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RESEARCH

The role of personality correlates in the pathogenesis of alcoholism: an intergenerational study among alcohol dependent and nondependent population

Mythili Hazarika, Dipesh Bhagabati1

Senior Lecturer of Clinical Psychology, 1Professor and Head, Department of Psychiatry, Gauhati Medical College Hospital, Guwahati, Assam, India

 

 

 

Abstract

Background: ‘Children of alcoholics (COAs)’ is a general term used to describe children or individuals with one or more parents with alcoholism. In Assam, there is no study done so far on COAs, and on parents of alcohol dependence, though the prevalence rate of alcohol is reported to be high.

Material and methods: Objectives were to examine the personality variables of the alcohol dependent fathers (ADF) and their sons (SADF), as well as the alcohol nondependent fathers (NADF) and their sons (SNADF). Tools administered were informed consent form, socio-demographic proforma, the Michigan Alcohol Screening Test (MAST), Kuppuswamy socio-economic scale (KPSS), checklist of various common ailments, and Eyesenck’s Personality Inventory (EPI). Data obtained was analysed using descriptive statistics such as mean, standard deviations and frequencies. Non-parametric test such as the chi-square test and parametric tests such as student’s ‘t’ test and analysis of variance (ANOVA) were carried out.

Results: There was no significant difference between the groups on the variables of age, education, occupation, family type, number of children, and socioeconomic status. There was an upward trend noted in alcohol use among SADF. Prevalence of illness was more among ADF. ADF were found to be high on neuroticism and extraversion, in comparison to NADF. SADF were higher on extraversion in comparison to SNADF, but there was no significant difference found in neuroticism in both the groups.

Conclusion: Clinicians must have a thorough knowledge of the impact of addiction upon the development of emotional ties when working with either COAs or adult COAs.

Hazarika M, Bhagabati D. The role of personality correlates in the pathogenesis of alcoholism: an intergenerational study among alcohol dependent and nondependent population. Dysphrenia. 2014;5:32-48.

Keywords: Family. Parents. Personality. Behaviour. Neuroticism. Extraversion.

Correspondence: hazarika.mythili@gmail.com

Received on 28 December 2012. Accepted on 26 April 2013.

 

 

Introduction

Alcohol affects each member of the family from the unborn child to the alcohol user’s spouse. Its far reaching affects result in not only physical problems for the alcohol users, but also may result in physical and psychological problems for other members of the family. Alcohol addiction is defined as a behaviour, over which an individual has impaired control with various harmful consequences and negative implications.[1,2] Alcohol use and abuse are health hazards, and the problems of addiction are not limited to individuals in certain social strata, but appear to affect people in all levels of the society. Murthy et al.[3] have rightly remarked that “Substance use patterns are notorious for their ability to change over time”. Jellinek[4] offered the following definition for alcohol problems: “Alcohol addiction is an uncontrollable craving for alcohol (i.e. physical dependence)”, while chronic alcoholism is referred to “the mental or physiological changes associated with prolonged use of alcohol”.

In psychiatry and psychological studies and treatment, the International Classification of Diseases, 10th revision (ICD-10), published in 1992, is used as it is the definitive international system of diagnosis, classification, and coding of diseases and related health problems. It is used worldwide to classify and record diagnoses in clinical practice and in hospital settings to capture disease occurrence for statistical monitoring. The ICD defines “alcohol abuse as repeated use despite recurrent adverse consequences; further defining alcohol dependence as alcohol abuse combined with tolerance, withdrawal, and an uncontrollable drive to drink”.[5]

In our country, both licit and illicit substance use cause serious public health concerns. National level prevalence has been calculated for many substances, but in the studies and surveys regional variations are quite evident. In the national prevalence studies, alcohol use/abuse prevalence in different regions is found to be varied from 167/1000 to 370/1000. Alcohol addiction for chronic alcoholism ranges from 2.36/1000 to 34.5/1000. In a meta analysis by Reddy and Chandrashekhar,[6] it is seen that in India, an overall substance use prevalence is 6.9/1000. Urban and rural rates vary, and it is found to be 5.8 and 7.3/1000 population. The rates of men and women were found to be different, i.e. 11.9% and 1.7% respectively. Among women, alcohol consumption is reported to be less in comparison to men in India, though alcohol use among women is found to be increasing as seen in epidemiological research. Various regional studies between 2001 and 2007 continue to reflect this variability. A study conducted in southern India by John et al.[7] showed that 14.2% of the population surveyed had hazardous alcohol use on the Alcohol Use Disorders Identification Test (AUDIT). Again a similar study by Sampath et al.[8] in the tertiary hospital showed that 17.6% admitted patients in the hospital settings had hazardous alcohol use.

