Metacognitive mastery moderates the relationship of alexithymia with cluster C personality disorder traits in adults with substance use disorders
Introduction
Cluster C personality disorder traits include dependent, avoidant and obsessive compulsive traits and represent anxious and fearful behaviors which include the seeking of excessive support, control, or avoidance (Cox, Clara, Worobec, & Grant, 2012). They have been noted to co-occur with a range of different mental health conditions (De Rick et al., 2009, Langås et al., 2012, Taylor et al., 1997) and are of interest in the area of substance use disorders given their potential as a barrier to recovery.
In order to develop interventions to address cluster C traits, research has sought to understand the factors which promote and sustain these traits. One potential cause of cluster C traits is alexithymia, or difficulties focusing on, identifying and describing feelings (Taylor et al., 1997). Alexithymia has been linked to interpersonal difficulties which closely parallel those seen in cluster C traits (Bekker, Croon, van Balkom, & Vermee, 2008; Joyce, Fujiwara, Cristall, Ruddy & Ogrodniczuk, in press; Taylor et al., 1997, Vanheule et al., 2007), and tied to poorer outcomes in substance use disorder including factors which portent risk of relapse (Saladin et al., 2012, Thorberg et al., 2009, Thorberg et al., 2011, Verrocchio et al., 2010).
While evidence has provided a direct link between alexithymia and cluster C traits in general clinical and substance abuse samples (De Rick and Vanheule, 2007, Honkalampi et al., 2001, Nicolò et al., 2011) contradictory findings have been reported. Alexithymia has not been linked, for instance, to outcomes in personality disorder (Joyce, Fujiwara, Cristall, Ruddy, & Ogrodniczuk, 2013) or alcohol use disorders (de Haan et al., 2012). Honkalampi et al. (2010) reported that alexithymia was not associated with depression, personality disorder traits, or alcohol use disorders.
One possible explanation for these contradictions is that the relationship between alexithymia and cluster C traits in substance use disorders occurs in only some conditions. In other words, the effects of alexithymia on cluster C personality traits may be mediated by other factors. One potential factor that might influence the relationship of alexithymia with cluster C traits is metacognitive dysfunctions. Metacognition refers to a spectrum of activities which involves thinking about thinking and stretches from consideration of discrete psychological phenomenon to the synthesis of discrete perception into an integrated representation of self and others. It has long been considered a problem underlying personality disorders (Dimaggio, Semerari, Carcione, Nicolò and Procacci, 2007, Dimaggio, Procacci, et al., 2007, Semerari et al., 2007, Semerari et al., 2003). Metacognition shares aspects in common with the construct of mentalization (Fonagy, Bateman, & Bateman, 2011) though the constructs diverge as mentalization is often considered in the context of attachment, while metacognition may be activated by any of a number of interpersonal motives and includes a specific focus on metacognitive mastery. Metacognitive mastery refers to the use of metacognitive knowledge to respond to psychological and social conflicts (Semerari et al., 2003, Semerari et al., 2007). Deficits in metacognitive mastery have been observed in persons with cluster C traits (Carcione et al., 2011, Dimaggio, Procacci, et al., 2007) and linked to outcome in a range of mental disorders including psychosis (Lysaker et al., 2010, Lysaker et al., 2011) and depression (Ladegaard, Larsen, Videbech, & Lysaker, submitted for publication) as well as medical conditions such as HIV (Ringer et al., submitted for publication).
To explore these possibilities, this study assessed alexithymia, metacognitive mastery and cluster C traits among a group of adults with substance use disorders. We predicted that alexithymia would be related to severity of cluster C traits, defined by the number of cluster traits, but that this relationship would be moderated by metacognitive mastery. Specifically, we anticipated that higher levels of cluster C traits would be found with participants with higher levels of alexithymia and lower levels of metacognitive mastery. To rule out the possibility that these findings were the result of heightened levels of psychopathology or severity of lifetime substance abuse we included these as covariates.
