Addictive Behaviors xxx (2013) xxx–xxx

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Addictive Behaviors

Metacognitive mastery moderates the relationship of alexithymia withcluster C personality disorder traits in adults with substance usedisorders

Paul H. Lysaker a,b,⁎, Kyle Olesek a, Kelly Buck a, Bethany L. Leonhardt c, Jenifer Vohs b, Jamie Ringer a,b,Giancarlo Dimaggio d, Raffaele Popolo d, Jared Outcalt a,b

a Roudebush VA Medical Center, Day Hospital 116H, 1481 West 10th St, Indianapolis, IN 46202, USAb Department of Psychiatry, Indiana University School of Medicine, Indianapolis, IN 46202, USAc School of Psychological Science, University of Indianapolis, Indianapolis, IN, USAd Center for Metacognitive Interpersonal Therapy, Rome, Italy

H I G H L I G H T S

• Cluster C personality disorder traits are common in substance use disorders.• Alexithymia may result in the expression of cluster C traits.• We tested if metacognition moderated the link of alexithymia with cluster C traits.• These constructs were assessed in adults with substance abuse.• More cluster C traits were found in persons with both alexithymia and poor mastery.

⁎ Corresponding author at: Roudebush VA Medical CeWest 10th St, Indianapolis, IN 46202, USA.

E-mail address: plysaker@iupui.edu (P.H. Lysaker).

0306-4603/$ – see front matter. Published by Elsevier Ltdhttp://dx.doi.org/10.1016/j.addbeh.2013.11.007

Please cite this article as: Lysaker, P.H., et al., Mtraits in adults with substanc..., Addictive Beh

a b s t r a c t

a r t i c l e i n f o

Available online xxxx

Keywords:Substance abusePersonalityAlexithymiaMetacognitionCluster C personality traits

Cluster C personality disorder traits have been observed in substance use disorders and linked with pooreroutcome. One potential factor which may cause these disturbances in personality function is alexithymia, orthe inability to name and express emotion. There may be other proximate factors which moderate the impactof alexithymia on the expression of cluster C traits, such as metacognitive mastery, which is the ability to useknowledge about mental states of self and others to cope with distress and solve social problems. To examinethe possibility thatmasterymediated the effects of alexithymia on cluster C traits, we assessed each of these con-structs using the Metacognitive Assessment Scale Abbreviated, Toronto Alexithymia Scale and SCID II among 58adults in an early phase of recovery from substancemisuse disorders in a residential setting. Results of amultipleregression revealed that, after controlling for symptom severity and severity of substance misuse history,metacognitivemasterymoderated the effect of alexithymia on number of cluster C traits. Amedian split and sub-sequent ANCOVA revealed that participants with higher levels of alexithymia and poorer metacognitive masteryhad more cluster C traits than the other groups. These findings may have clinical implications, suggesting thatpatients with substance use disorders may benefit from treatment which addresses metacognitive mastery.

Published by Elsevier Ltd.

1. Introduction

Cluster C personality disorder traits include dependent, avoidantand obsessive compulsive traits and represent anxious and fearful be-haviors which include the seeking of excessive support, control, oravoidance (Cox, Clara, Worobec, & Grant, 2012). They have beennoted to co-occur with a range of different mental health conditions(De Rick, Vanheule, & Verhaeghe, 2009; Langås, Malt, & Opjordsmoen,

nter, Day Hospital 116H, 1481

.

etacognitivemasterymoderaviors (2013), http://dx.doi.o

2012; Taylor, Bagby, & Parker, 1997) and are of interest in the area ofsubstance use disorders given their potential as a barrier to recovery.

In order to develop interventions to address cluster C traits, researchhas sought to understand the factors which promote and sustain thesetraits. One potential cause of cluster C traits is alexithymia, or difficultiesfocusing on, identifying and describing feelings (Taylor et al., 1997).Alexithymia has been linked to interpersonal difficulties which closelyparallel those seen in cluster C traits (Bekker, Croon, van Balkom, &Vermee, 2008; Joyce, Fujiwara, Cristall, Ruddy & Ogrodniczuk, inpress; Taylor et al., 1997; Vanheule, Desmet, Rosseel, Verhaeghe, &Meganck, 2007), and tied to poorer outcomes in substance use disorderincluding factors which portent risk of relapse (Saladin et al., 2012;

ates the relationship of alexithymiawith cluster C personality disorderrg/10.1016/j.addbeh.2013.11.007

Table 1Descriptive statistics of study variables (n = 58).

