INTRODUCTION

According to the most recent definition of DSM-IV-TR, a Criterion A1 traumatic event is ‘‘an event that involves actual or threatened death or serious injury, or other threat to one’s personal integrity’’ and includes ‘‘learning about the unexpected or violent death, serious harm, or threat of death or injury experienced by a family member or other close associate’’ (1). Exposure to both childhood and adulthood traumatic events has been linked to the development of psychopathology, including PTSD (2,3), substance use disorders (4-6) alcohol use disorders (7,8) and personality disorders (5).

Individuals who have experienced a psychological trauma but do not meet diagnostic criteria for PTSD often suffer similar functional impairment, health problems and increased health- care utilization as those with PTSD (9,10). Some argue that such findings support a continuous view of post-traumatic psychiatric sequelae, where any PTSD symptoms are viewed as a stress response to trauma along a continuum, with full PTSD being the most severe response (11). Although the course of treatment for alcohol dependent patients with PTSD has been well studied, little is known about trauma exposed alcohol dependent patients regardless the development of PTSD. Because these individuals are highly prevalent among alcohol dependent patients in treatment settings, it is important to determine trauma history and related factors with trauma in this population (10). Definitions of traumatic events and methods by which exposure to traumatic events has been established have varied markedly across studies. For example, ‘life events’ traumatized a higher proportion of individuals than ‘traumatic events’ in alcohol dependents (12). Nevertheless, individuals who have experienced a psychological trauma that do not meet the definition in DSM-IV-TR for traumatic events may also have higher severity of psychiatric symptoms dimensionally but not necessarily have a disorder.

Although prevalence varies in studies, experiencing a lifetime traumatic event is common among patients with substance use disorders (13,14). As many as 89% of substance use disorder patients report having experienced a traumatic event in their lifetime (15) and substance use is 1.5–5.5 times more prevalent in individuals with trauma histories than without (10). In a recent study, patients with alcohol-dependence were more severely affected by psychological trauma than opiate dependents (12). Particularly childhood maltreatment has been linked to alcohol abuse and dependence among an adult population (16,17). In the literature, a relatively large body of studies has reported that child maltreatment increases an individual’s risk for alcohol abuse, although current evidence is not sufficient to support this relationship among male adults who had been victims of childhood maltreatment (17,18). The high rate of trauma history in substance dependents may be a function of the fact that alcohol and other substances are used by trauma survivors to self-medicate psychological distress symptoms (8,19-21). Nevertheless, despite these high rates of comorbidity and suggested causal relationship, in clinical practice history of trauma among alcohol dependents seeking treatment is rarely addressed despite the importance of the issue (12).

The results of previous studies confirm that childhood trauma may have long-lasting and enduring effects on adult psychological functioning, as exposed individuals continually react more strongly to small stressors occurring in the natural flow of everyday life (22). Several studies found that particularly childhood trauma may have an enduring influence on the development of adult personality characteristics (23,24-26). One personality characteristic that is consistently associated with childhood trauma is neuroticism—a personality trait reflecting instability, vulnerability to stress, or anxiety proneness (24,25). The Temperament and Character Inventory (TCI) is a self-administered dimensional questionnaire constructed to assess the 7 basic dimensions of personality in 2 major components of personality: temperament and character (27). The psychobiological model assumes interactions between temperament and character scales. These interactions elicit secondary emotions and are important in the development of personality (28). Individual differences in personality structure and development have a strong influence on the risk of all forms of psychopathology, including alcohol abuse (29). Researches suggest that particularly novelty seeking (NS) represents a vulnerability factor for substance abuse in general (30,31), whereas low scores on self-directedness (S) is related with early onset alcoholism (32). A study documented that emotional and physical abuse were risk factors for increasing personality disorder symptomatology. In this study only harm avoidance (HA) dimension was the strongest and most consistent risk factor for development of personality dysfunction (33). Also among borderline personality disordered patients with trauma history, higher levels of HA predicted the severity of PTSD symptoms (complex PTSD) (34). Finally, significant relationship between early trauma and adult personality as exposure to emotional trauma predicted levels of S and cooperativeness (C) dimensions of the TCI among soldiers (35).

