بررسی رابطه آلکسی تایمیا برای اختلال در نظم هیجانی در یک نمونه درمان وابسته به الکل

Difficulties regulating emotions have implications for the development, maintenance, and recovery from alcohol problems. One construct thought to impede the regulation of emotion is alexithymia. Alexithymia is characterized by difficulties identifying, differentiating and expressing feelings, a limited imagination and fantasy life, and an externally-oriented thinking style (e.g., prefer talking about daily activities rather than feelings). Given that poor emotion regulation skills have been found to predict posttreatment levels of alcohol use, and that several defining characteristics of alexithymia bear similarity to deficits in emotion regulation skills, it is possible that alexithymia may predict poorer alcohol treatment outcomes. Thus, the present study first examined the relationship of alexithymia to several other emotion regulation measures and then investigated the impact of alexithymia on attrition and alcohol treatment outcomes in men and women (N = 77) enrolled in a 12-week cognitive-behavioral intervention for alcohol dependence. At baseline, higher scores on alexithymia were associated poorer emotion regulation skills, fewer percent days abstinent, greater alcohol dependence severity, and several high-risk drinking situations. Alexithymia was unrelated to attrition and to level of alcohol consumption at posttreatment. Overall, the construct of alexithymia is shown to be related to several theoretically-related constructs (e.g., emotion regulation, mindfulness) but demonstrated a limited relationship to drinking outcomes in those seeking treatment for alcohol dependence.

Negative emotions are a natural part of everyday life requiring the capacity for effective self-regulation. The combination of negative emotion and deficits in the ability to regulate emotion has implications for the development, maintenance and recovery from alcohol problems. For example, there is evidence that coping skills moderate the relationship between negative emotions and alcohol use (Holahan et al., 2001 and Holahan et al., 2003). Individuals who are prone to higher levels of coping-related alcohol use are those who have more alcohol-related problems. In addition, poor emotion regulation skills predict posttreatment levels of alcohol use (Berking et al., 2011) and may increase risk for relapse in situations involving negative emotion (Bandura, Caprara, Barbaranelli, Gerbino, & Pastorelli, 2003). Effective emotion regulation skills include the ability to be aware of emotions, identify and label emotions, correctly interpret emotion-related bodily sensations, and accept and tolerate negative emotions (Berking et al., 2011 and Gratz and Roemer, 2004). Alexithymia, first described by Sifneos (1973), is characterized by difficulties identifying and describing feelings, distinguishing between feelings and the bodily sensations of emotional arousal, and an externally oriented style of thinking. The defining features of alexithymia are in contrast to effective emotional regulation and research has demonstrated a relationship between alexithymia and maladaptive styles of emotion regulation (see reviews by Taylor, 2000 and Dubey, Pandey, & Mishra, 2010). For example, alexithymic individuals are more likely to use suppressive strategies and less likely to use reappraisal strategies as compared to non-alexithymic individuals (Chen et al., 2011 and Swart et al., 2009). Individuals who primarily use suppressive strategies manage stressful situations by masking their inner feelings and clamping down on their outward displays of emotion. These characteristics are most similar to the Difficulty Describing Feelings subscale of the Toronto Alexithymia Scale (TAS-20; Bagby, Parker, & Taylor, 1994), a widely used measure of alexithymia. Of the two emotion regulation strategies, suppression and reappraisal, suppression has been shown to be related to greater mental and physical health problems, and is therefore considered a less adaptive strategy for regulating one's emotions (e.g., Gross & John, 2003). Similarly, alexithymia has been found to be negatively correlated with several measures of mindfulness (Baer, Smith, Hopkins, Krietemeyer, & Toney, 2006) which includes interest in and observation of feelings. The inability to identify and describe affective and physiological experiences is itself associated with elevated negative affect (Connelly & Denney, 2007). Thus, this unpleasant experience might prompt individuals to engage in maladaptive behaviors, such as excessive alcohol consumption, in an effort to regulate emotions, or, more specifically, cope with negative emotional states (see Thorberg et al., 2011). Given that poor emotion regulation skills have been found to predict posttreatment levels of alcohol use, and that alexithymia has been found to be related to deficits in emotion regulation skills, it is possible that alexithymia may have a negative impact on alcohol consumption and alcohol treatment outcomes. Alexithymia has been shown to be associated with diverse medical and psychological disorders including eating disorders, pathological gambling, mood disorders, posttraumatic stress disorder, substance use