A study on alcohol use from Delhi by Mohan et al.[9] found that annual incidence of nondependent alcohol use and dependent alcohol use among men was three and two per thousand persons in a total cohort of 2937 households. Among the national level studies, the national household survey of drug use in the country by Ray[10] is the first systematic effort to document the nationwide prevalence of drug use. In his study, it was found that alcohol (21.4%) was the primary substance used apart from tobacco, followed by cannabis (three per cent) and opioids (0.7%). In the findings, 17 to 26% of alcohol users qualified for ICD-10 diagnosis of dependence, translating to an average prevalence of about four per cent. In a study by Murthy et al.,[3] a marked variation in alcohol use prevalence was found in different states of India; current use ranged from a low of seven per cent in Gujarat (officially under prohibition act) to 75% in Arunachal Pradesh which is situated in the north-east part of India.

In a retrospective study of emergency treatment in Sikkim between 2000 and 2005 by Bhalla et al.,[11] substance use emergencies constituted 1.16% of total psychiatric emergencies. The commonest cause of emergency was alcohol withdrawal which was reported to be 57.4% among group of patients in the inpatient setting. In Assam, in a study reported by Hazarika et al.,[12] alcohol users were 37% in rural Assam and a prevalence rate of 365/1000 population, which was greater than the national prevalence. Bhagabati and his colleagues’[13] research study, conducted in Assam during 2009, depicted that alcohol use among below 18 years is 22.2%, and the earliest use is 11 years. The intake of alcohol in Assam is higher than the national prevalence, and children as well as adolescent population is found to be using and abusing alcohol, which is a serious public health issue.[13] In Assam, there is no study done so far on children of alcoholics (COAs), and on parents of alcohol dependence, though the prevalence rate of alcohol is reported to be high.

‘COAs’ is a general term used to describe children or individuals with one or more alcoholic parents. Although the ramifications of living in a family with addicted, alcohol using parent are variable, nearly all children from alcohol user’s families are at risk for behavioural and emotional difficulties, and live with  physical and psychological scars as a result of parental alcoholism.[14] From prenatal influences leading to learning and memory problems to vulnerabilities in behavioural and emotional control and aggression in adulthood,[15,16] a significant number of COAs exhibit physical, psychological and/or interpersonal difficulties.[17] Parental alcoholism could also instill a legacy which affects the development of both individual and family members, and the habitual patterns are often carried forward from one generation to the next. Sons of alcohol using fathers are at fourfold risk compared with the men offspring of non-alcohol using fathers, as reported by Goodwin.[18] Though there are strong genetic causes for alcoholism in COAs as reported by the genetic studies, not all COAs become alcohol users. Hence, environmental and family studies gained importance in the early part of the 20th century which still continues.

From early 1970’s, research work on alcoholism had undergone a massive transition from only genetic studies to interactional/family studies, and from COAs to women with alcohol use and abuse. Of late there has been an increasing focus on COAs seeking to understand the adverse impact of parental alcoholism on their personality growth and psychosocial functioning. The effects of parental alcoholism can vary with a child’s developmental stage.[19,20] Hence, in studies from early childhood till late adulthood, there has been variety of dysfunctions noted among COAs, that could have a deep impact upon their psyche and well-being. The most common explanation for the adverse effects of parental alcoholism has been characterised by the general environmental mechanism.[21-23] According to this explanation, parental alcoholism is believed to produce disturbed family relationships and dynamics that has a deep negative impact on the personality and psychosocial well-being of children who grow up in such environments.

‘Personality’ typically refers to characteristic ways of thinking, feeling and behaving or acting out, that show some consistency when measured across situations and over time. Personality is defined by Allport[24] as “dynamic organisation within the individual of those psychophysical systems that determines his unique adjustment to his environment”. The belief that personality plays a role in alcoholism, and it may even be one of the major causes has a long tradition. Among studies in alcoholism, role of personality is one of the most common with respect to alcohol use. There have been a lot of discussions linking personality traits and addictive behaviours, which are commonplace in the psycho-social literature. Sleisinger[25] commented that “by definition a personality disorder underlies the habitual use of alcohol”.

