{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,8,31]],"date-time":"2026-08-31T14:57:30Z","timestamp":1788188250319,"version":"build-2803163510"},"reference-count":64,"publisher":"MDPI AG","issue":"3","license":[{"start":{"date-parts":[[2023,2,21]],"date-time":"2023-02-21T00:00:00Z","timestamp":1676937600000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["EJIHPE"],"abstract":"<jats:p>This study aimed to explore the relationships among the variables involved in a Comprehensive Model of Addiction (CMA), which posits that the presence and severity of addictive behaviors are related to the configuration of seven psychological variables, namely childhood trauma, insecure attachment, affect dysregulation, dissociation, impulsivity, compulsiveness, and obsessiveness. A vulnerability model was proposed, in which it was suggested that affect dysregulation and complex trauma mediated the association between insecure attachment and dissociation. Furthermore, a maintenance model was elaborated, in which it was hypothesized that dissociation influenced affect dysregulation via impulsivity, compulsiveness, and obsessiveness. A clinical sample of 430 individuals with substance use disorder was involved. All participants received a DSM-5 clinical diagnosis of Substance-Related and Addictive Disorders and were recruited from the Italian National Health System. A parallel mediation emerged, confirming the vulnerability model, with complex trauma and affect dysregulation mediating the relationship between insecure attachment and dissociation. Furthermore, a mixed serial\u2013parallel mediation described the maintenance model, where impulsiveness, compulsiveness, and obsessiveness significantly mediated the relationship between dissociation and affect dysregulation. Our findings offer a better understanding of the variables associated with addictive disorders, thus providing important indications for both treatment and preventive interventions.<\/jats:p>","DOI":"10.3390\/ejihpe13030039","type":"journal-article","created":{"date-parts":[[2023,2,22]],"date-time":"2023-02-22T05:01:32Z","timestamp":1677042092000},"page":"512-524","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":16,"title":["An Integrated Approach to Addictive Behaviors: A Study on Vulnerability and Maintenance Factors"],"prefix":"10.3390","volume":"13","author":[{"given":"Alessio","family":"Gori","sequence":"first","affiliation":[{"name":"Department of Health Sciences, University of Florence, Via di San Salvi 12, Pad. 26, 50135 Firenze, Italy"},{"name":"Integrated Psychodynamic Psychotherapy Institute (IPPI), Via Ricasoli 32, 50122 Florence, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-0849-1249","authenticated-orcid":false,"given":"Eleonora","family":"Topino","sequence":"additional","affiliation":[{"name":"Department of Human Sciences, LUMSA University of Rome, Via della Traspontina, 21, 00193 Rome, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Marco","family":"Cacioppo","sequence":"additional","affiliation":[{"name":"Department of Human Sciences, LUMSA University of Rome, Via della Traspontina, 21, 00193 Rome, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-5748-0592","authenticated-orcid":false,"given":"Giuseppe","family":"Craparo","sequence":"additional","affiliation":[{"name":"Faculty of Human and Social Sciences, UKE\u2014Kore University of Enna, Cittadella Universitaria, 94100 Enna, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-5181-2648","authenticated-orcid":false,"given":"Adriano","family":"Schimmenti","sequence":"additional","affiliation":[{"name":"Faculty of Human and Social Sciences, UKE\u2014Kore University of Enna, Cittadella Universitaria, 94100 Enna, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Vincenzo","family":"Caretti","sequence":"additional","affiliation":[{"name":"Department of Human Sciences, LUMSA University of Rome, Via della Traspontina, 21, 00193 Rome, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2023,2,21]]},"reference":[{"key":"ref_1","unstructured":"American Society of Addiction Medicine (2019, November 06). Public Policy Statement: Definition of Addiction. Available online: https:\/\/www.asam.org\/resources\/definition-of-addiction."},{"key":"ref_2","first-page":"137","article-title":"Genetic basis of drug dependence and comorbid behavioral traits. Nihon shinkei seishin yakurigaku zasshi","volume":"24","author":"Agatsuma","year":"2004","journal-title":"JPN J. Psychopharmacol."