Attachment Style, Alexithymia, and Psychiatric Disorders in Alcoholic Inpatients

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How Insecure Attachment Creates the Emptiness Within? 

This article (1) is one of the most profound studies into the effects of insecure attachment on alcohol dependence and co-occurring disorders. As such I would urge you to read it as it appears to satisfactorily explain possible mechanisms by which  insecure attachment creates the emotion (self) regulation and processing deficits in alcoholics which we have discussed many times before but also the co-occurring disorders which often accompany alcoholism and addiction.

There seems to be an aetiology here from insecure attachment (often accompanied by abuse, trauma) which results in the emotion processing deficits (e.g. alexithymia) and dysregulation which are often  characteristics of addicts and alcoholics.

Although we do not mention it here, the study also stated that alexthymia could be present in those with secure attachment also. As we are aware,  chronic substance abuse can also alter emotion processing and regulation. So this emotion dysregulation appears to be at the heart of addiction regardless of attachment and upbringing.

It may result, however,  in more a severe addiction in terms of having to treat  the more multitudinous aspects of addiction prompted by insecure attachment and trauma.

Either way, articles like this solidify our theoretical conception of addictive behaviour as an affective disorder prompted mainly by a developmental delay in affective and interpersonal (self) regulation.

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Alcohol Addiction and the Attachment System: An Empirical Study of Attachment Style, Alexithymia, and Psychiatric Disorders in Alcoholic Inpatients

“…attachment theory has important commonalities with psychoanalytic theory, which states that ego development and drive regulation take place in relation to significant others (Fonagy et al., 2002; Green, 1972, 2004; Verhaeghe, 2004). Notwithstanding the similarities in focusing on interpersonal and representational processes that underlie identity formation and affect regulation, attachment theory has elaborated in considerable detail the possible failures of these processes as well as their consequences with respect to broader mental and interpersonal functioning.

Since many persons with alcohol use-related problems also experience problems in establishing healthy interpersonal relationships (Dumbrava, 2000; Flores, 2004) and in regulating their emotions (Taieb et al., 2002), we wonder if attachment theory as reformulated by Fonagy et al. (2002) can shed new light on the phenomenon of alcohol addiction and especially on its high comorbidity with other psychiatric problems such as anxiety, depression, and personality disorders. Until now, empirical research on people manifesting alcohol use-related problems has focused either on the attachment style — meaning their ability or inability to feel secure in relation to others — or on their problems in regulating affects. The latter issue has especially been explained by the concept of alexithymia, which refers to difficulties with recognizing, processing, and regulating emotions (Taylor, Bagby, and Parker, 1997)…

We first examined whether it was reasonable to differentiate among subgroups of alcoholic inpatients, based on a combined assessment of their attachment style and their degree of alexithymia. We hypothesized that this indeed is the case. Second, we explored whether these groups differ with respect to the severity of alcohol use-related problems as assessed clinically by means of the EuropASI (European Addiction Severity Index) on the one hand, and anxiety, depression, and personality disorders (psychiatric disorders are commonly associated with addiction) on the other…


In this article we 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. We did so by combining a measurement of alcoholic inpatients’ adult attachment style and their degree of alexithymia. Latent class cluster analyses 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)…

gradations in the degree of disturbance of the attachment system can meaningfully be discerned.

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.

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. Our results revealed that the three groups differed in significant ways on severity of trait anxiety, severity of depressive symptoms, and the personality traits of the DSM-IV schizoid, avoidant, dependent, and depressive personality disorders. Exploring these differences in more detail 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.

Our observation that trait anxiety (a general tendency to respond with anxiety to threats in the environment) and not state anxiety (anxiety as a transient phenomenon) is significantly associated with disturbance of the attachment system indicates that in case of an impaired attachment system, problems in regulating anxiety are stable and ingrained rather than fluctuating. The association of attachment impairment with symptoms of personality disorders in its turn illustrates the pervasiveness of the impairment. 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.

… the presence of symptoms of personality disorders…importantly, suggests that a disturbed attachment has serious psychiatric consequences. At a detailed level, we observed that the schizoid and depressive personality traits, but especially the avoidant, correspond significantly and positively with deficiencies in the attachment system.

Symptoms of dependent personality disorders, on the other hand, were negatively associated. This pattern of association suggests that systematic avoidance or more radical indifferent seclusion from others with whom a significant bond could develop is highly significant. The possibility of dependency is warded off.

The subjective price paid for this type of evasion seems to be depressive emptiness, which is indicated both in the presence of elevated scores for depressive symptoms and in depressive personality traits in cases of a more severely impaired attachment system. As such it seems that this kind of depression, with its accent on emptiness, is different from a reactive depression. The depressive emptiness could very well be the final result of the lack of representational coping abilities.

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).

Within this line of reasoning, it may be obvious that a range of alcohol use-related problems cannot be classified under the category of classic psychopathology. Whereas in the latter, inner conflicts are handled through the construction of meaningful symptoms in relation to others, this is clearly not the case for alcoholic inpatients with severe or moderate deficiencies in their symbolic representational system.


  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.

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