Tuesday, January 24, 2012

Substance abuse and alexithemia

In substance use disorders (SUD), alexithymia rates of up to 67% have been reported, but evaluations of therapy in alexithymic SUD patients are scarce. Group cognitive behaviour therapy (CBT) was relatively successful in high-scoring alexithymic SUD patients, but alexithymia was associated with a lower attrition rate and with a larger Addiction Severity Index (ASI) alcohol composite score at follow-up.

From a clinical point of view the Authors of this study were interested in the predictive value of alexithymia at baseline on recovery. They hypothesized a negative relation of alexithymia with outcomes, which would be a strong argument for addressing alexithymia at intake and adjusting therapy for highly alexithymic patients. A total of 187 abstinent SUD inpatients were assessed at baseline by the Dutch version of the Toronto Alexithymia Scale (TAS-20) and the European ASI (EuropASI) at baseline and 3-month follow-up after an inpatient CBT as usual (CBT-TAU group) or CBT with shared decision making intervention (SDMI) (CBT-SDMI group).

All patients have been diagnosed according to the DSM-IV-TR as having 1 or more substance-related disorders. The mean score on the TAS-20 at baseline was 55.7 (SD = 11.3). According to the cutoff score, 36.9% were highly alexithymic and 33.2% were low scoring alexithymics. Highly alexithymic patients had fewer years of education [p =0.05] and were more often unemployed [p = 0.05] than low-scoring alexithymics.

Highscoring alexithymics showed more problems in the ‘work, income and education’ [p= 0.04] and ‘psychiatry’ domains [p<0.001]. The mean time of treatment (in days) for highly alexithymic patients (116.0, SD = 58.9) was not different from that for low scoring alexithymics [p = 0.26], and also the rate of completers was similar between high- (50.7%) and low-scoring alexithymics [p=0.41]. Fifty-four percent of the high-scoring, and 45.7% of the low-scoring alexithymics were abstinent at follow-up [p=0.41].

As concerns the Europ-ASI, differences between baseline high- and low-scoring alexithymic patients were found for the ‘work, income and education’ domain in the CBT-SDMI group, and for the ‘family and social relations’ and ‘drugs’ domains in the CBT-TAU group.

Overall, highly alexithymic patients improved on the EuropASI change scores at least equally well as low-scoring alexithymic patients, and alexithymia as a continuous score was predominantly positively associated with these change scores.

The results of this study show that highly alexithymic SUD patients can profit from CBT with or without SDMI, and that the degree of alexithymia is not negatively related to resulting outcomes. Limitations of this study were the absence of systematic urine or blood samples to confirm abstinence, and not having performed multimethod alexithymia assessments with an observer scale included.

However, in answering the question on whether a highly alexithymic SUD patient should be treated differently at the beginning of treatment, the Authors made use of the two extremes of categorical classification of alexithymia. As highly alexithymic SUD patients performed very well and alexithymia was associated with the treatment outcomes, CBT may be used in this population even if patients present alexithymic features at intervention entry.


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