|Ahead of print publication
A systematic review of childhood psychological traumas and alexithymia among persons with alcohol dependence syndrome
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, Wardha, Maharashtra, India
2 Department of Psychiatry, Parul Institute of Medical Sciences and Research, Parul University, Vadodara, Gujarat, India
|Date of Submission||07-May-2021|
|Date of Decision||30-May-2021|
|Date of Acceptance||10-Jun-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 traumas may occur during childhood in the form of physical abuse, sexual abuse, emotional abuse, physical neglect, and/or emotional neglect. Trauma may be experienced when a person experiences serious loss or his/her life is under grave threat. If such traumatic event is neither dealt effectively nor resolved completely, it may predispose such a person to development of mental health issues such as drug dependence including alcohol dependence syndrome (ADS). Persons who experience or suffer from childhood psychological trauma tend to consume alcohol in order to cope with their trauma related experiences. Hence, generally, onset of alcohol dependence is preceded by the occurrence of childhood psychological trauma(s). Childhood psychological trauma especially emotional abuse acts as a risk factor for the development of alexithymia in later life among persons with alcohol dependence. Alexithymia is a state of emotional dysregulation, which is characterized by the triad of difficulty in identifying one's own feelings, difficulty in distinguishing between the physical sensation and emotional arousal, and difficulty in explaining one's own feelings to others, which is known as externally oriented style of thinking. Alexithymia is itself a risk factor for the development of ADS. Thus, both childhood psychological trauma(s) and alexithymia play a significant role in the development of ADS. Findings of the present study showed that childhood psychological trauma(s), alexithymia, and ADS are interconnected. The present study findings conclude that significant relationship exists between childhood psychological traumas, alexithymia, and ADS.
Keywords: Alcoholism, alexithymia, emotional abuse, emotional neglect, physical abuse, physical neglect, sexual abuse
|How to cite this URL:|
Ghogare AS, Patil PS, Vankar GK. A systematic review of childhood psychological traumas and alexithymia among persons with alcohol dependence syndrome. Ann Indian Psychiatry [Epub ahead of print] [cited 2022 Jan 24]. Available from: https://www.anip.co.in/preprintarticle.asp?id=323188
| Introduction|| |
What is alcohol dependence syndrome?
Alcohol dependence syndrome (ADS) is a diagnostic terminology in International Classification of Diseases 10th edition Diagnostic Criteria for Research (ICD–10–DCR). As per the ICD 10-DCR diagnostic criteria, persons with ADS have problematic pattern of alcohol consumption, which leads to clinically significant impairment over a period from 1 month to 12 months., An operational definition of ADS incorporates a cluster of behavioral, cognitive, and physiological symptoms, in which alcohol consumption takes on a much higher priority for that individual than other behaviors which once had a greater value. These individuals often consume alcohol in larger amounts over a longer period of time than intended, and there is persistent desire or unsuccessful efforts to reduce or control the alcohol consumption. Such individuals spend more time in activities related to obtaining alcohol, consuming alcohol, or even recovering from its deleterious effects on their bodies and mind. They also develop craving or strong desire to consume alcohol recurrently. Such recurrent alcohol consumption results in their failure to fulfill important role obligations at work or at home. Individuals with ADS drink alcohol continuously despite having knowledge about alcohol-induced or exacerbated persistent and recurrent interpersonal as well as social problems. As the duration and severity of ADS increases, important social, occupational, or recreational activities are given up or reduced due to alcohol use. Alcohol use becomes recurrent in situations in which it is physically hazardous and alcohol use remains persistent despite persistent/recurrent physical and/or psychological disturbances that have been caused/exacerbated by alcohol use. Finally, continued alcohol use leads to tolerance, and when a patient rapidly decreases or stops drinking alcohol, he/she lands up into alcohol withdrawal.
Status and prevalence of alcohol dependence syndrome in India
ADS is widely prevalent across the globe including India. According to the recent global status report of the WHO on alcohol and health, the prevalence of alcohol dependence among Indian males is 9.1%, the prevalence of heavy episodic drinking among Indian males of age 15 and above is 28.4%, and the prevalence of heavy episodic drinking among Indian male drinkers only is 55.1%. An Indian study had found that the pattern of alcohol consumption had varied according to age, education level, religion, and type of drink. The same study had concluded that the alcohol consumption pattern had also varied between different societies and cultures with extensive changes in pattern of alcohol consumption over the last 20 years. In India, around 3 million people with ADS had died in 2016 and the consumption of alcohol per capita had doubled from 2005 (2.4 liters) to 2016 (5.7 liters) with 4.2 liters being consumed by males and 1.5 liters being consumed by females.