},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"257","DOI":"10.1146\/annurev.clinpsy.3.022806.091455","article-title":"Relapse and relapse prevention","volume":"3","author":"Brandon","year":"2007","journal-title":"Annu. Rev. Clin. Psychol."},{"key":"ref_4","doi-asserted-by":"crossref","unstructured":"Caretti, V., Gori, A., Craparo, G., Giannini, M., Iraci-Sareri, G., and Schimmenti, A. (2018). A new measure for assessing substance-related and addictive disorders: The addictive behavior questionnaire (ABQ). J. Clin. Med., 7.","DOI":"10.3390\/jcm7080194"},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"235","DOI":"10.1007\/s10899-021-10024-3","article-title":"A comprehensive model for gambling behaviors: Assessment of the factors that can contribute to the vulnerability and maintenance of gambling disorder","volume":"38","author":"Gori","year":"2022","journal-title":"J. Gambl. Stud."},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"789","DOI":"10.1016\/j.psychres.2016.10.046","article-title":"Impulsivity, Alexithymia and Dissociation among pathological gamblers in different therapeutic settings: A multisample comparison study","volume":"246","author":"Gori","year":"2016","journal-title":"Psychiatry Res."},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"312","DOI":"10.1002\/cbm.1999","article-title":"Psychopathological features in a sample of substance-abusing individuals with criminal history: Towards a definition of a personality prototype of an \u2018Addict with Criminal Conduct\u2019","volume":"27","author":"Gori","year":"2017","journal-title":"Crim. Behav. Ment. Health"},{"key":"ref_8","unstructured":"Flores, P.J. (2004). Addiction as an Attachment Disorder, Jason Aronson."},{"key":"ref_9","first-page":"3","article-title":"Problematic Internet use in lonely adolescents: The mediating role of detachment from parents","volume":"17","author":"Musetti","year":"2020","journal-title":"Clin. Neuropsychiatry"},{"key":"ref_10","doi-asserted-by":"crossref","unstructured":"Gori, A., Russo, S., and Topino, E. (2023). Love Addiction, Adult Attachment Patterns and Self-Esteem: Testing for Mediation Using Path Analysis. J. Pers. Med., 13.","DOI":"10.3390\/jpm13020247"},{"key":"ref_11","doi-asserted-by":"crossref","unstructured":"Topino, E., Cacioppo, M., and Gori, A. (2022). The Relationship between Attachment Styles and Compulsive Online Shopping: The Mediating Roles of Family Functioning Patterns. Int. J. Environ. Res. Public Health, 19.","DOI":"10.3390\/ijerph19138162"},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"107633","DOI":"10.1016\/j.addbeh.2023.107633","article-title":"The associations between attachment, self-esteem, fear of missing out, daily time expenditure, and problematic social media use: A path analysis model","volume":"141","author":"Gori","year":"2023","journal-title":"Addict. Behav."},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"552","DOI":"10.1080\/15299732.2017.1402400","article-title":"The trauma factor: Examining the relationships among different types of trauma, dissociation, and psychopathology","volume":"19","author":"Schimmenti","year":"2018","journal-title":"J. Trauma Dissociation"},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"61","DOI":"10.1080\/15289168.2002.10486420","article-title":"Organizing principles of interaction from infant research and the lifespan prediction of attachment: Application to adult treatment","volume":"2","author":"Beebe","year":"2022","journal-title":"J. Infant Child Adolesc. Psychother."},{"key":"ref_15","unstructured":"Taylor, G.J., Bagby, R.M., and Parker, J.D. (1999). Disorders of Affect Regulation: Alexithymia in Medical and Psychiatric Illness, Cambridge University Press."},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"158","DOI":"10.1016\/j.comppsych.2012.06.013","article-title":"The mediator roles of trait anxiety, hostility, and impulsivity in the association between childhood trauma and dissociation in male substance-dependent inpatients","volume":"54","author":"Evren","year":"2013","journal-title":"Compr. Psychiatry"},{"key":"ref_17","doi-asserted-by":"crossref","first-page":"338","DOI":"10.1080\/15299732.2015.1108948","article-title":"Dissociative experiences and dissociative minds: Exploring a nomological network of dissociative functioning","volume":"17","author":"Schimmenti","year":"2016","journal-title":"J. Trauma Dissociation"},{"key":"ref_18","doi-asserted-by":"crossref","first-page":"106","DOI":"10.1037\/a0038019","article-title":"Linking the overwhelming with the unbearable: Developmental trauma, dissociation, and the disconnected self","volume":"33","author":"Schimmenti","year":"2016","journal-title":"Psychoanal. Psychol."