Alexithymia is defined as inability to distinguish one’s own feelings from the accompanying bodily sensations, inability to express feelings, and an externally orientated cognitive style reflecting an absence of inner thoughts and fantasies (36). Many studies have indicated relatively high prevalence rates of alexithymia (ranging from 42–79%) in alcohol-related disorders (37-39). Recent studies have reported an association between alexithymia with primitive and immature ego defense styles, which implies a relatively primitive way of dealing with emotional problems (40,41). Alexithymic patients might be emotionally and cognitively restricted, unable to differentiate their feelings, verbalize them and solve the problem (42). In a recent study among alcohol dependents, high harm avoidance (HA) and self-transcendence (ST) and low self-directedness (S) were related with alexithymia suggesting that alexithymia can be explained by specific dimensions within Cloninger’s psychobiological model of personality in this population (43). Latest study on this subject suggested that although alexithymia is affected by the personality, state-dependent mood and anxiety may mediate the relationship between alexithymia and personality (44). Finally, among alcohol dependents, the number of childhood trauma the individual experienced was related with alexithymia in adulthood, particularly “difficulty in identifying feelings-DIF” factor of TAS-20. Also this study suggested that childhood emotional abuse might be a risk factor for alexithymia among inpatient substance dependents (42).

The aim of this study was to evaluate the relationship of trauma history with alexithymia and personality dimensions among alcohol dependent inpatients.

METHODS

Settings and sample

The study was conducted in Bakirkoy State Hospital for Psychiatric and Neurological Diseases, Alcohol and Drug Research, Treatment and Training Center (AMATEM) in Istanbul, between January 2007 and January 2008. AMATEM is a specialized center for substance use disorders with 85 inpatient beds, and accepts patients from all over Turkey. The Ethical Committee of the hospital approved the study. Each patient’s written informed consents was obtained after the study protocol was thoroughly explained.

One hundred and eighty consecutively admitted alcohol-dependent inpatients without history of any other substance abuse were considered for participation in the study. All participants fit the DSM-IV diagnostic criteria for alcohol dependence. Excluding criteria were illiteracy, mental retardation or cognitive impairment and comorbid psychotic disorder. Five patients were excluded due to illiteracy and three patients due to cognitive deficits. Although none of the patients refused to participate in the study, 16 patients were excluded because they did not completed the scales, did not give the forms back or left the treatment program prematurely, i.e. before filling the forms. A total of 156 alcohol-dependent inpatients participated in the study. Interviews with the study group were conducted after detoxification period, i.e. 4-6 weeks after the last day of alcohol use.

Measurements

All patients were assessed by using a semi-structured socio-demographic form. The diagnosis of alcohol or drug dependence in each participating patient based on the clinical examination, a screening interview based on the Structured Clinical Interview for DSM-IV (SCID-I) (45), Turkish version (46), conducted by a trained interviewer (CE).

Toronto Alexithymia Scale. Alexithymia was assessed with the Turkish version of the 20-item Toronto Alexithymia Scale (TAS-20) (47,48). The first factor (difficulty in identifying feelings; DIF) is for assessing the ability to identify feelings and to distinguish them from the somatic sensations that accompany emotional arousal. Factor 2 (difficulty in describing feelings; DDF) is for assessing the ability to describe feelings to other people. Factor 3 (externally oriented thinking; EOT) is for assessing externally oriented thinking. The total scores of the TAS-20 were dichotomized as a score of ≥61, which indicated alexithymia, and a score of <61, which indicated non-alexithymia. The approved form has been validated in a Turkish population study (49).

Temperament and Character Inventory. Dimensions of temperament were (1) harm avoidance (HA); (2) novelty seeking (NS); (3) reward dependence (RD); (4) persistence (P). Dimensions of character were (1) self-directedness (SD); (2) cooperativeness (C); (3) self-transcendence (ST) (50). The reliability and validity of the Turkish version of the TCI were supported by its psychometric properties and construct validity (51).

Traumatic Experiences Checklist (TEC): The TEC is a questionnaire including 29 types of traumatic experiences (52). Trauma area subscores are calculated for emotional neglect, emotional abuse, sexual approach, sexual abuse, and physical abuse/bodily threat (range 0-21). These subscores take into account qualitative characteristics of the trauma, including age of onset, duration, degree of closeness of the abuser, and related degree of distress. For each of the traumas, participants also indicated how much support they have received afterward (0=none, 1=some, 2=good). Good validity and reliability is reported with Cronbach’s alpha scores of 0.86 and 0.90 and test-retest reliability of r=0.91 (53).

