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Differences in impulsivity and sensation seeking between early- and late-onset alcoholics
Addictive Behaviors 31 (2006) 298 – 308
Differences in impulsivity and sensation seeking between early- and late-onset alcoholics G. Doma,T, W. Hulstijnb, B. Sabbec a
Psychiatric Centre Brothers Alexians, Provinciesteenweg 408, 2530 Boechout, Belgium Nijmegen Institute for Cognition and Information (NICI), Nijmegen, The Netherlands, University of Antwerp, Belgium c Coordinator CAPRI (Collaborative Antwerp Psychiatric Research Institute), University of Antwerp, Belgium
b
Abstract The personality traits of impulsivity and sensation seeking have been proposed as important features of earlyonset alcoholism. Early-onset (EOA, n = 62) and late-onset (LOA, n = 68 ) alcoholic inpatients were compared as to the severity of their substance use and related problems, and self-report scales measuring impulsivity (Barratt Impulsiveness Scale, version 11), sensation seeking (Sensation Seeking Scale), and aggressiveness (Buss Durkee Hostility Inventory). The symptom severity of the EOAs’ alcohol-use disorder and related problems was higher than that of the LOAs. Furthermore, the EOAs had higher levels of impulsivity, sensation seeking, and aggression relative to the LOAs. The differences in impulsivity remained after an analysis controlling for the effect of aggressiveness. Finally, cigarette smoking was positively correlated with impulsiveness across alcoholic subgroups. Active screening for impulsive traits in treatment-seeking alcohol-abusing populations is recommended to improve treatment planning and prevent early drop-out. D 2005 Elsevier Ltd. All rights reserved. Keywords: Impulsivity; Sensation seeking; Early-onset alcoholism; Late-onset alcoholism
1. Introduction Impulsivity is intimately related to substance abuse (Dawe, Matthew, & Loxton, 2004). Longitudinal studies have identified impulsivity in children as a high-risk factor for early substance use and later substance abuse (Dawes, Tarter, & Kirisci, 1997; Tarter et al., 2003). Cross-sectional studies show higher T Corresponding author. Tel.: +32 34557531. E-mail address: [email protected] (G. Dom). 0306-4603/$ - see front matter D 2005 Elsevier Ltd. All rights reserved. doi:10.1016/j.addbeh.2005.05.009
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levels of impulsiveness to be associated with substance use and abuse in college students (e.g. Jaffe & Archer, 1987). Within clinical populations it has been demonstrated that illicit drug abusers score higher than controls on inventories of impulsivity (Allen, Moeller, Rhoades, & Cherek, 1998; Petry, 2001). Furthermore, impulsivity proved to be linked to the severity of drug abuse and poor treatment retention (Moeller et al., 2001; Patkar et al., 2004). High levels of impulsive traits have also been found within alcohol-dependent patients (Patton, Stanford, & Barratt, 1995). However, alcoholism is a very heterogeneous disorder and in the past different typologies have been proposed to distinguish more homogeneous subgroups (Henderson & Galen, 2003; Windle & Scheidt, 2004). High trait levels for impulsivity and sensation-seeking have been associated with specific subgroups within the different classification systems, i.e. type II alcoholism (Cloninger, Bohman, & Sigvardsson, 1981), Type B alcoholism (Babor et al., 1992), and early-onset alcoholism in the univariate classification based on the age of alcoholism onset (Buydens-Branchey, Branchey, & Noumair, 1989; Varma, Basu, Malhotra, Sharma, & Mattoo, 1994). Irwin, Schuckit, and Smith (1990) found age at onset to be a robust predictor of the severity of alcohol dependence and showed it to be associated with a sensationseeking and impulsive temperament. This is consistent with a recent study revealing age at onset to be a valid classification criterion in male alcohol-dependent patients (Lykouras, Moussas, & Botsis, 2004). It was reported that early-onset alcoholics (EOAs) had more familial alcoholism, higher levels of family and professional instability and more impulsive behaviors compared to the late-onset alcoholics (LOAs). Finally, an increasing