},{"key":"ref_19","first-page":"64","article-title":"Video-terminal dissociative trance: Toward a psychodynamic understanding of problematic Internet use","volume":"14","author":"Schimmenti","year":"2017","journal-title":"Clin. Neuropsychiatry"},{"key":"ref_20","first-page":"41","article-title":"Problematic internet use and emotional dysregulation among young people: A literature review","volume":"18","author":"Gioia","year":"2021","journal-title":"Clin. Neuropsychiatry"},{"key":"ref_21","first-page":"65","article-title":"Online gaming and prolonged self-isolation: Evidence from Italian gamers during the COVID-19 outbreak","volume":"18","author":"Giardina","year":"2021","journal-title":"Clin. Neuropsychiatry"},{"key":"ref_22","doi-asserted-by":"crossref","first-page":"330","DOI":"10.4306\/pi.2014.11.3.330","article-title":"The relationships between early trauma, dissociation, and alexithymia in alcohol addiction","volume":"11","author":"Craparo","year":"2014","journal-title":"Psychiatry Investig."},{"key":"ref_23","doi-asserted-by":"crossref","first-page":"107431","DOI":"10.1016\/j.addbeh.2022.107431","article-title":"A trauma model of substance use: Elaboration and preliminary validation","volume":"134","author":"Schimmenti","year":"2022","journal-title":"Addict Behav."},{"key":"ref_24","doi-asserted-by":"crossref","unstructured":"Gori, A., Topino, E., and Griffiths, M.D. (2021). A screening tool for exercise addiction: The psychometric properties of the Italian Exercise Addiction Inventory. Int. J. Ment. Health Addict., Online first.","DOI":"10.1007\/s11469-021-00681-1"},{"key":"ref_25","doi-asserted-by":"crossref","first-page":"107274","DOI":"10.1016\/j.addbeh.2022.107274","article-title":"Assessment of online compulsive buying: Psychometric properties of the Italian compulsive online shopping scale (COSS)","volume":"129","author":"Gori","year":"2022","journal-title":"Addict. Behav."},{"key":"ref_26","first-page":"11","article-title":"Psychopathological features and drop-out predictors in a sample of individuals with substance use disorder under residenti al community treatment","volume":"17","author":"Gori","year":"2020","journal-title":"Clin. Neuropsychiatry"},{"key":"ref_27","doi-asserted-by":"crossref","first-page":"408","DOI":"10.1080\/03637750903310360","article-title":"Beyond Baron and Kenny: Statistical mediation analysis in the new millennium","volume":"76","author":"Hayes","year":"2009","journal-title":"Commun. Monogr."},{"key":"ref_28","doi-asserted-by":"crossref","first-page":"1173","DOI":"10.1037\/0022-3514.51.6.1173","article-title":"The moderator\u2013mediator variable distinction in social psychological research: Conceptual, strategic, and statistical considerations","volume":"51","author":"Baron","year":"1986","journal-title":"J. Pers. Soc. Psychol."},{"key":"ref_29","doi-asserted-by":"crossref","first-page":"363","DOI":"10.1037\/a0025461","article-title":"Attachment in psychotherapy: Psychometric properties of the Psychological Treatment Inventory Attachment Styles Scale (PTI-ASS)","volume":"21","author":"Giannini","year":"2021","journal-title":"J. Psychother. Integr."},{"key":"ref_30","unstructured":"Gori, A., Giannini, M., and Schuldberg, D. (2015). PTI\u2014Psychological Treatment Inventory, Giunti OS\u2013Organizzazioni Speciali."},{"key":"ref_31","doi-asserted-by":"crossref","first-page":"23","DOI":"10.1016\/0022-3999(94)90005-1","article-title":"The twenty-item Toronto Alexithymia Scale\u2014I. Item selection and cross-validation of the factor structure","volume":"38","author":"Bagby","year":"1994","journal-title":"J. Psychosom. Res."},{"key":"ref_32","doi-asserted-by":"crossref","first-page":"33","DOI":"10.1016\/0022-3999(94)90006-X","article-title":"The twenty-item Toronto Alexithymia Scale\u2014II. Convergent, discriminant, and concurrent validity","volume":"38","author":"Bagby","year":"1994","journal-title":"J. Psychosom. Res."},{"key":"ref_33","doi-asserted-by":"crossref","first-page":"551","DOI":"10.1016\/S0022-3999(96)00228-0","article-title":"Cross validation of the factor structure of the 20-item Toronto Alexithymia Scale: An Italian multicenter study","volume":"41","author":"Bressi","year":"1996","journal-title":"J. Psychosom. Res."