Journal of education and health promotion · 2024
Алекситимия и привязанность к психическому здоровью людей с множественным склерозом: посредническая роль воспринимаемой социальной поддержки и одиночества.
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Doostdari Farnaz, Kianimoghadam Amir Sam, Arzpeyma Mahyar, Fatollahzadeh Saina, Zakibakhsh Mohammadi Nassim, Masjedi-Arani Abbas, Hajmanouchehri Reza
Аннотация
Множественный склероз и его прогрессивный релапсирующий характер для пациентов с НР сопряжены с трудностями и оказывают значительное воздействие на психическое здоровье людей с НР. Мы изучили прямое воздействие алекситимии и привязанности на психическое здоровье и косвенное воздействие привязанности, алекситимии, одиночества и воспринимаемой социальной поддержки на психическое здоровье людей с MS. МАТЕРИАЛЫ И МЕТОДЫ: Триста сорок пять диагностированных множественных склерозов (MS) были признаны приемлемыми для включения в исследование и отобраны через Иранскую ассоциацию MS. К числу таких мер относятся: шкала Алекситимии Торонто (TAS20), Приложенный стильный вопросник (ASQ), Общий вопросник по здравоохранению (GHQ28), Шкала социальной и эмоциональной одиночества для взрослых (SELSA-S) и Вопросник о социальной поддержке семьи и друзей (PSS-FA и PSS-F). Психическое здоровье пациентов MS анализировалось с помощью структурных уравнений (SEM), изучая, как алекситимия, привязанность, социальная поддержка и одиночество прямо или косвенно влияют на их психическое здоровье. Приемлемость модели к данным была проанализирована с использованием функции расхождения, разделенной на степени свободы (CMIN/DF), Normed Fit Index (NFI), Taker-Lewis Index (TLI), Сравнительный индекс Fit Index (CFI) и Corporate Square Profile of Approximation (RMSEA). Результаты: Результаты показали, что модель подходит хорошо. Кроме того, полученные результаты показывают, что 28% (R2 = 0,28) изменений в психическом здоровье объясняются с помощью прогнозов исследований. Алекситимия и привязанность непосредственно влияют на психическое здоровье. Стиль привязки косвенно влияет на социальную поддержку и одиночество, в то время как одиночество и поддержка семьи косвенно влияют на психическое здоровье пациентов с синдромом MS.ЗАКЛЮЧЕНИЕ: Результаты исследования позволяют получить ценную информацию об основных структурах, влияющих на психическое здоровье людей с НР. Одиночество и социальная поддержка являются важнейшими факторами, влияющими на психическое здоровье этих пациентов. В предстоящие времена медицинские работники должны уделять приоритетное внимание привязанности, алекситимии, социальной поддержке и одиночеству в своем медицинском и психологическом вмешательстве для лиц, у которых диагностирован множественный склероз.
Оригинал публикации
Alexithymia and attachment on mental health of people with multiple sclerosis: The mediating role of perceived social support and loneliness.
BACKGROUND: Multiple sclerosis and its progressive relapsing-remitting nature for MS patients is challenging and significantly affects the mental health of people with MS. We examined the direct effects of alexithymia and attachment on mental health and the indirect effect of attachment, alexithymia, loneliness, and perceived social support on the mental health of people with MS.
MATERIALS AND METHODS: Three hundred and forty-five diagnosed with multiple sclerosis (MS) were deemed eligible for inclusion in the study and selected through the Iranian MS Association. Measures included the Toronto Alexithymia Scale (TAS20), Attachment Style Questionnaire (ASQ), General Health Questionnaire (GHQ28), Social and Emotional Loneliness Scale for Adults (SELSA-S), and Perceived Social Support from Family and Friends Questionnaire (PSS-FA and PSS-F). The mental health of MS patients was analyzed using structural equation models (SEM), examining how alexithymia, attachment, social support, and loneliness, directly and indirectly, affect their mental health. The fit of the model to the data was analyzed using the discrepancy function divided by degrees of freedom (CMIN/DF), Normed Fit Index (NFI), Tucker-Lewis Index (TLI), Comparative Fit Index (CFI), and Root Mean Square Error of Approximation (RMSEA).
RESULTS: The results showed that the model fit was good. Furthermore, findings indicate that 28% (R2 = 0.28) of the mental health changes are explained via study predictors. Alexithymia and attachment directly affect mental health. Attachment style indirectly affects social support and loneliness, while loneliness and family support indirectly affect the mental health of MS patients.
CONCLUSION: The study findings provide valuable insights into the fundamental structures that influence the mental health of individuals with MS. Loneliness and social support are critical mediating factors that significantly impact the mental well-being of these patients. In the times ahead, healthcare professionals must prioritize attachment, alexithymia, social support, and loneliness in their medical and psychological interventions for individuals diagnosed with multiple sclerosis.