body of research points to a relationship between impulsiveness and nicotine dependence. Studies using self-report measures of impulsivity (e.g. the Barratt Impulsiveness Scale) and those using behavioral tasks (e.g. delay-discounting) have consistently demonstrated higher levels of impulsiveness in smokers than in non-smoking subjects (Baker, Johnson, & Bickel, 2003; Bickel, Odum, & Madden, 1999; Dinn, Ayciceggi, & Harris, 2004; Jaroni, Wright, Lerman, & Epstein, 2004; Mitchell, 1999; Reynolds, Richards, Horn, & Karraker, 2004). Recently, Skinner, Aubin, Henri-Jean, and Berlin (2004) found smoking alcoholics to have higher levels of impulsivity than non-smoking alcoholics. In the present study we were interested in the differences between EOAs and LOAs as to their personality traits of impulsivity and sensation seeking. These traits were measured by two well-known selfreport scales: the Barratt Impulsiveness Scale (BIS 11; Patton et al., 1995) and the Sensation Seeking Scale (SSS; Zuckerman, Kolin, Price, & Zoob, 1964). Furthermore, since a recent study on cocaine-dependent patients demonstrated a high correlation between BIS scores and measures of aggressiveness (Moeller et al., 2002), we included the Buss Durkee Hostility Inventory (Buss & Durkee, 1957). The following hypotheses were put forward: (1) EOAs have higher trait levels of impulsivity and sensation seeking, (2) EOAs have a higher prevalence of paternal alcoholism, (3) EOAs were expected to have a more deteriorated pattern of alcohol and drug use as reflected by higher levels of social, family and legal problems compared to LOAs; and finally, (4) we anticipated higher impulsiveness in alcoholics with co-morbid nicotine dependence compared to those without.
2. Method 2.1. Participants All alcohol-dependent participants were recruited from an inpatient addiction treatment facility. During a period of 18 months (2003–2004) every second patient hospitalized for treatment of his/her
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alcohol problem was invited to participate in the present study. Abstinence on the ward was monitored by regular, randomized controls on alcohol, medication and illicit drug use. DSM-IV diagnosis (American Psychiatric Association, 1994) of alcohol dependence was made during a psychiatric interview and supplemented by collateral information (family), data from the European version of the Addiction Severity Index (EuropASI), and laboratory tests (blood and urine analysis). Patients with a current or lifetime history of psychotic disorders, amnesic disorders, brain disorders (e.g. trauma, epilepsy), or severe somatic disorders (liver cirrhosis, AIDS, thyroid disorders, visual problems) were excluded. Furthermore, patients who could not read or did not possess the required intellectual, social or educational level to respond to the questionnaires were excluded. Ultimately 130 alcohol-dependent subjects participated in this study. Sixty-two were classified as early-onset and 68 as late-onset alcoholics. EOAs were defined as having severe alcohol-use-related problems and symptoms of alcohol dependence before the age of 25 years. LOAs were defined as having symptoms of alcohol abuse or dependence after age 25. Age at onset was assessed during a clinical interview using the time-line method and complemented with data from the EuropASI interview and, if possible, collateral information. Family history of alcohol dependence was assessed by means of a clinical interview using a family-tree method (Mann, Sobell, & Sobell, 1985) and completed with the data from the EuropASI interview and, if possible, with additional collateral information (family, spouse). Paternal family history (PFH) and maternal family history (MFH) were defined as positive if the biological father or mother of the participant was diagnosed as (lifetime) alcohol dependent. Nicotine dependence was defined as the current and past year daily use of 10 or more cigarettes. The mean number of cigarettes used daily across all smoking alcoholics in the current sample was 26.8 (standard deviation 11.5). All participants gave their written informed consent as required by the Helsinki declaration. The study was approved by the clinic’s Medical Ethics Committee. 