Alexithymia and problematic alcohol use: A critical ...

Accepted Manuscript Alexithymia and problematic alcohol use: A critical update

K.E. Cruise, R. Becerra PII: DOI: Reference:

S0306-4603(17)30370-2 doi:10.1016/j.addbeh.2017.09.025 AB 5312

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Addictive Behaviors

Received date: Revised date: Accepted date:

15 April 2017 27 September 2017 29 September 2017

Please cite this article as: K.E. Cruise, R. Becerra , Alexithymia and problematic alcohol use: A critical update. The address for the corresponding author was captured as affiliation for all authors. Please check if appropriate. Ab(2017), doi:10.1016/j.addbeh.2017.09.025

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Alexithymia and Problematic Alcohol Use: A Critical Update Cruise, K.E. & Becerra, R.

Kate Cruise

School of Psychology and Social Sciences, Edith Cowan University; 270 Joondalup Drive, Joondalup, Western

School of Psychology and Social Sciences, Edith Cowan University; 270 Joondalup Drive, Joondalup, Western

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Rodrigo Becerra

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Australia, Australia 6027, [email protected]

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Australia, Australia 6027, [email protected]

Corresponding Author:

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Kate Cruise, Edith Cowan University,

Email: [email protected]

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Phone: +61 8 6304 2786

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270 Joondalup Drive, Joondalup, Western Australia, 6027


Abstract There has been a substantial growth in empirical research aimed at examining the cooccurrence of alexithymia and problematic alcohol use and alcohol use disorder (AUD) since Thorberg, Young, Sullivan, & Lyvers (2009) original review article. The objective of the

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present paper is therefore to provide a critical update review of research on alexithymia and problematic alcohol use published since 2009. A systematic search was conducted through

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PsychINFO, Medline, and ProQuest databases to obtain relevant literature published between

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2009 and 2016. Studies that involved measures of alexithymia and problematic alcohol use among clinical and non-clinical samples were included. Prevalence rates of alexithymia

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among Alcohol Dependent (AD) samples were identified between 30 and 49% and therefore

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much lower than originally reported. The findings of this update review highlight an indirect relationship between alexithymia and alcohol problem severity that is mediated by a number of psychological drinking constructs (e.g., alcohol expectancy, drinking motives, craving and

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alcohol related intrusive thoughts) and psychological risk factors for the development of

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alcohol related problems (e.g., mood and emotion dysregulation, attachment, trauma, and cognitive function). In addition, this review provides reasonable evidence to support

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alexithymia as an independent risk factor for alcohol related problems among clinical samples only. In conclusion, alexithymia is a multifaceted construct that has a complex relationship with various risk factors and psychological drinking constructs. The growing body of research highlights the demand for understanding the interrelationships between alexithymia, psychosocial risk factors, and problematic alcohol use in order to tailor and target therapeutic interventions. Key words: Alexithymia; Alcohol Use Disorder; Alcohol Dependence; Alcohol Related Problems; Problematic Alcohol Use


1. Introduction Alexithymia is a multidimensional personality trait, defined by a set of four characteristics: 1) difficulty identifying feelings and distinguishing feelings from bodily sensations of emotional arousal, 2) difficulty describing and communicating feelings to

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others, 3) evidence of an impoverished fantasy life, and 4) an externally oriented style of thinking (Sifneos, 1973; Taylor, Bagby, & Luminet, 2000). Alexithymia has been associated

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with numerous psychiatric disorders, depressive disorders in particular (Leweke, Bausch,

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Leichsenring, Walter, & Stingl, 2009); and has featured strongly among research aimed at investigating problematic alcohol use and alcohol dependence (AD)*. Thorberg and

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colleagues (Thorberg, Young, Sullivan, & Lyvers, 2009) conducted a critical review of the

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literature on alexithymia and alcohol related disorders, reviewing 24 studies published between 1973 and 2008. A high prevalence of alexithymia was identified among alcohol dependent (AD) populations (45-67%; Thorberg et al., 2009), however the review only

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provided preliminary evidence for a relationship between alexithymia and alcohol

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consumption, and limited evidence to support alexithymia as an independent risk factor for the development and maintenance of AD.

