Alexithymia, intolerance to uncertainty and mental health difficulties in adolescents with Type 1 diabetes mellitus

The literature suggests that various psychological and mental health variables impact complex medical conditions [1‐6]. Among the relevant studies in this field, some authors focus in particular on the role of psychological variables in the field of medicine. In particular, Fava and colleagues [1] suggest how the manuals and guidelines that refer to the conditions that have emerged as influenced by psychological functioning should include dedicated spaces. Specifically, in line with the studies of Levenson and Linton [2, 3], there is a need for assessment and treatment of psychological factors that interfere with clinical practice, worsening the patients’ quality of life and the conditions from which they suffer.

Some studies focus in particular on specific pathological domains, such as the cardiovascular one [4], others consider a broader field in which various systems are interfered by mental health difficulties and factors known as psychosomatic [5]. With reference to this last point, it seems clear that studies in the literature highlight the multiplicity of systems affected and the consequences due to these phenomena. The extension of this knowledge concerns an ever-increasing number of pathologies, including type 1 and 2 diabetes mellitus (T1DM and T2DM), whose understanding in terms of psychological manifestations and role is particularly relevant [7‐19].

In particular, recent studies have highlighted important factors related to children and adolescents suffering from Type 1 Diabetes, highlighting important associations between glycaemic control, sociodemographic status and psychological conditions, as well as in relation to relations with primary Figs. (7,8). In particular, Andrade and colleagues [7] highlight a negative association between psychological suffering and the management of diabetes (studied through glycated haemoglobin as a fundamental reference variable). Similarly, Barone and colleagues [8] highlight the need to intervene with respect to primary relationships and attachment figures, particularly in adolescence.

It is understandable how these phenomena can interfere with glycaemic control, as the need for control in T1DM over glycaemia is fundamental. Some studies have focused on sociodemographic [7] and relational variables [8], highlighting that low years of education and so-called ‘dysfunctional’ primary relationships decrease the chances of compliance with T1DM treatment. Adolescence, in particular, is characterized by significant variations in terms of development [9‐11], which may impact the management of diabetes; thus, a distinction between the paediatric and adult population is necessary. A particularly interesting study by van Duinkerken and colleagues [20] illustrates that the impact of socio-demographic differences, such as working life, parenting, couple size and mature relationships, for adults, while in children the psychological difficulties experienced are more influenced by affective difficulties such as anxiety, depression and cognitive difficulties. It is important to consider, as suggested by van Duinkerken, that the number of studies conducted in adults is consistently lower than those dedicated to developing-age participants, given the age at which diagnosis is usually set for type 1 diabetes. It is known that variables such as development and psychological maturation processes can interfere on the awareness of illness, on the cognition of the necessary diagnostic and pharmacological procedures, as well as on adherence to treatments [12‐15]. Fisher and colleagues [9] have long identified that there are significant psychological difficulties for people suffering from diabetes mellitus. The authors compared populations of adults and participants of developing age, specifying that it was particularly important to focus attention on stressors, particularly accidents, on the management of pathology. Furthermore, Greydanus et al. [10] specified how it was particularly important to be able to realize which variables influenced the management of the pathology in order to avoid further outcomes and chronic diseases. These studies, dating back several years ago, already highlighted how psychological factors influenced patients’ experiences, to the point that further studies clarified how emotional stress constituted particular needs for these individuals [11].

In particular, psychological factors, which have also been suspected for a long time to impact physical health conditions, emerge as particularly important in glycaemic control management and treatment compliance/adherence [21‐28]. Some authors clearly specify psychological difficulties related to diabetes and how they constitute opportunities to reduce adherence to treatments, highlighting the factors primarily involved in the phenomenon and often unconscious matrix and therefore not accessible to the consciousness of the individuals [12, 13, 21]. Particularly interesting are those studies that focus instead on the role of psychological factors compared to onset diabetes [14, 16, 18, 19]. Several contributions specify etiological dynamics that would stimulate the pathophysiology of diabetes. These studies identify in the affective, socio-relational and often unconscious dynamics underlying to stimulate the pathophysiology of the condition. Among the various phenomena involved in the management of therapies, illness denial, uncertainty, alexithymia and affective mental health difficulties insistent on the ideation of patients, appear more relevant than ever in clinical settings [29‐50].

