Alexithymia, Depressive Experiences, and Dependency in Addictive Disorders

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f:/MDI 2004/Ja/39-4/120030058_JA_039_004_R1.3d Substance Use & Misuse (JA)

SUBSTANCE USE & MISUSE

Vol. 39, No. 4, pp. 567–595, 2004

Alexithymia, Depressive Experiences and

Dependency in Addictive Disorders

Mario Speranza,1,* Maurice Corcos,2 Philippe Stephan,3

Gwenole Loas,4 Fernando Perez-Diaz,5 Francois Lang,6

Jean Luc Venisse,7 Paul Bizouard,8 Martine Flament,5

Olivier Halfon,3 and Philippe Jeammet2

1Centre Hospitalier Universitaire de Psychiatrie de l’Enfant et de

l’Adolescent, Fondation Vallee, Gentilly, France2Departement de Psychiatrie de l’Adolescent, Institut Mutualiste

Montsouris, Paris, France3Service de Psychiatrie de l’Enfant et de l’Adolescent,

Lausanne, Switzerland4Service Hospitalo-Universitaire de Psychiatrie, Hopital Pinel,

Amiens cedex 01, France5CNRS, UMR 7593 ‘Personnalite et conduites adaptatives’, Pavillon

Clerambault, Hopital de la Salpetriere, Paris, France6Service de Psychiatrie, CHU de Saint-Etienne,

Saint-Etienne, France7Unite des Addictions, Hopital Saint-Jacques, Nantes, France8Service de Psychiatrie, CHU de Besancon, Besancon, France

*Correspondence: Mario Speranza, M.D., Centre Hospitalier Universitaire de

Psychiatrie de l’Enfant et de l’Adolescent, Fondation Vallee, 7 rue Benserade,

94257, Gentilly, France; E-mail: [email protected].

567

DOI: 10.1081/JA-120030058 1082-6084 (Print); 1532-2491 (Online)

Copyright & 2004 by Marcel Dekker, Inc. www.dekker.com

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ABSTRACT

Alexithymia, depressive feelings, and dependency are interrelated

dimensions that are considered potential ‘‘risk factors’’ for addictive

disorders. The aim of this study was to investigate the relationships

between these dimensions and to define a comprehensive model of

addiction in a large sample of addicted subjects, whether affected by

an eating disorder or presenting an alcohol- or a drug use-related

disorder. The participants in this study were gathered from a multi-

center collaborative study on addictive behaviors conducted in

several psychiatric departments in France, Switzerland, and Belgium

between January 1995 and March 1999. The clinical sample was

composed of 564 patients (149 anorexics, 84 bulimics, 208 alcoholics,

123 drug addicts) of both genders with a mean age of 27.3� 8 years.

A path analysis was conducted on the 564 dependent patients and

518 matched controls using the scores of the Toronto Alexithymia

Scale, the Depressive Experiences Questionnaire, and the Inter-

personal Dependency Inventory. Statistical analyses showed good

adjustment (Goodness of Fit Index¼ 0.977) between the observable

data and the assumed model, thus supporting the hypothesis that a

depressive dimension, whether anaclitic or self-critical, can facilitate

the development of dependency in vulnerable alexithymic subjects.

This result has interesting clinical implications because identifying

specific patterns of relationships leading from alexithymia to

dependency can provide clues to the development of targeted

strategies for at-risk subjects.

Key Words: Goodness of fit index; Alexithymia; Self-criticism;

Anaclitism; Dependency; Addictive disorders; Eating disorders.

INTRODUCTION

Contemporary authors employ the term ‘‘addiction’’ to describe awide range of behaviors that share several features: craving or com-pulsion, loss of control, and persistence despite accruing adversebiological, psychological and social consequences (Goodman, 1990;Shaffer, 1997). Within such a construct are currently included alcohol-and drug use-related disorders (American Psychiatric Association, 1994),eating disorders such as anorexia and bulimia nervosa (Davis andClaridge, 1998), and habits such as compulsive buying (Lejoyeux et al.2000) or pathological gambling (Dickerson and Baron, 2000). Althoughnot all these conditions present a physiological withdrawal syndrome

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(which specifically defines dependence), it has been suggested that any

behavior that has the capacity to influence psychological states can be

potentially addictive. Neuroadaptation (tolerance and withdrawal), in

fact, can result from addictive behaviors that do not require ingestion of

psychoactive substances. Yet, addiction seems to be not simply a

property of a drug, it results from an intemperate relationship between a

person and the object of his or her addiction, which has the power to

reorganize the person’s personality. This is not simply a qualitative shift

in experience; it is a qualitative change in behavior patterns. This can be

true even for self-destructive behaviors so frequently observed in addicted

patients who attempt to regulate emotional distress (Karwautz et al.,

1996). The observation of a frequent association of such habits in the

same individuals has convinced some authors to raise the hypothesis of

an overall addictive dimension that could be shared by these behaviors

(Shaffer, 1997). Whether this dimension corresponds to a psychobio-

logical ‘‘vulnerability’’ to addiction or is a consequence of the addiction

itself is still controversial. By the concept of vulnerability, we mean a set

of developmentally based psychobiological factors that would predispose

to the development of an addiction, under specific conditions (as negative

life events).Several psychological features that have been adduced to explain

this vulnerability to addiction, alexithymia, and depression have

received particular attention. Alexithymia, literally ‘‘no words for

feelings’’ (Sifneos, 1972), refers to a cognitive-affective disturbance that

is characterized by a difficulty in identifying and describing feelings and

distinguishing them from bodily sensations, a diminution of fantasy and

a concrete and poorly introspective thinking (Taylor et al., 1997). Several

studies have reported high levels of alexithymia in addicted patients

whether drug-addicted, alcoholic, or eating-disordered patients (preva-

lence rates vary with a categorical approach from 40% to 60%), although

controversies still exist over the primary or secondary nature of this

dimension and its relations to depression and to the clinical status of the

patients (Taylor et al., 1997; Haviland et al., 1988). Some authors have

raised the hypothesis that, due to their cognitive limitations in identifying

and elaborating emotions, alexithymic subjects may be overwhelmed

by noncontrollable sensations and may resort to addictive behaviors to

self-regulate these disruptive emotions (Taylor et al., 1997). Alexithymic

people would become addicted to these activities because they lack

insight and self-knowledge. Addiction itself would later reduce their

ability to decode emotions, locking the subject into his or her rigid

functioning.