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The empirical base of alexithymia and AD research has grown quite substantially since Thorberg et al.’s (2009) review and includes a much broader range of psychological drinking constructs (i.e., alcohol expectancy, drinking motives, craving and alcohol related intrusive thoughts). Research in this area has also examined alexithymia and AD in relation to a range of psychological risk factors reported to be associated with the development of alcohol related problems including trauma, attachment security, mood and emotion regulation, and cognitive function. Given the substantial empirical growth, this paper aims to provide a critical update of the literature on alexithymia and problematic alcohol use and alcohol use disorders (AUD).


*[Footnote ] Of those studies reviewed that involved a diagnostic measure, all utilised DSM-IV criteria for Alcohol Dependence. The term Alcohol Dependence (AD) as opposed to Alcohol Use Disorder (AUD) is therefore referred to throughout the manuscript.

2. Methods This systematic review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines (Moher, Tetzlaff, Altman, & Group,

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2009). For identification of the relevant studies a combination of key words were used:

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‘alexithymia’, ‘alexithymic features’, ‘alexithymic’, ‘alcohol use disorder’, ‘alcohol

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dependence’, ‘alcohol abuse’, ‘alcohol use’, ‘alcoholism’, ‘binge drinking’, ‘alcohol intoxication’, ‘alcohol abstinence’, ‘alcohol problem’, ‘risky drinking’. A systematic search

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was conducted through PsychINFO, Medline, and ProQuest databases for relevant literature published in English, peer reviewed journals between 2009 and 2016 (7 November 2016).

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Only studies involving adult populations were selected. The reference lists of the articles included in the review were manually checked for relevant studies. Using these search

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strategies, 30 studies were found. Figure 1. summarises the identification, screening,

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eligibility, and inclusion process. Table 1. provides a description of all the studies in terms of sample size, sample type and methodology, and identifies the significant relationships between alexithymia and other psychological drinking constructs and risk factors and

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associated effect sizes.

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Figure. 1. Information flow on study selection


Table1 Descriptions and methodological aspects of studies reviewed Sample/Gen der comparison

Sample Type

Measu res

Methodol og y

Alcohol proble m measur e AUDIT

434, age (20.24±2.02). 236 males, 198 females. Combined

Athletes

TAS20 IPPA BFI

Cross sectional

Bruce et al. (2012)

862, age (26.1 ±9.12). 208 male, 654 female. Combined.

University

TAS20 DMQR TLFB

Cross sectional

Bujarski et al. (2010)

237, age (19.79±2.73). 73 males, 164 females. Combined.

University

Coriale et al. (2012)

110, age (44.3±9.7). 84 males, 26 females. Combined

Craparo et al.

117 AD, age (44.85±9.94).

Alexithymi a and psychologic al drinking constructs ES (d, f2 ) DIF associated with alcohol use (f2 = .14)

TLFB

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Andres et al. (2014)

Alexithymia and risk factors for alcohol related problems ES (d, f2 ) Maternal insecure attachment and low level of conscientiousne ss mediated the relationship between DIF and alcohol use1 . Not investigated

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Author

Cross sectional

AUDIT

AD inpatients

TAS20 COPENVI

Cross sectional

DSMIV LDH TLFB

AD inpatients

TAS20

Experimenta l

DSMIV-TR

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TAS20 APRA ETISRSF

Relationship between alexithymia and trauma predicted alcohol risk perception at high trauma (f2 =.14) Relationship between alcohol abuse and avoidance coping mediated by alexithymia2

Alexithymia predicted

Drinking motives (social, enhancemen t, coping) mediated relationship between alexithymia and alcohol consumptio n1. Not investigated .

