استراتژی های مقابله اجتناب، آلکسیتیمیا و سوء استفاده از الکل: تجزیه و تحلیل میانجیگری

Alexithymia and avoidance coping strategies are both associated with alcohol abuse, but their effects have been seldom studied simultaneously. The present study investigated the interplay between alexithymia and avoidance coping strategies in predicting the severity of alcohol abuse in an alcohol-dependent sample. The TAS-20 and COPE-NVI questionnaires were administered to 110 alcoholic inpatients enrolled into a recovery program at the Center for Alcohol Abuse of the Department of Clinical Medicine, Sapienza University of Rome, Italy. The alcohol abuse index consisted of the mean alcohol units consumed by participants and days of abstinence before being enrolled into the recovery program. Results showed that alexithymic alcoholics consumed significantly more alcohol and were less abstinent than non-alexithymic alcoholics. Concerning the relationship among alexithymia, coping strategies and alcohol abuse, data showed that alexithymia completely mediated the effects of avoidance coping strategies on alcohol abuse, suggesting that avoidance strategies have therefore an indirect effect on alcohol abuse among alcoholics. Theoretical and clinical implications of the results are discussed.

Alexithymia refers to difficulties identifying and describing subjective feelings, distinguishing between feelings and the bodily sensations of emotional arousal, fantasizing and using an internal oriented cognitive style, and a tendency to focus on real events and somatic symptoms (Nemiah, 1977 and Nemiah and Sifneos, 1970). Although initially described in the context of psychosomatic illnesses, alexithymic characteristics may be observed in patients with a wide range of both medical conditions (Lauriola et al., 2011 and Lumley et al., 2007) and psychiatric disorders (Salminen et al., 1999 and Wise et al., 1990). In the last three decades, the alexithymic concept has gained much popularity in cognitive psychology, where it has been redefined as a deficit in cognitive processing and regulation of emotions (De Rick and Vanheule, 2007 and Taylor et al., 1997). Alexithymics appear to be less able to recognize their emotional signals and regulate emotions effectively (Lindsay and Ciarrochi, 2009 and Taylor et al., 1997). They are more likely to misinterpret their emotions as being symptoms of illness (Taylor & Bagby, 2004) and can undertake a wide range of maladaptive regulation strategies such as eating and substance-related disorders (Taylor, 2000 and Taylor et al., 1997). Several studies have found a relationship between alexithymia and substance abuse (e.g., Cleland et al., 2005, De Rick and Vanheule, 2006 and Lindsay and Ciarrochi, 2009). Studies have reported the prevalence rates for alexithymia among recently abstinent drug- and alcohol-dependent patients to be 41.7 to 50.4% (Haviland et al., 1994, Haviland et al., 1988 and Taylor et al., 1990). These rates are higher than the levels of alexithymia found in non-clinical samples (4 to 18%) and psychiatric comparison group samples (12.5 to 33%; Taylor, 2000). When studies on alcohol-dependent inpatients are specifically considered, the range of alcohol-dependent individuals identified as alexithymic goes from 48 to 78% (Evren et al., 2008, Loas et al., 1997, Rybakowski et al., 1988, Sauvage and Loas, 2006, Taylor et al., 1990 and Uzun et al., 2003). In general, the literature suggests an association between alcohol-related disorders and alexithymia (De Rick and Vanheule, 2006, Kauhanen et al., 1992, Stasiewicz et al., 2012 and Taylor et al., 1997), together with an adverse impact of alexithymia on the treatment of alcohol abuse (Loas et al., 1997 and Ziólkowski et al., 1995).1 On the one hand, some authors suggest that alexithymia is a personality trait that places individuals at a greater risk of alcohol-related disorders (Uzun et al., 2003 and Ziólkowski et al., 1995); on the other hand, others consider it a consequence of alcohol use (De Rick and Vanheule, 2006, Haviland et al., 1994 and Taylor et al., 1997). Although empirical support can be found for both views, the trait paradigm seems to describe more persuasively the state of affairs in the alcoholic population (De Rick and Vanheule, 2006, Taylor et al., 1997 and Uzun et al., 2003). The reasons explaining