Alexithymia and interpersonal functioning in alcohol use disorders

All human beings experience emotion. However a number of individuals have difficulties recognizing, processing and regulating their emotions. This set of emotional "deficits' is classified as alexithymia, a multifaceted personality construct consisting of difficulties identifying feelings (DIF), difficulties describing feelings (DDF) and externally oriented thinking (EOT). The prevalence rate of alexithymia in alcohol use disorders is between 45 to 67%. A number of hypotheses related to the role of alexithymia in alcohol-dependence have been proposed, and it has been hypothesised that those with alexithymia use alcohol as a coping mechanism for stress, to become more assertive or improve interpersonal functioning. Yet, few research studies have comprehensively investigated alexithymia in alcohol­dependence. A lack of a theoretical framework examining alexithymia and alcohol is also apparent. Attachment theory and particularly parental bonding is considered a critical factor in the aetiology and development of alexithymia, but this hypothesis has not been thoroughly investigated. Thus, the purpose of Study 1 using meta-analysis was to explore, clarify and report the strength of the relationship between parenting style and alexithymia. The evidence indicated moderate to strong relationships of maternal care with overall alexithymia score, DDF and DIF. Moderate relationships were reported for maternal overprotection with DDF and overall alexithymia score. Moderate associations between paternal overprotection, DDF and total alexithymia score were also found. The findings of Study 1 confirmed an important association between maternal care and key elements of alexithymia, and highlighted the potential of attachment as a theoretical :framework for further research on alexithymia and alcohol-dependence. The objective of Study 2 was to explore the factorial validity of the Toronto Alexithymia Scale (TAS-20), the most commonly used assessment tool for alexithymia, in a sample of210 alcohol-dependent individuals. This group of participants had an alcohol use disorder diagnosis and were attending a Cognitive Behavioral Treatment (CBT) outpatient program. Data from this sample was used in Studies 2, 3, 4 and 5 with minor variations in the actual number of participants in each of these studies. Confirmatory factor analyses were conducted using Structural Equation Modelling to evaluate the factor structure of the TAS-20. Based on previously reported factor structures, both a two-factor and a three-factor model were examined, using maximum likelihood estimation. Four of the five fit indices and a chi-square difference test indicated a superior fit for the three-factor model compared to the two-factor model. Taken together these findings demonstrated that the original three-factor model of the TAS-20 was a more plausible fit to the data than the two­factor model. Given alexithymia's high prevalence in alcohol use disorders, valid assessment tools are critical. Study 2 confirmed the factorial validity of a self-report measure of alexithymia, the TAS-20. An objective assessment, the Observer Alexithymia Scale (OAS), has also been recommended to increase the validity of data collected. The objective of Study 3 was therefore to assess the validity and reliability of the Observer Alexithymia Scale (OAS) and the TAS-20. Data from the same 210 alcohol-dependent participants was used for Study 3. These participants were administered the TAS-20 at assessment and upon treatment completion at 12 weeks. Clinical psychologists provided observer assessment data for a subsample of 159 patients. The findings confirmed acceptable internal consistency, test-retest reliability and scale homogeneity for both the OAS and TAS-20. The TAS-20 was more strongly associated with alcohol-dependence than the OAS and also provided stronger predictive utility towards alcohol-dependence. Problems with the discriminant and convergent validity of the OAS were evident. These findings suggest that the T AS-20 was a more psychometrically robust instrument to measure alexithymia in alcohol use disorder outpatients compared to the OAS. A number of studies have examined alexithymia in relation to alcohol use disorders, yet there has been a lack of a theoretical framework to explore essential mechanisms in the link between alexithymia and alcohol-dependence. Study 4 introduced an integrative framework of attachment and expectancy theory, and examined theoretical relationships between attachment, alexithymia, alcohol expectancies and alcohol-dependence, in the same sample of 230 alcohol-dependent participants. Path analyses were conducted via Hierarchical Regression Analyses (for observed variables) and Structural Equation Modelling (for latent variables). Attachment was a significant predictor of alexithymia, but not for alcohol-dependence. There was also a significant prediction of DIF for the alcohol expectancy domain Assertion. The relationship between DIF and alcohol-dependence was partially mediated through the alcohol expectancy Affective Change, a key mechanism that contributes to our understanding of the link between DIF and alcohol-dependence. Taken together, these findings confirmed the importance of Affective Change in elucidating the highly rewarding effects of alcohol in those with combined alexithymia and alcohol-­dependence. Given that alexithymia may have an impact on the adherence and efficacy of psychological treatments, Study 5 examined potential differences on sociodemographic variables, alexithymia, attachment, alcohol expectancies, mood, craving and measures of alcohol-dependence between those who completed treatment and non-completers. The relationship between alexithymia and craving was also examined at baseline and at 12 week follow-up. Two hundred and eighty six consecutively treated participants diagnosed with an alcohol use disorder in an outpatient CBT program were included in the present study. There were significant differences between completers and non-completers on age, alcohol problem severity, dependent attachment, overall alexithymia score and DIF. This indicated more severe alcohol-dependence and attachment issues as well as higher levels of alexithymia in non-completers. Significant correlations between alexithymia, DIF and craving were evident as well as a significant relationship between DDF at baseline and craving at 12-week follow-up. To date, this is the first study to investigate alexithymia in relation to craving among those with alcohol-dependence, and suggests that a lack of emotional insight and confusion about feelings are associated with a stronger desire to drink alcohol. These findings highlight the potential importance of alexithymia in relation to treatment completion, and further research is needed to elucidate the role of alexithymia in relation to more standardised treatment outcome variables among those with alcohol use disorders. The developmental social-cognitive model presented partially integrates expectancy theory within attachment theory and for the first time provides a unified model to examine alexithymia in alcohol use disorders. The theoretical and clinical implications of this model are discussed in relation to a theoretical extension, molecular genetic factors, treatment approaches and future prevention of alcohol­dependence