Greater alcohol consumptio n (d=.82), shorter period of abstinence (d= .45) for alexithymic than nonalexithymic. Alexithymic ≠ borderline alexithymic. Not investigated


(2014)

117 HC, age (43.98±9.57). 60 males, 57 females. Separate 156, age not reported. All male.

HC

DES-II TEC

dissociation in the AD group (f2 =.56)

AD inpatients

TAS20 TCI TEC

Cross sectional

AD inpatients

TAS20 MINI

Prospective

DSMIV

Greater trauma Not exposure investigated among alexithymic compared to nonalexithymic participants (.d=.33). Higher DIF (d=.47) and TAS-20 total (d=.42) among trauma group. Not investigated TAS-20 did not predict risk for relapse or alcohol related problems. No difference between high, moderate, low alexithymia for alcohol or psychiatry measures at baseline and 1 year follow-up. Three groups No identified based significant on attachment difference style and between alexithymia. three Depression (f2 = cluster .20), trait groups for anxiety (f2 =.25), severity of and personality alcohol use. (f2 =.69) differentiated between groups. Relationship Not between investigated alexithymia and alcohol problem severity

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Dalbudak et al. (2010)

60 males, 57 females.

100, age (low alexithymic 44.2±9.2; moderate alexithymic 44.7±8.3; high alexithymic 40.8±9.7). All male.

De Rick et al. (2009)


AD inpatients

BVAQ AAQ STAI BDI ADPIV

Cross sectional

EuropA SI

Evren et al. (2009)

176, age (43.1±8.3). 176 males. All male.

AD inpatients

TAS20 TCI BDI BAI

Cross sectional

DSMIV MAST

EuropA SI

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de Haan et al. (2012)


156, age (44.21±9.10). 156 males. All male.

AD inpatients

TAS20 CAPS TCI

Cross sectional

DSMIV (SCIDI)

Evren et al. (2010b)

156, age (44.21±9.10). 156 males. All male

AD inpatients

TAS20 TCI SF-36

Cross sectional

DSMIV (SCIDI) MAST

Evren et al. (2012)

118 AD, age (42.50±9.88) 60 HC, age (35.27±11.84) . All male.

AD inpatients HC

TAS20 TCI DSQ

Experimenta l

Honkala mpi et al. (2010)

290, no information on age or sex.

Communit y

Luminet et al. (2016)

158, age (58.76±10.39) . 103 males, 55 females. Separate.

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DSMIV (SCIDI)

TAS20 BDI

Prospective

DSMIV SCID-I

TAS20 OCDS PANA S BDI

Cross sectional

Not assessed

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Evren, et al. (2010a)

AD inpatient

predicted depression (f2 =.51), state anxiety (f2 =.54) and trait anxiety (f2 =1.56). Higher TAS-20 total (d= .55), DIF (d=.58) and DDF (d=.34) for PTSD than non-PTSD group.DIF predictor of PTSD group 1 . TAS-20 total, DIF, and DDF correlated negatively with physical (d=.80, .90, .53) and mental dimensions (d=.85, .95, .60) of QoL Immature defense style for alexithymic than nonalexithymic (d= .85). DIF correlated with immature defense (d=.63). Depression but not alexithymia predicted subsequent depressive disorder, personality disorder, or alcohol disorder. Depression predicted alexithymia (f2 =.56) Low but not high EOT predicted obsessive craving among men (f2 =.14). Interaction between depression and DDF predicted compulsive craving among

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STAI

Not investigated

Higher alcoholrelated problem severity for alexithymic than nonalexithymic group (d=.60). Not investigated

Higher alcohol dependency at 3 year follow-up for high compared to low alexithymia (d=.66).

Not investigated


262, age (26.83±8.34). 84 males, 178 females. Separate.