Statistical Methods

The statistical package SPSS 11.5 for Windows was used for all analyses. Categorical variables were compared by chi-square statistics. We used independent t test to compare the groups on continuous variables and we used Mann-Whitney U test when these variables were not normally distributed. Correlation analyses (Pearson, bivariate) between the number of trauma type and alexithymia and personality dimensions were performed. Taken the presence of trauma history as a dependent variable, Forward Logistic Regression model was performed. Taken the number of trauma types experienced as a dependent variable, Stepwise Linear Regression model was performed. For all statistical analysis p values were two-tailed and differences were considered significant at p<0.05.

RESULTS

Among alcohol dependent inpatients 77 (49.4%) were considered as the group with trauma history according to the DSM-IV-TR definition. These individuals had experienced stressful life events that met the DSM-IV-TR Criterion A1 definition of a traumatic stressor (Table 1).

Rate of being single and alexithymic were higher in the group with a trauma history than the group without a trauma history. Odds Ratio (95% Confidence Interval) for trauma history was 2.65 (1.30-5.41) times higher in alexithymic group than non-alexithymic group. Current age, employment status, age of regular alcohol use and duration of education did not differ between groups (Table 2). In alexithymic patiens, mean number of trauma type experienced (5.02±3.07) was higher than non-alexithymic patiens (3.94±3.43) (z=-2.43, p=0.015).

Types of the trauma experiences were also evaluated with TEC. According to this checklist, 144 (92.3%) had experienced at least one stressful event, which may not have met the DSM-IV-TR Criterion. Mean number of trauma type experienced was 4.26±3.35 (range, 0-17). Frequency of trauma types, age at the time of trauma and degree of influence were shown on Table 3 (Table 3). Individuals who had experienced stressful life events that met the DSM-IV-TR Criterion A1 definition of a traumatic stressor (traumatic group) had higher mean TEC score (5.38±3.57) than individuals who had not met this criterion (non-traumatic group) (3.18±2.74) (t=-4.32, p<0.001).

Mean scores of difficulty in identifying feelings (DIF), alexithymia, NS, HA and ST were higher in traumatic group, whereas S and C were lower in the traumatic group (Table 4). Number of trauma was positively correlated with DIF of TAS-20 (r=0.23, p<0.01) and negatively correlated with cooperativeness (r=-0.32, p<0.001). Other than these, TAS factors and personality dimensions did not show significant correlation with the number of trauma type experienced. Among those with trauma history (n=77), number of trauma type was not related with alexithymia or personality dimensions (not shown).

Lower S score was determinant for any trauma history in Forward Logistic Regression model. When the alexithymic (n=47, 30.1%) and non-alexithymic groups were evaluated separately, S still was related with the presence of trauma, whereas there was no related personality dimension with the presence of the trauma in the alexithymic group (Table 5). Lower C scores predicted the number of trauma in Stepwise Linear Regression model. When the alexithymic and non-alexithymic groups were evaluated separately, C was still related with the number of the trauma experienced in the non-alexithymic group, whereas NS was related with the number of the trauma experienced in the alexithymic group (Table 6). Age, alexithymia factors, and dimensions of TCI were independent variables in both of these models when the whole sample was evaluated. When the alexithymic and non-alexithymic groups were evaluated separately, age and dimensions of TCI were independent variables in these models.

DISCUSSION

In line with previous results, we found that the majority of patients with alcohol dependency (49.4%) have been exposed to at least one trauma in their life time, according to the DSM-IV-TR Criterion A1 definition of a traumatic stressor. This is important because these patients may have additional psychiatric disorders or higher severity of psychiatric symptoms. Results also showed that, consistent with previous studies, rates of traumas that do not necessarily met the DSM-IV-TR Criterion A1 definition of a traumatic stressor was as much as 92.3% (10,15).

Although other sociodemographic variables did not differ between traumatic and non-traumatic groups, rate of being single were higher in traumatic group, which suggested that these patients may have less support, and problems with interpersonal relationships. The age of onset for alcohol use was lower in traumatic group, meaning abusing alcohol during adolescence, which is an important period in terms of physiological and psychosocial development. Higher rate of physical, social and psychological problems may be expected among these individuals. Thus, these may cause vulnerability for psychopathologies secondary to traumas that were experienced or may increase the risk of experiencing traumas. Nevertheless, traumas experienced early in life may cause early onset of alcohol use by means of self-medicating symptoms of psychological distress caused by these traumas (8,19-21).

