiatry. 1978;39:25–37.Search in Google Scholar

[36] Toskala A, Kangasniemi K, Vasarainen A, Nurmikko T. Pain and symbolic function. Psychiatr Fenn. 1993;24:101–12.Search in Google Scholar

[37] Turner JA, Clancy S. Strategies for coping with chronic low back pain: Relationships to pain and disability. Pain. 1986 Mar;24(3):355–64. 10.1016/0304-3959(86)90121-1.Search in Google Scholar PubMed

[38] Linton SJ. The behavioral management and prevention of chronic pain. In: Caddy GR, Byrne R. DC, editors. Behavioral medicine: International perspectives. Vol. 2. Norwood: Ablex Publ; 1992. Ch. 11, G. p. 253–94.Search in Google Scholar

[39] Pearlin L, Schooler C. The structure of coping. J Health Soc Behav. 1978 Mar;19(1):2–21.10.2307/2136319Search in Google Scholar

[40] Rosenstiel AK, Keefe FJ. The use of coping strategies in chronic low back pain patients: Relationship to patient characteristics and current adjustment. Pain. 1983 Sep;17(1):33–44. 10.1016/0304-3959(83)90125-2.Search in Google Scholar PubMed

[41] Rotter JB. Generalized expectancies for internal versus external control of reinforcement. Psychol Monogr. 1966;80(1):1–28.10.1037/h0092976Search in Google Scholar

[42] Crisson JE, Keefe FJ. The relationship of locus of control to pain coping strategies and psychological distress in chronic pain patients. Pain. 1988 Nov;35(2):147–54. 10.1016/0304-3959(88)90222-9.Search in Google Scholar

[43] Jensen MP, Turner JA, Romano JM, Karoly P. Coping with chronic pain: a critical review of the literature. Pain. 1991 Dec;47(3):249–83. 10.1016/0304-3959(91)90216-K.Search in Google Scholar

[44] Weinryb RM, Rössel R. Karolinska psychodynamic profile-KAPP. Acta Psychiatr Scand Suppl. 1991;363:1–23.10.1111/j.1600-0447.1991.tb10573.xSearch in Google Scholar

[45] Durand Y. La formulation expérimentale de l’imaginaire et ses modéles. Circé Il. 1970;151–278.Search in Google Scholar

[46] Kourinka L, Jonsson B, Kilbom Å, Vinterberg H, Biering-Sorensen F, Andersson G, et al. Standardized nordic questionnaires for the analysis of musculosceletal symptoms. Appl Erg. 1987 Sep;18(3):233–7. 10.1016/0003-6870(87)90010-x.Search in Google Scholar

[47] Fugl-Meyer AR, Bränholm LB, Fugl-Meyer KS. Happiness and domain- specific life satisfactions in adult northern Swedes. Clin Rehabil. 1991;5:25–33.10.1177/026921559100500105Search in Google Scholar

[48] Cohen SR, Mount BM, Tomas JJ, Mount LF. Existential well-being is an important determinant of quality of life. Evidence from the McGill quality of life questionnaire. Cancer. 1996 Feb;77(3):576–86. 10.1002/(SICI)1097-0142(19960201)77:3<576::AID-CNCR22>3.0.CO;2-0.Search in Google Scholar

[49] Eisemann M, Perris C, Palm U, Palm A, Peris H. LOC-presentation of a Swedish instrument for assessing locus of control. Cognit Psycho-Ther. 1988;45–8.Search in Google Scholar

[50] Schalling D. Contribution to the validation of some personality concepts, Rep. Dept. Psychol. Stockholm, Sweden: Stockholm Univ., suppl f; 1970.10.1037/e425282004-001Search in Google Scholar

[51] Gross AR. The effects of coping strategies on the relief of pain following surgical intervention for lower back pain. Psychosom Med. 1986 Mar-Apr;48(3–4):229–41. 10.1097/00006842-198603000-00008.Search in Google Scholar

[52] Keefe FJ, Caldwell DS, Queen K, Gil KM, Martinez S, Crisson JE, et al. Osteoarthritic knee pain: A behavioral analysis. Pain. 1987 Mar;28(3):309–21. 10.1016/0304-3959(87)90066-2.Search in Google Scholar

[53] Heikkilä H, Heikkilä E, Eisemann M. Predictive factors for the outcome of a multidisciplinary pain rehabilitation programme on sick-leave and life satisfaction in patients with whiplash trauma and other myofascial pain: a follow-up study. Clin Rehabil. 1998 Dec;12(6):487–96. 10.1191/026921598670569564.Search in Google Scholar PubMed

[54] Cloninger R. The temperament and character inventory (TCI): A guide to its development and use. St. Louis, MO: Center for Psychobiology of Personality, Washington University; 1994. ISBN 978-0-9642917-1-3.Search in Google Scholar

[55] Cloninger R, Syrakic DM, Przybeck TR. A psychobiological model of temperament and character. Arch Gen Psychiatry. 1993;50(12):075–990. 10.1001/archpsyc.1993.01820240059008.Search in Google Scholar PubMed