Alexithymia, Depressive Experiences 569

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Depression is another common feature of addicted patients, whetheras a predisposing factor or as a consequence of the behavior. Thiscomorbidity mainly concerns dysthymic rather than bipolar disorders(Lynskey, 1998). The large literature concerning the association betweenaddictive behaviors and depression highlights the role played bypersonality disorders, especially borderline and narcissistic personalitydisorders (Skinstad and Swain, 2001). Moreover, it must be recalled thatdysphoric affects, addictive behaviors, and narcissistic sensitivity areamong the diagnostic criteria of borderline personality disorders. Forseveral authors, these dimensions are correlated in a dynamic way andaddictive behaviors (whether a substance-related disorder or an eatingdisorder) would play the role of compensating for feelings of emptinessand ineffectiveness and for the disturbed identity associated with thesenarcissistic personality features. For these reasons, it seems worthwhile inaddictive disorders to look for depression not only in a categorical way,but also in a dimensional way in the context of personality features. Thisapproach has been proposed by some authors who have identified twotypes of fundamental depressive experiences along a continuum fromnormality to pathology. The first one focused on concerns associatedwith disruption in relationships with others (with feelings of loss,abandonment, and loneliness) and the second one centered on problemsconcerning identity (associated with low self-esteem, feelings of failure,culpability, lack of self-confidence) (Beck, 1983; Blatt and Zuroff, 1992).Blatt and colleagues characterized as introjective or self-critical the axisconcerned with the development of the sense of self and of identity, andas anaclitic or dependent the axis concerned with interpersonal relation-ships. If addicted patients can experience both dimensions, the anaclitic/dependent axis could be more specific to these patients.

Dependency as a personality trait, separated from the diagnosis of aparticular addiction, is a specific personality style characterized by amarked need for guidance and approval from others, a perception of theself as powerless and ineffective, and a tendency to seek for constantsupport and reassurance from others (Bornstein, 1993). It has beensuggested that this personality dimension, making individuals morevulnerable to the effects of adverse life events, could be a potential ‘‘riskfactor’’ for the development of various psychiatric disorders, amongwhich are addictive disorders (Greenberg and O’Neill, 1988; Loas et al.,2000). The few studies exploring the relationships between alexithymiaand dependency have found contradictory results, probably related to thedifferent assessment tools used. Although some studies have found apositive correlation (Taylor et al., 1992; Fukunishi et al., 1996), othershave failed to identify such a link (O’Neill and Bornstein, 1996). Loas and

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colleagues (Loas et al., 2000), using the Interpersonal DependencyInventory (IDI; Hirschfeld et al., 1977) and the 20-item TorontoAlexithymia scale (TAS-20), reported a significant correlation betweenthe cognitive component of the TAS-20 and the Perceptual Dependencyand the Affirmation of Autonomy subscales of the IDI in a sample ofalcoholic patients. They hypothesized that this cognitive style could be astable trait in addicted patients and that alexithymic features could favordependency by reducing the insight and self-knowledge of these patients.

Alexithymia, self-critical, or anaclitic depression and dependency areall interrelated dimensions that can be considered as potential risk factorsfor the development of addictive disorders. Some studies have exploredone or two of these dimensions in selected samples of general psychiatric(O’Neill and Bornstein, 1996) or addicted patients (Loas et al., 2000). Nostudy until now has tried to link these dimensions in a unified modelexploring different addictive behaviors.

This study investigates the relationships between alexithymia,self-critical or anaclitic depression, and dependency in a large sampleof addicted subjects, whether dependent on alcohol or illicit drugs oraffected by an eating disorder. We assumed that a comprehensivemodel considering these dimensions could well describe a general patternof addiction, as well as highlight specific psychopathological profiles ofdifferent addictive disorders.

METHODS

Subjects

Participants in this study were recruited from a large multicentercollaborative study on addictive behaviors (Institut National de laSante et de la Recherche Medicale, Dependence Network 1994–2000no. 494013), conducted in several psychiatric departments in France,Switzerland, and Belgium, and investigating the common clinical andpsychopathological features shared by different disorders (eatingdisorders and substance-related disorders) gathered under the heuristicconcept of addiction. The psychiatric departments were specialized in thetreatment of substance-related disorders and eating disorders. Subjectswere all consecutive male or female in- or outpatients, ages 18–45 years,referred to one of the network’s departments with a current DSM-IVdiagnosis of substance-related disorder (alcohol or illicit abuse ordependence) or anorexia nervosa or bulimia nervosa. Exclusion criteriawere psychotic disorder, mental retardation, chronic or severe somatic


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disorders, and refusal to participate in the study (refusal rates variedbetween 2% and 5%, depending on the research center).

A sample of healthy subjects was recruited by announcement innursing schools and in medical facilities. Each subject was individuallymatched with a control subject by age (�1 year between 15 and 29,�3 years between 30 and 45), gender, and professional status accordingto five broad categories, as defined by the French National Institute ofStatistics and Economic Studies. In particular, students were matchedwith students. Control subjects were screened to eliminate current andlifetime substance use-related disorders and eating disorders. Allassessments were conducted by trained clinicians (a psychiatrist or aclinical psychologist expert in the field of addictive disorders) whoparticipated in training sessions prior to completing the evaluation. Datawere collected between January 1995 and March 1999. The protocol wasapproved by the local ethics committee (Paris-Cochin Hospital). Subjects(patients and controls) were asked to participate in a clinical researchproject investigating the common personality features shared byindividuals presenting an addictive disorder. After full information wasprovided, all subjects gave written consent to participate in the study.

Assessment Procedure

All subjects completed a research protocol that consisted in a clinicalinterview [including subject identification, history of lifetime psychiatrictreatments, a structured diagnostic evaluation using the Mini-International Neuropsychiatric Interview (MINI) (Sheehan et al., 1998)and assessment of the social adjustment] completed by a self-ques-tionnaire eliciting psychopathological features. The different parts of thequestionnaire were jointly defined by the network and pretested to assessthe feasibility of the protocol (less than 1% dropped out during theassessment). All instruments are well known and validated in English andFrench. The average time needed to respond to the entire researchprotocol varied between 50 and 90 minutes (Table 1). The assessment wasmade in the first week for consulting outpatients and during the first twoweeks for hospitalized inpatients.

Eating disorder diagnoses were made using DSM-IV diagnosticcriteria, whether of anorexia nervosa (restrictive or bulimic/purgingsubtype) or bulimia nervosa (bulimic/purging or nonpurging subtype).Diagnoses of substance use-related disorders were established using theMINI, a structured, validated diagnostic instrument jointly designed byFrench and American teams (Sheehan et al., 1998) that explores, in a

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Table

1.

Evaluationinstruments

oftheresearchprotocol.

Instruments

Authors

Method

Evaluationcontent

No.item

s/time

MiniInternational

Neuropsychiatric

Interview

(MIN

I)

Sheehanet

al.,1992

Sem

istructured

interview

Mentalhealthdiagnosis

(DSM-IV

criteria)

40min

Groningen

Social

DisabilitiesSchedule

(GSDS-II)

Wiersmaet

al.,1990

Sem

istructured

interview

Socialadjustment.