Mental health hazards of alcohol dependence syndrome
Apart from physical health hazards, the chronic alcohol consumption can lead to mental health hazards in the form of cognitive impairment,, impairment in sexual functioning, and other mental health issues such as alcohol-induced sleep disorders, psychotic disorders, and mood disorders.
An impact of childhood psychological traumas among the persons with alcohol dependence syndrome
Occurrence of childhood psychological trauma generally precedes the onset of ADS. Early onset alcoholism or type B alcoholism, i.e. consumption of alcohol prior to an age of 22 years, is generally associated with much higher psychopathology like many childhood risk factors such as childhood psychological traumas, severe alcohol dependence, early onset of alcohol-related problems, disrupted and pathological home environment, a strong family history of alcoholism, frequent polysubstance abuse, a long history of alcohol treatment, and a lot of severe life stresses., Trauma occurs typically when a person's life is either in a serious loss or under the serious threat. Childhood trauma existed in various forms such as physical abuse, emotional abuse, sexual abuse, physical neglect, and emotional neglect.
If childhood psychological traumatic experiences are neither resolved nor dealt with effectively, such a person can't cope with such painful experiences and may fall victim to the development of mental health issues, including ADS in later life. They tend to consume drugs including alcohol to cope with their traumatic experiences. Hence, most of the time, occurrence of childhood psychological trauma precedes the onset of ADS. A study had found a strong positive relationship between exposure to childhood psychological traumas and development of ADS later in life.
Prevalence of childhood psychological traumas among the persons with alcohol dependence syndrome
The prevalence of traumatic events among persons with ADS is as high as 89% and alcohol use is 1.5–5.5 times more prevalent among persons with a history of trauma than those without trauma.,
An impact of alexithymia among the persons with alcohol dependence syndrome
Alexithymia was first described in a population of persons with psychosomatic illnesses by Sifneos. It is a state characterized by a triad of difficulty in identifying one's own feelings, difficulty in distinguishing between the physical sensations and emotional arousal, and difficulty in explaining feelings to others known as externally oriented style of thinking.,
Few studies had demonstrated that the link existed between alexithymia and craving for various substances of dependence including ADS., Another study had observed that the significant relationship existed between childhood psychological trauma and alexithymia among males with ADS.
Prevalence of alexithymia among the persons with alcohol dependence syndrome
According to a study, the prevalence of alexithymia among persons with ADS is 43.5%. The prevalence of alexithymia among persons with ADS is 45% to 67% as compared to only 5% to 17% in the general population.
Link between childhood psychological traumas and alexithymia among the persons with alcohol dependence syndrome
According to the study, the number of childhood psychological traumas among the persons with ADS was associated with alexithymia during adulthood. The same study had concluded that among the three components of triad of alexithymia, a single component of “difficulty in identifying one's own feelings (DIF)” of Toronto alexithymia scale–20 item (TAS–20) was associated with the history of childhood psychological trauma. The same study also concluded that childhood emotional abuse was the risk factor for the development of alexithymia among persons with ADS who were receiving treatment as inpatients. The same study had observed that the rates of childhood abuse or neglect and alexithymia were high among the persons with ADS. Ghogare et al. found that the person with ADS who had alexithymia had more severity of childhood psychological traumas than those with ADS without alexithymia.
Rationale for the present study
The present manuscript is a part of Doctor of Philosophy project in the subject of psychiatry. After searching and reviewing the literature, we found that there is lack of detailed literature on the assessment of relationship between childhood psychological traumas and alexithymia among persons with ADS. A study had suggested that the evidence was insufficient to draw the conclusion regarding the relationship between childhood trauma and ADS among men, while the same study had concluded that among women with ADS, there was a higher likelihood of existence of the relationship between childhood trauma and development of ADS.
Another study had found that only the preliminary evidence indicated the relationship between alexithymia, alcohol use, and severity of alcohol-related problems. The same study concluded that premature notion that alexithymia acts as a risk factor for the development of ADS requires further research to explore the relationship between alexithymia, ADS, and alcohol-related problems. Hence, detailed assessment of both childhood psychological trauma(s) and alexithymia among persons with ADS early in the treatment is needed and may be helpful as the maximum part of the treatment of persons with ADS depends on the verbalization which is otherwise impaired due to coexisting alexithymia among persons with ADS.
