Authors' reply to the comment ‘The importance of measurement content and study design’ by Veirman et al. (2023)

We read with interest the issues raised by Veirman et al. (2023) about our article, ‘The Relationship of Alexithymia to Pain and Other Symptoms in Fibromyalgia: A Systematic Review and Meta-analysis’ (Habibi Asgarabad et al., 2023). Here, we reflect on some of the points they raised—agreeing with some and challenging others. Regarding the assessment of alexithymia with the TAS, we agree that self-report scales have their limitations, and various criticisms have long been made about the self-report of alexithymia generally and of the TAS specifically. Although a few non-self-report measures of alexithymia and emotional awareness exist, the vast majority of studies have used the TAS for assessing alexithymia, as noted in a larger review and meta-analysis of the role of alexithymia in chronic pain (i.e., Aaron et al., 2019). Also, there are long-discussed concerns about the reliability and validity of the externally oriented thinking facet of the TAS, although the scale developers have advocated for interpreting only the full scale rather than the separate facets. Importantly, we noted all of these concerns about the TAS in our article's discussion, appropriately reporting the limitations and pointing to alterative interpretations, including the recommendation that future studies assess alexithymia using observer-rated measures or structured interviews. But our larger goal was to review and meta-analyse the literature as it currently exists, despite its measurement limitations. Veirman et al. (2023) remind us to be mindful of the fact that validity of a measure may vary across populations and contexts, that we should be cautious when using the TAS in people with medical conditions and that some of its items might better reflect constructs other than alexithymia. We generally agree with these concerns, although we find it ironic that they justify these points by referring to their own research (Veirman et al., 2021), which was conducted on a small sample of healthy college students, not people with pain or health problems, which was the focus of our review. Nonetheless, it is noteworthy that Veirman et al. (2021) found support for the validity of two facets of the TAS (difficulty identifying feeling and difficulty describing feelings) in their sample of students. We also agree with the need for caution regarding the interpretation of the observed cross-sectional associations as indicating that alexithymia is a risk factor for FM, and we noted in our discussion that there are alternative interpretations (third-variable and reverse causality). We agree that prospective studies are desirable, and there exist prospective studies that support the view that various emotionally salient problems or emotionally dysregulating events predict later widespread pain and FM. More generally, there is evidence for the role of traumatic events, post-traumatic stress disorder and other emotion dysregulations as contributing to FM and related centralized problems. We consider alexithymia to be one common manifestation of emotional dysregulation; thus, although prospective research on alexithymia per se as a risk for FM may be lacking, there is substantial research on related processes. Furthermore, there are several valuable integrative models of the development of FM, and disturbed emotional processes such as alexithymia play a role in such models—albeit certainly not the only role (Pinto et al., 2023). Yet, even prospective studies are limited. Not only are they difficult to conduct well and require years to complete, but they remain correlational and susceptible to uncontrolled variables, competing constructs and complex iterative processes. Prospective studies commonly yield continued questions and debate, which can lead to the usual recommendation of ‘more research is needed’. Rather than waiting for decades for a sufficient number of prospective studies of alexithymia and FM to be conducted, we recommend another approach to test possible causality of a risk factor for a health problem: one can experimentally reduce or eliminate the risk factor and determine the effects on the health problem. Indeed, our recommendation for using emotion-focused therapies for FM follows this logic. It also has the advantage of actually trying to help people with FM now, rather than wait for the slow accretion of supportive correlational evidence before (possibly) intervening. Intervention research can and should be conducted both to test hypotheses and help people in need—sooner rather than later. Finally, we challenge the authors' core thesis: ‘Extraordinary claims require extraordinary evidence’. Did we make an ‘extraordinary claim’? Such a charge would fit if we claimed the validity of supernatural cures, extrasensory perception or alien abduction. Few scholars, however, find ‘extraordinary’ the claim that problematic emotional processes, often stemming from difficult developmental experiences, contribute to many cases of FM and related centralized problems, and research should test interventions to address these problems. All authors declare no conflict of interest.

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