Patients with high NS may be impulsive and have risky life style, which may increase the probability of experiencing trauma in these individuals. Researches also suggest that NS represents a vulnerability factor for substance abuse in general (30,31), is associated with craving scores (54) and a predictor of relapse in detoxified male alcohol dependents (55). HA dimension was found to be a risk factor for the development of personality dysfunction (33) and predicted the severity of psychiatric reaction to the trauma experienced (34). Studies conducted among different populations usually demonstrated that mainly high HA scores and low S scores are related with both anxiety and depression (56,57). In a previous study, Akvardar et al. found higher HA scores among Turkish alcoholics compared to healthy controls. In this study, it was suggested that individuals with high HA scores might use alcohol to relieve negative emotions (58). Thus, the results of the present study suggest that while NS seems to be a risk factor for experiencing trauma, HA may be both the cause and the consequence of trauma.

Nevertheless, the main finding of the present study was that, other than being lower in traumatic group, the character dimension S was related with the presence of trauma (according to the DSM-IV) and C, with the number of the traumas (according to TEC) experienced. The previous studies suggested that all categories of personality disorders are distinguished by low SD (50), particularly among substance abusers (59). Low SD is defined by poor impulse control or weak ego strength and is described as being irresponsible, purposeless, immature, weak, fragile, blaming, destructive, ineffective, unreliable, helpless, poorly integrated, and low in self-acceptance. Basiaux et al. (60) reported that alcohol dependents were characterized by higher NS and lower SD than nonpsychiatric control subjects. Likewise, most individuals with personality disorders are low in C, which is defined by poor interpersonal functioning and described as being intolerant, narcissistic, hostile or disagreeable, critical, unhelpful, revengeful, and opportunistic (27,61). Thus, our findings suggest that the rates and the severity of personality disorders are higher in the traumatized group. Nevertheless, the prevalence of personality disorders was not assessed in the present study, which is a limitation of the study. Extreme expressions in one or more temperament dimensions combined with an immature character in terms of low or very low expressions of S and C are important indicators of the incidence of a personality disorders (62,63). Low scores on RD is indicative for rare and eccentric individuals (cluster A), high scores on NS is indicative for dramatic and emotional subjects (cluster B), and high scores on HA is indicative for anxious and fearful individuals (cluster C) (62). Thus, finding high NS scores and high HA scores for the traumatized group in the present study suggests that cluster B and C personality disorders might be well represented in this group.

Cloninger’s assumption of the importance of low S and C as substantial constituents of personality disorders corresponds with the suggestion of Fonagy et al. (64) that individuals with a personality disorders are characterized by an impaired mentalizing capacity implying an impaired ability to make sense of their own mental states and that of others, causing problematic interpersonal relationships and impairments in the development of the self. Trauma experienced in childhoood have been strongly implicated as a risk factor in the development of personality disorders (65). Rojas and Pappagallo (66) considered sexual and physical abuse to be risk factors that contribute to the development of borderline and antisocial personality disorders. Many other studies have shown that childhood trauma deforms the personality (67). Prolonged torture experiences or early trauma exposure may impair personality formation by enhancing the effects of cognitive, affective and behavioural vulnerabilities (68). In another study, victims of physical abuse demonstrated social, emotional and behavioural maladjustments as a result of their personality impairments (69). Also patients with trauma history may have immature personality traits related with poor response to challenging life events resulting in alcohol use in order to self-medicate negative emotions.

Associations between experiencing trauma and alexithymia are not well understood. A few studies have assessed alexithymia among adults who report history of childhood physical or sexual abuse (40,70-72). Among psychotherapy patients, Berenbaum (70) found a strong association between history of childhood abuse and “difficulty in identifying feelings-DIF” feature of alexythymia. In a study conducted among female psychiatric inpatients, association between history of childhood sexual abuse and alexithymia was not found to be significant (71). In another study among substance abusing outpatients (72), a history of sexual abuse was relatively strongly associated with alexithymia. Finally, Kooiman et al. (73) found that childhood sexual or physical abuse did not predict alexithymia in psychiatric outpatients and they suggested that other factors in addition to these might also play an important role in the development of inadequate affect regulation. As cogently argued by Zlotnick et al. (74), alexithymia in adulthood may develop when a caretaker fails to teach a child how to differentiate among distinctive emotional states, to regulate arousal, and to respond adaptively to challenging life events. It is therefore possible that emotional neglect and/or maltreatment that occurs during childhood may obstruct the normal development of emotional processing skills, leading to alexithymia and vulnerability to experience trauma in adulthood (75). This is consistent with the Evren et al.’s suggestion that childhood emotional abuse might be a risk factor for alexithymia among inpatient substance dependents (42). One of our main findings was that traumatized patients showed significantly more alexithymic phenomena (particularly DIF subscale of TAS-20). Rate of being alexithymic and mean total score of alexithymia were higher in traumatic group and this differences were related to DIF factor. Similar with the results of the present study, the number of childhood trauma type was positively correlated with DIF among inpatient substance dependents (42). Interestingly, when alexithymic and non-alexithymic groups were evaluated separately, different relatonships were found between trauma and personality in alexithymic group than the whole group.