},{"key":"ref_34","first-page":"200","article-title":"The psychometric characteristics of the Traumatic Experiences Checklist (TEC): First findings among psychiatric outpatients","volume":"9","author":"Nijenhuis","year":"2022","journal-title":"Psychol. Psychother."},{"key":"ref_35","first-page":"16","article-title":"An update on the Dissociative Experiences Scale","volume":"6","author":"Carlson","year":"1993","journal-title":"Dissociation"},{"key":"ref_36","unstructured":"Hayes, A.F. (2018). Introduction to Mediation, Moderation, and Conditional Process Analysis Second Edition: A Regression-Based Approach, Guilford Press."},{"key":"ref_37","doi-asserted-by":"crossref","first-page":"879","DOI":"10.3758\/BRM.40.3.879","article-title":"Asymptotic and resampling strategies for assessing and comparing indirect effects in multiple mediator models","volume":"40","author":"Preacher","year":"2008","journal-title":"Behav. Res. Methods"},{"key":"ref_38","doi-asserted-by":"crossref","first-page":"e88881","DOI":"10.5812\/ijpbs.88881","article-title":"Multi-Level Approach to Theories of Addiction: A Critical Review","volume":"13","author":"Shafiee","year":"2019","journal-title":"Iran J. Psychiatry Behav. Sci."},{"key":"ref_39","doi-asserted-by":"crossref","first-page":"1570","DOI":"10.3389\/fpsyg.2018.01570","article-title":"Trauma, temperament, alexithymia, and dissociation among persons addicted to alcohol: Mediation model of dependencies","volume":"9","year":"2018","journal-title":"Front. Psychol."},{"key":"ref_40","first-page":"2","article-title":"Childhood trauma, attachment and psychopathology: A correlation network approach","volume":"8","author":"Midolo","year":"2020","journal-title":"Mediterr. J. Clin. Psychol."},{"key":"ref_41","unstructured":"Bowlby, J. (1988). A Secure Base: Clinical Applications of Attachment Theory, Routledge."},{"key":"ref_42","doi-asserted-by":"crossref","first-page":"358","DOI":"10.1521\/bumc.2021.85.4.358","article-title":"The vulnerability of insecure minds: The mediating role of mentalization in the relationship between attachment styles and psychopathology","volume":"85","author":"Santoro","year":"2021","journal-title":"Bull. Menn. Clin."},{"key":"ref_43","unstructured":"Damasio, A.R. (2003). Looking for Spinoza: Joy, Sorrow, and the Feeling Brain, Houghton Mifflin Harcourt."},{"key":"ref_44","unstructured":"Gedo, J. (1986). Conceptual Issues in Psychoanalysis, Analytic Press."},{"key":"ref_45","doi-asserted-by":"crossref","first-page":"300","DOI":"10.1080\/17542863.2017.1307434","article-title":"Alexithymia and psychological symptomatology: Research conducted on a non-clinical group of Italian adolescents","volume":"10","author":"Pellerone","year":"2017","journal-title":"Int. J. Cult. Ment. Health"},{"key":"ref_46","doi-asserted-by":"crossref","first-page":"96","DOI":"10.1037\/pap0000084","article-title":"The developmental roots of dissociation: A multiple mediation analysis","volume":"34","author":"Schimmenti","year":"2017","journal-title":"Psychoanal. Psychol."},{"key":"ref_47","doi-asserted-by":"crossref","unstructured":"Topino, E., Gori, A., and Cacioppo, M. (2021). Alexithymia, dissociation, and family functioning in a sample of online gamblers: A moderated mediation study. Int. J. Environ. Res. Public Health, 18.","DOI":"10.3390\/ijerph182413291"},{"key":"ref_48","doi-asserted-by":"crossref","unstructured":"Gori, A., and Topino, E. (2023). The Association between Alexithymia and Social Media Addiction: Exploring the Role of Dysmorphic Symptoms, Symptoms Interference, and Self-Esteem, Controlling for Age and Gender. J. Pers. Med., 13.","DOI":"10.3390\/jpm13010152"},{"key":"ref_49","doi-asserted-by":"crossref","unstructured":"Gori, A., Topino, E., Pucci, C., and Griffiths, M.D. (2021). The Relationship between Alexithymia, Dysmorphic Concern, and Exercise Addiction: The Moderating Effect of Self-Esteem. J. Pers. Med., 11.","DOI":"10.3390\/jpm11111111"},{"key":"ref_50","doi-asserted-by":"crossref","first-page":"277","DOI":"10.1080\/00952990802013441","article-title":"Child sexual abuse, dissociation, and alcohol: Implications of chemical dissociation via blackouts among college women","volume":"34","author":"Klanecky","year":"2008","journal-title":"Am. J. Drug Alcohol Abus."