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Introduction
Multiple sclerosis (MS) is a progressive autoimmune disease with the loss of myelin sheaths on neurons and neurodegeneration.[ 1 ] It could be characterized by the spread of lesions or plaques throughout the brain and spinal cord, resulting in a wide range of physiological and cognitive symptoms.[ 2 ] Because of the variable distribution and unpredictable nature of these lesions, patients with MS may experience impairments in motor and neuropsychiatric function, visual perception, and cognitive processing.[ 3 ] MS affects approximately 2 million individuals worldwide, and in Iran, the prevalence of MS is estimated at 15–30 cases per 1000 people.[ 4 ] The onset of MS in early adulthood can be burdensome for patients and their families, and QOL is generally lower compared to the general population.[ 5 ] There is extensive literature on psychiatric disorders associated with multiple sclerosis, including a spectrum from mood disorders to abnormalities affecting cognition.[ 6 ] Since multiple sclerosis is a stressful situation, and stressors could be associated with the disease’s activity, the mental health of patients with multiple sclerosis should be a crucial issue.[ 7 ] We can define mental health as a state of existence involving biopsychosocial elements that help people’s mental condition and ability to operate in the environment.[ 8 ] Mental disorders lead to physical diseases, dysfunction, and multi-morbidity outcomes.[ 9 ] Mental illness in patients with MS has a crucial effect on their quality of life; one of these mental conditions is alexithymia.[ 10 ]
Alexithymia is a personality trait that could be identified by having trouble recognizing and specifying emotions and extraversion in thinking style.[ 11 ] Also, it includes having a problem with mentalization and empathy, which could lead to problems with having proper social interaction and mental health or medical issues.[ 12 13 ] Some studies have shown that the prevalence of alexithymia in MS patients is not significantly different from the non-MS population. However, alexithymic MS patients have a higher level of fatigue, negative affect, anxiety, and depression than non-alexithymic patients.[ 14 ] Other studies showed that patients with MS are more alexithymic than the non-MS population and could not correctly identify emotions like happiness, sadness, anger, and fear.[ 15 ] Interpersonal difficulties associated with alexithymia can be reflected in underlying attachment issues, and during the stage of adulthood, alexithymic individuals exhibit an insecure attachment approach that hinders the establishment and sustenance of intimate relationships with others. Individuals with elevated levels of alexithymia may be limited in their ability to access or utilize social support resources to manage and navigate experiences of emotional distress effectively.[ 16 ]
Attachment in adults is a permanent desire to seek and build a connection with particular persons to find some physical and psychological safety.[ 17 18 ] A secure attachment style can indicate decreasing suicidal ideation and attempt and any anxiety disorder; in contrast, an insecure attachment style (avoidant and anxiety) could predict many mental problems.[ 19 ] The study by Besharat et al . showed that attachment style is one of the most crucial parameters in acceptance and coping with an illness, and MS patients have a more insecure attachment style than healthy populations.[ 20 ]
It has been evident that loneliness has a clear role in well-being and mental health. Loneliness is a recognized lack of social relations; studies have shown its connection to alexithymia and attachment.[ 21 22 ] We can divide loneliness into two main classes: emotional loneliness (lack of attachment and close relationships) and social loneliness (an outcome of the absence of social reassurance and a reaction to social deficiencies).[ 23 ] Emotional loneliness is linked to attachment quality, and social loneliness is connected to social integration. There is a significant relationship between insecure attachment style, lack of closeness in relationships, and perceived loneliness.[ 23 ] Also, evidence has shown that alexithymia is linked to a higher level of perceived loneliness.[ 24 ] We can see in many studies that MS is connected to higher levels of loneliness; also, women with MS report loneliness much more than men with MS.[ 25 ] Loneliness significantly affects people with MS, leading to increased levels of depression and anxiety, impairment of daily functioning, including lack of energy and fatigue, and decreased mental health and overall quality of life.[ 26 ]
Studies define social support as the social relationships in one network and the supportive resources that come with them.[ 27 ] Social support has many sources like partners, friends, and family.[ 27 ] Family support is the social support that someone could feel from their familial environment, and research has shown that alexithymia patients have problem profiting from it.[ 28 ] Attachment is believed to affect one’s understanding of social support. When contrasted with individuals who have secure attachments, insecurely attached people are less inclined to view others as capable of offering help when required.[ 29 ] Family and social support have an undeniable role in mental health and providing social support for coping with stresses in patients with MS.[ 30 ]
This research aims to explore a broader framework regarding the mental health of patients with MS. Based on psychiatric studies conducted on the mental health of people with MS, there is a wide range from diverse problems of mood and affect to a particular profile of cognitive impairment that affects the mental health of patients with MS. However, there is a need for more research to understand factors that can influence MS patients’ mental health.[ 6 31 ] Thus, we conducted this research to examine the direct and indirect effects of alexithymia, attachment, social support, and loneliness on the mental health of MS patients [see Figure 1 ]. These variables can influence the potential for intervention and improvement in treatment methods, ultimately leading to improved mental health in people with MS. The present study employed structural equation modeling (SEM) to effectively model the underlying variables and enable the examination of both direct and indirect effects on mental health.
Graphical model of research
Materials and Methods
Study design and setting
The present research is a cross-sectional study conducted in 2022–2023 to examine the role of alexithymia, attachment, social support, and loneliness on the mental health of people with multiple sclerosis.
Participants and sampling
Our study utilized G Power 3.1.9.2 software to estimate the appropriate sample size. Based on effect size (0.02), power (0.80), predictor variables (4), and alpha (0.5), the software suggested a sample size of 311 individuals. However, to mitigate the effects of missing data, we decided to consider a sample size of 345 individuals. Three hundred and forty-five individuals who received a definitive diagnosis of multiple sclerosis were selected for the analysis through the Iranian MS Association. Considering the large sample size, the convenience sampling method was used for easier access and to save time and cost. This study’s inclusion criteria are that participants meet the following prerequisites: (1) being above the age of 18, (2) possessing basic reading and comprehension skills, and (3) exhibiting the physical, cognitive, and mental ability to sign the consent form. The criteria for exclusion were as follows: (1) a history of alcohol and drug abuse, (2) a diagnosis of any chronic disease apart from multiple sclerosis, and (3) a history of major psychiatric disorders distinct from major depressive episodes. After obtaining permission to recruit participants from Iran’s MS Association, the purpose of the research, confidentiality of information, and ethical considerations were explained to all participants. After that, the questionnaire link was shared with them. They gave their written informed consent and then completed a questionnaire containing socio-demographic responses that were saved anonymously on the server and downloaded for analysis.