2.2. Assessments In the following sections a brief description of the measures the alcoholic patients completed during the first 2 weeks after admission is given. 2.2.1. EuropASI The patients completed the Belgian adaptation of the Dutch version of the Addiction Severity Index, European version (EuropASI; Hendricks, Kaplan, Van-Limbeek, & Geerling, 1989). This structured interview provides reliable, valid and sensitive measures of problem severity in seven domains for the 30-day period preceding the interview, with higher scores reflecting more severe problems. All subjects were interviewed by a certificated ASI trained interviewer. 2.2.2. Barratt Impulsiveness Scale The Barratt Impulsiveness Scale (BIS-11; Patton et al., 1995) is a self-report scale that is structured to assess long-term patterns of behavior by asking the respondents to answer questions about the ways they act and think without reference to any specific period and is thus frequently used as a trait measure of impulsivity. The BIS-11 has a total score (BIS_T) and contains three subscales related to impulsiveness. The first scale measures motor impulsiveness and lack of perseverance (BIS_M; sample item: bI am restless at the theatre or lecturesQ), the second measures cognitive impulsivity (BIS_C) by assessing inattention and
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cognitive instability (sample item: bI have racing thoughtsQ), and the third scale evaluates non-planning impulsivity (BIS_NP) by scoring lack of self-control and intolerance of cognitive complexity (sample item: bI plan tasks carefullyQ). The reliability and validity of the BIS has repeatedly been shown in a variety of languages (Bayle et al., 2000; Fossati, Di Ceglie, Acquarini, & Barratt, 2001; Patton et al., 1995; Somey et al., 2001). 2.2.3. Buss Durkee Hostility Inventory The Buss Durkee Hostility Inventory (BDHI; Buss & Durkee, 1957) is a widely used true–false questionnaire. The Dutch version (BDHI_D) consists of three subscales: direct aggression, indirect aggression, and social likeability. The psychometric properties of the BDHI-D are well examined and show good reliability and validity (Lange et al., 1995). 2.2.4. Sensation Seeking Scale The Zuckerman Sensation Seeking Scale (SSS; Zuckerman et al., 1964) was developed to evaluate sensation-seeking constructs that have been linked to impulsivity (Zuckerman, 1984). The questionnaire contains five subscales: General Sensation Seeking (SSS_G; sample item: bI like to explore a strange city or section of town by my myself, even if it means getting lostQ), Thrill and Adventure Seeking (SSS_TAS; bI enjoy many of the rides at amusement parksQ), Experience Seeking (SSS_ES; bI would like to hitchhike across the countryQ), Disinhibition (SSS_DIS; bI like wild, uninhibited partiesQ), and Boredom Susceptibility (SSS_BS; bI get bored seeing the same old facesQ). Substance-abusing participants were asked to fill out the Dutch version of the Sensation Seeking Scale (SSS_D). The SSS_D has been tested in a Dutch population showing good reliability and validity. Norm scores for different age groups are available (Feij, Dekker, Koopmans, & Boomsma, 1997). 2.3. Statistical analysis Student t-tests were used for continuous variables and Chi-square tests for dichotomous variables. Comparisons of the self-report scores between early- and late-onset alcoholic subjects were made using a GLM multivariate analysis. Since age inversely correlated with impulsivity measures, all subsequent analyses included age as a covariate, except for the analysis of the SSS where the scores were normalized for age. Furthermore, because gender differences have been reported, we also controlled for this factor. Pearson correlation analyses were performed to assess the relationship between the impulsivity and aggression measures. To control for the effect of aggression on impulsivity, in a second analysis the BDHI scores for direct and indirect aggression were included as covariates. Pearson correlation analysis was performed to evaluate the relationship between age at onset, the BIS11 total score and the SSS total score.
