|Ahead of print publication
A case series of study of childhood psychological trauma and alexithymia among persons with alcohol dependence syndrome attending inpatient de-addiction facility from central rural India
Ajinkya Sureshrao Ghogare1, Pradeep Shriram Patil1, Ganpatlal Kodarbhai Vankar2
1 Department of Psychiatry, Jawaharlal Nehru Medical College, Datta Meghe Institute of Medical Sciences (Deemed to be University), Sawangi (Meghe), Wardha, Maharashtra, India
2 Department of Psychiatry, Parul Institute of Medical Sciences and Research, Parul University, Vadodara, Gujarat, India
|Date of Submission||04-Apr-2021|
|Date of Decision||02-May-2021|
|Date of Acceptance||30-May-2021|
|Date of Web Publication||05-Aug-2021|
Ajinkya Sureshrao Ghogare,
PhD Scholar and Assistant Professor, Department of Psychiatry, Jawaharlal Nehru Medical College, Datta Meghe Institute of Medical Sciences (Deemed to be University), Sawangi (Meghe), Wardha, Maharashtra
Source of Support: None, Conflict of Interest: None
Psychological trauma occurs when a person suffers from serious threat or loss to his/her life. Childhood psychological trauma can be of various forms such as physical abuse, sexual abuse, emotional abuse, physical neglect, and emotional neglect. Such adverse childhood experiences, if not effectively dealt or resolved, may lead to the development of drug dependence including alcohol dependence syndrome (ADS) in adult life. In many cases, development of ADS is preceded by the occurrence of childhood psychological trauma(s). Such a person with a history of childhood psychological traumas may consume alcohol to cope with his/her trauma-related distress. Alexithymia is a state characterized by a triad of difficulty in identifying one's own feelings, difficulty in differentiating between physical sensations and emotional arousal, and difficulty in explaining one's own feelings to others. Alexithymia has a role in the development of drug dependence including ADS. The number of childhood psychological trauma among persons with ADS was associated with alexithymia in adulthood. Childhood psychological traumas, mainly emotional abuse, might act as a predisposing factor for the development of alexithymia in persons suffering from ADS. This case series presented clinical picture of two individuals with ADS in which both childhood psychological trauma(s) and alexithymia were assessed by using standard and psychometrically valid psychological tools such as Childhood Trauma Questionnaire and Toronto Alexithymia Scale-20 item, respectively. This case series is unique because the assessment of childhood psychological trauma(s) and alexithymia is neglected area in Indian psychiatric research field and detailed ample of literature is not available at present in which the relationship between childhood psychological traumas, alexithymia, and ADS has been assessed. In the present case series, first individual with ADS had clinically significant alexithymia, severe emotional abuse, severe emotional neglect, moderate physical abuse, and moderate physical neglect, while second individual with ADS had no alexithymia but he had moderate-level emotional neglect and mild levels of emotional abuse, physical abuse, and physical neglect.
Keywords: Alcoholism, emotional abuse, emotional dysregulation, emotional neglect, physical abuse, physical neglect, sexual abuse
|How to cite this URL:|
Ghogare AS, Patil PS, Vankar GK. A case series of study of childhood psychological trauma and alexithymia among persons with alcohol dependence syndrome attending inpatient de-addiction facility from central rural India. Ann Indian Psychiatry [Epub ahead of print] [cited 2022 Aug 9]. Available from: https://www.anip.co.in/preprintarticle.asp?id=323186
| Introduction|| |
Alcohol dependence syndrome (ADS) is defined as per the International Classification of Mental and Behavioral Disorders 10th Revision Diagnostic Criteria for Research (ICD 10-DCR) as a pattern of alcohol consumption, leading to clinically significant impairment over a period of 1–12 months. ADS is one of the most prevalent psychiatric disorders among all societies across the world.,,,, ADS is characterized by the impairment in behavioral, cognitive, and physiological domains.,,, The prevalence of ADS among Indian males is 9.1%. The prevalence of heavy episodic drinking among Indian males above 15 years of age is 28.4%, while the prevalence is 55.1% among Indian male drinkers. An ADS in India is especially important to watch out for as consumption of country liquor is higher among rural population. A study from East Rural India reported current alcohol consumption in 19% of men and 2.4% of women. Persons with ADS generally consume alcohol over a longer period in greater amounts than intended. They tend to have unsuccessful efforts and persistent desire to reduce their alcohol consumption. They often spend greater amount of time in activities such as obtaining, consuming, and recovering from effects of alcohol. Over a period of time, they often develop a strong desire or craving to consume alcohol repeatedly. Recurrent alcohol consumption leads to failure in fulfilling important role obligations at home or at work. Alcohol use persists despite having awareness about alcohol-induced/exacerbated