the prevalence of alexithymics in the alcoholic population are not clear yet. Some researchers have argued that alexithymic individuals use alcohol as a coping mechanism for stress or to improve interpersonal functioning (e.g., verbal and emotional functions; Kauhanen et al., 1992 and Rybakowski et al., 1988), since alexithymic people often feel uncomfortable in social situations (Uzun et al., 2003 and Wise et al., 1992). It has also been suggested that alexithymics consume alcohol in an effort to cope with negative emotional states (Stasiewicz et al., 2012 and Thorberg et al., 2011). The rewarding experience with alcohol may eventually lead to the development of dependence (Rybakowski et al., 1988 and Uzun et al., 2003). Coping skills have found to be significant predictors of alcohol consumption (Bussey Rask et al., 2006). In particular, avoidance coping strategies are more closely linked to drinking behavior than more active strategies both among social drinkers (McKee, Hinson, Wall, & Spriel, 1998) and alcoholics (Hasking & Oei, 2007). Coping skills may also predict the outcome of the treatment of alcoholics (Bussey Rask et al., 2006). A study in a sample of treated alcoholics found that use of active coping strategies increased the odds of remaining abstinent compared to use of avoidance coping strategies (Moser & Annis, 1996). Another study found that increasing coping skills during treatment significantly predicted abstinence among alcohol abusers (Litt, Kadden, Cooney, & Kabela, 2003). The association of alexithymia and alcohol consumption and abuse has been reasonably established in non-clinical samples (Bruce et al., 2012, Kauhanen et al., 1992 and Rybakowski et al., 1988). Among alcoholics, however, only a handful of studies have investigated how much alexithymia is connected to alcohol consumption in terms of actual alcohol units consumed (Stasiewicz et al., 2012). These researchers found that higher scores of alexithymia were associated with fewer percent days abstinence and greater alcohol dependence severity (Stasiewicz et al., 2012). The present paper aimed first to investigate alcohol consumption among alcohol abusers who were also alexithymics, comparing them to non-alexithymics. Getting to know the differences between them could be interesting for the clinical consequences of alcohol abuse treatment. We expected alexithymic participants to consume more alcohol and be less abstinent than non-alexithymic participants. We would also estimate how many alcohol units could be traced back to increases in the levels of alexithymia. Secondly, this paper aimed to analyze the relationship between alexithymia, avoidance coping skills and alcohol abuse. Research studies have proposed that alexithymic individuals use alcohol to cope with stress or negative emotional states, or to improve interpersonal functioning (Evren et al., 2008, Kauhanen et al., 1992, Loas et al., 1997, Sauvage and Loas, 2006, Thorberg et al., 2011 and Uzun et al., 2003). On the other hand, avoidance coping strategies seem to be closely linked to drinking behavior (Chung et al., 2001 and Williams and Clark, 1998). However, alexithymia and coping strategies may be to some extent linked, which renders it difficult to interpret their separate linkages with alcohol abuse. Given the relationship between alexithymia and alcohol abuse (e.g., Evren et al., 2008 and Uzun et al., 2003) and the relationship between avoidance coping strategies and alcohol abuse (e.g., Carver et al., 1989, Chung et al., 2001 and Williams and Clark, 1998), we explored if alexithymia or avoidance coping strategies serves as a mediator of the other variable effect on alcohol abuse. Recently published research reported that coping strategies mediated the effects of alexithymia on alcohol consumption (Bruce et al., 2012). However, this evidence was found in a social drinkers sample and therefore the specific mediation pattern recovered could be specific for non-addicted alcohol consumption. Instead, another recent paper relying on an alcoholic sample did not find a significant correlation between alexithymia and coping styles (Stasiewicz et al., 2012). Thus, it appears worthwhile to investigate the associations and different patterns of mediation involving alcohol consumption, alexithymia and avoidance coping in an alcoholic sample.