},{"key":"ref_51","doi-asserted-by":"crossref","first-page":"219","DOI":"10.1177\/1077559514551944","article-title":"Pathways from childhood maltreatment to emerging adulthood: Investigating trauma-mediated substance use and dating violence outcomes among child protective services\u2013involved youth","volume":"19","author":"Faulkner","year":"2014","journal-title":"Child Maltreat"},{"key":"ref_52","doi-asserted-by":"crossref","unstructured":"Gori, A., Topino, E., Fioravanti, G., and Casale, S. (2022). Exploring the Psychodynamics of Compulsive Shopping: Single and Moderated Mediation Analyses. Int. J. Ment Health Addiction, Advanced Online Publication.","DOI":"10.1007\/s11469-022-00977-w"},{"key":"ref_53","doi-asserted-by":"crossref","first-page":"21","DOI":"10.1007\/s40429-019-0235-1","article-title":"The Relationship Between Dissociative Experiences and Cannabis Use: A Systematic Review","volume":"6","author":"Sideli","year":"2019","journal-title":"Curr. Addict. Rep."},{"key":"ref_54","doi-asserted-by":"crossref","first-page":"1892","DOI":"10.1176\/appi.ajp.157.11.1892","article-title":"Treating addiction as a human process","volume":"157","author":"Gold","year":"2000","journal-title":"Am. J. Psychiatry"},{"key":"ref_55","doi-asserted-by":"crossref","first-page":"5","DOI":"10.1080\/15294145.2003.10773403","article-title":"Understanding addictive vulnerability: An evolving psychodynamic perspective","volume":"5","author":"Khantzian","year":"2003","journal-title":"Neuropsychoanalysis"},{"key":"ref_56","doi-asserted-by":"crossref","first-page":"355","DOI":"10.3928\/0048-5713-19930701-05","article-title":"Obsessive-compulsive spectrum disorders: An overview","volume":"23","author":"Hollander","year":"1993","journal-title":"Psychiatr. Ann."},{"key":"ref_57","doi-asserted-by":"crossref","first-page":"406","DOI":"10.1176\/appi.ajp.2011.11020289","article-title":"Neural correlates of stress-induced and cue-induced drug craving: Influences of sex and cocaine dependence","volume":"169","author":"Potenza","year":"2012","journal-title":"Am. J. Psychiatry"},{"key":"ref_58","first-page":"112","article-title":"Socioeconomic disparities and self-reported substance abuse-related problems","volume":"10","author":"Hossain","year":"2018","journal-title":"Addict. Health"},{"key":"ref_59","doi-asserted-by":"crossref","first-page":"1812","DOI":"10.1002\/cpp.2756","article-title":"Self-report measures of secure attachment in adulthood: A systematic review","volume":"29","author":"Morris","year":"2022","journal-title":"Clin. Psychol. Psychother."},{"key":"ref_60","doi-asserted-by":"crossref","unstructured":"George, C., Kaplan, N., and Main, M. (1985). Adult Attachment Interview, Unpublished Manuscript, University of California at Berkeley.","DOI":"10.1037\/t02879-000"},{"key":"ref_61","doi-asserted-by":"crossref","first-page":"226","DOI":"10.1037\/0022-3514.61.2.226","article-title":"Attachment styles among young adults: A test of a four-category model","volume":"61","author":"Bartholomew","year":"1991","journal-title":"J. Pers. Soc. Psychol."},{"key":"ref_62","doi-asserted-by":"crossref","unstructured":"Brennan, K.A., Clark, C.L., and Shaver, P.R. (1998). Experiences in Close Relationships Inventory [Database Record], APA PsycTests.","DOI":"10.1037\/t23266-000"},{"key":"ref_63","doi-asserted-by":"crossref","first-page":"615","DOI":"10.1037\/a0022898","article-title":"The experiences in close relationships\u2014Relationship Structures Questionnaire: A method for assessing attachment orientations across relationships","volume":"23","author":"Fraley","year":"2011","journal-title":"Psychol. Assess."},{"key":"ref_64","doi-asserted-by":"crossref","unstructured":"Gori, A., Topino, E., Cacioppo, M., Craparo, G., Schimmenti, A., and Caretti, V. (2022). An Addictive Disorders Severity model: A chained mediation analysis using structural equation modelling. J. Addict. Dis., Online first.","DOI":"10.1080\/10550887.2022.2074762"}],"container-title":["European Journal of Investigation in Health, Psychology and Education"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/2254-9625\/13\/3\/39\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,10,10]],"date-time":"2025-10-10T18:37:57Z","timestamp":1760121477000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/2254-9625\/13\/3\/39"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2023,2,21]]},"references-count":64,"journal-issue":{"issue":"3","published-online":{"date-parts":[[2023,3]]}},"alternative-id":["ejihpe13030039"],"URL":"https:\/\/doi.org\/10.3390\/ejihpe13030039","relation":{},"ISSN":["2254-9625"],"issn-type":[{"value":"2254-9625","type":"electronic"}],"subject":[],"published":{"date-parts":[[2023,2,21]]}}}