Quality

ofsocialrelationships

over

thelast

fourweeks

15min

BeckDepression

Inventory

(BDI-13)

Becket

al.,1961

Self-report

Depressivesymptomatology

13item

s/5min

DepressiveExperience

Questionnaire(D

EQ)

Blattet

al.,1976

Self-report

Quality

ofdepression:

–Self-criticism

–Anaclitism

–Efficacy

66item

s/10min

Toronto

Alexithymia

Scale

(TAS-20)

Tayloret

al.,1992

Self-report

Alexithymia:

–Difficultiesidentifyingfeelings

–Difficultiesdescribingfeelings

–Externallyorientedthinking

20item

s/5min

Interpersonal

Dependency

Inventory

(IDI)

Hirschfeld

etal.,1977

Self-report

Dependency:

–Emotionalreliance

–Lack

ofsocialself-confidence

–Assertionofautonomy

48item

s/10min


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standardized fashion, each criterion necessary for the establishment ofcurrent and lifetime DSM-IV axis I main diagnoses. Following DSM-IVcriteria, the exclusive diagnosis of abuse or dependence was establishedfor any given substance.

Social adjustment was assessed using a semistructured interview, theGroningen Social Disabilities Schedule (GSDS-II) (Wiersma et al., 1990),which explores the quality of relationships and the frequency and extentof contacts with other people over the last 4 weeks (4 weeks prior tohospitalization for inpatients). The score is rated 0 (no disability) to 3(severe disability). Alexithymia was rated using the French translation ofthe revised TAS-20 (Bagby et al., 1994; Loas et al., 1995; Taylor et al.,1992). The scores of the subfactors were calculated using the Frenchfactor structure (Loas et al., 2001), which has identified three factorscorresponding to the theoretical dimensions of the alexithymia construct:Difficulties Identifying Feelings (DIF) Difficulties Describing Feelings(DDF), and Externally Oriented Thinking (EOT). The cut-off point usedfor alexithymia was �56 (Loas et al., 1996).

Depression was measured using two different instruments: the abrid-ged version of the BeckDepression Inventory (BDI-13) and theDepressiveExperiences Questionnaire (DEQ).

The BDI-13 (Beck et al., 1961) is a well-known instrument formeasuring depression in clinical and normal samples. Like the completeversion, the metrological parameters of the abridged form of the BDIhave been repeatedly studied in French samples (Bobon et al., 1981). Inthis study, we used the dimensional score of the BDI-13 (0–39).

The DEQ (Blatt et al., 1976) is a 66-item self-report scale rated on a7-point Likert scale ranging from 1 (strongly disagree) to 7 (stronglyagree), which was designed to assess the introjective and anacliticpersonality dimensions hypothesized by Blatt and Zuroff (1992) tounderlie different forms of depressive experiences related to develop-mental issues. A principal component analysis has identified twoprincipal depressive factors. The first factor involves items that areinternally directed and reflects concerns about self-identity (self-criticism). The second factor consists of items that are more externallydirected and refers to a disturbance of interpersonal relationships(anaclitism). A third factor has emerged, assessing the good functioningof the subject and the confidence in his or her resources and capacities(efficacy). Scales derived from these factors have shown high internalconsistency and substantial test–retest reliability (Bagby et al., 1992;Zuroff et al. 1990). In the present study, we used a French factor analysisshowing the same three factors as the original study (Loas et al.,(in press)).

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Dependency was assessed with the IDI (Hirschfeld et al., 1977),which contains 48 items distributed in three subscales: EmotionalReliance on other people (ER), Lack of Social Self-confidence (LSS),and Assertion of Autonomy (AUT). The first two subscales assess theemotional dependency and the third assesses autonomy, a certain numberof dependent subjects denying their dependency. The French version ofthe IDI has shown satisfactory psychometric properties (Loas et al., 1993;1997).

Statistical Analysis

The samples of dependent subjects and matched controls were firstcompared for sociodemographic and psychopathological variables.Comparisons between patients and controls were made with the chi-square test for categorical variables and with an analysis of variance(ANOVA) test for continuous variables, as appropriate. ANOVAwith gender and age as confounding variables was used to compareclinical groups. Bivariate correlations were computed to evaluate therelationships between the variables.

To test the hypothesis of a specific psychopathological pattern inaddictive disorders, we used the SPSS statistical tool for path analysis.This procedure tests ideal models of unidirectional causal relationshipsbetween a certain number of observed variables. This analysis determinesif the observable data approximate the ideal model. The results of theanalysis give different indices reflecting the total adjustment of the datato the model. Goodness of Fit Index (GFI) and Adjusted for Degrees ofFreedom Index (AGFI) are used as indicators of the reliability of themodel. A high score on these indices is a reflection of the relevance ofthe model. A path analysis model is built on a double basis. The includedvariables must be clinically sounded for the model and must be almostmoderately correlated with the other variables. The model must also beparsimonious and limited to single nonredundant variables, as can be thecase for strongly correlated subfactors of a variable.

Six groups were defined for the analysis: anorexic women (AN),bulimic women (BN), alcohol dependents (AD) separated into men(ADM) and women (ADW), and drug dependents (DD) separated intomen (DDM) and women (DDW). Men and women were separated indifferent samples because in preliminary analyses we had observedseveral differences in psychopathological measures related to gender andage. Such variables were systematically considered when comparing


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clinical groups. Comparisons between patients and controls were notadjusted for these variables because patients and controls were matched.

Partial correlations with BDI as constant, followed by a Fisher Z testto compare independent correlations, were computed to evaluate therelationships between variables in the different diagnostic subgroups.

Results are presented as mean� standard deviation. Statisticalanalyses were performed with SPSS, version 10.1.

RESULTS

Sample Description

This study identifies a model relating a set of psychopathologicalvariables commonly observed in addictive disorders, whether alcohol orsubstance use-related disorders or eating disorders. To assess the strengthof the model for the entire sample and for each different addicted group,patients presenting a comorbid diagnosis of eating-, alcohol- or drug use-related disorders were excluded from the sample: 29 patients (4.7% of thetotal sample) were dismissed (mostly with two comorbid diagnoses). Fouranorexic men and seven bulimic men were excluded because there weretoo few cases for statistical analysis. Fourteen alcoholic and 15 ‘‘drugabusers’’ were part of the starting group. We compared these patientswith their dependent counterparts. We found no significant differencebetween abuser and dependent patients on the majority of the ratingscales. This analysis allowed us to gather abuser patients in thecorresponding dependent group. Only subjects having completed theentire questionnaire were entered in the study (38 patients wereeliminated).

The final sample comprised 564 addicted patients divided into sixsubgroups (149 anorexics, 84 bulimics, 59 alcoholic women, 45 drug-addicted women, 149 alcoholic men, and 78 drug-addicted men) and 518matched controls. This large sample of patients is representative of theclinical population of the psychiatric departments participating in thestudy.