recurrent and persistent personal as well as interpersonal problems. Persons with ADS often give up important social, recreational, and occupational activities at an expense of recurrent and persistent alcohol consumption. They often consume alcohol in physically hazardous situations such as driving a vehicle under the influence of alcohol, which may lead to fatal road traffic accidents. In ADS, alcohol use becomes recurrent and persistent despite recurrent and persistent psychological and/or physical problems that are either caused or exacerbated by alcohol consumption. Later on, the persistent alcohol consumption leads to tolerance. Finally, persistent consumption of alcohol lands a person into alcohol withdrawal when a person suddenly stops or reduces the quantity of alcohol use. Uncomplicated alcohol withdrawal is characterized by the symptoms of sympathetic hyperactivity such as hand tremors, palpitation, insomnia and anxiety. Complicated alcohol withdrawal is characterized by visual and/or auditory hallucinations, generalized tonic–clonic seizure (GTCS), and delirium tremens. Early-onset drinking is defined as onset of consumption of alcohol before an age of 22 years. Binge drinking is defined as five or more drinks on a single occasion in a prior 1-month period. In the present study, severity of ADS was divided into mild, moderate, and severe levels based on scores of severity of alcohol dependence questionnaire (SADQ). On SADQ, scores of <16, 16–30, and 31 or higher indicate mild, moderate, and severe alcohol dependence, respectively. In the present study, severity of alcohol withdrawal was assessed by using Clinical Institute Withdrawal Assessment of Alcohol Scale–Revised (CIWA–Ar). On CIWA-Ar, the scores of 0–9, 10–19, and 20 or more indicate absent/minimal, mild-to-moderate, and severe alcohol withdrawal, respectively.
A study had observed that the number of childhood psychological trauma among persons with ADS was associated with alexithymia in later life. The same study observed that out of three components of alexithymia, “difficulty in identifying feelings (DIF)” as assessed by Toronto Alexithymia Scale-20 item (TAS-20) was associated with a history of childhood psychological trauma. The same study concluded that childhood emotional abuse might act as a predisposing factor for alexithymia development in persons with ADS.
Psychological trauma occurs typically when a person's life is under jeopardy or when experiences a serious loss. If such psychological trauma occurred during childhood is neither resolved nor dealt effectively, then it may predispose that person to drug addictions including ADS. Hence, it is evident from available literature that psychological traumas during childhood may trigger or precipitate psychological issues in later life including ADS. Such persons with a history of childhood psychological trauma may consume alcohol to cope with their trauma-related negative experiences. Hence, on most occasions, the onset of ADS is preceded by occurrence of childhood trauma(s). From available literature, it has been evident that a strong positive link exists between an exposure to childhood psychological trauma(s) and occurrence of ADS during adulthood. Childhood trauma may occur in about 89% of persons with substance dependence, and substance use including ADS is 1.5–5.5 times more prevalent among persons with a history of childhood psychological trauma(s) than those without such history. Childhood psychological trauma includes various forms such as emotional abuse, physical abuse, sexual abuse, emotional neglect, and physical neglect, and each of them is divided into various levels of severity such as mild, moderate, severe, and extreme based on scores of childhood trauma questionnaire (CTQ). In the present study, the presence and severity of childhood psychological traumas were assessed retrospectively by using CTQ. On CTQ, the cutoff scores for sexual abuse, physical abuse, emotional abuse, physical neglect, and emotional neglect are ≥8, ≥8, ≥10, ≥8, and ≥15, respectively., For the present study, CTQ was purchased from Pearson India for research purpose as it is copyrighted.
Sifneos was first to describe alexithymia in persons with psychosomatic illnesses. Alexithymia manifests with “a relative paucity of fantasy life or day-dreaming, impaired emotional functioning, and difficulty in finding right words to express one's own emotions known as externally oriented style of thinking.” Alexithymia is a state characterized by a triad of “difficulty in identifying one's own feelings, difficulty in differentiating between emotional arousal and physical sensations, and difficulty in explaining one's own feelings to others.” In the present study, alexithymia was assessed by using TAS-20. TAS-20 has three subscales: (i) DIF, (ii) difficulty describing feelings, and (iii) externally oriented thinking. Based on TAS-20 scores, alexithymia is divided into three different levels such as clinically significant, borderline, and no alexithymia. On TAS-20, scores of more than 61, 52–61, and 51 or below indicated clinically significant, borderline, and no alexithymia, respectively., For the present study, permission from author of TAS-20 was obtained regarding the use of TAS-20 for research purpose.