Even if the growing number of studies indicate with increasing precision what the target phenomena are, there is an evident need to establish a comparison between studies and secondly to implement existing knowledge through new and more reliable clinical tools [20, 51‐58]. Based on the known literature, the application of the uncertainty intolerance (UI) model to type 1 diabetes, together with knowledge on alexithymia and the affective dynamics of the participants, would constitute an example of innovative research useful for the evaluation of these not fully conscious phenomena [59‐64]. Alexithymia has been shown to be present in many pathological conditions and represented in the general population [59, 65‐67]. In particular, it is known that this phenomenon is common in the general population, representing a variable diffused at different levels (dimensional approach). With particular reference to T1DM, it is known how this phenomenon can interfere with physical condition [68]. In particular, alexithymia has emerged in many important studies as present in participants affected by T1DM, involved in fundamental areas such as glycaemic control [69, 70], adherence to treatments and the aforementioned psychological and mental health difficulties dynamics [71‐73]. Similarly, intolerance to uncertainty can be considered as a common phenomenon for populations, but it can pose a threat to the health of participants when levels exceed an acceptable threshold. In particular, some studies related to T1DM have highlighted the role of intolerance to uncertainty. In a 2019 study, Perez and colleagues [74] highlight how intolerance to uncertainty can be a limit in the individual’s adaptation to existential conditions. The method used by the authors included 29 parents of participants suffering from Type 1 Diabetes, so the related experience was mediated by representations of parents. A recent review by Gibson and colleagues [75] suggests it is necessary to study in depth the role of the variable Uncertainty in participants affected by this condition. In addition to suggesting the absence of data consistent with the literature, the researchers also point out that the available data refer more to physical health outcomes such as hba1c in people with type 2 diabetes. Recently, thanks to an exploratory and differential study [64] it has been possible to highlight how people affected by Type 1 Diabetes in adolescence have high levels of Uncertainty, Alexithymia and mental health difficulties in accordance with the studies mentioned above. In particular, positive correlations emerged between alexithymia (well-studied in the literature for T1DM) and uncertainty. The correlations were positive to indicate the same direction taken by the phenomena. In addition, variables such as age and years of education turned out to take significant and negative directions with respect to alexithymia, demonstrating how the mentalization acquired with growth and years of education can represent important variables with respect to alexithymia. However, there were no significant relationships between age and years of education predictors and uncertainty variables. Other studies have shown that uncertainty often addresses the issue of chronicity, given the duration and temporality of the chronic condition [76] and also in this case we believe that the issue should be considered with reference to the degree of development of the participants. It is clear that the impact of the diagnosis and the prolonged psychological distress represented by the chronicity of the disease are for the subject occasion of the onset of other conditions. In the strict sense, Carpentier and colleagues [77] highlight how the issue can be a critical existential point in the life of participant to caregivers, such as to have to be treated and treated in order to limit the impact. In both cases alexithymia and intolerance to uncertainty represent common phenomena to the population, whose presence does not indicate pathology per se. In this sense, the assessment of these phenomena must be considered in dimensional terms and declined to any particular diagnoses that could constitute an impact. Recent research also emphasizes the impact of these diagnoses on family members and relatives, which is expressed differently relative to specific age groups [78], in childhood [79, 80], adolescence [81, 82] and adulthood [83‐88]. Gender is an important variable in terms of differential and presentation of the above variables compared to Type 1 Diabetes. In particular, some studies have referred to gender to clarify the role and dynamics of gender. Enzlin and colleagues [89] highlighted how women reported more depressive symptomatology than men and how significant gender differences were also found in psychological adjustment to diabetes. The authors make it clear that this variable is often neglected in literature and that there is a need to produce studies that clarify its role and scope. In most of the cases, in fact, it is suggested a greater propension for the female population in the onset of affective symptoms [90], variables considered essential in the management of diabetes. Other studies [91] suggest high overall levels of distress in people suffering from Type 1 Diabetes Mellitus, with particular reference to the female population. In detail, there was higher physician-related distress and lower regimen-related distress than males. The authors referred to the problem of a greater propensity of the female population to report the affective symptomatology [92], compared to the male population [93]. The fact that these data refer almost exclusively to adult populations reinforces the need to produce further data in order to understand the dynamics involved in adolescent and infant populations.

In this sense, the need to deepen the understanding in this area is evident. The suggested in-depth analysis would constitute an opportunity for the scientific structuring of targeted interventions supported by a comprehensive understanding of intrapsychic processes typical in this population.

Descriptive statistics (mean and standard deviation) are reported in Tables 1, 2, 3, 4 and 5.