Some research findings are also suggestive of an interaction between a personality trait called “novelty seeking” and parental alcoholism, which increase the risk of, or protect against, developing individual alcoholism. High novelty seeking is a strong risk factor for alcoholism among COAs. Low novelty seeking appears to protect against the risk of developing alcoholism among the same.[26] Some factors have been identified as “disinhibitory personality traits”, which refers to risk-taking, extraversion and exploratory, thrill-seeking and sometimes impulsive personality characteristics. Some studies have also reported that children, especially boys, who exhibit these characteristics have a high likelihood of becoming alcohol user as adults.[26]

https://file1.hpage.com/004238/12/bilder/personality_correlates_in_alcoholism_figure_0.jpg

The most pressing research problem in this area has centred around the difficulty (often, the impossibility) of separating personality factors as well as behaviours that are consequences of alcoholism or drug abuse from those that are integral to or coincident with abuse. Majority of studies confirm the role of personality factors for alcoholism and maintenance of the problem of addiction among vulnerable population and children of COAs, while some investigators have moved beyond the simple comparison of families with and without alcoholic member, their genetic transmission and personality factors, and have chosen to assess the impact of the alcohol user’s family’s home environment and interaction style with the children. The COAs have been characterised as an at-risk population because of the dysfunctional family environments that disrupt their psychosocial growth and development due to their exposure to parental alcoholism.

Methodology

Objectives

1. To examine the personality variables of the alcohol dependent fathers (ADF) and their sons.

2. To examine the personality variables of the alcohol nondependent fathers (NADF) and their sons.

Hypotheses

1. Fathers with alcohol dependent syndrome (ADS) will not differ from fathers with nondependent use of alcohol on extraversion.

2. Fathers with ADS will be higher on neuroticism than fathers with nondependent use of alcohol.

3. Sons of alcohol dependent fathers (SADF) will not differ on extraversion from sons of fathers with nondependent use of alcohol (SNADF).

4. SADF will be higher on neuroticism than SNADF.

Sample

The present study was a case-control study with four groups of subjects comprising ADF, NADF, SADF, and SNADF. The four groups were the following:

1. Fifty numbers of non-tribal individuals/fathers with ADS and their sons of more than 15 years of age (N = 50).

Research throws light that the patterns of alcohol consumption and the reactivity of the family to alcohol use in family members would differ from one ethnic group to another, and will not be the same. It is seen that in Assam, the tribals consider drinking alcohol as a norm and a part of their traditions and customs whereas in the plain areas, alcohol use is considered to be a health hazard. Hence, the view toward alcoholism differs for which tribal population was excluded in our sample.

2. Fifty number of non-tribal individuals/fathers with non-alcohol dependence syndrome (NADS) and their sons of more than 15 years of age (N = 50).

Total sample size: 200 subjects.

Inclusion criteria

Group I: ADF

Indoor patients of Gauhati Medical College Hospital (GMCH) diagnosed as ADS by ICD-10 criteria; patients with ADS from other hospitals and de-addiction centres, following the same treatment regimen for alcoholics.

Age: 40-60 years.

Ethnicity: Non-tribal.

Sex: Men.

Socioeconomic status (SES): Middle class.

Education: Minimum qualification of Xth standard.

The Michigan Alcohol Screening Test (MAST) score of > 13.

Group I A: SADF

Age: 15 years and above.

SES: Middle class.

Education: Minimum qualification of Xth standard.

Group II: NADF

Individuals with nondependent use of alcohol were recruited using the snow-ball technique.

Age: 40-60 years.

Ethnicity: Non-tribal.

Sex: Men.

SES: Middle class.

Education: Minimum qualification of Xth standard.

Score of < 13 in MAST scale.

Group II A: SNADF

Age: 15 years and above.

SES: Middle class.

Education: Minimum qualification of Xth standard.

Exclusion criteria

History of psychotic disorders, major depressive disorder, bipolar affective disorder, treatment for any psychiatric disorder in the past, epilepsy or past history of generalised tonic-clonic seizures (excluding withdrawal seizures), organic brain disorder or dysfunctions, any chronic debilitating  physical illness, mental retardation, past and present history of other drug use and multiple substance abuse/dependence.

Tools administered

Informed consent form, socio-demographic proforma, MAST, Kuppuswamy socio-economic scale (KPSS), checklist of various common ailments, Eyesenck’s Personality Inventory (EPI).