Measures Mean sd Range

SCID II cluster C traits 4.70 3.40 0–14Avoidant traits 1.48 1.80 0–7Dependent traits 1.00 1.62 0–6Obsessive compulsive traits 2.22 1.42 0–5SCID II total traits 17.56 11.46 1–49TAS total 51.42 13.81 23–81MAS-A Mastery 3.97 1.35 2–7SCL-90 GSI T score 46.43 10.04 30–69

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Thorberg, Young, Sullivan, & Lyvers, 2009; Thorberg et al., 2011;Verrocchio, Conti, & Fulcheri, 2010).

While evidence has provided a direct link between alexithymia andcluster C traits in general clinical and substance abuse samples (De-Rick& Vanheule, 2007; Honkalampi, Hintikka, Antikainen, Lehtonen, &Viinama¨ki, 2001; Nicolò et al., 2011) contradictory findings have beenreported. Alexithymia has not been linked, for instance, to outcomes inpersonality disorder (Joyce, Fujiwara, Cristall, Ruddy, & Ogrodniczuk,2013) or alcohol use disorders (de Haan et al., 2012). Honkalampiet al. (2010) reported that alexithymia was not associated with depres-sion, personality disorder traits, or alcohol use disorders.

One possible explanation for these contradictions is that the rela-tionship between alexithymia and cluster C traits in substance use dis-orders occurs in only some conditions. In other words, the effects ofalexithymia on cluster C personality traits may be mediated by otherfactors. One potential factor that might influence the relationship ofalexithymia with cluster C traits is metacognitive dysfunctions. Meta-cognition refers to a spectrum of activities which involves thinkingabout thinking and stretches from consideration of discrete psycholog-ical phenomenon to the synthesis of discrete perception into an inte-grated representation of self and others. It has long been considered aproblem underlying personality disorders (Dimaggio, Semerari,Carcione, Nicolò, & Procacci, 2007; Dimaggio et al., 2007; Semerari,Carcione, Dimaggio, Nicolò, & Procacci, 2007; Semerari et al., 2003).Metacognition shares aspects in common with the construct ofmentalization (Fonagy, Bateman, & Bateman, 2011) though the con-structs diverge asmentalization is often considered in the context of at-tachment, while metacognitionmay be activated by any of a number ofinterpersonal motives and includes a specific focus on metacognitivemastery. Metacognitive mastery refers to the use of metacognitiveknowledge to respond to psychological and social conflicts (Semerariet al., 2003, 2007). Deficits in metacognitive mastery have beenobserved in persons with cluster C traits (Carcione et al., 2011;Dimaggio, Procacci, et al., 2007) and linked to outcome in a range ofmental disorders including psychosis (Lysaker, Glynn, Wilkness, &Silverstein, 2010; Lysaker et al., 2011) and depression (Ladegaard,Larsen, Videbech, & Lysaker, submitted for publication) as well as med-ical conditions such as HIV (Ringer et al., submitted for publication).

To explore these possibilities, this study assessed alexithymia,metacognitive mastery and cluster C traits among a group of adultswith substance use disorders. We predicted that alexithymia would berelated to severity of cluster C traits, defined by the number of clustertraits, but that this relationship would be moderated by metacognitivemastery. Specifically, we anticipated that higher levels of cluster C traitswould be found with participants with higher levels of alexithymia andlower levels of metacognitive mastery. To rule out the possibility thatthese findings were the result of heightened levels of psychopathologyor severity of lifetime substance abuse we included these as covariates.

2. Method

2.1. Participants

Fifty five men and three women with SCID confirmed DSM-IV diag-noses of a substance use disorder were recruited from a residentialtreatment center associated with VA Medical Center. Seventeen had aprimary diagnosis of alcohol dependence, six of alcohol abuse, 31 ofpolysubstance dependence, two of opiate dependence and two of co-caine dependence. All participants were receiving ongoing treatmentand in a post-acute or stable phase of their disorder, defined as no hos-pitalizations or changes in medication in the last month. All had beenabstinent from alcohol and substances for a minimum of one monthas confirmed with random drug screens and breathalyzers performedat the residential center. Participants with a SCID confirmed diagnosisof a schizophrenia spectrum disorder were excluded. Participants hada mean age of 43.75 (sd = 10.32), a mean educational level of

Please cite this article as: Lysaker, P.H., et al., Metacognitivemasterymodertraits in adults with substanc..., Addictive Behaviors (2013), http://dx.doi.o

13.06 years (sd = 1.99) with a mean of 244 (sd = 130.14) months oflifetime drug or alcohol abuse. Forty three participants were Caucasian,14 African American, and one Latino.