Objective of the present study
The primary objective of the study was to assess the relationship between childhood psychological trauma, alexithymia, and ADS.
| Methods|| |
The eligibility/inclusion criteria adopted for the present study were (a) studies which were conducted on adults, i.e. those above 18 years of age, (b) studies which were conducted on persons who fulfilled ICD–10–DCR diagnostic criteria for ADS, (c) studies which were conducted on persons who fulfilled diagnostic and statistical manual of mental disorders–fifth edition diagnostic criteria for alcohol use disorder (AUD), (d) studies which were conducted on persons who fulfilled diagnostic and statistical manual of mental disorders–fourth edition diagnostic criteria for alcohol dependence, (e) studies which were conducted on persons who fulfilled diagnostic and statistical manual of mental disorders–third edition diagnostic criteria for alcohol dependence, (f) those studies which primarily focused on the impacts of childhood psychological traumas and alexithymia among persons with ADS or AUD, and (g) those studies which were in English language.
A literature search of this manuscript was collected online from the following sources: (a) PubMed, (b) Psych articles, (c) Google scholar, (d) J GATE, (e) Research Gate, (f) Psychology and Behavioral Sciences Collection, (g) Science direct, and (h) ProQuest.
The research was restricted to review, meta-analysis, and original articles in English language which were published in between 1985 and 2021. The studies having participants above an age of 18 years old were included and the studies with participants below the stated age were excluded as including the studies with participants below an age of 18 years was out of the scope of the present study. The studies which included participants with purely substance dependence other than ADS were excluded from the present systematic review. For this purpose, a literature search and review were planned using the keywords such as alcoholism, alcohol dependence syndrome, alcohol use disorder, alexithymia, emotional abuse, emotional neglect, physical abuse, physical neglect, and sexual abuse.
Selection and data collection processes
In the present study, a four-phase process of the preferred reporting items for systematic reviews and meta-analyses (PRISMA) statement was used to label the items. The initial searches with the abovementioned keywords resulted in 56 articles. After the first phase, the authors left with 56 articles. Then, in the second phase, based on information in the titles of the articles, two articles were excluded as one article was on study participants with heroin dependence and another one was on study participants with cocaine dependence. Hence, at the end of second phase, the authors were left with 54 articles. In the next phase, i.e. in the third phase, abstracts were reviewed, whose abstract matched with inclusion criteria and were in English language. The reading of full papers of the abovementioned articles left with total 25 articles out of 54 articles. Hence, in the last, i.e. fourth phase, 25 articles were reviewed and included in the study as they were fully relevant to the present study. The details of all the four phases are depicted in a flowchart shown in [Figure 1] according to the PRISMA guideline.
|Figure 1: The flowchart of the article search strategy based on the preferred reporting items for systematic reviews and meta-analyses statement|
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| Results|| |
Relationship between childhood psychological trauma(s) and alcohol dependence syndrome
[Table 1] shows that significant relationship exists between the childhood psychological trauma(s) and ADS. The number of childhood psychological traumatic experiences had shown graded relationship with alcohol dependence among individuals with alcoholism. Higher the rates of childhood psychological adverse events, higher were the chances that the link exists between childhood victimization and development of ADS in later life. History of childhood psychological trauma was associated with the severity of ADS as well as the severity of alcohol-related problems. Among various types of childhood traumas, physical abuse during childhood was associated with the development of ADS in later life. It was seen that physical abuse, sexual abuse, emotional abuse, and emotional neglect were the risk factors for the development of ADS in adulthood. It was also evident that childhood physical and sexual abuses were more prevalent among individuals with ADS. Multiple regression models have shown that childhood emotional abuse predicts alcohol-related symptoms and problems among adult males with ADS, thus confirming a link between childhood psychological trauma and ADS in later life. Individuals with ADS who had a history of traumatic exposures during childhood had higher levels of marker of inflammation like elevated cortisol levels. More women than men with ADS had a history of childhood psychological traumas, with rates of both sexual as well as physical abuses being more among females with ADS than their male counterparts.
|Table 1: The relationship between childhood trauma(s) and alcohol dependence syndrome|
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Relationship between alexithymia and alcohol dependence syndrome
[Table 2] shows that the high prevalence of alexithymia exists among the persons with ADS, but the evidence is preliminary and so the notion that alexithymia acts as a risk factor for development of ADS is premature. Individuals with ADS had shown higher prevalence of alexithymia than the individuals with psychosomatic illnesses as well as general population. Individuals with ADS with suicidal ideation had high prevalence (66.6%) of alexithymia, as alexithymia manifests as the difficulty in identifying and verbalizing one's own feelings. Those individuals who had a family history of alcoholism and so had higher genetic risk for the development of alcohol dependence had higher level of alexithymia than the control group. Family history of alcoholism in father was associated with the presence of alexithymia among 50% individuals with AUD (P = 0.004), especially associated with DIF component of alexithymia as measured by the TAS–20 scores (P = 0.02). Indirect link exists between alexithymia and ADS-related problems, which was mediated by psychological drinking constructs as well as psychological risk factors for the development of ADS.