The present study has several limitations. First of all, because the current study utilized a cross-sectional design, it is not possible to make conclusive statements about the temporal order between the measures of trauma and personality. Second, there is the possibility of reporting bias. Participants may underreport their actual levels of exposure to certain traumatic events because of feelings of shame, fear or discomfort with the subject matter, lack of trust in the interviewer, reticence to share personal information with a stranger (76), or all of the above. Thirth, all the patients were male. Trauma, alcohol use disorder and personality interaction may differ between genders. Thus, gender specific aspects of these relationships needs further inquiry.

Alexithymia, temperament and character may all be related with trauma history in male alcohol dependent inpatients. Finding low S score predicting the presence of trauma history and low C score predicting the severity of trauma suggest that trauma experienced in lifetime is related with higher probability of personality disorders, although causal relationship is not clear. Nevertheless, a previous study found that among alcohol dependent patients, drop-out rates from treatment was higher in patients with low C scores and time to drop-out was shorter in patients with low C and S scores (77). Thus, this suggest that trauma and the number of the trauma experienced regardless of DSM-IV definition, may negatively effect treatment. The results of the present study also suggest that evaluation of trauma (both dimensionaly and categoricaly) is important, since trauma may be an influential factor in determining the manner and extent of psychopathology that is expressed in alcohol dependent inpatients (10,78).

REFERENCES

1. American Psychiatric Association. Diagnostic and statistical manual of mental disorders. Fourth Edition, Text Revision. Washington, DC: Author, 2000.

2. Breslau N, Davis GC, Andreski P, Peterson E. Traumatic events and posttraumatic stress disorder in an urban population of young adults. Arch Gen Psychiatry 1991; 48: 216-222.

3. Kessler RC, Sonnega A, Bromet E, Hughes M, Nelson CB. Posttraumatic stress disorder in the National Comorbidity Survey. Arch Gen Psychiatry 1995; 52: 1048-1060.

4. Dunn GE, Ryan JJ, Dunn CE. Trauma symptoms in substance abusers with and without histories of childhood abuse. J Psychoactive Drugs 1994; 26: 357-360.

5. Bernstein DP, Stein JA, Handelsman L. Predicting personality pathology among adult patients with substance use disorders: effects of childhood maltreatment. Addict Behav 1998; 23: 855-868.

6. Brems C, Johnson ME, Neal D, Freemon M. Childhood abuse history and substance use among men and women receiving detoxification services. Am J Drug Alcohol Abuse 2004; 30: 799-821.

7. Stewart SH. Alcohol abuse in individuals exposed to trauma: A critical review. Psychol Bull 1996; 120: 83–112.

8. Stewart SH, Pihl RO, Conrod PJ, Dongier M. Functional associations among trauma, PTSD, and substance-related disorders. Addict Behav 1998; 23: 797–812.

9. Arnow BA. Relationships between childhood maltreatment, adult health and psychiatric outcomes, and medical utilization. J Clin Psychiatry 2004; 65 (Suppl 12):10-15.

10. Norman SB, Tate SR, Anderson KG, Brown SA. Do trauma history and PTSD symptoms influence addiction relapse context? Drug Alcohol Depend 2007; 90: 89-96.

11. Ruscio AM, Ruscio J, Keane TM. The latent structure of posttraumatic stress disorder: a taxometric investigation of reactions to extreme stress. J Abnorm Psychol 2002; 111: 290-301.

12. Shora S, Stone E, Fletcher K. Substance use disorders and psychological trauma. Psychiatr Bull 2009; 33: 257-260.

13. Westermeyer J, Wahmanholm K, Thuras P. Effects of childhood physical abuse on course and severity of substance abuse. Am J Addict 2001; 10: 101-110.

14. Simpson TL, Miller WR. Concomitance between childhood sexual and physical abuse and substance use problems. A review. Clin Psychol Rev 2002; 22: 27-77.

15. Farley M, Golding JM, Young G, Mulligan M, Minkoff JR. Trauma history and relapse probability among patients seeking substance abuse treatment. J Subst Abuse Treat 2004; 27: 161-167.