2.2. Instruments

2.2.1. Indiana Psychiatric Illness InterviewIndiana Psychiatric Illness Interview (IPII; Lysaker, Clements,

Plascak-Hallberg, Knipscheer, & Wright, 2002) is a semi-structured in-terview typically lasting 30 to 60 min. Responses are audio taped andlater transcribed. The interview asks participants to describe and dis-cuss: i) the story of their life in general, ii) whether they think theyhave a mental illness or substance abuse condition and, if so, how thathas affected and not affected their life, iii) how this condition controlsand is controlled by them; iv) how it affects, and is affected by othersand v)what they see in the future. The IPII differs from other psychiatricinterviews in that minimal content is introduced and metacognitive ca-pacities appear spontaneously.

2.2.2. Metacognition Assessment Scale AbbreviatedMetacognition Assessment Scale Abbreviated (MAS-A; Semerari

et al., 2003) was originally designed to studymetacognitionwithin psy-chotherapy transcripts. It has been abbreviated and adapted for thestudy of IPII transcripts (Lysaker et al., 2005). For this study weemployed the Mastery subscale. Lower Mastery scores reflect difficul-ties in plausibly describing psychological challenges. Intermediaterange scores indicate plausible descriptions of psychological problemswith a limited ability to respond to them. Higher scores reflect an abilityto respond to psychological challenges effectively on the basis of psy-chological knowledge. Good interrater reliability was found in thisstudy (intraclass correlation = 0.82). Evidence of the validity of thisscale has been presented elsewhere (Lysaker et al., 2011).

2.2.3. The Symptom Checklist-90-RThe Symptom Checklist-90-R (SCL-90-R; Derogatis, 1977) is a 90

item self-report inventory designed to assess psychiatric symptom. Inthis studyweused the general psychopathology called theGlobal Sever-ity Index.

2.2.4. Toronto Alexithymia ScaleToronto Alexithymia Scale (TAS-20; Bagby, Parker, & Taylor, 1994) is

a self-report instrument that assesses awareness of emotional states.For this study we utilized the total score which is a summary of thethree subscales. This scale has been used successfully in previous studiesof alexithymia (Nicolò et al., 2011).

2.3. Procedure

All procedures were approved by the appropriate research reviewcommittees. Following informed consent, diagnoses of substanceabuse were determined using the Structured Clinical Interview forDSM-IV (SCID). Participants were then administered the SCID II, TAS,SCL-90 and IPII interview.Mastery was later rated on the basis of a tran-scription of the IPII using the MAS-A.

ates the relationship of alexithymiawith cluster C personality disorderrg/10.1016/j.addbeh.2013.11.007

Table 2ANCOVA comparing number of cluster C traits among participants with high and low levels of alexithymia and metacognitive mastery controlling for the SCL-90 Global Severity Index.

Group 1High TAS high Mastery(n = 15)

Group 2High TAS low Mastery(n = 15)

Group 3Low TAShigh Mastery(n = 19)

Group 4Low TAS low Mastery(n = 9)

TAS effectF(1,54) =

Mastery effectF(1,54) =

Interactiona

F(1,54) =

Number of cluster C traits M (sd) 4.53 (3.48) 7.73 (3.17) 3.68 (2.51) 2.11 (1.45) 8.56⁎⁎ 0.61 6.57⁎

a Fisher's LSD comparisons controlling for SCL-90 GSI T score: Group 2 N groups 1, 3, 4; p b .05; *p b .05; **p b .0001.

3P.H. Lysaker et al. / Addictive Behaviors xxx (2013) xxx–xxx

3. Results

Mean scores for the key variables are presented in Table 1. Themodal number of cluster C traits was 2 (n = 12), and the median 3.Twenty-six subjects had five or more cluster C traits. Number of clusterC traits was not significantly correlated with age (r = .05; p = ns), re-ported lifetimemonths of drug and alcohol use (r = 0.19, p = ns), ed-ucation (r = 0.17; p = ns) or MAS-A Mastery scores (r = −0.16;p = ns). Cluster C traits did not differ between participants with diag-noses of abuse vs. dependence, drug use vs. alcohol use and men vs.women. Number of cluster C traits was significantly related to higherGlobal Severity Index Scores (GSI; r = 0.46, p b .001) and TAS totalscores (r = 0.58; p b .001). The TAS total and Mastery score were in-versely related to one another at the trend level (r = −0.25; p = .06).