|Table 2: The relationship between alexithymia and alcohol dependence syndrome|
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Relationship between childhood psychological trauma and alexithymia among the persons with alcohol dependence syndrome
[Table 3] shows that the significant relationship exists between the alexithymia and presence as well as severity of childhood psychological traumas among the persons with ADS. The presence of alexithymia among individuals with ADS was related with the history of childhood traumatic experiences. Avoidant attachment style of individuals with ADS with their parents was associated with higher intensity of childhood trauma and higher level of alexithymia. AUD operates a link between childhood psychological trauma and alexithymia among individuals with alcohol dependence as well as among healthy controls. Alexithymia plays a mediator role in a relationship between the severities of trauma experiences and alcohol dependence. The presence of suicidal behavior or self-mutilating behavior among individuals with substance dependence including the alcohol warrants an assessment for history of childhood trauma and alexithymia, as such individuals with alexithymia tend to have difficulty in verbalizing their painful feelings related to their childhood traumatic experiences.
|Table 3: The relationship between childhood trauma(s) and alexithymia among the persons with alcohol dependence syndrome|
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| Discussion|| |
A general interpretation of the results in the context of other evidence
Association between childhood psychological trauma(s) and alcohol dependence syndrome
Exposure to childhood abuse is postulated to have an association with the development of alcohol abuse and dependence, which may be either a causative event or it may be a consequence. Childhood psychological traumas involve physical abuse, emotional abuse, sexual abuse, physical neglect, and emotional neglect. Physical abuse involves intentional body injury and the examples include pinching, slapping, kicking, chocking, shoving, or inappropriate use of physical restraints or drugs. Sexual abuse involves a nonconsensual unwanted sexual contact and the examples include unwanted inappropriate touching, rape, coerced nudity, sodomy, sexually explicit photography, etc. Emotional abuse includes deliberately caused emotional or mental pain and the examples include harassment, ridiculing, coercion, intimidation, isolating from other family members or peers or regular activities, and yelling or swearing which may cause mental distress. Neglect includes either action or inaction which deprives other individual of the care necessary for maintaining mental as well physical health of that individual. Examples of neglect include deprivation of basic things like water, food, shelter, clothing, medicines, or health care. A study had concluded that experiencing childhood psychological trauma increases that individual's risk for the development of ADS and alcohol-related problems during adult life. The same study concluded that parental alcohol dependence may act as a risk factor for sexual or physical abuse of their children. Ammerman et al. had found that parents with alcohol abuse had higher potential for the childhood psychological traumas in their children than did the parents without alcohol abuse. Miller et al. found a modest association between parental alcoholism and parental perpetration of childhood psychological abuse. The same study concluded that mothers with histories of alcoholism were more likely to be punitive against their children than those mothers without histories of alcoholism. Hence, while assessing a person with ADS, it is necessary to evaluate him/her in depth for the history of childhood traumatic experiences in hands of their parents who themselves had a history of alcoholism. Widom had found an inconsistent evidence regarding relationship between parental alcohol dependence and childhood psychological trauma.
Few studies have found that the stressful relationship between the parents can significantly increase the probability of childhood psychological abuse., This reflects an importance of sound relationship between the parents in avoidance of occurrences of childhood psychological traumas. These observations reflect on the notion that parental alcoholism and conflictual relationship between the parents act as risk factors for the occurrences of childhood traumatic event(s), which, in turn, eventually act as a risk factor for the development of ADS in adult life. ADS is a complex genetic disorder, and twin studies from Europe and US suggest that around 45% to 65% of the liability for the development of ADS is due to genetic factors.,,, These findings prove the notion that ADS is a genetic disorder and genetic counseling was found to be significantly beneficial by 62% of the study participants. Ireland and Widom in their prospective case–control study found that a history of childhood psychological abuse greatly predicted adult alcohol and other drugs related arrests among the females.
Widom et al. had conducted a follow-up study and found that a significant relationship exists between childhood psychological victimization and subsequent alcoholism among women, but not among the males.
A review of prospective studies had also detected a similar finding that childhood physical abuse among males was not associated with the development of alcoholism in them. The same review study of retrospective studies had found that the rates of childhood physical or sexual abuse among men with alcohol dependence were similar or somewhat higher than the rates found in nonalcoholic general population. The same review study concluded that among females, there was a significant likelihood of alcoholism and alcohol-related problems if they had childhood history of physical or sexual abuse.