16. Anda RF, Whitfield CL, Felitti VJ, Chapman D, Edwards VJ, Dube SR, Williamson DF. Adverse childhood experiences, alcoholic parents, and later risk of alcoholism and depression. Psychiatr Serv 2002; 53: 1001-1009.

17. Dube SR, Anda RF, Felitti VJ, Edwards VJ, Croft JB. Adverse childhood experiences and personal alcohol abuse as an adult. Addict Behav 2002; 27: 713-725.

18. Widom CS, Hiller-Sturmhöfel S. Alcohol abuse as a risk factor for and consequence of child abuse. Alcohol Res Health 2001; 25: 52-57.

19. Chilcoat HD, Breslau N. Posttraumatic stress disorder and drug disorders: testing causal pathways. Arch Gen Psychiatry 1998; 55: 913-917.

20. Coffey SF, Saladin ME, Drobes DJ, Brady KT, Dansky BS, Kilpatrick DG. Trauma and substance cue reactivity in individuals with comorbid posttraumatic stress disorder and cocaine or alcohol dependence. Drug Alcohol Depend 2002; 65: 115-127.

21. Miranda R Jr, Meyerson LA, Long PJ, Marx BP, Simpson SM. Sexual assault and alcohol use: exploring the self-medication hypothesis. Violence Vict 2002; 17: 205-217.

22. Glaser JP, van Os J, Portegijs PJ, Myin-Germeys I. Childhood trauma and emotional reactivity to daily life stress in adult frequent attenders of general practitioners. J Psychosom Res 2006; 61: 229-236.

23. Herman JL, Perry JC, van der Kolk BA. Childhood trauma in borderline personality disorder. Am J Psychiatry 1989; 146: 490–495.

24. Roy A. Childhood trauma and neuroticism as an adult: possible implication for the development of the common psychiatric disorders and suicidal behaviour. Psychol Med 2002; 32: 1471– 1474.

25. Bunce SC, Larsen RJ, Peterson C. Life after trauma: personality and daily life experiences of traumatized people. J Pers 1995; 63: 165– 188.

26. Kendler KS, Kuhn JW, Prescott CA. Childhood sexual abuse, stressful life events and risk for major depression in women. Psychol Med 2004; 34: 1475– 1482.

27. Kose S. A psychobiological model of temperament and character: TCI. New Symposium 2003; 41: 86-97.

28. de la Rie SM, Duijsens IJ, Cloninger CR. Temperament, character, and personality disorders. J Personal Disord 1998; 12: 362-372.

29. Cloninger CR, Svrakic DM. Integrative psychobiological approach to psychiatric assessment and treatment. Psychiatry 1997;60:120-141.

30. Hosak L, Preiss M, Halir M, Cermakova, Csemy L. Temperament and character inventory (TCI) personality profile in metamphetamine abusers: a controlled study. Eur Psychiatry 2004; 19: 193-195.

31. Gabel S, Stallings MC, Schmitz S, Young SE, Fulker DW. Personality dimensions and substance misuse: relationships in adolescents, mothers and fathers. Am J Addict 1999; 8: 101-113.

32. Evren C, Dalbudak E, Cakmak D. Personality dimensions in male patients with early-onset alcohol dependence who seek treatment. Isr J Psychiatry Relat Sci 2009 46: 204-206.

33. Carter JD, Joyce PR, Mulder RT, Luty SE. The contribution of temperament, childhood neglect, and abuse to the development of personality dysfunction: a comparison of three models. J Pers Disord 2001; 15: 123-35.

34. Barnow, S, Plock K, Spitzer C, Hamann N, Freyberger HJ. Traumatic life events, temperament and character in patients with borderline personality disorder and complex posttraumatic stress disorder. Verhaltenstherapie 2005;15:148-156.

35. Rademaker AR, Vermetten E, Geuze E, Muilwijk A, Kleber RJ. Self-reported early trauma as a predictor of adult personality: a study in a military sample. J Clin Psychol 2008; 64: 863-875.

36. Taylor GJ, Bagby RM. Affect dysregulation and alexithymia. In: Taylor GJ, Bagby RM, Parker JDA (eds). Disorders of Affect Regulation. Cambridge University Press, Cambridge, MA, 1997; 26-45.

37. Evren C, Can S, Evren B, Cakmak D. The relationship between alexithymia and depression, anxiety and erectile dysfunction in a sample of male alcoholic inpatients: A controlled study. Bulleten of Clinical Psychopharmacology 2002; 12: 165–173 (Turkish).