3. Results 3.1. Demographic characteristics The EOAs were younger, had longer substance-abusing careers and lower educational levels than the LOAs (see Table 1). As can be seen in Table 2, the EOA group also contained more males (marginally
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Table 1 Main demographic characteristics and differences between the early-onset alcoholics (EOA) and the late-onset alcoholics (LOA) Mean
EOA (n = 62)
LOA (n = 68)
t ( p)
Age Number of years at day-school Age at onset Years of alcohol abuse Daily cigarette use of smoking participants
37.53 12.29 17.69 19.84 28.7
45.47 13.67 33.57 11.90 25.2
4.995 (b 0.001) 2.704 (0.008) 15.765 (b 0.001) 5.310 (b0.001) ns
(9.43) (3.18) (3.20) (9.61) (12.5)
(8.69) (2.61) (7.35) (7.38) (10.4)
significant), a higher proportion of smokers and more participants with a positive paternal family history of alcohol dependence (PFH+) than the LOAs. Finally, polysubstance abuse, defined as lifetime or current abuse or dependence of at least one illicit drug in association with the current alcohol dependence (DSM-IV criteria; APA, 1994) was more prevalent in the EOAs. 3.2. Self-report questionnaires 3.2.1. Differences between EOA and LOA Overall, the results of the GLM multivariate analysis including all scales (BIS, SSS, BDHI) and all EuropASI items was significant for Group (EOA v. LOA; F(18,81) = 2.968; p b 0.001). The GLM multivariate analysis with both Gender and Group as fixed factors and Age as covariate revealed that the EOAs had higher scores on all BIS, BDHI, SSS scales and subscales as compared to the LOAs, except for the SSS_TAS subscale (see Table 3). Gender differences were not significant, with the exception of the BIS_C subscale (mean score for men = 16.97, F 5.72; women = 20.85, F 3.60; F(1,112) = 4.375; p = 0.039). 3.2.2. Effect of nicotine dependence A GLM multivariate analysis with Age as covariate and both Group and Nicotine (Y/N) as fixed factors did not change the statistical significance of the differences found between the EOAs and LOAs on the BIS, BDHI, and SSS scales. There was a marginally significant effect of smoking, showing nicotine-dependent alcoholics to have higher scores on the BIS_NP subscale than the non-smoking alcoholics ( F(1,112) = 3.442; p = 0.066). Within the smoking alcoholics (controlled for age) the number of daily cigarettes correlated positively with BIS_NP (r = 0.2283; p = 0.047), BIS_T (r = 0.2455; p = 0.033) and SSS_BS (r = 0.254; p = 0.023). Table 2 Gender distribution, number of nicotine-dependent participants, number of polysubstance abusers, and number of participants with a positive paternal (PFH+) or maternal (MFH+) family history of alcohol dependence for the early-onset alcoholics (EOA) and late-onset alcoholics (LOA) Men Smokers Polysubstance abusers PFH+ MFH+
EOA (%)
LOA (%)
v 2(1) ( p)
77 92.5 61 49 20
62 71 10 30 15
3.731 (0.053) 8.747 (0.003) 37.264 (b 0.001) 4.794 (0.029) ns
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Table 3 Differences between the early-onset alcoholics (EOA) and the late-onset alcoholics (LOA) for (1) the Barratt Impulsiveness Scale (BIS): cognitive impulsiveness (BIS_C), motor impulsiveness (BIS_M), non-planning impulsiveness (BIS_NP), and the total BIS score (BIS_T), (2) the Sensation Seeking Scale (SSS): thrill and adventure seeking (SSS_TAS), experience seeking (SSS_ES), boredom susceptibility (SSS_BS), disinhibition (SSS_DIS), and the general sensation seeking score (SSS_G), and (3) the subscales of the Buss Durkey Hostility Inventory (BDHI): Direct Aggression (BDHI_DA), Indirect Aggression (BDHI_IA), and Social Likeability (BDHI_SL) BIS_C BIS_M BIS_NP BIS_T SSS_TAS SSS_ES SSS_BS SSS_DIS SSS_G BDHI_DA BDHI_IA BDHI_SL
EOA Mean (sd)
LOA Mean (sd)
F( p) Group
17.98 19.30 23.82 61.10 5.75 7.56 6.37 8.00 7.44 9.64 11.04 1.70
14.84 13.17 17.92 45.94 5.90 6.34 5.23 7.02 6.44 5.92 8.27 2.29
6.285 (0.014) 17.400 (b0.001) 17.951 (b0.001) 25.182 (b0.001) ns 8.589 (0.004) 7.088 (0.009) 10.209 (0.002) 8.543 (0.004) 14.048 (b0.001) 9.253 (0.003) ns
(5.49) (7.84) (7.29) (15.37) (2.90) (2.58) (2.73) (2.23) (2.33) (3.29) (4.71) (1.43)
(5.88) (5.82) (8.06) (14.70) (2.92) (2.86) (2.96) (2.45) (2.66) (3.79) (4.09) (1.45)
3.2.3. Correlations Pearson correlation analysis showed that there was a significant, negative relationship between the age at onset of alcohol abuse and both the total BIS score (r = 0.365; p b 0.001) and the General SSS score (r = 0.230; p = 0.013). Furthermore, the total BIS-11 score correlated positively with the BDHI direct aggression subscale (BDHI_DA; r = 0.362; p b 0.001) and the BDHI indirect aggression subscale (BDHI_IA; r = 0.563; p b 0.001). 3.2.4. Effect of aggression as a covariate To control for aggression, a GLM multivariate analysis with the BDHI_DA and BDHI_IA scores as covariates was conducted to examine group differences in impulsivity. The results showed that the group difference for the BIS-11 total scores (BIS_T) remained significant ( F(1,112) = 8.655; p = 0.004).
