Alexithymia and Addiction

Alexithymia was first described by Sifneos [1] as difficulty identifying and communicating feelings, differentiating feelings and somatic sensations of emotional arousal, a diminution of fantasy and imagination and an externally oriented cognitive style [2]. Studies have found that alexithymia is present across 18 different ethnic and racial groups [3]. Alexithymia is seen in around 6 and 10% in the general population [4-5]. However, when compared to non-addicted individuals, those with substance-use disorders more frequently exhibit alexithymia [6]. In patients with alcohol-use disorders percentages typically range from 45 to 67% [7]. Alexithymia can also be seen in people with a family history of alcoholism [8]. Some evidence suggests that alexithymia may have an adverse impact on the treatment of alcohol use disorders [9,10] and given the substantial cost of such disorders worldwide [11] this relationship warrants closer attention. Alexithymia is also commonly found in patients who are undergoing treatment for another drug abuse [12].

Substance-use disorders are linked with affective disorders, and alexithymia is seen in association with depressive [13,14] and anxiety disorders [15]. Thus, alexithymia may be seen in substance-use disorders simply because alexithymia is commonly observed in affective disorders that often accompany substance-use disorders. Thus, such individuals may seek to relieve depression or anxiety brought about by alexithymia by consuming alcohol or other drugs [16]. However, alexithymia may represent a separate entity, [17] consistent with observations that not all individuals with co-occurring alexithymia and substance dependence exhibit affective disorders [18]. Reports on alexithymia have shown a link between alexithymia and a chronically elevated stress response [19], perhaps because an inability to identify negative emotion makes such emotions harder to regulate. Alexi thymic individuals demonstrated more displacement behaviors, such as self-grooming and scratching, which may denote a failure to regulate distress [20]. Imaging studies using fMRI indicate that subjects with alexithymia have reduced activation of the temporoparietal junction and dorsomedial prefrontal cortex in the brain. These areas are related to mentalizing ability. These findings indicate that alexithymia is associated with an impairment in mentalizing ability resulting in an inability to understand the perspective of others [21]. Individuals with alexithymia also showed decreased executive function capabilities, with reductions in performance across multiple domains of executive function, including inhibition [22]. Since people with alexithymia usually feel uncomfortable in social situations [23], some studies have proposed that alexithymia individuals use alcohol as a coping mechanism for stress or to improve interpersonal functioning [24,25]. Studies suggest association between alexithymia and craving for drugs or alcohol, although the directionality has not been seen consistently. Negative correlations between alexithymia and subjective measures of craving for alcohol in response to alcohol cues have been found among patients with alcohol dependence [26], whereas positive correlations between alexithymia and cue-induced craving for methamphetamine have been seen in patients with methamphetamine dependence [27]. High alexithymia in heavy alcohol users is associated with increased craving for alcohol, compulsive urge to drink, and obsessive thoughts about alcohol [28].

De Haan et al. [29] in a study on inpatients with alcohol use disorder and found that the baseline alexithymia showed no relation to abstinence, time in treatment or changes in disorder severity at 1-year follow-up [29]. In another study de Haan et al. [29] showed that alexithymia was not related to abstinence, and high scoring alexithymics did not differ from low-scoring alexithymics in mean time in treatment or dropout rates (50 vs. 43%) [29]. It can also predict treatment engagement especially session attendance and working alliance, as it was found by Cleland et al. [30] That drug-dependent outpatients who were higher in alexithymia attended fewer sessions and formed weaker alliances [31]. A prospective study on subjects with alcohol dependence by Junghanns et al. [32] in 2005 found that alexithymia scores were not associated with the risk of relapse at 6-week follow-up [32]. A recent research confirmed that alexithymia was not associated with treatment adherence or retention in an 8-week randomized clinical trial by Morie et al. [18] in 2015 [18]. Thus, evidence on the relationship between alexithymia and treatment outcome is limited and non-univocal. Substance use treatment is hindered by high rates of relapse (60–70%) and premature termination, to the extent that it is more common for a patient to drop out of addiction treatment than to complete the treatment [32-35]. According to Hser et al. [34] completion of addiction treatment is one of the most consistent factors associated with a favorable treatment outcome [34,36]. This shows the importance of identifying predictors of treatment retention and adherence in such patients. Thus, there is evidence that alexithymia plays a role in development of alcohol use disorders and has the potential to interfere with its treatment. Unfortunately, it is neither assessed nor addressed in routine management of addictive disorders. Welldesigned studies are needed to establish the role of alexithymia in management and whether management of alexithymia can play a role in the treatment of substance use disorders.

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