38. Evren C, Eken B, Cakmak D. Alexithymia among alcohol dependent patients and its relationship with depression, anxiety and personality disorders. Journal of Dependence 2003; 4: 47–52 (Turkish).

39. Thorberg FA, Young RM, Sullivan KA, Lyvers M. Alexithymia and alcohol use disorders: a critical review. Addict Behav 2009; 34: 237-245.

40. Kooiman CG, Spinhoven P, Trijsburg RW, Rooijmans HG. Perceived parental attitude, alexithymia and defense style in psychiatric outpatients. Psychother Psychosom 1998; 67: 81–87.

41. Parker JD, Taylor GJ, Bagby RM. Alexithymia: relationship with ego defense and coping styles. Compr Psychiatry, 1998; 39: 91-98.

42. Evren C, Evren B, Dalbudak E, Ozcelik B, Oncu F. Childhood abuse and neglect as a risk factor for alexithymia in adult male substance dependent inpatients. J Psychoactive Drugs 2009; 41: 85-92.

43. Evren C, Kose S, Sayar K, Ozcelik B, Borckardt JP, Elhai JD, Cloninger CR. Alexithymia and temperament and character model of personality in alcohol-dependent Turkish men. Psychiatry Clin Neurosci 2008;62:371-378.

44. Lee YJ, Yu SH, Cho SJ, Cho IH, Koh SH, Kim SJ. Direct and indirect effects of the temperament and character on alexithymia: a pathway analysis with mood and anxiety. Compr Psychiatry 2010;51:201-206.

45. First MB, Spitzer RL, Williams JBW. Structured Clinical Interview for DSM-IV (SCID). Washington, DC: American Psychiatric Association, 1997.

46. Corapcioglu A, Aydemir O, Yildiz M, Esen A, Koroglu E. DSM-IV Eksen I Bozuklukları (SCID-I) için yapılandırılmış klinik görüşme, Klinik versiyon. Ankara. Hekimler Yayın Birliği, 1999.

47. Bagby MR, Parker JDA, Taylor GJ. The twenty-item Toronto Alexithymia Scale–I: Item selection and cross-validation of the factor structure. J Psychosom Res 1994; 38: 23–32.

48. Bagby MR, Taylor GJ, Parker JDA. The twenty-item Toronto Alexithymia Scale–II: Convergent, discriminant, and concurrent validity. J Psychosom Res 1994; 38: 33–40.

49. Gulec H, Kose S, Gulec MY, Citak S, Evren C, Borckardt J, Sayar K. Reliability and factorial validity of the Turkish version of the 20-item Toronto alexithymia scale (TAS-20). Bull Clin Psychopharmacol 2009;19: 214-220.

50. Cloninger CR, Svrakic DM, Przybeck TR. A psychobiological model of temperament and character. Arch Gen Psychiatry 1993; 50: 975–990.

51. Kose S, Sayar K, Kalelioglu U, Aydın N, Ak I, Kırpınar I, Reeves RA, Przybeck TR, Cloninger CR. Turkish version of the TCI: Reliability, validity, and factorial structure. Bulleten of Clinical Psychopharmacology 2004; 14: 107–131.

52. Nijenhuis ERS, Van der Hart O, Kruger K. The psychometric characteristics of the Traumatic Experiences Checklist (TEC): First findings among psychiatric outpatients. Clin Psychol and Psychother 2002; 9: 200-210.

53. Nijenhuis ERS, Van der Hart O, Vanderlinden J. The Traumatic Experiences Checklist (TEC). In: Nijenhuis ERS (Editor). Somatoform dissociation: Phenomenia, measurement, and theoretical issues. Assen, The Netherlands: Van Gorcum, 1999, 188-193.

54. Zilberman ML, Tavares H, el-Guabaly N. Relationship between craving and personality in treatment-seeking women with substancerelated disorders. BMC Psychiatry 2003;3:1.

55. Meszaros K, Lenzinger E, Hornik K, Füreder T, Willinger U, Fischer G, Schönbeck G, Aschauer HN. The Tridimensional Personality Questionnaire as a predictor of relapse in detoxified alcohol dependents. The European Fluvoxamine in Alcoholism Study Group. Alcohol Clin Exp Res 1999; 23: 483-486.

56. Pelissolo A, Corruble E. Personality factors in depressive disorders: contribution of the psychobiologic model developed by Cloninger. Encephale 2002; 28: 363-373.