Mean age differed in the clinical subgroups. Alcoholic men andwomen were the oldest patients of the sample, anorexics the youngest.Drug-addicted women and bulimics were placed in between drug-addicted men and anorexics. These differences are commonly observed inclinical practice and reflect the mean age range of therapeutic demands.

The majority of anorexic patients were inpatients, whereas bulimicpatients were almost all outpatients. Alcoholics were recruited primarily

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in hospital treatment settings. Drug-addicted patients were recruited inspecial treatment centers for drug substitution, mainly with methadone.Concerning the social adjustment, the sample showed a moderatedisability of social functioning with a marked reduction in the frequencyand quality of interpersonal contacts (1.4� 1.1). The most disabledgroups were the alcoholics (men and women). Sociodemographic data forthe patient groups are shown in Table 2.

Rating Scales

Alexithymia

Mean scores on the TAS-20 were significantly higher in patientsthan in controls for the total score (55.3� 11 vs. 46.4� 11, p< 0.001) andfor the subfactors DIF (20.9� 6.0 vs. 15.0� 5.3, p< 0.001) and DDF(16.2� 4.1 vs. 13.6� 4.5, p< 0.001) of the TAS-20. There was nodifference between patients and controls in the cognitive factor of theTAS-20, EOT (18.5� 4.8 vs. 17.8� 4.6, ns). From a categoricalperspective, the rates of subjects scoring over the cut-off of 55 on theTAS-20 were significantly higher in addicted patients compared withcontrols (52.8% vs. 22.4%, p< 0.001). These rates for control subjects areclose to those found in the literature (Taylor et al. 1997).

The average TAS total score varied from 52.1 in drug-addictedwomen to 57.3 in alcoholic men. The differences between these groupswere not significant. It is noteworthy, however, that the highest scoreswere found among anorexics and in the two subgroups of alcoholics.These nonsignificant results were also found in the percentages ofalexithymia in each group. Again, the groups of anorexics and alcoholicshad the highest rates of alexithymia, up to 64% in alcoholic men.

Depression

Patients scored higher than controls on the BDI-13 (11.3� 7 vs.3.1� 4, p< 0.001). The clinical groups showed some significant differ-ences. Women were more depressed than men (13.0� 8 vs. 9.1� 7,p< 0.001). The most depressed were those with eating disorders (AN:13.9� 8; BN: 13.4� 8), the least the drug-addicted patients (DDW:9.8� 7; DDM: 7.0� 5). There were significant differences betweenAN/BN and DDW/DDM at p< 0.01.


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Table

2.

Dem

ographic

data

oftheclinicalsample.

Variables

AN

a(N

¼149)

BN

b(N

¼84)

ADW

c(N

¼59)

DDW

d(N

¼45)

ADM

e(N

¼149)

DDM

f(N

¼78)

ANOVA/chi2

Mean

SD

Mean

SD

Mean

SD

Mean

SD

Mean

SD

Mean

SD

F(df)

Age

20.8

5.2

23.1

5.0

36.4

5.0

23.4

5.3

36.2

6.7

26.0

6.6

149.64(5)

<.0001

GSDS-II(0–3)g

1.3

1.1

1.0

1.0

1.9

1.1

1.3

1.1

1.7

1.1

1.2

0.9

8.49(5)

<.0001

N%

N%

N%

N%

N%

N%

chi2

Education

–<Bachelor

12

8.2

56

15

26.3

16

36.4

36

24.7

27

34.2

105.3

(10)<0.0001

–Bachelor

49

33.6

15

17.9

23

40.4

18

40.9

77

52.7

26

32.9

–>Bachelor

85

58.2

64

76.2

19

33.3

10

22.7

33

22.6

26

32.9

Maritalstatus

–Single

132

89.2

68

81

26

44.1

35

77.8

97

65.1

66

83.5

58.90(5)

<0.0001

–Married

16

10.8

16

19

33

55.9

10

22.2

52

34.9

13

16.5

Professionalstatus

–Noactivity

96

22.4

46.8

12

26.7

96

10

12.7

368.5

(20)<0.0001

–Students

109

73.2

38

45.2

00

10

22.2

10.7

18

22.8

–Skilledworker

10.7

11.2

58.5

12.2

74

49.7

21

26.6

–Employees

23

15.4

25

29.8

39

66.1

19

42.2

47

31.5

19

24.1

–Executives

74.7

18

21.4

11

18.6

36.8

18

12.1

11

13.9

–Inpatients

108

73.0

14

16.9

54

91.5

18

47.4

135

90.0

29

47.5

166.2

(5)

<0.0001

aAN¼Anorexia

nervosa.

bBN¼Bulimia

nervosa.

cADW

¼Alcoholic-dependentwomen.

dDDW

¼Drug-dependentwomen.

eADM

¼Alcoholic-dependentmen.

f DDM

¼Drug-dependentmen.

gGSDS-II¼Groningen

SocialDisabilitiesSchedule.

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The self-critical subscale of the DEQ differentiated patients fromcontrols (all addicted: 1.3� 1 vs. controls: 0.06� 1, p< 0.001). Scores onthe anaclitic subscale were significantly different between patients andcontrols (all addicted: 0.6� 1 vs. controls: 0.05� 1, p< 0.001), with theexception of the drug-addicted patients (DDW: 0.3� 1 vs. controls:0.07� 1, ns; DDM: 0.1� 1 vs. controls: 0.06� 1, ns). The efficacysubscale showed no great differences between patients and controls (alladdicted: 0.2� 1 vs. controls: 0.04� 1, ns), with the exception ofalcoholic women (ADW: 0.3� 1 vs. controls: 0.04� 1, p< 0.02).

There were some significant differences between clinical groups inthe DEQ subscales. Globally women scored higher than men (DEQ1:men: 1.0� 1 vs. women: 1.5� 1, p< 0.001; DEQ2: men: 0.4� 1 vs.women: 0.7� 1, p< 0.001). Anorexics and bulimics scored significantlyhigher than drug-addicted men and women on the self-critical andanaclitic subscales of the DEQ (AN: 1.5� 1; BN: 1.8� 1; DDW: 1.0� 1;DDM: 0.8� 1, p< 0.01).

Dependency

Finally, addicted patients had higher levels than controls onalmost all the subscales of the IDI. Drug-addicted men and womenhad significantly lower scores than the other groups on the total score ofthe IDI. (AN: 223� 30; BN: 225� 29; ADW: 230� 28; DDW: 205� 21;ADM: 222� 30; DDM: 205.2� 36. Significant differences at p< 0.01between AN/BN/ADW/ADM and DDW/DDM). The results of therating scales are presented in Table 3.