Communit y+ University

TAS20 SPSR Q DMQ

Cross sectional

Lyvers et al. (2012b)


Communit y+ University

TAS20 FrSBe

Cross sectional

Lyvers et al. (2014a)

113, age (22.11±.35). 35 males, 78 females. Combined.

University

Lyvers et al. (2014b)


AUDIT

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Lyvers, et al. (2012a)

women (f2 =1.94) Alexithymia group x gender interaction for males only (d=.77).

TAS20 SPSR Q FrSBe TRI BAI

Cross sectional

AUDIT

TAS20 DEQ DMQ

Cross sectional

AUDIT

Frontal lobe dysfunction mediated the relationship between alexithymia and risky alcohol use (d=.06). Children of alcoholic sig greater DIF than nonalcoholic child (d=.11) Frontal lobe dysfunction mediated relationship between alexithymia and CEP1 .

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AUDIT CAST

University

Not investigated

Alexithymi a was not related to risky drinking. DIF and Coping mediated by Sensitivity to Punishment . SP and risky drinking mediated by Coping 2 Alexithymi a predicted risky alcohol use (f2 =.02)

Alexithymi a predicted risky alcohol use (f2 =.04). Intrusive alcohol related thoughts mediated relationship between alexithymia and alcohol related problems (f2 = 05). Alexithymi cs higher on Coping motives (d=.62) and affective change expectancie s (d= .75)


AD inpatients

TAS20 MINI LAT

Cross sectional

DSMIV-TR SADQ

Family history of alcoholism associated with significantly higher alexithymia and DIF scores 1 .

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Sig higher TAS-20 Total (d=.31) and subscale scores (DIF: d=.40, DDF d=.047, EOT: d=.64) for Type IV than Type III (TAS20 Total. Sig higher TAS-20 (d=.70) and subscale scores (DIF: d=.31, DDF: d= .42, EOT: d=.61) for Type IV than Type II. Type IV and Type I ns. Relationship between alexithymia and risky alcohol consumption mediated by depersonalisatio n. Not investigated

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Pombo et al. (2015)

TAS20 MBIHSS

Cross sectional

AUDIT

University

TAS20 UPPSP

Cross sectional

DDQ-M YAAC Q

1841, age not reported. 875 males, 966 females. Combined.

Shishido et al. (2013)


Physicians

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Pedersen et al. (2016)

than nonalexithymic s. No relationship between alexithymia and risky drinking. No sig correlation between alexithymia and onset of alcohol use, level of alcohol dependence , or current drinking status.

Direct effect of alexithymia on risky alcohol consumptio n1. Relationshi p between alexithymia and alcohol consumptio n mediated by positive urgency (f2 =.25). Alexithymi a and alcohol problems mediated by negative urgency


Cross sectional

DSMIV IDTS SADD DrInC TLFB

Alexithymia was predicted emotion dysregulation as measured by subscales of the DERS (f2 range: 31-.92). and ERQ suppression (f2 = .47)

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TAS20 MINI ERQ DERS NMR Q KIMS MAAS CRI

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AD outpatients

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Stasiewic z et al. (2012)

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Alexithymia was a sig predictor of avoidance coping (f2 =.23) and mindfulness domains (f2 range=.51-1.56)

159, age (37.60±11.44) . 111 males, 48 females. Combined.

AD outpatients

TAS20 OAS

Prospective

DSMIV-TR AUDIT bMAST

Not investigated

Thorberg et al. (2010 b)


AD outpatients

TAS20

Cross sectional

DSMIV-TR AUDIT bMAST

Not investigated

Thorberg , et al.

210, age (38.17±10.82)

AD outpatients

TAS20

Cross sectional

DSMIV-TR

Adult attachment

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Thorberg et al. (2010 a)

(f2 =.56). Positive urgency and alexithymia mediated alcohol problems at high levels of alexithymia (f2 =.12) Alexithymi a was a sig predictor of alcohol problem severity (f2 =.26) Alexithymi a was a sig predictor of drinking situations (unpleasant emotions, physical discomfort, conflict with others, social pressure, urges/tempt ations) (f 2 range= .19.30) DIF (f2 =.46) and OAS subscale UNS (f2 =.39) were significant predictors of total alcohol related problems. CFA identified 3 factor model (DIF, DDF, EOT) as best fit 2 Not investigated


. 144 males, 66 females. Separate.

