Metacognitive mastery moderates the relationship of alexithymia with cluster C personality disorder traits in adults with substance use disorders

Highlights

• Cluster C personality disorder traits are common in substance use disorders.

• Alexithymia may result in the expression of cluster C traits.

• We tested if metacognition moderated the link of alexithymia with cluster C traits.

• These constructs were assessed in adults with substance abuse.

• More cluster C traits were found in persons with both alexithymia and poor mastery.

Abstract

Cluster C personality disorder traits have been observed in substance use disorders and linked with poorer outcome. One potential factor which may cause these disturbances in personality function is alexithymia, or the inability to name and express emotion. There may be other proximate factors which moderate the impact of alexithymia on the expression of cluster C traits, such as metacognitive mastery, which is the ability to use knowledge about mental states of self and others to cope with distress and solve social problems. To examine the possibility that mastery mediated the effects of alexithymia on cluster C traits, we assessed each of these constructs using the Metacognitive Assessment Scale Abbreviated, Toronto Alexithymia Scale and SCID II among 58 adults in an early phase of recovery from substance misuse disorders in a residential setting. Results of a multiple regression revealed that, after controlling for symptom severity and severity of substance misuse history, metacognitive mastery moderated the effect of alexithymia on number of cluster C traits. A median split and subsequent ANCOVA revealed that participants with higher levels of alexithymia and poorer metacognitive mastery had more cluster C traits than the other groups. These findings may have clinical implications, suggesting that patients with substance use disorders may benefit from treatment which addresses metacognitive mastery.

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.