Description of the tools

MAST: MAST was developed by Selzer,[27] and it is one of the oldest and most accurate alcohol screening tests available to identify dependent drinkers with up to 98 per cent accuracy. There have been several variations of the MAST that includes the brief MAST, the short MAST, as well as the self-administered MAST. The MAST is a 22-question self-administered test and is a revised version which helps one to be aware of use or abuse of alcohol. The questions relate to the patient’s self-appraisal of social, vocational, and family problems frequently associated with heavy drinking. It assesses symptoms and consequences of alcohol abuse, such as guilt about drinking; blackouts; delirium tremens; loss of control; family, social, employment, and legal problems following drinking bouts; and help-seeking behaviours, such as attending Alcoholics Anonymous meetings or entering a hospital because of drinking. This test specifically focuses on use and abuse of alcohol, and not on the use of other drugs. It has been productively used in a variety of settings with varied populations. The MAST, when compared with other diagnostic criteria of alcohol problems, gave validity measures with the following span: predictive positive value (PVpos) 0.24–0.96, predictive negative value (PVneg) 0.78–1, sensitivity 0.36–1, and specificity 0.36–0.96.[28] The studies indicate that the long version of the MAST possesses good internal-consistency reliability, as indicated by Cronbach’s alpha coefficients of .83 to .93.[29]

In our study, to avoid chances and over-inclusion, we applied MAST to patients already diagnosed as alcohol dependent in the clinic settings. Selzer[27] scores seven for alcohol abuse, and in many studies more than 13 for dependency in alcohol was reported. Ross et al.[30] compared scores on the MAST to diagnoses of alcoholism obtained from the National Institute of Mental Health Diagnostic Interview Schedule (NIMH-DIS).[31] In the study, the MAST cut-off score for ADS that yielded the highest overall accuracy was 13 or greater. Hence, in our study we kept 13 as the cut-off for ADS group.

KPSS[32]: KPSS is a simple instrument to measure SES of a person. Education, occupation and income were selected as three variables which are found to contribute to SES of a person. KPSS has been in use as an important aid to measure SES of families in urban communities. The original 1976 version has been updated by Mishra and Singh[33] and Kumar et al.[34] Mishra and Singh[33] have pointed out that due to inflation, the economic criteria in a scale lose their relevance over time. For this reason, they had proposed a revision of the original scale. The scale was last revised in 2007 to bring income classification up to date and published in public domain in 2007. This latest update may be applicable in the studies ongoing in 2012, which is done using latest consumer price index numbers for industrial workers, CPI(IW), for January, 2012.[35] Each variable was scaled from one to 12 points providing equal weightage to the different variables. Total number of items is 21. The scale has ranges from three to 29. The social classes were divided into the following groups:

 

Upper

26-29

Middle

16-25

Lower middle

11-15

Upper lower

5-10

Lower

< 4

 

KPSS update of income range follows as:

Score

2012

12

= 30375

10

15188-30374

6

11362-15187

4

7594-11361

3

4556-7593

2

1521-4555

1

= 1520

 

Validity of the scale was matched against outside criterion, and it was found to be satisfactory. In distribution pattern also, it was found to give very satisfactory results. When all the three variables were included, the multiple biserial reliability was found to be .885 which is quite significant.

One moderator of parental alcoholism, which is found to influence the well-being of the child and conflicts in family atmosphere is socioeconomic stress and adversity. Economic difficulty is associated with alcoholism[36,37] and in turn, alcoholism frequently results in downward occupational drift leading to dysfunctional family atmosphere.[36] Studies related to SES and alcoholism indicates mixed results. Hence, we had administered this scale and had proposed to take only middle SES in order to control the sampling bias, and to reduce the influence of SES to alcoholism and family dysfunction.

EPI:[38] EPI measures neuroticism and extraversion, and consists of two parallel forms - A and B -  thus making retesting possible without the interference of memory factors. A lie score is also incorporated to assess the possible role of “desirability response set”. EPI form A was administered in the present study. The scale consists of 57 items. The two personality dimensions, extraversion and neuroticism, were described in the 1947 bookDimensions of Personality.[39] It is extensively used in psychosomatic research. It is extensively used to measure neuroticism and extraversion in preference to other personality questionnaire by virtue of its brevity, its high reliability, and negligible correlation with variables such as age and sex. It is highly correlated to the M-R score of the Cornell Medical Index. Many of the claims of Eyesenck regarding the various aspects of EPI have been confirmed in Indian population, after the scale was standardised in Indian population by Abraham et al.[40] and presented in the Annual Conference of the Indian Psychiatric Society in 1976. The cut-off scores are for extraversion - mean 11.3 (±) 3.5, neuroticism - mean 11.6 (±) 4.6, and lie score - 4. This scale is widely used in India since the last decade due to high reliability and validity in Indian population.