Study tools
The instruments used in the present research included a demographic characteristics questionnaire, General Health Questionnaire, Adult Attachment Inventory, Perceived Social Support from Family and Friends questionnaire, Toronto Alexithymia Scale-20, and Social and Emotional Loneliness scale.
Demographics characteristics questionnaire
Demographic characteristics include data about patient age, sex, marital status, education status, employment status, and MS stage.
Mental health
The mental health of participants was assessed through the GHQ-28. The questionnaire consists of 28 items rated on a 4-point Likert scale. Four different subscales are used to measure a person’s mental health: their levels of anxiety and insomnia, social dysfunction, somatic complaints, and depression. The subscale scores range from 0 to 21.[ 32 ] The Persian version of GHQ-28 has acceptable validity (Cronbach’s alpha, somatic complaints = 0.88, anxiety = 0.90, social dysfunction = 0.87, major depression = 0.94, total psychopathology index = 0.97).[ 33 ]
Attachment styles
To assess attachment styles, the Adult Attachment Inventory (AAI) was employed, which is based on Hazan and Shaver’s (1987) attachment style.[ 34 ] The inventory includes 15 items, categorized into three types: secure, avoidant, and ambivalent/anxious attachments. Each item is rated on a 5-point Likert scale, ranging from very low (1) to very high (5). Cores for each subscale vary from 5 to 25. The Persian version of the Adult Attachment Inventory exhibits good internal consistency for all three attachment styles – secure, avoidant, and ambivalent/anxious – with Cronbach’s alpha values of 0. 91, 0.87, and 0.90.[ 35 ]
Social support
The Perceived Social Support was assessed with the Perceived Social Support from Family and Friends questionnaire (PSS-FA and PSS-F). The inventory consists of 40 items and assesses the level of support received in terms of quality and quantity from family and friends. Participants are required to respond to these questions by choosing either “Yes,” “No,” or “Don’t know.” The Cornbrash’s alpha for (PSS-Fr) and (PSS-Fa) stands at 0.88 and 090, respectively.[ 36 ] For the sample of this research, the Cornbrash’s alpha was good (Cronbach’s alpha = 0.89).
Alexithymia
The presence of alexithymia was assessed using the Toronto Alexithymia Scale-20 (TAS-20). This includes four points, three for different aspects, namely, Difficulty Identifying Feelings (DIF), Difficulty Describing Feelings (DDF), Externally Oriented Thinking (EOT), and a total score for alexithymia. The TAS consists of 20 items, and each item is scored on a 5-point Likert scale ranging from 1 (strongly disagree) to 5 (strongly agree).[ 37 38 ] The Persian version of the TAS-20 exhibits good validity. The Cronbach’s alpha for TAS-20, DIF, DDF, and EOT was 0.85, 0.82, 0.75, and.72 for the total sample.[ 39 ]
Loneliness
The degree of loneliness was assessed using the short version of the Social and Emotional Loneliness Scale (SELSA_S).[ 40 ] It comprises 15 items, and the three subscales, romantic, family, and social loneliness rated on a 7-point Likert scale (1= strongly disagree; 7= strongly agree). The Persian version of SELSA_S has acceptable validity; Cronbach’s alpha for romantic, social, and family loneliness was 0.92, 0.84, and 0.78, respectively.[ 41 ]
Ethical consideration
This study was performed in line with the principles of the Declaration of Helsinki, and the study undertaken investigated has received approval from the Research Ethics Committees of the Shahid Beheshti University of Medical Science under reference number IR.SBMU.RETECH.REC.1400.504. Before starting the study, the purpose of the research, confidentiality of information, and ethical considerations were explained to all participants, and they gave their written informed consent.
Statistical analysis
We used SPSS version 24 and AMOS 22 for Windows to analyze data and test the research hypothesis. Descriptive statistics were used to summarize the data and assess normality. The normality of the data distribution was evaluated using the Kolmogorov–Smirnov test. The value of skewness and kurtosis ranges from +1 to -1 for all research variables. Therefore, the normality of the data was confirmed (see [ Table 1 ]). Also, the convenience sampling method has been used to conduct this study. Pearson’s correlation coefficient was used to investigate the relationship between variables. The fitness of the constructed model was assessed using fit statistics derived from structural equation modeling (SEM) analysis. During this process, we used the Normed Fit Index (NFI >0.95; Bentler and Bonett, 1980), discrepancy function divided by degrees of freedom (CMIN/DF >5; Marsh and Hocevar, 1985), Tucker–Lewis Index (TLI >0.9; Bentler and Bonett 1980), Comparative Fit Index (CFI >0.95; Hu, L. T., and Bentler; Wes t et al ., 2012), and Root Mean Square Error of Approximation (RMSEA <0.08; Hooper, D., Coughlan, J., and Mullen, M. R. 2008)
Table 1 Variable means, standard deviations, and normality ( n =345) Variable M SD Minimum Maximum Skewness Kurtosis Attachment Alexithymia Social support Loneliness Mental health 43.20 63.23 26.94 34.43 32.43 6.31 10.06 9.15 10.70 15.70 29 33 0 14 2 66 91 40 70 83 0.47 -0.10 -0.29 0.57 0.60 0.13 -0.12 -0.86 0.15 -0.09
Variable means, standard deviations, and normality ( n =345)
Results
Sociodemographic and clinical characteristics
Three hundred and forty-five patients with MS met the inclusion criteria. Information about the participants can be seen in Table 2 .