At present, there is no literature available in the Indian psychiatric research field where a relationship between childhood psychological trauma and alexithymia has been assessed among persons with ADS. Hence, this case series is unique in a way that it has an aim of assessment of relationship between the level of alexithymia and presence as well as severity of childhood psychological trauma among persons with ADS. The theme of conducting present study related to Doctor of Philosophy (PhD) in Psychiatry is explained in detail in the “research protocol”, and explained in brief in “[Figure 1]”.
| Case Series|| |
Index person was a 43-year-old divorced male, farmer by occupation, who presented with his mother to drug de-addiction unit with the presentation of disturbed sleep, tremulousness of hands, hearing of voices not heard by others, seeing images not seen by others, fearfulness, sweating, and one episode of GTCS. The symptoms were for the past 3 days and an episode of GTCS occurred on the 2nd day. His last alcohol consumption was 4 days back when he had consumed four quarters of country liquor. He was diagnosed as a case of ADS with complicated alcohol withdrawal based on the ICD-10-DCR diagnostic criteria. On SADQ, he scored 40 which was suggestive of severe alcohol dependence. On CIWA-Ar, he scored 27 which was suggestive of severe alcohol withdrawal. He was started on intravenous lorazepam 12 mg/day on day of hospitalization which was slowly tapered off over a period of 1 week. He was also given intravenous fluids support. Along with it, he was given intravenous thiamine in a dose of 300 mg/day. After 1 week, his CIWA-Ar score was reduced to 9, which was suggestive of the absence of alcohol withdrawal. After initial 1 week detoxification, he was shifted on oral thiamine in a dose of 200 mg/day. After an initial period of 1 week detoxification, he was assessed in detail regarding history of alcohol consumption, childhood trauma, and alexithymia. He had a history of alcohol consumption for the last 27 years, i.e., started consuming alcohol at an age of 16 years which was suggestive of early onset of drinking. According to him, he was compelled by his father to take the first drink of his life when his father was under the influence of alcohol. He had consumed about 30 ml of country liquor at that time against his will. According to index person and his mother, his father had alcohol dependence who used to be daily drinker. According to them, under the influence of alcohol, father used to become verbally as well as physically abusive towards index person as well as other family members. For an initial 5-year period, according to the index person, he had binge drinking and was consuming alcohol once or twice in a month without company of others. He admitted that, at times, he had stolen alcohol from his father's pocket at home. According to index person and his mother, they were the constant targets of physical and verbal abuse of the father who had ADS. Throughout the day, he used to feel frustrated because of his father's behavior and on multiple times had physical fights with the father. He was not able to cope with his father's behavior, and to get relief on his friend's advice, he started consuming alcohol on a daily basis. Then, he started consuming liquor on a daily basis along with his friends and started consuming about 90 ml/day. Gradually, consumption of country liquor went on increasing to the current quantity of 300 ml/day. In the last 4 years, whenever he tried to suddenly stop or reduce the quantity of alcohol consumption, he tend to had complicated alcohol withdrawal episodes such as tremulousness of hands, sleep disturbances, sweating, palpitations, visual and auditory hallucinations, and GTCS episodes. On multiple occasions, he was admitted in hospitals for detoxification for alcohol withdrawal episodes. His father died 5 years back due to alcohol-related liver disease. He got divorced 3 years back due to alleged conflicts with his spouse due to alcohol consumption. He was assessed for alexithymia by using TAS-20 and for childhood trauma retrospectively by using CTQ. On TAS-20, he had a score of 65 which was suggestive of clinically significant alexithymia. He was then assessed retrospectively for childhood psychological trauma by using CTQ. On CTQ, he had scores suggestive of severe emotional abuse, severe emotional neglect, moderate physical abuse, and moderate physical neglect.
Index person was a 42-year-old married male, teacher by occupation, presented with his spouse to drug de-addiction unit with the presentation of disturbed sleep, tremulousness of hands, sweating, palpitations, and anxiety for the last 2 days. His last alcohol intake was 3 days back. He was diagnosed as a case of ADS with uncomplicated alcohol withdrawal based on the ICD-10-DCR diagnostic criteria. On SADQ, he scored 30 which was suggestive of moderate alcohol dependence. On CIWA-Ar, he scored 19 which was suggestive of moderate alcohol withdrawal. He was started on oral lorazepam in a dose of 10 mg/day on day of hospitalization which was gradually tapered off over a period of 1 week. Along with it, he was given oral thiamine in a dose of 200 mg/day. After initial 1-week detoxification period, he was shifted to oral thiamine in a dose of 100 mg/day. After an initial 1-week period of detoxification, his CIWA-Ar score dropped down to 7 which was suggestive of the absence of alcohol withdrawal. After detoxification phase, he was assessed in detail regarding history of alcohol consumption, childhood trauma, and alexithymia. He had a history of alcohol consumption for the last 17 years, i.e., started consuming alcohol at an age of 25 years which was suggestive of late onset of alcoholism. He had started consuming alcohol secondary to worrying thoughts about alleged verbal as well as physical conflicts between his parents over an issue of alcohol consumption by his father. According to index person and his spouse, his father had a history of alcohol consumption which was suggestive of ADS and under influence of alcohol his father used to verbally and physically abuse index person's mother as well as other family members such as index person, his spouse, and his younger brother. To cope with pathological home environment, he started consuming country liquor. Initially, he started consuming one quarter of beer once in a week on weekend for initial 1-year period. Gradually, over the next 2 years, he started consuming one quarter of beer every day in the evening. However, due to financial constraints, he then shifted to country liquor as it was available in a cheaper prize as compared to beer. Over the last 14 years, he has been consuming country liquor on every day, about two- to three-quarters throughout the day. Over the last 8 years, whenever he tried to suddenly stop or suddenly reduce the quantity of his alcohol consumption, he tend to develop alcohol withdrawal episodes on multiple occasions in the form of sympathetic hyperactivity symptoms such as insomnia, hand tremors, sweating, anxiety, and palpitations. Due to multiple alcohol withdrawal episodes, he has taken multiple leaves from his teaching job and was suspended from job on two occasions. Due to persistent and increased alcohol consumption, there occurred alleged conflicts between him and his spouse. On TAS-20, he had scored 50 which was suggestive of the absence of alexithymia. Based on scores of CTQ, he had moderate-level emotional neglect and mild levels of emotional abuse, physical abuse, and physical neglect.