The current article investigated the presence of mental health issues together with presence and role of alexithymia and uncertainty in participants suffering from T1DM. The data indicated the presence of depression, anxiety and somatic symptoms in participants with T1DM. This datum appears to be clinically concerning, considering the young age of participants involved in the study.

These phenomena appear to be in line with current studies [110, 111] as well as with recent systematic studies, meta-analyses and longitudinal studies [95, 112, 113]. In particular, anxiety and depression represent the main difficulties in adolescence [114, 115] associated with diabetes according to most recent reviews [116, 117]. Effectiveness of interventions showed its impact on these populations, encouraging their presence in the care domain [118].

In line with mental health difficulties associated with T1DM, alexithymia and uncertainty were associated with T1DM in the current sample. Starting with alexithymia, its presence was consistent in our participants (mostly borderline scores), confirming previous literature results [71, 119‐121].

Mental health difficulties and psychosomatic complications related to alexithymia are well known, such that its presence must be considered a consistent risk factor for the onset and course of the pathology (T1DM). Dermatological, respiratory, cardiovascular and gastrointestinal outcomes due to the presence of alexithymia are widely discussed in literature [71, 119‐124].

Results concerning the role of uncertainty in participants’ psychological functioning highlighted a clear role of alexithymia. The role of uncertainty appears to be less investigated than alexithymia with respect to physical disorders. With particular reference to diabetes, its role needs to be more extensively investigated due to a lack of knowledge in the current state of the art. Most studies reported uncertainty and alexithymia role in maladjustment, emotion processing and eating disorders [73, 125‐129].

In an article of particular interest, Lumely and colleagues [73] critically analysed the role of alexithymia with respect to physical pathologies. The hypothesis accepted and carried forward by the studies also reported that alexithymia is associated with what is called a tonic physiological hyperarousal, subsequent unhealthy behaviours and a biased perception of somatic sensations including symptoms. In this sense, it is interesting to note how the positive correlation emerged between alexithymia and intolerance to uncertainty represents important data in the understanding their physical outcomes.

It is clear from this study that alexithymia is a serious influence on illness behaviour. Given the field of interest, namely Type 1 Diabetes Mellitus, the variables that affect adherence to treatments are of primary interest. Understanding the complexity of the phenomena produces a level of knowledge useful for clinical intervention. The reference to eating disorders is therefore supported by the degree of co-morbidity that includes diabetes, where it is clear that alexithymia and affective disorders produce adverse outcomes in the management of conditions. Brown and colleagues [125] report on intolerance to uncertainty within eating disorder conditions, clarifying their role in producing a consistent vulnerability for participants. The same, through their systematic review and meta-analysis, find studies that confirm the positive correlation between intolerance to uncertainty and alexithymia [124, 130]. In addition, Larkin and colleagues [126] highlight the predictive role of intolerance to uncertainty compared to somatic symptoms in healthy and pathological participants. This predictive role, related to the maladaptive outcomes of alexithymia [127] produces a strong incidence in the psychological maladjustment of participants, requiring clinical attention and evidence-based data.

In our perspective, alexithymia represents a key point in the understanding of some relevant phenomena. Difficulties in mentalizing emotions and affective dynamics may lead to the onset of physical disorders, a proposition substantiated by current and past literature. Recent contributions in the literature confirm the role of alexithymia as a predictor, in several ways. Alexithymia appeared as a strong predictor of negative outcomes in the treatment of functional and chronic pathologies, in line with what Lumely suggested [73]. The phenomenon is also treated as a predictor of poor compliance and poor outcomes related to different pathologies [131‐134]. It is particularly involved in somatization processes, where the lack of processing of affective experiences is addressed to target organs. More concretely, the persistence of non-mentalized affective phenomena would produce changes in hormonal structures such as to invest target organs.

With direct reference to the neurobiological functioning linked to alexithymia, Meza-Concha and colleagues [135] recently published a clinical review purely based on the phenomenon of alexithymia. The results of the study confirmed the validity of the phenomenon also on the neurobiological level, through several studies that accurately framed phenomena of functional and structural alteration of different areas. In particular, alexithymia was previously linked to reduced interhemispheric brain connection.

In terms of what was defined as a traumatic perspective, the right prefrontal cortex and the network of predefined modes would undergo changes, first hypermetabolic (linked to dopaminergic dysregulation and glutamatergic) and then hypometabolic-dissociative (related to serotonergic and opioid dysregulation), resulting in distortion of interoceptive and emotional awareness, typical of alexithymia in its own sense.

