Some addicted patients have social cognition deficits that require therapists to have special skills to ensure treatment success. Specific remediation techniques that teach addicted patients to look at the relevant emotional cues when interacting with people should be tested as adjunctive treatment. Almost two decades after the first studies reporting reduced ability to read non-verbal signals in alcohol dependence 1, Bora & Zorlu's meta-analysis confirms further that social cognitive impairments comprise an important research topic in the field of addiction 2. Social abilities are fundamental to human behaviour. Patterns of body language, including facial expressions and body postures, translate into a tuned ballet between interacting partners that binds and bonds people together 3. In this context, it appears inevitable that difficulties decoding non-verbal inputs could lead to interpersonal difficulties in alcohol-dependent patients 4. Bora & Zorlu evoke possible aetiologies to explain social cognitive deficits in alcohol-dependent patients. A toxic effect of chronic alcohol consumption on connectivity between brains areas devoted to social cues decoding has been described 5. However, social cues decoding difficulties have also been seen in other substance-related addictions (e.g. opiates 6). Additionally, non-verbal emotion decoding impairments have been highlighted recently in pathological gambling; that is, an addiction without a substance 7. This suggests that non-verbal emotion decoding impairments in addiction could occur in the absence of any toxic effect of a substance on the brain. In this commentary, I propose that attachment styles could impact significantly upon alcohol-dependent patients’ ability to decode non-verbal emotions. Insecure attachment is associated with alcohol dependence and constitutes a risk factor for its development 8. The majority of alcohol-dependent patients display an abnormal attachment style and experience difficulties in securing stable interpersonal relationships 9. Because impaired interpersonal attachment is associated with an inability to buffer life's emotional turmoil effectively 9, alcohol might be used as a coping strategy. Attachment problems impair emotion decoding in faces, as they are associated with gaze avoidance towards informative cues in childhood. Children with callous/unemotional traits show low levels of eye contact towards their mothers; in other words, they fail to attend to the eyes of attachment figures 10. Impaired ability to seek out and make use of the eye regions is also present in autism, and improves with oxytocin administration 11. Specific neuronal structures are considered important in the monitoring of gaze: amygdala regions are involved in the processing of gaze and eye fixation, as illustrated by deficits of facial emotion processing in patients with amygdala lesions 12. Interestingly, alcohol-dependent patients have been shown to exhibit lowered amygdalar responses when looking at emotional faces 13. This pattern of activation has also been found among young people with a high risk of alcoholism (i.e. from families with a history of alcohol dependence 14, 15). This supports the idea that non-verbal language processing difficulties might partly precede the development of an addiction. Consequently, we encourage future studies on alcohol dependence to examine the association between attachment styles and patterns of eye movements during facial emotion decoding. On a therapeutic level, addicted patients’ social cognition deficits could interfere significantly with psychotherapeutic interventions. Patients with addiction show a very high level of dropout from treatment, which might partly reflect attachment problems. The effectiveness of treatment relies heavily upon strong interpersonal skills, independently of theoretical psychotherapeutic background 16. It is therefore important that the therapist is aware of patients’ lowered ability to decode non-verbal emotional states and finds ways of interacting with them despite these difficulties. Indeed, high emotional tuning characterizes psychotherapies with higher symptom reduction 17, and might be difficult to achieve with some addicted patients. As well as psychotherapeutic interventions, cognitive remediation procedures could help to improve social cognition deficits in addiction, and should also be examined in future studies. For instance, training patients to look at the right cues when decoding emotional faces (i.e. the eyes and the mouth) has been shown to be effective in the treatment of impaired emotion decoding in child psychopathy 10 and in schizophrenia 18. Moreover, an emotion perception intervention combined with cognitive remediation has been shown to improve both emotion recognition and social functioning in chronic schizophrenia 19. In summary, we need further research to explore the relationship between social cognition deficits and abnormal attachment styles in addiction. Improving these deficits in adult addicted patients might still be possible through effective psychotherapeutic interventions and specific cognitive remediation procedures, aiming at a positive impact upon their social life and their substance use. None.
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