Design of the study

The study involved two phases: pilot study and the main study. In the pilot study, the translations of the selected scales in vernacular language were carried out. Three mental health professionals did the translation of the scales. They did the translations independently, and then met to discuss each item of the translated questionnaire. And then two other psychiatrists did the back translation into English language. These scales were administered on two ADF and their sons, and two NADF and their sons. The investigator got familiarised with the tools, and it took nearly two hours for the administration of the tools.

In the main study, inpatients of the tertiary care teaching hospital and other alcohol detoxification centres were considered. In the general population, MAST was administered, and the individuals who met the criteria for alcoholism in the MAST score were excluded from the study. Those who were included for the study were screened with a clinical checklist interview for associated physical and mental illnesses. From the tertiary care teaching hospital, the patients taking part had to undergo the unit’s standard regimen in order to keep the withdrawal process under control. Patients were requested to stop all consumption of alcoholic beverages and non-prescribed drugs from their first hospital day.

At the end of the second week of abstinence, they were screened using the semi-structured interview for present or previous alcohol dependence, significant somatic or psychiatric disorder at the time of the study, significant psychiatric disorder in the past, and antecedents of affective or psychotic disorders and other psychiatric comorbidity. Benzodiazepines are used to control the withdrawal symptoms during the first seven to ten days, and they might affect cognitive functions. The washout period of long acting benzodiazepine is seven days, and persons may have features of Wernicke’s encephalopathy, which may cause cognitive disturbance. This would affect the findings in the assessment as they would be confounding factors in the study population; so, only after two weeks, the assessments were done. Because all addicts in the present study were of more than two weeks abstinent at the time of testing, the observed group differences are not attributable to residual drug effects or withdrawal effects.

Table 1. Chi-square test for testing the association between alcohol dependent fathers (ADF) and alcohol nondependent fathers (NADF) on the socio-demographic variables

Socio-demographic variables

ADF

NADF

Total

c2value

“p” value

Age groups

40-50

25

25

50

.00

1.000

 

50-60

25

25

50

Total

50

50

100

Education

Up to graduate

43

42

85

.078

.779

Post graduate

7

8

15

Total

50

50

100

Occupation

Unemployed

2

4

6

4.991

.417

Self-employed

9

13

22

Public sector

20

19

39

Private sector

9

9

18

Professional

10

4

14

Retired and others

0

1

1

Total

50

50

100

Family type

Joint

22

18

40

1.239

.538

Nuclear

24

25

49

Extended

4

7

11

Total

50

50

100

Number of children

1 child

12

9

21

.576

.750

2-4

29

32

61

5-6

9

9

18

Total

50

50

100

Socio-economic status

Lower middle class

43

38

81

1.624

.202

Upper middle class

7

12

19

Total

50

50

100

Significance level is at p < 0.05

 MAST was administered as a screening tool. Socio-demographic profoma with KPSS were asked to be filled in, and the checklist for major physical illnesses was administered, followed by EPI scale. Their sons, as per the inclusion criteria, were administered the same scales following the same procedure as mentioned above. For the second group recruited from the general population, scales were administered in the above mentioned ways, after they fulfilled all the inclusion and exclusion criteria required for the study.

Ethical considerations

Written informed consent was obtained from the study population. The group from the hospital and institution were continuing their standard treatment regimen. Necessary precautions were taken, so that participation in the study by them didn’t affect their treatment process. Participation was purely on voluntary basis, and they were informed that there would be no direct or indirect benefits for participating in the study. Confidentiality and anonymity was assured. The participants could withdraw from the study at any point of time. They were assured of the researcher’s availability if any assistance was required from the researcher.

Results

Data obtained was analysed using descriptive statistics such as mean, standard deviations and frequencies. Non-parametric test such as the chi-square test and parametric tests such as student’s ‘t’ test and analysis of variance (ANOVA) were carried out to determine the variables on which the groups differed significantly as well as to examine the associations between the variables.

Socio-demographic characteristics of the sample and clinical data Creative Commons License
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