Variable Correlations

In the whole sample of addicted patients, there were strongcorrelations between all studied variables (Table 4). The only exceptionsconcerned the correlations including the externally oriented thinkingfactor of the Toronto Alexithymia Scale (TAS-EOT), the efficacy factorof the Depressive Experience Questionnaire (DEQ-EFF), and theautonomy factor of the Interpersonal Dependency Inventory (IDI-AUT). Only significant correlations have been included in Table 4;selected results of the nonsignificant correlations are presented in the text.

Concerning the two measures of depression, the BDI-13 and theDEQ, we observed a strong correlation between the BDI-13 and the self-critical depression (DEQ1) (0.63) and a moderate correlation between the


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Table

3.

Scoresontheratingscales.

Variables

AN

a

(N¼149)

BN

b

(N¼84)

ADW

c

(N¼59)

DDW

d

(N¼45)

ADM

e

(N¼149)

DDM

f

(N¼78)

Controls

(N¼518)

Differences

betweengroupsk

M(SD)

M(SD)

M(SD)

M(SD)

M(SD)

M(SD)

M(SD)

TASg—

Totalscore

55.8

(11)

54.7

(10)

55.3

(10)

52.1

(12)

57.3

(9)

52.6

(11)

46.4

(11)

n.s.

TAS—

Identification

21.7

(6)

22.2

(6)

20.9

(5)

19.7

(7)

20.8

(5)

19.2

(6)

15.0

(5)

n.s.

TAS—Description

16.8

(4)

16.0

(4)

15.6

(4)

15.5

(4)

16.3

(3)

15.4

(4)

13.6

(4)

n.s.

TAS—Externallyoriented

17.3

(4)n.s.

16.4

(5)n.s.

18.9

(5)n.s.

17.0

(4)n.s.

20.1(4)n.s.

17.9

(5)n.s.

17.9

(5)

(g)

TAS�56

80(54%)

41(49%)

28(47%

)19(42%)

95(64%)

32(40%

)115(22%)

n.s.

BDI-13h

13.9

(8)

13.4

(8)

12.3

(7)

9.8

(7)

10.0

(7)

7.0

(5)

3.1

(4)

(c,b,e,i)

DEQ1—Self-criticali

1.5

(1.0)

1.8

(0.8)

1.4

(0.9)

1.0

(1.1)

1.1

(0.9)

0.8

(0.9)

0.06(0.9)

(e,g,h,i,l)

DEQ2—

Anaclitic

0.8

(0.8)

0.8

(0.9)

0.8

(0.9)

0.3

(1.0)n.s.

0.6

(0.8)

0.1

(0.9)n.s.�0.05(0.9)

(e,d,h,i)

DEQ3—

Efficacy

�0.1

(0.8)n.s.�0.1

(0.7)n.s.

0.3

(0.9)

�0.1

(0.9)n.s.

0.6

(0.9)n.s.

0.3

(1.0)n.s.

0.04(0.9)

(b,c,e,g,i)

IDIj—

Totalscore

222.9

(30)

225.4

(29)

230.0

(28)

204.7

(21)n.s.221.8

(30)

205.2

(36)

192.3

(29)

(d,e,i,h,l,m

)

IDI—

Emotionalreliance

52.0

(8)

53.2

(8)

53.9

(8)

47.8

(11)n.s.

51.7

(8)

47.0

(10)n.s.

44.1

(8)

(e,i,l)

IDI—

Lack

socialconfidence

39.1

(9)

38.0

(9)

37.0

(7)

32.0

(7)n.s.

36.7

(7)

32.3

(7)n.s.

31.6

(6)

(b,d,e,g,h,i)

IDI—

Autonomy

27.9

(6)n.s.

27.7

(7)n.s.

31.3

(6)

29.2

(6)n.s.

32.0

(6)

31.7

(6)

28.2

(6)

(c,e,g,i)

aAN¼Anorexia

nervosa.

bBN¼Bulimia

nervosa.

cADW

¼Alcoholic-dependentwomen.

dDDW

¼Drug-dependentwomen.

eADM

¼Alcoholic-dependentmen.

f DDM

¼Drug-dependentmen.

gTAS¼Toronto

Alexithymia

Scale.

hBDI¼BeckDepressionInventory.

i DEQ¼DepressiveExperience

Questionnaire.

j IDI¼InterpesonalDependency

Inventory.

kAnalysisofcovariance

betweenclinicalgroups.Bonferronipost-hoctest(p<0.05):(a)AN

vs.BN;(b)AN

vs.ADW;(c)AN

vs.ADM;(d)AN

vs.

DDW;(e)AN

vs.DDM;(f)BN

vs.ADW;(g)BN

vs.ADM;(h)BN

vs.DDW;(i)BN

vs.DDM;(l)ADW

vs.DDM;(m

)ADM

vs.DDM;(n)

DDM

vs.DDW;(o)ADM

vs.ADW;(p)ADM

vs.DDM;(q)ADM

vs.DDW;(r)DDM

vs.DDW.

n.s. T-testforindependentsamples.Nonsignificantdifferences(>

0.05)betweenpatients

andcontrolgroup.

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BDI-13 and the anaclitic depression (DEQ2) (0.40). These two depressivedimensions were correlated strongly between them, but not with theefficacy dimension of the DEQ (0.02; 0.01, ns). Correlations betweenthe TAS scores and the depression scores (BDI-13 and DEQ) were overallhighly significant with just the exceptions of the correlations concerningthe DEQ-EFF (0.01, ns) and the TAS-EOT (0.03, ns).

Strong correlations were also found in the entire sample betweenthe dependency scale and the self-critical dimension of the DEQ (0.66) orthe anaclitic dimension of the DEQ (0.40). The dependency scale was

Table 4. Correlations between variables in addicted individuals.r

Variables ANa BNb ADWc DDWd ADMe DDMf All sample

TASg/DEQ1h 0.48 0.51 0.39 0.59 0.31 0.36 0.41

TAS/DEQ2i 0.36 0.51 0.38 0.52 0.07q 0.25p 0.30

IDI/DEQ1 0.75 0.69 0.58 0.78 0.58 0.78 0.66

IDI/DEQ2 0.73 0.61 0.60 0.83 0.60 0.83 0.66

TAS/IDIj 0.38 0.42 0.54 0.41 0.54 0.41 0.40

BDIk/DEQ1 0.60 0.67 0.32 0.60 0.52 0.60 0.63

BDI/DEQ2 0.42 0.44 0.14q 0.50 0.14q 0.50 0.40

TAS/BDI 0.41 0.51 0.45 0.51 0.27 0.43 0.40

TAS DIFl/TAS 0.82

TAS DDFm/TAS 0.79

IDI ERn/IDI 0.96

IDI LLSo/IDI 0.75

aAN¼Anorexia nervosa.bBN¼Bulimia nervosa.cADW¼Alcoholic-dependent women.dDDW¼Drug-dependent women.eADM¼Alcoholic-dependent men.fDDM¼Drug-dependent men.gTAS¼Toronto Alexithymia Scale.hDEQ1¼Depressive Experience Questionnaire: Self-criticism.iDEQ2¼Depressive Experience Questionnaire: Anaclitic.jIDI¼ Interpersonal Dependency Inventory.kBDI¼Beck Depression Inventory.lTAS DIF¼Difficulties Identifying Feelings.mTAS DDF¼Difficulties Describing Feelings.nIDI ER¼Emotional Reliance.oIDI LLS¼Lack of Social Self-Confidence.pCorrelation is significant at p< 0.05.qCorrelation is not significant at p< 0.05rAll correlations are significant at p< 0.01.