Wilsnack et al. had retrospectively assessed childhood sexual abuse (CSA) using self-reports and found that those women who had histories of CSA had significant one or more problems like alcohol intoxication in the year prior to the survey interview, alcohol consumption in 30 days prior to the survey interview, one or more alcohol-related problems (fights with family members, home accidents, problems in their work, and problems with their children) in the year prior to the survey interview, and/or one or more symptoms of ADS (morning drinking/eye opener drinking, memory lapses while drinking alcohol, and inability to reduce or stop alcohol consumption) in the year prior to the survey interview. The same study had concluded that women that experienced CSA tend to develop substance abuse, sexual dysfunction, and psychopathology in adult life. A study had observed that exposure to both physical and sexual abuse is associated with 5 times increased risk of alcoholism in later life and 10 times increased risk of illicit drug use.
All types of childhood psychological traumas are found to be the risk factors for the development of substance use disorders (SUDs) including AUD among adolescents as well as adults., Former and current persons with ADS with histories of childhood psychological traumas tend to have early onset drinking, and more likely to consume alcohol to cope with the negative impacts of adverse childhood experiences (ACEs) than those without ACEs.
Childhood psychological traumas are associated with negative impact on the treatment course of persons with SUDs including AUD., Individuals with ADS who had histories of childhood traumas tend to have worst treatment outcomes including more severe dependence, frequent lifetime treatment histories, severe morbid course of their illness in adulthood,, and premature treatment dropouts.
Association between alexithymia and alcohol dependence syndrome
Thorberg et al. had observed that individuals with ADS who had higher level of alexithymia had more prevalence of “binge drinking” and unwanted after-effects of alcohol intoxication. The same study observed that higher degree and frequency of alcohol consumption were associated with alexithymia. Ghogare et al. observed that individual with ADS who had clinically significant alexithymia had severe alcohol dependence than the individual who had no alexithymia. A study had observed that alexithymia acts as a risk factor for the development of ADS and has potential to interfere with treatment outcomes. It proves the notion that alexithymia manifests in the form difficulty in verbalization of the feelings and most part of treatment of ADS depends on verbalization. Many other studies have also hypothesized that alexithymia acts a risk factor for the development of ADS.,,
Association between childhood psychological trauma(s) and alexithymia among individuals with alcohol dependence syndrome
Evren et al. had found that among 159 individuals with substance dependence, 57% had at least one type of childhood abuse and neglect, and 45.3% had alexithymia. The same study had concluded that childhood emotional abuse acts as a risk factor for the development of alexithymia among individuals with substance dependence including ADS. Ghogare et al. observed that individual with ADS who had clinically significant alexithymia had a history of severe childhood traumas than those without alexithymia. This signifies that the relationship exists between childhood psychological traumas and alexithymia among individuals with ADS.
Limitations of the evidence included in the review
The studies reviewed had limitations like recall bias regarding remembering the past events of childhood traumatic experiences and social desirability bias when an individual who had been asked regarding details of his/her alcohol consumption might had portrayed him/herself in good light by giving falsifying history about alcohol consumption.
Limitations of the review process
Few limitations were faced while reviewing the literature. Many studies were available regarding the relationship between childhood trauma and ADS. However, lesser evidence is available regarding the relationship between alexithymia and ADS. Furthermore, inadequate literature is available regarding the assessment of the relationship between childhood trauma and alexithymia among individuals with ADS that too in Indian psychiatric research field.
Conclusion and implications of the results for practice, policy, and future research
Based on the findings of this study, we conclude that significant relationship exists between childhood psychological traumas and alexithymia among individuals with ADS. We also conclude that both childhood psychological traumas and alexithymia act as inclination forecasting factors toward development of ADS.
The findings of this study warrant future research regarding assessment of the relationship between childhood psychological traumas and alexithymia among individuals with ADS as trauma informed care and helping in verbalization of emotions may play major role in effective management of individuals with ADS. In-depth studies are required in Indian context as ADS is rampant among all the societies across the country.
The present systematic review is related to Doctor of Philosophy (PhD) project in Psychiatry. We sincerely thank to institute for the financial grant for purchasing childhood trauma questionnaire (CTQ) for the research purpose.
Financial support and sponsorship
The present study was supported financially by the institutional grant for purchasing childhood trauma questionnaire (CTQ) for Doctor of Philosophy (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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[Table 1], [Table 2], [Table 3]