Emotional unawareness in psoriatic arthritis: decoding the impact of alexithymia on pain perception, disease activity, and treatment response

Objectives: Psychological distress influences pain and disease severity perception among patients affected by psoriatic arthritis (PsA). Alexithymia, a personal trait characterised by the difficulty in recognising and articulating emotions, has been observed in other rheumatic diseases, but its role in PsA remains underrecognised. We investigated the prevalence of alexithymia in PsA and its association with disease activity, psychological burden, and treatment complexity. Methods: A cross-sectional observational study was conducted across three Italian rheumatology centers, enrolling PsA patients on stable biological therapy. Toronto Alexithymia Scale (TAS-20), Pain Catastrophising Scale (PCS), Beck's Depression Inventory (BDI), Widespread Pain Index (WPI), Symptom Severity Scale (SSS), alongside Disease Activity Index for PsA (DAPSA), Bath Axial Spondyloarthritis Disease Activity Index (BASDAI), and Axial Spondyloarthritis Disease Activity Index-C Reactive Protein (ASDAS-CRP) were assessed at last follow-up. Associations with alexithymia were explored by univariate analyses, Spearman correlation, and multivariable logistic regression. Results: Among 207 PsA patients, 63 (30.4%) were classified as alexithymic (TAS≥61). Patients with alexithymia exhibited significantly higher pain-VAS, patient and physician global assessment, tender joint count, PCS, WPI+SSS, and BDI scores, as well as elevated DAPSA, BASDAI, ASDAS-CRP, while inflammatory markers and swollen joint count were similar between groups. Alexithymic patients underwent multiple biological therapy lines and reported increased conventional synthetic DMARDs and non-steroidal anti-inflammatory drug usage. A strong correlation emerged between TAS-20 and PCS, alongside female sex, concomitant fibromyalgia and higher DAPSA were independent predictors of alexithymia in multivariable model. Conclusions: Alexithymia is present in PsA and is linked to increased pain perception, disease activity and treatment burden.