disorders, somatoform disorders, and functional gastrointestinal disorders (e.g., Bydlowski et al., 2005, Honkalampi et al., 2004, Parker et al., 2008, Toneatto et al., 2009 and Waller and Scheidt, 2004). Although a recent taxometric analysis provides evidence in support of alexithymia as a dimensional (rather than categorical) construct, studies utilizing the upper cut-off score on the Toronto Alexithymia Scale (TAS-20; Bagby et al., 1994) have reported prevalence rates ranging between 5 and 17% in community samples and between 30 and 60% in clinical samples (see Parker et al., 2008). The prevalence of alexithymia in studies investigating alcohol use disorders falls within the range identified above for clinical samples (i.e., 30–60%). The prevalence of alexithymia among individuals with alcohol use disorders raises the question of whether alexithymia is a risk factor for alcohol problems. Although some authors have conjectured that alexithymia plays a role in the development and maintenance of alcohol use disorders (e.g., de Timary et al., 2008 and Taylor et al., 1997), the empirical literature exploring this relationship is limited (see Thorberg, Young, Sullivan, & Lyvers, 2009 for a review). In one study, Finn, Martin, and Pihl (1987) investigated the presence of alexithymia among males at varying levels of genetic risk for alcoholism. They found that the high risk for alcoholism group was more likely to be alexithymic than the moderate and low genetic risk groups. In another study of Turkish alcohol dependent inpatients, alexithymia was found to be related to several dimensions of Cloninger's psychobiological model of personality (Evren et al., 2008). Specifically, high harm avoidance and self-transcendence and low self-directedness were identified as independent predictors of alexithymia. Although the study utilized a correlational design, the authors' suggest that alexithymia may be a risk factor for alcohol dependence. Finally, Honkalampi et al. (2010) conducted a prospective study using a small subsample drawn from Finland's National Population Register and found that alexithymia did not predict future alcohol use disorders directly. Rather, the results revealed an indirect effect that was mediated by depressive symptoms. Although the number of studies investigating alexithymia as a risk factor for the development of an alcohol use disorder are few, the studies reviewed here suggest that the relationship between alexithymia and alcohol use disorders may be both multifaceted (e.g., includes both environmental and genetic contributions) and indirect such that the effects of alexithymia on alcohol use and alcohol problems may be mediated by other variables previously shown to be predictive of alcohol use disorders (Honkalampi et al., 2010 and Thorberg et al., 2011). Future research utilizing prospective longitudinal designs will need to be conducted to examine further the links between alexithymia and the development of alcohol problems. A better understanding of these relationships could prove helpful in terms of prevention as well as treatment. With regard to treatment for alcohol problems, little is known about the impact of alexithymia on treatment process and outcomes. The few studies that have been conducted have shown that higher alexithymia scores are significantly, negatively correlated with both the number of treatment sessions attended and patients' ratings of the therapeutic alliance (Cleland, Magura, Foote, Rosenblum, & Kosanke, 2005). Other studies have shown that alexithymia predicted poor outcome in those patients who received either inpatient or outpatient treatment for an alcohol use disorder (Loas et al., 1997 and Ziolkowski et al., 1995). In the study by Cleland et al. (2005), a higher level of alexithymia at baseline was associated with poorer alcohol treatment outcomes, but only among those with an alcohol use disorder only (i.e., no co-occurring drug use or drug use disorder). Taken together, the limited empirical research shows that higher levels of alexithymia may negatively impact treatment attendance and treatment outcomes. Still, research on the role of alexithymia in alcohol dependence treatment is lacking and the present study was conducted to address several issues identified in a recent review of the alexithymia and alcohol use disorder literature as requiring additional research (Thorberg et al., 2009). The present study had three main objectives; 1) to investigate the relationship between alexithymia and several related variables (i.e., emotion regulation, mindfulness variables), including drinking variables, within an alcohol dependent sample, 2) examine the relationship between alexithymia and attrition rates within a clinical sample, and 3) examine the effect of pretreatment levels of alexithymia on alcohol treatment outcomes. With regard to the first objective, we hypothesized that alexithymia would be positively related to alcohol problem severity and negatively related to several related constructs (e.g., emotion regulation, mindfulness). Given the limited empirical data on the relationship of alexithymia to treatment process and alcohol outcomes for alcohol dependence, analyses for the second and third objectives were exploratory.