Table 2 Sociodemographic and clinical characteristics of patients with MS ( n =345) n =345 Demographic data Age 18-36 37-57 201 (58.62%) 144 (41.74%) Sex Female Male 276 (80%) 69 (20%) Marital status Single Married 156 (45.2%) 189 (54.8%) Education level Undergraduate 3 (0.9%) Diploma 102 (29.6%) Associated 32 (9.3%) Bachelor 143 (41.4%) Master 53 (15.4%) Philosophy doctorate 11 (3.2%) Professional doctorate 1 (0.3%) Employment status Employed Unemployed 150 (43.5%) 195 (56.5%) Clinical data MS. Stages (CIS) (RRMS) (SPMS) (PPMS) Unknown 13 (3.8%) 141 (40.9%) 24 (7%) 12 (3.5%) 155 (44.9)
Sociodemographic and clinical characteristics of patients with MS ( n =345)
SEM analysis
First, correlations between variables were examined (see [ Figure 2 ]). The results fit indices related to the initial research model showed that these indicators are not within the acceptable range. The Root Mean Square Error of Approximation (RMSEA) is 0.35 (RMSEA <0.08), the Comparative Fit Index (CFI) is 0.83 (CFI >0.95), the Normed Fit Index (NFI) is 0.83 (NFI >0.95), and the Tucker–Lewis index (TLI) is 0.41 (TLI >0.9). The minimum discrepancy function divided by degrees of freedom (CMIN/Df) is 43.32 (CMIN/Df <5). The initial model was modified to achieve excellent fit indices. The Root Mean Square Error of Approximation (RMSEA) is 0.07, the Comparative Fit Index (CFI) is 0.98, the Normed Fit Index (NFI) is 0.98, the Tucker–Lewis index (TLI) is 0.95, and the minimum discrepancy function divided by degrees of freedom (CMIN/Df) is 3.13. We can conclude that the modified model has appropriate fit indices, and it is possible to test the research hypotheses.
Pearson’s correlation coefficients of research variables
Direct effects
SEM provided the direct effects of predictor variables on mental health, including attachment and alexithymia. This analysis indicated that attachment has significant direct effects on mental health (β =0.58, P < .001), and alexithymia has significant direct effects on mental health (β =0.48, P < .001).
Indirect effects
SEM provided the indirect effects of predictor variables on mental health, including attachment, alexithymia, loneliness, and social support. This analysis indicated that attachment significantly indirectly affects social support (β = -0.43, P < .001). Social support has a significant indirect effect on mental health (β = -0.35, P < .05). Loneliness has a significant indirect effect on mental health (β =0.32, P < .05), and attachment has a significant indirect effect on loneliness (β =0.63, P < .001).
Total effects
SEM provided the total effects of predictor variables, including attachment, alexithymia, loneliness, and social support. This analysis indicated that attachment has significant effects on mental health (β = 0.36, P < .001), alexithymia has significant effects on mental health (β = 0.45, P < .001), attachment significantly affects social support (β = -0.44, P < .001), social support has a significant effect on mental health (β = -0.21, P < .05), loneliness has a significant effect on mental health (β =0.23, P < .05), and attachment has a significant effect on loneliness (β = 0.64, P < .001). The graphical result of the total effect is shown in Figure 3 .
Graphical results of the total effects
By carefully examining the data, it is found that the results support our hypothesis that attachment and alexithymia directly affect mental health in people with MS. Furthermore, the results support our hypothesis about the indirect effect model variables such as alexithymia’s indirect effect on loneliness and social support. Also, social support and loneliness indirectly affect mental health.
In the general model, 28% (R 2 =0.28) of the mental health changes are explained via the predictor variable (attachment, alexithymia, loneliness, and social support). Hence, the research model for predicting mental health by predictor variables is small.[ 42 ]
Discussion
According to what we saw in the result, 28% of the mental health changes are explained via predictor variables (attachment, alexithymia, loneliness, and social support). Studying the variables that affect mental health is crucial, given the high prevalence of mental disorders in patients with multiple sclerosis. Our study indicates that various variables, such as attachment style, social support, loneliness, and alexithymia, affect the mental health of MS patients. Alexithymia and attachment directly affect mental health. Attachment style indirectly affects social support and loneliness, while loneliness and family support indirectly affect the mental health of MS patients.
The two dimensions of attachment are anxiety and avoidance. The avoidance dimension leads to dismissing the importance of interpersonal relationships and emotional distance from relationships.[ 43 ] Attachment plays a significant role in social perception, one of the most important predictors of loneliness.[ 44 45 ] On the other hand, the anxious dimension is related to loneliness through the mediating role of self-esteem or social support.[ 22 46 ] Our study’s findings align with previous research that highlighted the role of attachment in explaining how family support can influence well-being.[ 47 ] Furthermore, our results are consistent with another study that indicated attachment style as a predictor of family support.[ 48 ] These findings suggest a robust relationship between attachment style and the dynamics of family support in influencing individual well-being.
It is worth noting that different attachment types can lead to different mental health problems. Avoidant and ambivalent/resistant attachments can lead to externalizing and internalizing problems, respectively.[ 49 ] Additionally, attachment style is related to mental health through the mediating role of self-esteem and mattering.[ 50 ] Moreover, loneliness can predict mental health, and, notably, the report of chronic diseases such as MS is elevated in lonely people.[ 51 52 ] Loneliness is associated with greater internalizing and externalizing problems, which lower mental health.[ 53 54 55 ]
Previous studies have indicated that social support from family members is significantly associated with mental health through resilience in patients with MS.[ 56 ] Perceived social support from family and friends explained 24% of the variance in mental health of MS patients.[ 57 ] A previous study also indicated that family support is related to loneliness, which can affect mental health disorders through the mediating role of loneliness.[ 58 ]
Alexithymia manifests as a complex set of personality traits, with a prevalence range of approximately 10–53% in individuals diagnosed with MS.[ 12 ] Alexithymia patients exhibited considerably slower, greater levels of depression and fatigue compared to non-alexithymia patients.[ 14 ] In the explanation of the previous sentence, we can say brain structure plays a crucial role in slowing down information and processing speed, causing fatigue and depression.[ 59 ] Christopoulos, Poulios, and Pavlopoulos (2020) showed that there is a relationship between alexithymia and mental health problems in MS patients.[ 60 ] Our study is in line with previous research, which showed that the mental health of alexithymic MS patients stems from their tendency toward alexithymia and their inclination to experience anhedonia and negative affect.[ 61 ]
Furthermore, research could explore the biological mechanisms underlying the observed associations between these psychosocial variables and mental health outcomes in MS patients. For example, studies have suggested that stress-related physical responses, such as different cortisol levels, are associated with developing mental health disorders in individuals with MS.[ 62 ] Future studies could investigate the role of these biological mechanisms in the relationship between psychosocial variables and mental health outcomes in MS patients.