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moderately correlated with the BDI-13 (0.40). The first subscales of theTAS were strongly correlated with the total score (respectively: TAS-DIF/TAS total score¼ 0.82; TAS-DDF/TAS total score¼ 0.79). Thefirst scales of the IDI were equally strongly correlated with the total score(IDI-ER/IDI total score¼ 0.96; IDI-LSS/IDI total score¼ 0.7). Finally,the total score of the IDI was significantly correlated with the total scoreof the TAS-20, but not with the TAS-EDT (0.10).

Path Analysis

Starting from the correlations observed between the variables, wehave employed path analysis to construct a model to understand therelationships between alexithymia, depressive symptomatology, anddependency in addictive behaviors.

Correlations between the different variables had shown that theTAS-EDT, the DEQ-EFF, and the IDI-AUT were nonsignificantlycorrelated with the total scores of the other variables. Their weight in themodel could be considered as nonsignificant and disregarded. Moreover,the DIF and DDF factors of the TAS and the ER and LSS factors of theIDI were highly correlated with their respective total scores. Theirinclusion in the model could be considered as redundant.

The final model that best described addictive behavior included theDEQ1, DEQ2, TAS (total score), and IDI (total score). A commonpsychopathological profile to explain addictive disorders was based on theclinical hypothesis, supported by the literature, that in addictive disordersalexithymia predicts a dependent profile via a self-critical or anaclitic formof depression. Moreover, if this model fits the entire addictive sample,it should also show some specificities in the different groups.

Statistical results have confirmed the assumed model and haveshown its relevance (Fig. 1). The indices of reliability of the general modelwere high and significant (GFI¼ 0.977 and AGFI¼ 0.77). Data concern-ing female patients fitted better than those concerning male patients.The model fitted best for patients with anorexia nervosa (GFI¼ 0.999,AGFI¼ 0.995) and less well for female alcoholics (GFI¼ 0.937,AGFI¼ 0.368). Despite some differences between subgroups, the overalladjustment of the model was excellent for all groups. This is not the casefor the control group whose data fitted less well than those of the clinicalgroups (GFI¼ 0.774, AGFI¼ 0.274), thus supporting the specificity of themodel for addictive disorders. In the entire group, alexithymia predictedthe scores of the two dimensions of DEQ with a significant strongestprediction for the self-critical factor (DEQ1: 0.42) compared with the

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anaclitic factor (DEQ2: 0.29) (z¼ 2.57, p¼ 0.012). These two dimensionsof depression predicted dependency in the same way (0.41 for DEQ1 and0.38 for DEQ2).

DISCUSSION

This is the first study to gather under a unified model alexithymia,depressive experiences, and dependency in a large sample of addictedpatients. Our results replicate published studies showing that addictedpatients score higher than controls on almost all variables. Moreover,these psychopathological dimensions are interrelated in specific ways inaddictive disorders. Although the overall alexithymia scores do not differbetween groups, women are globally more depressed and dependent thanmen, and eating disorder and alcoholic patients are more depressed anddependent than drug-addicted patients. Results concerning depressionmeasured with the BDI-13 or the DEQ follow almost the same pattern.

TAS

0.42 0.29 ≠

DEQ1 DEQ2

0. 40 0.38

IDI

Addicted patientsChi2 = 26.758 p = >0.0001 GFI = 0.977 AGFI = 0.766

TAS

0.31 n.s.

DEQ1 DEQ2

0. 39 0.27

IDI

Drug-addicted menChi2 = 9.993p = 0.0016GFI = 0.949AGFI = 0 485

TAS

0.38 0.27

DEQ1 DEQ2

0. 35 0.34

IDI

Alcoholic menChi2 = 7.708p = 0.0055 GFI = 0.974 AGFI = 0 744

TAS

0.58 0.39

DEQ1 DEQ2

0. 43 0.49

IDI

Drug-addicted womenChi2 =0.626p = 0.428 GFI = 0.994 AGFI = 0 937

TAS

0.46 0.35

DEQ1 DEQ2

0. 37 0.35

IDI

Alcoholic womenChi2 = 10.296 p = 0.0013 GFI = 0.937 AGFI = 0.368

TAS

0.47 0.39

DEQ1 DEQ2

0. 49 0.39

IDI

AnorexicsChi2 = 0.137p = 0.711GFI = 0.999AGFI = 0.995

TAS

0.53 0.27 ≠

DEQ1 DEQ2

0. 50 0.29

IDI

BulimicsChi2 = 3.055p = 0.0712GFI = 0.982AGFI = 0 823

TAS

0.25 n.s.

DEQ1 DEQ2

0. 32 n.s.

IDI

Control subjectsChi2 = 18.52 p = 0.0001 GFI = 0.774 AGFI = 0.274

Figure 1. Structural models in addicted patients.


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Finally, the most interesting result comes from the path analysis,which supports our hypothesis that a synergy between an alexithymicprofile and a depressive process could describe the high levels ofdependency found in the addictive functioning of these patients.

However, we have also observed that globally the relationshipbetween alexithymia and dependency seems to be based more on a self-critical than on an anaclitic depressive style. The observed data of theentire group of addicted patients fit the theoretical model better thanthose of the matched controls, thus supporting the specificity of thismodel for addictive disorders. The hypothesis that alexithymia maypredispose to the development of substance use-related disorders hasbeen raised by several authors who have suggested that addictivebehaviors in alexithymic subjects could represent a way to compensatefor the inability to modulate distressing affects shown by these patients(Finn et al., 1987). Kauhanen and colleagues observed in a large epide-miological study that alexithymic men drink more than nonalexithymicmen, probably as a way to cope with their distressing inner feelings(Kauhanen et al., 1992). Finally, Finn and colleagues raised the hypo-thesis that resorting to alcohol could facilitate in alexithymic peopleverbal and emotional interpersonal contacts for which they feelincompetent (Finn et al., 1987).