[56] Kwast Rabben O, Libelius R, Heikkilä H, Fagerlund M. Digital nerve somatosensory evoked potentials and MRI. Correlation analysis in patients with symptomatic cervical spine disorders. Acta Neurol Scand. 2008;117(2):122–7. 10.1111/j.1600-0404.2007.00918.x.Search in Google Scholar PubMed

[57] Kwast Rabben O, Heikkilä H, Fagerlund M. Specificity and sensitivity of electromyography in evaluation of C6 and C7 root involvement in patients with symptomatic cervical spine disorders. Correlation analysis between electromyography and magnetic resonance imaging. Clin Neurophysiol. 2011;122(1):S78. 10.1016/S1388-2457(11)60267-8.Search in Google Scholar

[58] McDougal J. Plea for a measure of abnormality. New York: International Universities Press; 1980.Search in Google Scholar

[59] Winnicott DW. Ego distortion in terms of true and false self. In The maturational processes and the facilitating environment. New York: International Universities Press; 1965. p. 140–52.10.4324/9780429482410-12Search in Google Scholar

[60] Bollas C. Meaning and melancholia: Life in the age of bewilderment. New York and London: Routledge; 2018.10.4324/9781351018500Search in Google Scholar

[61] Harris R. ACT made simple: An easy-to-read primer on acceptance and commitment therapy. United States: New Harbinger Publications; 2009.Search in Google Scholar

[62] Kennedy M, Franklin J. Skills-based treatment for alexithymia: An exploratory case series. Behav Change. 2002;19:158–71.10.1375/bech.19.3.158Search in Google Scholar

[63] Taylor GJ, Bagby R, Parker J. Disorders of affect regulation: Alexithymia in medical and psychiatric illness. UK: Cambridge University Press; 1999.Search in Google Scholar

[64] Neumann D, Malec J, Hammond F. Reductions in alexithymia and emotion dysregulation after training emotional self-awareness following traumatic brain injury: A phase I trial. J Head Trauma Rehabil. 2017;32(5):286–95. 10.1097/HTR.0000000000000277.Search in Google Scholar PubMed PubMed Central

[65] Lane R, Lee S, Reidel R, Weldon V, Kaszniak A, Schwartz G. Impaired verbal and nonverbal emotion recognition in alexithymia. Psychosom Med. 1996;58:203–10. 10.1097/00006842-199605000-00002.Search in Google Scholar PubMed

[66] Luminet O, Vermeulen N, Demaret C, Taylor G, Bagby R. Alexithymia and levels of processing: Evidence for an overall deficit in remembering emotion words. J Res Pers. 2006;40:713–33. 10.1016/j.jpr.2005.09.001.Search in Google Scholar

[67] Lundh LG, Johnsson A, Sundqvist K, Olsson H. Alexithymia, memory of emotion, emotional awareness, and perfectionism. Emotion. 2002;2:361–79. 10.1037/1528-3542.2.4.361.Search in Google Scholar PubMed

[68] Suslow T, Junghanns K. Impairments of emotion situation priming in alexithymia. Pers Individ Differ. 2002;32:541–50. 10.1016/S0191-8869(01)00056-3.Search in Google Scholar

[69] Vermeulen N, Luminet O, Corneille O. Alexithymia and the automatic processing of affective information: Evidence from the affective priming paradigm. Cogn Emot. 2006;20:64–91. 10.1080/02699930500304654.Search in Google Scholar

[70] Bilotta E, Giacomantonio M, Leone L, Mancini F, Coriale G. Being alexithymic: Necessity or convenience. Negative emotionality × avoidant coping interactions and alexithymia. Psychol Psychoter. 2016;89:261–75. 10.1111/papt.12079.Search in Google Scholar PubMed

[71] Coriale G, Bilotta E, Leone L, Cosimi F, Porrari R, De Rosa F, et al. Avoidance coping strategies, alexithymia and alcohol abuse: A mediation analysis. Addict Behav. 2012;37:1224–9. 10.1016/j.addbeh.2012.05.018.Search in Google Scholar PubMed

[72] Panayiotou G, Leonidou C, Constantinou E, Hart J, Rinehart K, Sy J, et al. Do alexithymic individuals avoid their feelings? Experiential avoidance mediates the association between alexithymia, psychosomatic, and depressive symptoms in a community and a clinical sample. Compr Psychiatry. 2015;56:206–16. 10.1016/j.comppsych.2014.09.006.Search in Google Scholar PubMed

[73] Krystal H. Trauma: Consideration of severity and chronicity. In: Krystal H, Niederland W, editors. Psychic traumatization. Boston: Little Brown; 1971. p. 11–28.Search in Google Scholar

Received: 2024-01-05

Revised: 2024-11-25

Accepted: 2024-12-02

Published Online: 2025-03-17

This work is licensed under the Creative Commons Attribution 4.0 International License.

Articles in the same Issue

https://doi.org/10.1515/sjpain-2024-0002

Keywords for this article

symbolic function; cervical pain; coping strategies; locus of control; vocational outcome; normopathy; sick leave

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