Strengths and limitation
When interpreting the results, it is essential to consider a number of limitations in this study. First, self-report measures have the potential to incur inherent biases, namely, social desirability and recall bias; these tendencies can impede the accuracy of the result. Second, the cross-sectional design provides a snapshot of variables at a specific point in time. Future research should use a longitudinal study. Additionally, the survey was administered electronically, signifying that patients with MS who contend with pronounced fatigue or attentional deficits and have experienced motor or visual impairments might have encountered impediments to their participation; despite these limitations, this analysis is supported by the large sample size and wide age range, showing good generalizability of these results. The present study is one of the first to use structural equation models, allowing both direct and indirect pathways to be tested, the role of attachment, alexithymia, social support, and loneliness on mental health. Enhanced comprehension of the underlying factors contributing to mental health can augment clinical interventions to improve the condition of people with MS.
Conclusion
The findings of this study provided evidence for the complex interplay of various psychosocial variables and their impact on the mental health of patients with MS. The results suggested that attachment style, social support, loneliness, and alexithymia are all critical factors that directly and indirectly affect the mental health of MS patients. The attachment played a significant role in determining the level of social support and loneliness, which impacted the mental health of MS patients. In summary, findings of this study are essential in creating strategies to enhance the mental health of individuals with MS. Clinicians and healthcare providers should consider the impact of attachment style, social support, loneliness, and alexithymia when developing treatment plans for MS patients and should focus on promoting social support and resilience as critical components of these interventions.
Conflict of interest
There are no conflicts of interest.
Multiple sclerosis (MS) is a progressive autoimmune disease with the loss of myelin sheaths on neurons and neurodegeneration.[ 1 ] It could be characterized by the spread of lesions or plaques throughout the brain and spinal cord, resulting in a wide range of physiological and cognitive symptoms.[ 2 ] Because of the variable distribution and unpredictable nature of these lesions, patients with MS may experience impairments in motor and neuropsychiatric function, visual perception, and cognitive processing.[ 3 ] MS affects approximately 2 million individuals worldwide, and in Iran, the prevalence of MS is estimated at 15–30 cases per 1000 people.[ 4 ] The onset of MS in early adulthood can be burdensome for patients and their families, and QOL is generally lower compared to the general population.[ 5 ] There is extensive literature on psychiatric disorders associated with multiple sclerosis, including a spectrum from mood disorders to abnormalities affecting cognition.[ 6 ] Since multiple sclerosis is a stressful situation, and stressors could be associated with the disease’s activity, the mental health of patients with multiple sclerosis should be a crucial issue.[ 7 ] We can define mental health as a state of existence involving biopsychosocial elements that help people’s mental condition and ability to operate in the environment.[ 8 ] Mental disorders lead to physical diseases, dysfunction, and multi-morbidity outcomes.[ 9 ] Mental illness in patients with MS has a crucial effect on their quality of life; one of these mental conditions is alexithymia.[ 10 ]
Alexithymia is a personality trait that could be identified by having trouble recognizing and specifying emotions and extraversion in thinking style.[ 11 ] Also, it includes having a problem with mentalization and empathy, which could lead to problems with having proper social interaction and mental health or medical issues.[ 12 13 ] Some studies have shown that the prevalence of alexithymia in MS patients is not significantly different from the non-MS population. However, alexithymic MS patients have a higher level of fatigue, negative affect, anxiety, and depression than non-alexithymic patients.[ 14 ] Other studies showed that patients with MS are more alexithymic than the non-MS population and could not correctly identify emotions like happiness, sadness, anger, and fear.[ 15 ] Interpersonal difficulties associated with alexithymia can be reflected in underlying attachment issues, and during the stage of adulthood, alexithymic individuals exhibit an insecure attachment approach that hinders the establishment and sustenance of intimate relationships with others. Individuals with elevated levels of alexithymia may be limited in their ability to access or utilize social support resources to manage and navigate experiences of emotional distress effectively.[ 16 ]
Attachment in adults is a permanent desire to seek and build a connection with particular persons to find some physical and psychological safety.[ 17 18 ] A secure attachment style can indicate decreasing suicidal ideation and attempt and any anxiety disorder; in contrast, an insecure attachment style (avoidant and anxiety) could predict many mental problems.[ 19 ] The study by Besharat et al . showed that attachment style is one of the most crucial parameters in acceptance and coping with an illness, and MS patients have a more insecure attachment style than healthy populations.[ 20 ]
It has been evident that loneliness has a clear role in well-being and mental health. Loneliness is a recognized lack of social relations; studies have shown its connection to alexithymia and attachment.[ 21 22 ] We can divide loneliness into two main classes: emotional loneliness (lack of attachment and close relationships) and social loneliness (an outcome of the absence of social reassurance and a reaction to social deficiencies).[ 23 ] Emotional loneliness is linked to attachment quality, and social loneliness is connected to social integration. There is a significant relationship between insecure attachment style, lack of closeness in relationships, and perceived loneliness.[ 23 ] Also, evidence has shown that alexithymia is linked to a higher level of perceived loneliness.[ 24 ] We can see in many studies that MS is connected to higher levels of loneliness; also, women with MS report loneliness much more than men with MS.[ 25 ] Loneliness significantly affects people with MS, leading to increased levels of depression and anxiety, impairment of daily functioning, including lack of energy and fatigue, and decreased mental health and overall quality of life.[ 26 ]
