Theory of mind, empathy, and alexithymia in adolescents with systemic lupus erythematosus: associations with fatigue and internalizing symptoms

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Abstract
This study aimed to examine theory of mind (ToM), empathy, and alexithymia in adolescents with systemic lupus erythematosus (SLE) compared to typically developing controls (TDC) and to investigate the associations of these socio-emotional measures with fatigue and internalizing symptoms. In this two-center cross-sectional study, 21 adolescents with SLE (median age 16 years; 90.5% female) and 21 age- and sex-matched TDC underwent comprehensive assessment including the Faux Pas Recognition Test, Reading the Mind in the Eyes Test, Empathy and Systemizing Quotient, Alexithymia Questionnaire for Children, Revised Child Anxiety and Depression Scale, Fatigue Severity Scale, Sleep Disturbance Scale for Children, and the Wechsler Intelligence Scale for Children-IV. ToM, empathy, and systemizing scores did not differ between groups, despite a generalized trend toward lower WISC-IV performance in the SLE group and a nominally significant, exploratory deficit in Vocabulary (p = .014, r = .380). Alexithymia, particularly the difficulty identifying feelings dimension, showed strong positive correlations with fatigue and internalizing symptoms in both groups (all r ≥ .74, p < .001). Within the SLE group, an exploratory unadjusted analysis showed that longer disease duration was associated with lower empathy (r = - .592, p = .005); this finding was attenuated after adjustment for age at diagnosis. Fatigue tended to be higher in the SLE group (p = .051) without parallel differences in sleep disturbance. Externally directed social cognition did not differ from controls in stable SLE despite nominally lower vocabulary performance, although the small sample limited power to detect modest differences; internally directed emotional processing, by contrast, emerged as a transdiagnostic correlate of fatigue and internalizing symptoms. In an unadjusted exploratory within-group analysis, longer disease duration was associated with lower empathy. These findings are hypothesis-generating and require replication in larger samples with prespecified multiplicity correction. Key Points • Theory of mind and empathy did not differ from controls in adolescents with stable childhood-onset SLE. • Alexithymia strongly correlates with fatigue and internalizing symptoms in pediatric SLE. • In an unadjusted exploratory analysis, longer disease duration was associated with lower empathy.

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