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AUDIT bMAST

security predicted alexithymia (f2 =.35), with insecure styles of close and anxiety accounting for sig additional variance. Both Alexithymic and borderline alexithymic sig higher attachment insecurity than non-alexithymic (Close: d=.84; Depend: d=.53, Anxiety: d=.96) Sig greater insecure attachment for alexithymic vs. non-alexithymic AD (d=.78)

AD outpatients

TAS20 OCDS RAAS Anxiet y

Cross sectional

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DSMIV-TR AUDIT

Thorberg , et al. (2011c)

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Thorberg , et al (2011b)

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(2011a)


AD outpatients

Relationship between alexithymiaand craving partially mediated by insecure attachment 1 .

TAS20 DEQ

Cross sectional

DSMIV-TR AUDIT

Relationship between alexithymia and alcohol related problems partially mediated by drinking expectancies of assertion (f2 = .173) and affective change (f2 =.011)

Sig greater alcohol problem severity for alexithymic than nonalexithymic AD (d=.69). Sig difference between alexithymic and non alexithymic AD for total craving (d=.53), resistance/c ontrol (d=.48 ) and obsession (d=.47) Alexithymi a predicted alcohol problem severity (f2 =.053)


Thorberg et al. (2013)

AD outpatients

OAS

Cross sectional

Not reported

Not investigated

AD outpatients

TAS20 DEQ

Cross sectional

DSMIV AUDIT

Not investigated


AD outpatients

TAS20 DEQ

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Thorberg et al. (2016b)

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Thorberg et al. (2016a)

192, age (37.23±11.42) . 136 males, 56 females. Combined 255, age (38.67±10.95) . 244 males, 111 females. Separate.

Prospective

DSMIV AUDIT

Not investigated

CFA could not find any support for any tested model. Alexithymi a and borderline alexithymia sig higher affective change expectancy scores than nonalexithymic (d=.67) Alexithymi c sig higher assertion expectancy than borderline (d= .37) and nonalexithymic (d=.75) Sig decrease in total alexithymia (d=.64), DIF (d=.77) and DDF (d=.56) from baseline to 3 month follow up. Assertion expectancy partially mediated the relationship between total alexithymia (f2 =.62), DIF (f2 =.39) and DDF (f2 =.47) change T1 to T2.

Note: Adult Attachment Style Questionnaire (AAQ), Alcohol Perceived Risks Assessment (APRA), Alcohol Use Identification Test (AUDIT), Assessment of DSM-IV Personality Disorders (ADP-IV), Beck Anxiety Inventory (BAI),Beck Depression Inventory (BDI), Bermond-Vorst Alexithymia Questionnaire