57. Jylha P, Isometsa E. Temperament, character and symptoms of anxiety and depression in the general population. Eur Psychiatry 2006; 21: 389-395.

58. Akvardar Y, Arkar H, Gul S, Akdede BB. Alkol kullanım bozukluklarında kişilik özellikleri. National Psychiatry Congress October 14-19 2003, Turkey 2003, 603-604.

59. Gutierrez F, Sangorrin J, Martin-Santos R, Torres X, Torrens M. Measuring the core features of personality disorders in substance abusers using the Temperament and Character Inventory (TCI). J Personal Disord 2002; 16: 344-359.

60. Basiaux P, le Bon O, Dramaix M, Massat I, Souery D, Mendlewicz J, Pelc I, Verbanck P. Temperament and Character Inventory (TCI) personality profile and sub-typing in alcoholic patients: a controlled study. Alcohol Alcohol 2001; 36: 584-587.

61. Cloninger CR. A practical way to diagnosis personality disorder: a proposal. J Personal Disord. 2000; 14: 99-108.

62. Svrakic DM, Draganic S, Hill K, Bayon C, Przybeck TR, Cloninger CR. Temperament, character, and personality disorders: etiologic, diagnostic, treatment issues. Acta Psychiatr Scand 2002; 106:189-195.

63. Richter J, Brändström S. Personality disorder diagnosis by means of the Temperament and Character Inventory. Compr Psychiatry 2009; 50: 347-352.

64. Fonagy P, Gergely G, Jurist EL, Target M. Affect regulation, mentalization, and the development of the self. New York: Other press; 2008.

65. Tyrka AR, Wyche MC, Kelly MM, Price LH, Carpenter LL. Childhood maltreatment and adult personality disorder symptoms: influence of maltreatment type. Psychiatry Res 2009; 165: 281-287.

66. Rojas V, Pappagallo M. Risk factors for PTSD in Children and Adolescents. In: Silva RR (editor). Posttraumatic Stress Disorders in Children & Adolescents. New York: Norton & Company, 2004, 38–59.

67. Herman JL. Trauma and Recovery. 1992, Basic Books, New York.

68. Daud A, af Klinteberg B, Rydelius PA. Trauma, PTSD and personality: the relationship between prolonged traumatization and personality impairments. Scand J Caring Sci 2008; 22: 331-340.

69. Pelcovitz D, Kaplan S, Goldenberg B, Mandel F, Lehane J, Guarrera J. Post-traumatic stress disorder in physically abused adolescents. J Am Acad Child Adolesc Psychiatry 1994; 33: 305–312.

70. Berenbaum H. Childhood abuse, alexithymia and personality disorder. J Psychosom Res 1996; 41: 585-595.

71. Zlotnick C, Shea MT, Pearlstein T, Simpson E, Costello E, Begin A. The relationship between dissociative symptoms, alexithymia, impulsivity, sexual abuse, and self-mutilation. Compr Psychiatry 1996; 37: 12-16.

72. Scher D, Twaite JA. The relationship between child sexual abuse and alexithymic symptoms in a population of recovering adult substance misusers. J Child Sex Abus 1999; 8: 25-40.

73. Kooiman CG, van Rees Vellinga S, Spinhoven P, Draijer N, Trijsburg RW, Rooijmans HG. Childhood adversities as risk factors for alexithymia and other aspects of affect dysregulation in adulthood. Psychother Psychosom 2004; 73: 107-116.

74. Zlotnick C, Mattia J, Zimmerman M. Clinical features of survivors of sexual abuse with major depression. Child Abuse Negl 2001; 25: 357-367.

75. Frewen PA, Dozois DJ, Neufeld RW, Lanius RA. Meta-analysis of alexithymia in posttraumatic stress disorder. J Trauma Stress 2008; 21: 243-246.

76. Fullilove MT, Fullilove RE, Smith M, Winlder K, Michael C, Panzer PG, Wallace R. Violence, trauma, and posttraumatic stress disorder among women drug users. J Trauma Stress 1993; 6: 533-543.

77. Arnau MM, Mondon S, Santacreu JJ. Using the temperament and character inventory (TCI) to predict outcome after inpatient detoxification during 100 days of outpatient treatment. Alcohol Alcohol 2008; 43: 583-588.

78. Marx BP, Sloan DM. The effects of trauma history, gender, and race on alcohol use and posttraumatic stress symptoms in a college student sample. Addict Behav 2003; 28: 1631-1647.