Although our study points in the same direction as these previousstudies, it adds the hypothesis that a depressive dimension, whetheranaclitic or self-critical, could facilitate the development of dependency invulnerable alexithymic subjects. Moreover, we observed that in the entiregroup this dual pathway leading from alexithymia to dependency is morestrongly based on a self-critical depression than on an anacliticdepression (Haviland et al., 1994).

From a clinical standpoint, the presence of these two interrelateddimensions in addicted behaviors is interesting. Taylor and colleagueshave related the high levels of dysphoric feelings observed in addictivepatients to their ego’s fragility (Taylor et al., 1990). Self-critical depressioncould reflect this fragility and facilitate the recourse to acting outstrategies to control these dysphoric states. Addictive behaviors could bethought of as ways to regulate disruptive emotions and to reinforce self-esteem through self-soothing behaviors (Finn et al., 1987; Grotstein, 1986).Some of these patients add to this floating identity a strong dependencyon significant others. This result is not surprising, particularly concerninganorexics, because their restrictive/controlling defenses have been consi-dered as strategies to protect themselves from strong feelings of loss orrejection in relationships (Jeammet, 1989). If the addictive strategiesprotect these patients from their perturbing depressive feelings, it is only

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at the price of replacing a relation to a human object with a dependenceon an external object or behavior with immediate availability, whichallows a denial of the dependence but deprives the individual of thepositive regulating function of the interpersonal relationships (Speranzaet al., Submitted to Psychiatry Res.).

The results of our study have interesting clinical implications becauseidentifying specific patterns of relationship leading from alexithymia todependency can give clues in developing targeted strategies for at-risksubjects and yield information on their therapeutic needs. On the basisof our data, we can consider alexithymic individuals to be at risk of devel-oping a specific dependent behavior, all the more so because they have aself-critical or anaclitic depressive personality. Further explorations areneeded to identify other factors involved in the onset of these behaviors.

It should be recalled that, although alexithymia, self-critical, andanaclitic personality dimensions are important features in addictivedisorders, they correspond to phenomena that are placed on a continuumfrom normality to pathology and are not analogous to clinical diagnoses.In terms of the therapeutic approach, however, working on psycho-pathological dimensions seems quite fruitful in addictive disorders todefine specific clinical profiles to guide therapeutic strategies. Blatt, forexample, considers that individuals with a more pronounced anaclitic/dependent functioning are more likely to benefit from the holdingfunction of the therapeutic relationship, whereas individuals with astrong introjective/self-critical personality are more likely to benefit frominterpretations (Blatt and Zuroff, 1992). Addicted subjects who showa strong anaclitic depression could benefit more from a cognitive-behavioral approach, whereas patients with a self-critical depressionwould be more suitable for a psychodynamic approach. Kristal (Krystal,1982), for example, who has extensive experience in the treatment ofaddicted patients, considered alexithymia as the most important singlefactor responsible for the failure of psychodynamic psychotherapies. Theobservation of a specific inability to identify and communicate emotionsto other people and of a cognitive style that shows a preference for theexternal details of everyday life, rather than feelings and fantasies of aperson’s inner experience, should alert the clinician to the presence of analexithymic functioning that might demand a special psychotherapeuticintegrated approach for addictive disorders.

Several of this study’s limitations must be acknowledged. Theproposed model of the relationships between alexithymia, depressiveexperiences, and dependency is a static one observed in a cross-sectionalstudy. Only a longitudinal study observing relationships betweenvariables changing over time could give some clues to the causal nature


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of these relationships. The general approach to addictive disorders thathas been used in this article is a statistical one, although the researchproject from which the subjects were taken was based on clinical grounds.This kind of approach is necessarily restrictive of the clinical complexityof the persons affected by these devastating behaviors. However, pathanalysis has proved to be an interesting way to test working models forresearch and to describe unidirectional causal relationships between acertain number of observed variables. This method is especially suited toareas of clinical research in which many important questions cannot beaddressed through traditional experimental designs and analysis and inwhich the aim is to emphasize similarities more than differences(Haviland et al., 1994; Berthoz et al., 1999). Whereas the entire samplewas large enough to proceed to a path analysis, the sample size of thesubgroups was relatively small. Thus, only results concerning the overallmodel can be considered.

Moreover, the path analysis establishes whether the observable datafit with the supposed model. It cannot define whether the model is thebest possible one. Alternative models should be tested considering othervariables. Although the choice of the variables was based on previousstudies, we may question their pertinence as the best descriptors of thepsychological characteristics of subjects suffering from an addictivedisorder. It would be interesting to further explore these disorders,including other personality dimensions such as sensation seeking,impulsivity, or anxiety. Haviland and colleagues, for example, suggestedthat, in alcoholic patients, alexithymic features could be a defensivestrategy to face disrupting feelings related to hospitalization andabstinence, and could be a factor facilitating access to cure in thispopulation. (Haviland et al., 1988). This factor raises the question of theplace of anxiety and of depression in a model relating alexithymia anddependency in addictive disorders. It also highlights the importance ofconsidering the clinical status of the patients which could complicate theunderstanding of the observed results. This is certainly a topic thatdeserves further investigation. Enlarging the exploration of personalityfeatures and conducting longitudinal studies could reveal more clues onhow to develop strategies to identify at-risk subjects.

GLOSSARY

Addiction. An intemperate relationship with an activity that hasadverse biological, social, or psychological consequences for the personengaging in these behaviors. Within such a construct are currently

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included substance-related disorders, eating disorders, compulsive

buying, or pathological gambling (Shaffer, 1997).Dependence. A state of neuroadaptation that is manifested by a

specific withdrawal syndrome that can be produced by abrupt cessation

or rapid reduction of a drug or a behavior.Alexithymia. Literally ‘‘no words for feelings’’; refers to a cognitive-

affective disturbance characterized by a difficulty in identifying and

describing feelings and distinguishing them from bodily sensations, a

diminution of fantasy, and a concrete and poorly introspective thinking.

Alexithymia can be assessed using the revised Toronto Alexithymia Scale

(Taylor et al., 1992)Anaclitic depression or Dependency. A personality dimension

focused on concerns associated with disruption in relationships with

others, with feelings of loss, abandonment, and loneliness. It is assessed

by the Depressive Experiences Questionnaire (Blatt et al., 1992).Introjective depression or Self-criticism. A personality dimension

focused on problems concerning identity, associated with low self-esteem,

feelings of failure, culpability, and lack of self-confidence. It is assessed

by the Depressive Experiences Questionnaire (Blatt et al., 1992).Dependency. A specific personality style characterized by a marked

need for guidance and approval from others, a perception of the self as

powerless and ineffective, and a tendency to seek constant support and

reassurance from others (Bornstein, 1993). This personality dimension

is assessed by the Interpersonal Dependency Inventory (Hirschfeld et al.,

1977).