The issue directly based on unconscious processing and traumatic experiences underlying alexithymia involves an early hypermetabolic state implying the activation of sympathetic nervous system through the start-up of neuroendocrine axis, based on corticotropin release factor, the increase in catecholaminergic and mineralocorticoid activity, to produce a dopaminergic and glutamatergic dysregulation [136]. The issue is closely linked to dissociative phenomena and experiences, as proposed by Schore [136] and colleagues, in this case it would not be dissociative phenomena in its own sense even if the pathways of neurobiological production of alterations would be similar. Other forms of study have analysed the role of mirror neurons [137, 138] in the theory of mind in the light of alexithymia, suggesting the continuity between some forms of autism and alexithymia compared to a deficient hemodynamic activity in some regions of mirror neurons system. Difficulties in recognizing and managing affective dynamics can be considered as a reflective phenomenon of alexithymia, where the impossibility to recognize emotions assume the same direction of intolerance to uncertainty. The positive correlations emerged support this common direction assumed by alexithymia and intolerance to uncertainty. In our experience the interpretation of this significant link should be linked to the shared basis by these two phenomena.

In phenomenological and dynamic terms, the absence of an object to which mental functioning is directed has been attributed to anguish. In a proper sense, anguish is defined as a feeling without an object, unlike anxiety that involves an object of anxiety. The reference matrix of alexithymia and intolerance to uncertainty would therefore lie in the absence of an object to be processed. This statement needs further clarification. The absence of the object towards which the operation is directed does not imply the non-existence of the same, as a failure to process and therefore the fact that the participant unable by alexithymia to process properly a coherent mental representation can only experience uncertainty. The absence of a specific object appears to be closer to anguish than to anxiety, whose distinction is clear in psychopathology and phenomenological studies concerning object-relations (114,139). Finally, in the light of these results, having acquired the presence of consistent mental health issues, alexithymia and intolerance to uncertainty in people with T1DM, a clear need for interventions emerges. Considering the data emerged and the confirmation of the hypotheses it was possible to realize the presence of intolerance to uncertainty, alexithymia and mental health difficulties. The necessary interventions should focus on the presence of these phenomena and their relationships. In particular, having emerged a consistent link between intolerance to uncertainty and alexithymia, it would be necessary to start psychotherapeutic programs useful for the treatment of phenomena themselves and their relationships. Given the close link between intolerance to uncertainty and alexithymia, interventions aimed at treating these variables are necessary. In line with the literature and therefore with the results of high-level studies, the predictive role of alexithymia must be taken into account. This requires intervention on the maladaptive variables, known for their role as well as predictive even inauspicious on biological treatments, compliance and the course of the main disease, as compared to the risk of occurrence of substantial mental health difficulties.

The current research paper entails some strengths and limitations. Starting with strengths, it represents research conducted through valid and well-known instruments investigating relevant dynamics. Studying psychological functioning of participants suffering from T1DM in a specific area, where a lack of knowledge of psychological issue is clear, represents a strength to be considered. Moreover, this first step would represent a scientific basis for the use of specific interventions based on solid psychodiagnostic evaluations. However, some limitations are present. First, the number of included participants is low; even if sufficiently represented, the population must be investigated widely and including other variables such as biochemical markers. Moreover, the absence of a control group represents a limitation for the study. Moreover, the reliance of self-report instruments introduces limitations to the study, due to a possible bias linked to inaccuracies in self-assessment. Subsequent research should take into account causal relations among the included variables, leading to the identification of predictors of negative outcomes. As a pilot study, the current manuscript represents a first step in psychological assessment of participants suffering from chronic diseases.

Investigating mental health difficulties in adolescents affected by T1DM represents a necessary step to avoid the onset and the maintenance of associate pathological issues. In these terms, this paper included a sufficient number of adolescents suffering from a chronic condition capable of serious consequences. The emergence of the above-mentioned psychopathological phenomena constitutes the first necessary step for structuring specific interventions involving people with T1DM. Through the use of valid psychological assessment instruments, some concerning issues emerged within the sample. Beyond mental health difficulties, alexithymia and intolerance to uncertainty appeared to be consistently represented. Considering the maladaptive nature of these phenomena, the first step consisted of assessing adolescents suffering from T1DM in order to detect the extent of phenomena and to highlight the need for interventions. Current clinical practices should integrate classical medical procedures with psychological interventions in order to circumvent further pathological exacerbations. In these terms, psychological assessment and interventions based on evidence can be integrated into care for people with T1DM.