To test the hypothesis that Mastery moderates the relationship ofalexithymiawith severity of cluster C pathology, independent of generalpsychopathology, a regression was performed in which the normalizedSCL90 GSI score, TAS total and MAS-A Mastery scores were first forcedto enter to predict number of cluster C traits and then in a second stepthe mastery–alexithymia interaction term was allowed to enter. Thisproduced a significant overall model (F(4,53) = 9.85). The R2 for thefirst step was 0.36 (p b .001) with the interaction raising the total R2

for the model to 0.43 (p b .05). The standardized beta coefficient forthe interaction term was−0.27 (p b .05).

Given a significantmoderation analyses, we next performed amedi-an split and divided participants into high and low groups on the TAStotal and MAS-A Mastery scores. Means of these groups are presentedin Table 2. As also revealed in Table 2, an ANCOVA comparing groupson number of cluster C traits, controlling for the SCL-90 GSI, revealed asignificant group effect for TAS total score and a significant interactionbetween TAS total score and MAS-A Mastery. Examination of meanscores revealed it was only the group with both higher TAS total scoresand lower Mastery scores that had significantly more cluster C traits.

Finally, to explore whether there was a relationship betweenPersonality Disorder traits in general, alexithymia and metacognition,we repeated the regression this time predicting total traits on theSCID II. This analysis revealed a significant predictor equation(F(4,53) = 10.92; p b .001) with a significant relationship evidencedbetween the total traits with the TAS total and the SCL-90 GSI (stan-dardized coefficient beta = 0.38; p b .05; and 0.34; p b .001 respec-tively). There was however no significant evidence of moderation.

4. Discussion

Results suggest that the relationship of alexithymia and severity ofcluster C traits in a sample of persons with substance use disorders inearly remissionwasmoderated bymetacognitivemastery, or the abilityto use awareness of mental states to respond to emotional distress andsolve interpersonal problems. Specifically, we found that relatively highlevels of alexithymia were more closely linked with greater number ofcluster C traits only in the presence of deficits in metacognitive masteryafter controlling for global psychopathology. Severity of substance usehistory and type of substance abuse history were unrelated to clusterC traits.

While the cross sectional nature of the data precludes drawing caus-al conclusions, findings may suggest some hypotheses for future

Please cite this article as: Lysaker, P.H., et al., Metacognitivemasterymodertraits in adults with substanc..., Addictive Behaviors (2013), http://dx.doi.o

research. For one, it is possible that being unable to name one's ownfeelings does not necessarily develop into fearful or anxious patternsof interpersonal relationships in substance use disorders on its own,but that itmust only occur in the absence of the ability to use knowledgeabout oneself and others.

Importantly, there are limitations. Participants were mostly men intheir 40s involved in treatment. More research is needed with youngerpersons, females, or among persons who decline treatment. Severity ofsubstance misuse was calculated in terms of lifetime months of abuseand forms of substance use and thus nuances may have been lost.More research is also necessary which involves collecting a broaderarray of data at multiple time points.

With replication, our findingsmay have several clinical implications.In particular it may be useful to consider interventions that targetmeta-cognition. One promising avenue of therapy now being developed isMetacognitive Interpersonal Therapy (Dimaggio, Attinà, Popolo, &Salvatore, 2012) which targets cluster c problems. Persons with co-occurring substance abuse and cluster C traits may benefit from thiskind of treatment which is aimed at helping them use metacognitiveknowledge to take a critical distance from their negative expectationsabout others and balance themwith views of themselves as realisticallyeffective, able and deserving of appreciation.

Role of funding sourceThis studywas funded by the Indiana Institute for Medical Research. This body played

no role in study design; the collection, analysis and interpretation of data, in thewriting ofthe report; and in the decision to submit the paper for publication.

ContributorsLysaker and Outcalt designed the study. Lysaker performed all data analysis. Lysaker,

Olesek, Buck, Leonhardt, Vohs, Ringer, Dimaggio, Popolo andOutcalt contributed to the lit-erature review and the manuscript preparation including interpretation of findings.

Conflict of interestThere are no conflicts of interest or disclosures.

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