Studies define social support as the social relationships in one network and the supportive resources that come with them.[ 27 ] Social support has many sources like partners, friends, and family.[ 27 ] Family support is the social support that someone could feel from their familial environment, and research has shown that alexithymia patients have problem profiting from it.[ 28 ] Attachment is believed to affect one’s understanding of social support. When contrasted with individuals who have secure attachments, insecurely attached people are less inclined to view others as capable of offering help when required.[ 29 ] Family and social support have an undeniable role in mental health and providing social support for coping with stresses in patients with MS.[ 30 ]
This research aims to explore a broader framework regarding the mental health of patients with MS. Based on psychiatric studies conducted on the mental health of people with MS, there is a wide range from diverse problems of mood and affect to a particular profile of cognitive impairment that affects the mental health of patients with MS. However, there is a need for more research to understand factors that can influence MS patients’ mental health.[ 6 31 ] Thus, we conducted this research to examine the direct and indirect effects of alexithymia, attachment, social support, and loneliness on the mental health of MS patients [see Figure 1 ]. These variables can influence the potential for intervention and improvement in treatment methods, ultimately leading to improved mental health in people with MS. The present study employed structural equation modeling (SEM) to effectively model the underlying variables and enable the examination of both direct and indirect effects on mental health.
Graphical model of research
Materials and Methods
Study design and setting
The present research is a cross-sectional study conducted in 2022–2023 to examine the role of alexithymia, attachment, social support, and loneliness on the mental health of people with multiple sclerosis.
Participants and sampling
Our study utilized G Power 3.1.9.2 software to estimate the appropriate sample size. Based on effect size (0.02), power (0.80), predictor variables (4), and alpha (0.5), the software suggested a sample size of 311 individuals. However, to mitigate the effects of missing data, we decided to consider a sample size of 345 individuals. Three hundred and forty-five individuals who received a definitive diagnosis of multiple sclerosis were selected for the analysis through the Iranian MS Association. Considering the large sample size, the convenience sampling method was used for easier access and to save time and cost. This study’s inclusion criteria are that participants meet the following prerequisites: (1) being above the age of 18, (2) possessing basic reading and comprehension skills, and (3) exhibiting the physical, cognitive, and mental ability to sign the consent form. The criteria for exclusion were as follows: (1) a history of alcohol and drug abuse, (2) a diagnosis of any chronic disease apart from multiple sclerosis, and (3) a history of major psychiatric disorders distinct from major depressive episodes. After obtaining permission to recruit participants from Iran’s MS Association, the purpose of the research, confidentiality of information, and ethical considerations were explained to all participants. After that, the questionnaire link was shared with them. They gave their written informed consent and then completed a questionnaire containing socio-demographic responses that were saved anonymously on the server and downloaded for analysis.
Study tools
The instruments used in the present research included a demographic characteristics questionnaire, General Health Questionnaire, Adult Attachment Inventory, Perceived Social Support from Family and Friends questionnaire, Toronto Alexithymia Scale-20, and Social and Emotional Loneliness scale.
Demographics characteristics questionnaire
Demographic characteristics include data about patient age, sex, marital status, education status, employment status, and MS stage.
Mental health
The mental health of participants was assessed through the GHQ-28. The questionnaire consists of 28 items rated on a 4-point Likert scale. Four different subscales are used to measure a person’s mental health: their levels of anxiety and insomnia, social dysfunction, somatic complaints, and depression. The subscale scores range from 0 to 21.[ 32 ] The Persian version of GHQ-28 has acceptable validity (Cronbach’s alpha, somatic complaints = 0.88, anxiety = 0.90, social dysfunction = 0.87, major depression = 0.94, total psychopathology index = 0.97).[ 33 ]
Attachment styles
To assess attachment styles, the Adult Attachment Inventory (AAI) was employed, which is based on Hazan and Shaver’s (1987) attachment style.[ 34 ] The inventory includes 15 items, categorized into three types: secure, avoidant, and ambivalent/anxious attachments. Each item is rated on a 5-point Likert scale, ranging from very low (1) to very high (5). Cores for each subscale vary from 5 to 25. The Persian version of the Adult Attachment Inventory exhibits good internal consistency for all three attachment styles – secure, avoidant, and ambivalent/anxious – with Cronbach’s alpha values of 0. 91, 0.87, and 0.90.[ 35 ]
Social support
The Perceived Social Support was assessed with the Perceived Social Support from Family and Friends questionnaire (PSS-FA and PSS-F). The inventory consists of 40 items and assesses the level of support received in terms of quality and quantity from family and friends. Participants are required to respond to these questions by choosing either “Yes,” “No,” or “Don’t know.” The Cornbrash’s alpha for (PSS-Fr) and (PSS-Fa) stands at 0.88 and 090, respectively.[ 36 ] For the sample of this research, the Cornbrash’s alpha was good (Cronbach’s alpha = 0.89).