Section snippets
Participants
Fifty five men and three women with SCID confirmed DSM-IV diagnoses of a substance use disorder were recruited from a residential treatment center associated with VA Medical Center. Seventeen had a primary diagnosis of alcohol dependence, six of alcohol abuse, 31 of polysubstance dependence, two of opiate dependence and two of cocaine dependence. All participants were receiving ongoing treatment and in a post-acute or stable phase of their disorder, defined as no hospitalizations or changes in
Results
Mean scores for the key variables are presented in Table 1. The modal number of cluster C traits was 2 (n = 12), and the median 3. Twenty-six subjects had five or more cluster C traits. Number of cluster C traits was not significantly correlated with age (r = .05; p = ns), reported lifetime months of drug and alcohol use (r = 0.19, p = ns), education (r = 0.17; p = ns) or MAS-A Mastery scores (r = − 0.16; p = ns). Cluster C traits did not differ between participants with diagnoses of abuse vs. dependence, drug
Discussion
Results suggest that the relationship of alexithymia and severity of cluster C traits in a sample of persons with substance use disorders in early remission was moderated by metacognitive mastery, or the ability to use awareness of mental states to respond to emotional distress and solve interpersonal problems. Specifically, we found that relatively high levels of alexithymia were more closely linked with greater number of cluster C traits only in the presence of deficits in metacognitive
Role of funding source
This study was funded by the Indiana Institute for Medical Research. This body played no role in study design; the collection, analysis and interpretation of data, in the writing of the report; and in the decision to submit the paper for publication.
Contributors
Lysaker and Outcalt designed the study. Lysaker performed all data analysis. Lysaker, Olesek, Buck, Leonhardt, Vohs, Ringer, Dimaggio, Popolo and Outcalt contributed to the literature review and the manuscript preparation including interpretation of findings.
Conflict of interest
There are no conflicts of interest or disclosures.
References (30)
- et al.
The twenty-item Toronto Alexithymia Scale-I. Item selection and cross validation of the factor structure
Journal of Psychosomatic Research
(1994) - et al.
Metacognitive mastery dysfunctions in personality disorder psychotherapy
Psychiatry Research
(2011) - et al.
Is alexithymia a risk factor for major depression, personality disorder, or alcohol use disorders? A prospective population-based study
Journal of Psychosomatic Research
(2010) - et al.
Alexithymia in personality disorders: Correlations with symptoms and interpersonal functioning
Psychiatry Research
(2011) - et al.
Alexithymia and alcohol use disorders: A critical review
Addictive Behaviors
(2009) - et al.
Alexithymia, craving and attachment in a heavy drinking population
Addictive Behaviors
(2011) - et al.
Predicting individual differences in autonomy-connectedness: The role of body awareness, alexithymia, and assertiveness
Journal of Clinical Psychology
(2008) - et al.
An empirical evaluation of the structure of DSM-IV personality disorders in a nationally representative sample: Results of confirmatory factor analysis in the national epidemiologic survey on alcohol and related conditions waves 1 and 2
Journal of Personality Disorders
(2012) - et al.
The level of alexithymia in alcohol-dependent patients does not influence outcomes after inpatient treatment
American Journal of Drug and Alcohol Abuse
(2012) - et al.
Attachment styles in alcoholic inpatients
European Addiction Research
(2007)
Alcohol addiction and the attachment system: An empirical study of attachment style, alexithymia, and psychiatric disorders in alcoholic inpatients
Substance Use & Misuse
SCL-90-R, administration, scoring & procedures manual-I for the revised version
Poor metacognition in narcissistic and avoidant personality disorders: Analysis of four psychotherapy patients
Clinical Psychology & Psychotherapy
Psychotherapy of personality disorders: Metacognition, states of mind and interpersonal cycles
The widening scope of mentalization: A discussion
Psychology and Psychotherapy
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