| Discussion|| |
In the present case series, first individual with ADS had clinically significant alexithymia while the second individual had no alexithymia. First individual with ADS who had clinically significant alexithymia had severe emotional abuse, severe emotional neglect, moderate physical abuse, and moderate physical neglect. Second individual with ADS who was non-alexithymic had moderate emotional neglect and mild emotional abuse, physical abuse, and physical neglect. These findings suggest that an individual with ADS who had clinically significant alexithymia had higher severity of multiple childhood psychological traumas as assessed by TAS-20 and CTQ, respectively.
Evren et al. found the similar finding to the present study that among individuals with ADS, the number of childhood psychological trauma was associated with alexithymia in adult life. The same study observed that DIF component of alexithymia as assessed by TAS-20 scale was associated with a history of childhood psychological trauma. They conclude that childhood emotional abuse acts as a predisposing factor for the development of alexithymia in individuals with ADS. If childhood psychological trauma is neither resolved nor dealt effectively, then it may lead to development of ADS in later life as such individuals tend to consume alcohol to cope with their childhood psychological trauma-related experiences. In the present case series, both individuals had family history of ADS in their fathers, i.e., both were children of alcoholics (COAs) and their psychological assessment was suggestive of occurrence of childhood psychological traumas. Similar finding was observed by another study which concluded that COAs were exposed to emotional, physical, and verbal abuse at the hands of their fathers who had ADS. From the available literature, it has been evident that COAs were more likely to develop alcohol and drug abuse with particular greater risk among boys, which was similar to the present study finding. About 89% of persons with ADS tend to have had history of childhood psychological trauma, and among those with childhood psychological trauma, ADS is 1.5–5.5. times more prevalent., The prevalence rate of alexithymia among persons with ADS is between 45% and 67%. A study has found that male COAs had emotional problems which might later manifest as alexithymia and may predispose such COAs to the development of ADS in them.
This study has few limitations. First limitation includes the social desirability bias. Social desirability bias comes in play when individuals are asked about the history of their past and current alcohol consumption, answer in such a way as to reflect themselves in a good light in view of others, and give falsifying history such as reducing the amount and duration of alcohol consumption in their interview with examiner. We had tried to reduce the social desirability bias, by encouraging the participants to give honest details regarding their history of alcohol consumption. Second limitation includes recall bias. Recall bias might be there like difficulty in remembering about the childhood trauma. Recall bias could affect accurate scoring of CTQ. By keeping in view this fact, we not only tried to encourage participants to get comfortable with examiner as well as study setting but also tried to provide them adequate time so that they were able to answer the questions during their interview.
| Conclusion|| |
Significant relationship exists between level of alexithymia and presence as well as severity of childhood psychological traumas among individuals with ADS. Individual with ADS who had clinically significant alexithymia tend to have more severe childhood psychological traumas than those with ADS without alexithymia.
This study was approved by the institutional ethics committee (IEC) with reference number of DMIMS(DU)/IEC/Dec-2019/8549, dated December 16, 2019.
Declaration of patient consent
The authors certify that they have obtained all appropriate individual consent forms. In the form, individuals had given consent for clinical information to be reported in the journal. Index individuals understand that the names and initials will not be published, and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
The present case series is related to PhD project in Psychiatry. We sincerely thank to individuals who participated in this research project.
Financial support and sponsorship
The present study was supported financially by the Institutional Grant for purchasing CTQ for PhD project in Psychiatry with purchase order (PO) number: (PO No. 59931, dated December 19, 2020).
Conflicts of interest
There are no conflicts of interest.
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