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(BVAQ), Big Five Inventory (BFI), Brief Michigan Alcohol Screening Test (bMAST), Children of Alcoholics Screening Test (CAST), Clinical-Administered PTSD Scale (CAPS),Cognitive Emotional Preoccupation (CEP) with alcohol, Coping Orientation to Problems Experienced (COPE-NVI), Coping Response Inventory (CRI),Daily Drinking Questionnaire Revised (DDQ-R), Difficulties in Emotion Regulation (DERS), Drinking Expectancies Questionnaire (DEQ), Drinking Motives Questionnaire (DMQ), Drinker Inventory of Consequences (DrInC), Drinking Motives Questionnaire-Revised (DMQ-R), Defense Style Questionnaire (DSQ), Early Trauma Inventory Short Form (ETISR-SF), Emotion Regulation Questionnaire (ERQ), European Addiction Severity Index (EuropASI), Frontal Systems Behavior Scale (FrSBe), Impulsive Behavior Scale (UPPS-P), Inventory of Drug Taking Situations (IDTS), Inventory of Parent and Peer Attachment (IPPA), Kentucky Inventory of Mindfulness Skills (KIMS)Lesch Alcoholism Typology (LAT), Lifetime Drinking History (LDH), Maskach Burnout Inventory Human-Services-Survey (MBIH), Michigan Alcohol Screening Test (MAST), Mindfulness Awareness Scale (MAAS), Mini International Neuropsychiatric Interview (MINI), Modified Daily Drinking Questionnaire (DDQ-M), Multivariate Analysis of Covariance, Multivariate Analysis of Variance (MANOVA), (MANCOVA), Negative Mood Regulation Expectancies Questionnaire (NMRQ), Obsessive-Compulsive Drinking Scale (OCDS), Observer Alexithymia Scale (OAS),[ OSA subscales: Distant (DIS), Uninsightful (UNS), Somatising (SOM) Humourless (HUM), Rigid (RI)], Positive Affectivity Negativity Schedule (PANAS), Revised Adult Attachment Scale (RAAS)-Anxiety, Short Alcohol Dependence Data Questionnaire (SADD), Sensitivity to Punishment and Sensitivity to Reward Questionnaire (SPSRQ), Severity Alcohol Dependence Questionnaire (SADQ), State Trait Anxiety Inventory (STAI), Structured Clinical Interview for DSM-IV (SCID-I), Structural Equation Modelling (SEM), Temptation and Restraint Inventory (TRI), Temperament and Character Inventory (TCI), The Short Form 36 (SF-36), Time Line Follow Back (TLFB), Toronto Alexithymia Scale (TAS-20) [TAS-20 Subscales Difficulty Identifying Feelings (DIF), Difficulty Describing Feelings (DDF), Externally Oriented Thinking (EOT)], Traumatic Experiences Checklist (TEC), Young Adult Alcohol Consequences Questionnaire (YAACQ) Insufficient information available to calculate effect size for significant results. 2 χ2 > 1df, effect size could not be calculated.

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3. Results

The following section integrates the results of alexithymia and alcohol use/disorder research

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published since Thorberg et al.’s (2009) review. This section is divided into subcategories to provide a research update on the prevalence estimates of alexithymia in AD, relationship between alexithymia and alcohol problem severity, and the relationship between alexithymia and both psychological drinking constructs and more well established risk factors for AD. The following section also reviews current evidence pertaining to the psychometric measurement of alexithymia in AD and the absolute and relative stability of alexithymia in AD populations. 3.1 Prevalence of alexithymia in alcohol dependence


The prevalence rate of alexithymia among AD populations has been estimated between 45-67% (Thorberg et al., 2009). Review of relevant studies published since 2009 suggest that the prevalence rate of alexithymia among AD populations is much lower than originally reported, ranging between 30-49% (Coriale, Bilotta, Leone, Cosimi, Porrari, De Rosa, et al., 2012; Craparo, Vittoria, Alessio, & Vincenzo, 2014; Evren, Dalbudak, Cetin,

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Durkaya, & Evren, 2010a; Evren, Dalbudak, Durkaya, Cetin, & Evren, 2010b; Evren, Evren,

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& Dalbudak, 2009; Pombo, da Costa, Ismail, Cardoso, & Figueira, 2015; Thorberg, Young,

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Sullivan, Lyvers, Connor, & Feeney, 2011b). One exception was a substantially lower prevalence rate (21%) reported by Thorberg, Young, Sullivan, Lyvers, Hurst, Connor, et al.

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(2016b) who attributed this finding to sample characteristics, arguing that the self-referring sample may have exhibited greater emotional awareness. The prevalence rates outlined in

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Thorberg et al.’s (2009) review are argued to be inflated based on the small sample sizes among the studies reviewed (N