Alexithymia
The presence of alexithymia was assessed using the Toronto Alexithymia Scale-20 (TAS-20). This includes four points, three for different aspects, namely, Difficulty Identifying Feelings (DIF), Difficulty Describing Feelings (DDF), Externally Oriented Thinking (EOT), and a total score for alexithymia. The TAS consists of 20 items, and each item is scored on a 5-point Likert scale ranging from 1 (strongly disagree) to 5 (strongly agree).[ 37 38 ] The Persian version of the TAS-20 exhibits good validity. The Cronbach’s alpha for TAS-20, DIF, DDF, and EOT was 0.85, 0.82, 0.75, and.72 for the total sample.[ 39 ]
Loneliness
The degree of loneliness was assessed using the short version of the Social and Emotional Loneliness Scale (SELSA_S).[ 40 ] It comprises 15 items, and the three subscales, romantic, family, and social loneliness rated on a 7-point Likert scale (1= strongly disagree; 7= strongly agree). The Persian version of SELSA_S has acceptable validity; Cronbach’s alpha for romantic, social, and family loneliness was 0.92, 0.84, and 0.78, respectively.[ 41 ]
Ethical consideration
This study was performed in line with the principles of the Declaration of Helsinki, and the study undertaken investigated has received approval from the Research Ethics Committees of the Shahid Beheshti University of Medical Science under reference number IR.SBMU.RETECH.REC.1400.504. Before starting the study, the purpose of the research, confidentiality of information, and ethical considerations were explained to all participants, and they gave their written informed consent.
Statistical analysis
We used SPSS version 24 and AMOS 22 for Windows to analyze data and test the research hypothesis. Descriptive statistics were used to summarize the data and assess normality. The normality of the data distribution was evaluated using the Kolmogorov–Smirnov test. The value of skewness and kurtosis ranges from +1 to -1 for all research variables. Therefore, the normality of the data was confirmed (see [ Table 1 ]). Also, the convenience sampling method has been used to conduct this study. Pearson’s correlation coefficient was used to investigate the relationship between variables. The fitness of the constructed model was assessed using fit statistics derived from structural equation modeling (SEM) analysis. During this process, we used the Normed Fit Index (NFI >0.95; Bentler and Bonett, 1980), discrepancy function divided by degrees of freedom (CMIN/DF >5; Marsh and Hocevar, 1985), Tucker–Lewis Index (TLI >0.9; Bentler and Bonett 1980), Comparative Fit Index (CFI >0.95; Hu, L. T., and Bentler; Wes t et al ., 2012), and Root Mean Square Error of Approximation (RMSEA <0.08; Hooper, D., Coughlan, J., and Mullen, M. R. 2008)
Table 1 Variable means, standard deviations, and normality ( n =345) Variable M SD Minimum Maximum Skewness Kurtosis Attachment Alexithymia Social support Loneliness Mental health 43.20 63.23 26.94 34.43 32.43 6.31 10.06 9.15 10.70 15.70 29 33 0 14 2 66 91 40 70 83 0.47 -0.10 -0.29 0.57 0.60 0.13 -0.12 -0.86 0.15 -0.09
Variable means, standard deviations, and normality ( n =345)
Results
Sociodemographic and clinical characteristics
Three hundred and forty-five patients with MS met the inclusion criteria. Information about the participants can be seen in Table 2 .
Table 2 Sociodemographic and clinical characteristics of patients with MS ( n =345) n =345 Demographic data Age 18-36 37-57 201 (58.62%) 144 (41.74%) Sex Female Male 276 (80%) 69 (20%) Marital status Single Married 156 (45.2%) 189 (54.8%) Education level Undergraduate 3 (0.9%) Diploma 102 (29.6%) Associated 32 (9.3%) Bachelor 143 (41.4%) Master 53 (15.4%) Philosophy doctorate 11 (3.2%) Professional doctorate 1 (0.3%) Employment status Employed Unemployed 150 (43.5%) 195 (56.5%) Clinical data MS. Stages (CIS) (RRMS) (SPMS) (PPMS) Unknown 13 (3.8%) 141 (40.9%) 24 (7%) 12 (3.5%) 155 (44.9)
Sociodemographic and clinical characteristics of patients with MS ( n =345)
SEM analysis
First, correlations between variables were examined (see [ Figure 2 ]). The results fit indices related to the initial research model showed that these indicators are not within the acceptable range. The Root Mean Square Error of Approximation (RMSEA) is 0.35 (RMSEA <0.08), the Comparative Fit Index (CFI) is 0.83 (CFI >0.95), the Normed Fit Index (NFI) is 0.83 (NFI >0.95), and the Tucker–Lewis index (TLI) is 0.41 (TLI >0.9). The minimum discrepancy function divided by degrees of freedom (CMIN/Df) is 43.32 (CMIN/Df <5). The initial model was modified to achieve excellent fit indices. The Root Mean Square Error of Approximation (RMSEA) is 0.07, the Comparative Fit Index (CFI) is 0.98, the Normed Fit Index (NFI) is 0.98, the Tucker–Lewis index (TLI) is 0.95, and the minimum discrepancy function divided by degrees of freedom (CMIN/Df) is 3.13. We can conclude that the modified model has appropriate fit indices, and it is possible to test the research hypotheses.
Pearson’s correlation coefficients of research variables
Direct effects
SEM provided the direct effects of predictor variables on mental health, including attachment and alexithymia. This analysis indicated that attachment has significant direct effects on mental health (β =0.58, P < .001), and alexithymia has significant direct effects on mental health (β =0.48, P < .001).
Indirect effects
SEM provided the indirect effects of predictor variables on mental health, including attachment, alexithymia, loneliness, and social support. This analysis indicated that attachment significantly indirectly affects social support (β = -0.43, P < .001). Social support has a significant indirect effect on mental health (β = -0.35, P < .05). Loneliness has a significant indirect effect on mental health (β =0.32, P < .05), and attachment has a significant indirect effect on loneliness (β =0.63, P < .001).
