Attachment Style, Alexithymia, and Psychiatric Disorders in Alcoholic Inpatients

This excellent article (1) presented the idea, formulated by Fonagy et al. (2002) that the way people’s attachment system is organized, corresponds both with their representational capacities and with their style of relating to others.

They combine a measurement of alcoholic inpatients’ adult attachment style and their degree of alexithymia.

Their results revealed “that it is reasonable to distinguish three subgroups of alcoholic inpatients: a group with an impaired attachment system manifesting itself in the incapacity to develop secure interpersonal relationships and problems with affect regulation (group 1), a group with a well-established attachment system characterized by the ability to form secure relationships and the capacity for affect regulation (group 3), and a group with a moderately functioning representational system with either difficulties in affect regulation or in interpersonal functioning (group 2).

We observed that the majority of the alcoholic inpatients were situated in group 1 (52%), a smaller number belonged to group 2 (34.5%), and only 13.5% could be placed in group 3. These results indicate that in our study, most of the alcoholic inpatients show moderate to high deficiencies in their attachment system, as a consequence of which we can hypothesize a lag in self-development and affect regulation. They are missing the capacity to form mental representations of self and others and as such lack the capability of interpersonal interpretation and affect regulation.

Subsequently, we explored whether these three groups differ in the severity of alcohol use-related problems.

We observed no differences among the groups.

This means that the impairment of the attachment system does not correspond with the severity or duration of problematic alcohol use. The disturbance of the attachment system is not a side effect of the alcohol use problem itself; neither is it a result of cognitive and social impairment due to chronic alcohol use.

This result implies that it is reasonable to consider disturbances in organization of the attachment system independent of the severity of the problematic alcohol use itself. It also suggests that the disruption of the attachment system stems from a time before the alcohol use problem started, and that it can be thought of as a developmental problem.

With regard to symptoms of psychiatric disorders commonly found in alcoholic inpatients (anxiety, depression, personality disorders), meaningful distinctions among the three groups were found.

…We found that the more impaired an alcoholic inpatient’s attachment system and the more severe the trait anxiety and the depressive symptoms, the higher the scores on the traits of avoidant, schizoid, and depressive personality disorders, but the lower the scores on symptoms of dependent personality disorder.

As there were no differences among the groups with regard to the duration and onset of alcohol misuse, the associated psychiatric disorders were not seen as consequences of the alcohol abuse. These results suggest that psychiatric symptoms commonly associated with alcoholism correspond dynamically with the degree of impairment of the attachment and representational system. These results are in line with the attachment literature that points to a strong association between attachment disturbances and psychiatric disorders (Fonagy, 2001; Fonagy et al., 2002).

Within current psychiatric thinking (American Psychiatric Association, 2000), a personality disorder is identified by a pattern of inner experience and behavior that is abnormal with respect to any two of the following: (1) the way one perceives and thinks about oneself and others (cognitions), (2) the range, intensity, liability, and adequacy of emotional reactions (affects), (3) interpersonal functioning, and (4) impulse control. It can be noted that similar variables to the ones taken into account by current attachment theory (i.e., disturbances in affect regulation and interpersonal functioning) occupy an important place in the conceptualization of personality disorders.

The statistically significant association we observed between the degree of disturbance of the attachment system and the presence of symptoms of personality disorders not only illustrates the clinical validity of the clustering we made, but, more importantly, suggests that a disturbed attachment has serious psychiatric consequences.

The pattern of correspondence between the symptoms of personality disorders and the increased impairment of the attachment system can be interpreted through the work of Stein et al. (2002), who view attachment in terms of underlying dimensions of insecurity and strategies for coping with insecurity in relationships. These authors indicate that the two main ways for dealing with insecurity are: either shutting down or hyperactivating the attachment system. Our results show that alcoholic inpatients with an impaired attachment system are clearly shut down from others. This is in line with psychoanalytic theories highlighting the exclusion of the other as an important function of alcohol consumption (Loose, 2002; Verhaeghe, 2004).

Moreover, our results clearly show that because of a disruption in the relation to signifying others, those subjects with a deficient attachment system not only fail to rely on others, but also fail to develop a representational handling of their affects and have to fall back on a nonrepresentational way of handling them such as the use of alcohol (Loose, 2002; Verhaeghe, 2004).

That alcohol is used to alter affective states that are experienced as unbearable has especially been elaborated in self-psychology and object relation theories. Furthermore, the unbearable and overwhelming nature of these affective states has been related to the lack of psychic representation that has its roots in the early child–caregiver relationship (Johnson, 1999; Morgenstern and Leeds, 1993).

Interpreting our results from a psychoanalytical point of view, we suggest that alcoholic inpatients can be placed on a continuum of psychic development with insecure attachment and alexithymia (severe impaired attachment system) at one end and secure attachment and alexithymia (well-established representational system) at the other.

We also suggest that the patient’s position on this continuum is of primary importance for treatment. Depending on where the patient is located on this continuum, treatment should balance between a sociotherapeutic and a psychotherapeutic stance. The latter, in focusing especially on the content of self and interpersonal interpretations, is only possible in case of a well-established representational system.

While in the case of a deficient symbolic representational system, treatment should primarily focus on the installation or restoration of this system by creating a secure environment in which secondary-order representations can be constructed and meaning can come into being.

Reference

1. De Rick, A., Vanheule, S., & Verhaeghe, P. (2009). Alcohol addiction and the attachment system: an empirical study of attachment style, alexithymia, and psychiatric disorders in alcoholic inpatients. Substance use & misuse, 44(1), 99-114.