ACKNOWLEDGMENTS

This work was conducted within the clinical research project,

‘‘Dependence Network 1994–2000,’’ which was funded by the Institut

National de la Sante et de la Recherche Medicale (Reseau Inserm no.

494013) and the Fondation de France. The project is sponsored by the

Institut Mutualiste Montsouris. We want to thank the anonymous

reviewers for their helpful advice on previous versions of this article.

RESUMEN

La alexitimia, los sentimientos depresivos y la dependencia inter-

personal son dimensiones interrelacionadas que se consideran como


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factores de riesgo para los trastornos adictivos. Los objetivos deeste estudio son en primer termino investigar las relaciones entre estasdimensiones en una muestra amplia de sujetos adictivos, cuyos trastornoscomprometen ya sea las conductas alimentarias, ya sea el uso del alcohol odrogas y, en segundo termino, proponer un modelo comprensivo de laadiccion. Los participantes en este estudio proceden de un estudiomulticentrico sobre las conductas adictivas realizado en distintosdepartamentos de psiquiatrıa en Francia, Suiza y Belgica entre enero de1995 y marzo de 1999. La muestra clınica consta de 564 pacientes (149anorecticos, 84 bulımicos, 208 alcoholicos, 123 toxicomanos) de ambossexos y con una edad media de 27.3�8. Se efectuo un analisis de pistascausales en los 564 pacientes adictivos y en los 518 controles apareados,utilizando los resultados de la� Toronto Alexithymia Scale� (TAS-20),del � Depressive Exeperience Questionnaire � (DEQ) y del �

Interpersonal Dependency Inventory � (IDI). El analisis estadısticomostro un buen ajuste (GFI¼ 977) entre los datos observados y el modelopropuesto, lo que apoya la hipotesis segun la cual una dimensiondepresiva, sea esta anaclıtica o autocrıtica, puede facilitar el desarrollode una dependencia interpersonal en sujetos alexitımicos vulnerables. Esteresultado tiene implicaciones clınicas interesantes en la medida en queidentificar modelos especıficos de relacion que llevan de la alexitimia a ladependencia puede conducir a disenar estrategias especıficas para sujetosen situacion de riesgo.

RESUME

L’alexithymie, les sentiments depressifs et la dependanceInterpersonnelle sont des dimensions correlees qui sont considereescomme des facteurs de risque pour les troubles addictifs. L’objectif decette etude est d’investiguer les relations entre ces dimensions chez unlarge echantillon de sujets addictifs, qu’ils soient atteints d’un trouble desconduites alimentaires ou d’un troubles de l’usage de l’alcool ou dedrogues et de proposer un modele comprehensif de l’addiction. Lesparticipants de cette etude proviennent d’une etude multicentrique sur lesconduites addictives menee dans differents departements de psychiatrieen France, en Suisse et en Belgique entre Janvier 1995 et Mars 1999.L’echantillon clinique se compose de 564 patients (149 anorexiques, 84boulimiques, 208 alcooliques, 123 toxicomanes) des deux sexes avec unage moyen de 27.3�8. Une analyse de pistes causales a ete effectuee surles 564 patients addicitfs et sur les 518 controles apparies en utilisant les

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scores de la Toronto Alexithymia Scale (TAS-20), du DepressiveExperience Questionnaire (DEQ) et du Interpersonal DependencyInventory (IDI). L’analyse statistique a montre un bon ajustement(GFI¼ .977) entre les donnees observees et le modele propose, ce quisoutient l’hypothese qu’une dimension depressive, qu’elle soit anaclitiqueou auto-critique, peut faciliter le developpement d’une dependanceinterpersonnelle chez des sujets alexithymiques vulnerables. Ce resultat ades implications cliniques interessantes car, identifier des modelesspecifiques de relation conduisant de l’alexithymie a la dependancepeut conduire a des strategies ciblees pour des sujets a risque.

THE AUTHORS

Mario Speranza, M.D., is child andadolescent psychiatrist. He is currentlythe Head of the adolescent inpatientunit of the University Hospital ofBicetre (France). His main interestsare developmental psychopathology ofeating disorders and depressivedisorders.

Maurice Corcos, M.D., is psychiatristand psychoanalyst at the Adolescentand Young Adult Department ofPsychiatry of the Institute MutualisteMontsouris (Paris, France). His maininterests are alexithymia and depres-sion related to addiction and eatingdisorders.


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Philippe Stephan, M.D., is consultant

at the outpatient unit for adolescents of

the Department of Child and

Adolescent Psychiatry at the

University of Lausanne (Switzerland).

He is mainly interested in addiction

epidemiology and alexithymia.

Gwenole Loas, M.D., Ph.D., Professor

of Psychiatry, is the head of the

University Department of Psychiatry,

Hospital Pinel (Amiens, France). His

main interests are anhedonia, alexithy-

mia, dependent personality, and sub-

jective symptoms in schizophrenia.

Fernando Perez-Diaz is a research

engineer. He is currently working for

the National Research Council in the

Unit for Personality and adaptative

behaviours at the Hopital de la

Salpetriere (Paris, France). His main

interests are on statistical and mathe-

matical models for addictive behaviors.

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Francois Lang, M.D., is professor of child and adolescent psychiatry and

Head of the University Department of Child Psychiatry of Saint Etienne

(France).

Jean Luc Venisse, M.D., is a professor

of psychiatry and Head of the

Addiction Unit of the Psychiatry

Department of the University

Hospital Saint-Jacques of Nantes

(France). He has largely contributed

research on eating disorders and addic-

tive disorders, and has co-edited several

books on these topics.

Paul Bizouard, M.D., is a Professor of child and adolescent psychiatry

and Head of the University Department of Psychiatry of Besancon

(France).

Matine Flament, M.D., Ph.D., psychiatrist, is research fellow at the

INSERM/CNRS UMR 7593. Her main interests are obsessive-compul-

sive disorders and addictive disorders in adolescents and young adults.

Olivier Halfon, M.D., is a professor and Head of the Hospital Unit for

Children and Adolescents, Department of Child and Adolescent

Psychiatry, University of Lausanne (Switzerland). His main research

interests are focused on addictive behaviors (bulimia nervosa, anorexia

nervosa, drug abuse, and suicidal attempts), primarily from neurobiolo-

gical and epidemiological point of view.


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Philippe Jeammet, M.D., Ph.D., is a

professor of adolescent psychiatry (Uni-

versity of Paris VI) and Head of the

Adolescent and Young Adult Depart-

ment of Psychiatry of the Institute

Mutualiste Montsouris (Paris, France).

He is currently the president of the

European Society for Child and

Adolescent Psychiatry. His main

research interests are focused on

psychodynamic treatments of eating

disorders and depression.

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Alexithymia, Depressive Experiences, and Dependency in Addictive Disorders

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