Total effects
SEM provided the total effects of predictor variables, including attachment, alexithymia, loneliness, and social support. This analysis indicated that attachment has significant effects on mental health (β = 0.36, P < .001), alexithymia has significant effects on mental health (β = 0.45, P < .001), attachment significantly affects social support (β = -0.44, P < .001), social support has a significant effect on mental health (β = -0.21, P < .05), loneliness has a significant effect on mental health (β =0.23, P < .05), and attachment has a significant effect on loneliness (β = 0.64, P < .001). The graphical result of the total effect is shown in Figure 3 .
Graphical results of the total effects
By carefully examining the data, it is found that the results support our hypothesis that attachment and alexithymia directly affect mental health in people with MS. Furthermore, the results support our hypothesis about the indirect effect model variables such as alexithymia’s indirect effect on loneliness and social support. Also, social support and loneliness indirectly affect mental health.
In the general model, 28% (R 2 =0.28) of the mental health changes are explained via the predictor variable (attachment, alexithymia, loneliness, and social support). Hence, the research model for predicting mental health by predictor variables is small.[ 42 ]
Discussion
According to what we saw in the result, 28% of the mental health changes are explained via predictor variables (attachment, alexithymia, loneliness, and social support). Studying the variables that affect mental health is crucial, given the high prevalence of mental disorders in patients with multiple sclerosis. Our study indicates that various variables, such as attachment style, social support, loneliness, and alexithymia, affect the mental health of MS patients. Alexithymia and attachment directly affect mental health. Attachment style indirectly affects social support and loneliness, while loneliness and family support indirectly affect the mental health of MS patients.
The two dimensions of attachment are anxiety and avoidance. The avoidance dimension leads to dismissing the importance of interpersonal relationships and emotional distance from relationships.[ 43 ] Attachment plays a significant role in social perception, one of the most important predictors of loneliness.[ 44 45 ] On the other hand, the anxious dimension is related to loneliness through the mediating role of self-esteem or social support.[ 22 46 ] Our study’s findings align with previous research that highlighted the role of attachment in explaining how family support can influence well-being.[ 47 ] Furthermore, our results are consistent with another study that indicated attachment style as a predictor of family support.[ 48 ] These findings suggest a robust relationship between attachment style and the dynamics of family support in influencing individual well-being.
It is worth noting that different attachment types can lead to different mental health problems. Avoidant and ambivalent/resistant attachments can lead to externalizing and internalizing problems, respectively.[ 49 ] Additionally, attachment style is related to mental health through the mediating role of self-esteem and mattering.[ 50 ] Moreover, loneliness can predict mental health, and, notably, the report of chronic diseases such as MS is elevated in lonely people.[ 51 52 ] Loneliness is associated with greater internalizing and externalizing problems, which lower mental health.[ 53 54 55 ]
Previous studies have indicated that social support from family members is significantly associated with mental health through resilience in patients with MS.[ 56 ] Perceived social support from family and friends explained 24% of the variance in mental health of MS patients.[ 57 ] A previous study also indicated that family support is related to loneliness, which can affect mental health disorders through the mediating role of loneliness.[ 58 ]
Alexithymia manifests as a complex set of personality traits, with a prevalence range of approximately 10–53% in individuals diagnosed with MS.[ 12 ] Alexithymia patients exhibited considerably slower, greater levels of depression and fatigue compared to non-alexithymia patients.[ 14 ] In the explanation of the previous sentence, we can say brain structure plays a crucial role in slowing down information and processing speed, causing fatigue and depression.[ 59 ] Christopoulos, Poulios, and Pavlopoulos (2020) showed that there is a relationship between alexithymia and mental health problems in MS patients.[ 60 ] Our study is in line with previous research, which showed that the mental health of alexithymic MS patients stems from their tendency toward alexithymia and their inclination to experience anhedonia and negative affect.[ 61 ]
Furthermore, research could explore the biological mechanisms underlying the observed associations between these psychosocial variables and mental health outcomes in MS patients. For example, studies have suggested that stress-related physical responses, such as different cortisol levels, are associated with developing mental health disorders in individuals with MS.[ 62 ] Future studies could investigate the role of these biological mechanisms in the relationship between psychosocial variables and mental health outcomes in MS patients.
Strengths and limitation
When interpreting the results, it is essential to consider a number of limitations in this study. First, self-report measures have the potential to incur inherent biases, namely, social desirability and recall bias; these tendencies can impede the accuracy of the result. Second, the cross-sectional design provides a snapshot of variables at a specific point in time. Future research should use a longitudinal study. Additionally, the survey was administered electronically, signifying that patients with MS who contend with pronounced fatigue or attentional deficits and have experienced motor or visual impairments might have encountered impediments to their participation; despite these limitations, this analysis is supported by the large sample size and wide age range, showing good generalizability of these results. The present study is one of the first to use structural equation models, allowing both direct and indirect pathways to be tested, the role of attachment, alexithymia, social support, and loneliness on mental health. Enhanced comprehension of the underlying factors contributing to mental health can augment clinical interventions to improve the condition of people with MS.
Conclusion
The findings of this study provided evidence for the complex interplay of various psychosocial variables and their impact on the mental health of patients with MS. The results suggested that attachment style, social support, loneliness, and alexithymia are all critical factors that directly and indirectly affect the mental health of MS patients. The attachment played a significant role in determining the level of social support and loneliness, which impacted the mental health of MS patients. In summary, findings of this study are essential in creating strategies to enhance the mental health of individuals with MS. Clinicians and healthcare providers should consider the impact of attachment style, social support, loneliness, and alexithymia when developing treatment plans for MS patients and should focus on promoting social support and resilience as critical components of these interventions.
Conflict of interest
There are no conflicts of interest.