Table 4 Differences (mean, standard deviation) between the early-onset alcoholics (EOA) and late-onset alcoholics (LOA) on the different domains of the European version of the Addiction Severity Index (EuropASI) EOA Health Vocational Alcohol Drugs Legal Social Psychiatric
2.82 3.05 7.30 5.37 4.35 5.63 6.46
LOA (1.80) (2.21) (12.54) (12.91) (12.90) (12.80) (12.62)
Higher scores are indicative of a higher problem severity.
2.15 2.77 6.02 1.46 1.21 3.08 4.57
F( p) (1.80) (1.88) (1.38) (1.81) (1.52) (1.44) (2.25)
4.503 (0.036) ns 3.469 (0.065) 11.717 (0.001) 7.545 (0.007) 7.720 (0.006) 5.801 (0.018)
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3.3. EuropASI severity scores A multivariate GLM analysis with Gender and Group as fixed factors revealed that the EOAs had significantly higher severity scores on all EuropASI domains, with the exception of the vocational domain (see Table 4). Gender differences were prominent. The female alcoholics had significantly higher severity scores on Vocational ( F(1,117) = 4.567; p = 0.035), Alcohol ( F(1,117) = 4.096; p = 0.045), Drug ( F(1,117) = 6.738; p = 0.011), Social ( F(1,117) = 7.023; p = 0.009), and Psychiatric ( F(1,17) = 8.469; p = 0.004) domains.
4. Discussion The criterion of age at onset of alcohol dependence generated two alcoholic subgroups that differed substantially with respect to their demographic characteristics, personality traits of impulsivity, aggressiveness and sensation seeking, and substance use severity and related problems. Furthermore, in accordance with our hypothesis, more EOAs had a positive paternal family history of alcoholism. Finally, the alcoholic inpatients with co-morbid nicotine dependence were more impulsive than those without. The EOAs had higher levels of impulsivity as measured with the BIS-11 than the LOAs. This difference was independent of concomitant aggressiveness traits. Furthermore, age at onset correlated inversely with the BIS scores, a finding that has been documented before for cocaine-dependent patients (Moeller et al., 2002). In addition, the sensation-seeking scores of the EOAs were higher than those of the LOAs. Sensation seeking is similar to the dimensions related to impulsivity in Eysenck’s and Cloninger’s personality models (Zuckerman & Cloninger, 1996; Zuckerman, Kuhlman, Joireman, Teta, & Kraft, 1993). The trait has been associated with a variety of illegal and/or risky behaviors such as the use of illicit drugs, smoking and alcohol use (Stephenson, Hoyle, Palmgreen, & Slater, 2003). In a recent study both higher sensation-seeking levels on the SSS and higher direct-aggressiveness scores on the BDHI were associated with concomitant illicit drug and alcohol abuse (polysubstance abuse; Gerra et al., 2004). It is of interest that, in line with our present findings, a recent study by Bakken, Landheim, and Vaglum (2004) also reported a high prevalence of polysubstance abusers in early-onset alcoholic populations. Taken together, both impulsivity and sensation-seeking traits are highly prevalent in early-onset alcoholics. Although these findings do not allow us to separate cause from consequence, a growing body of research suggests that high levels for these two traits in children and adolescents are associated with an early start of substance use and an increased risk of substance abuse later in life (Martin et al., 2003; Sollof, Lynch, & Moss, 2000; Wagner, 2001). Possibly, sensation seeking and impulsivity may have a differentiated impact on substance use and the development of abuse or dependence. A high level of sensation seeking may be a powerful incentive to start experimenting with alcohol or illicit drugs at an early age, while impulsive traits may be more involved in the subsequent loss of control and the development of abuse or dependence. However, further longitudinal research is needed to confirm this hypothesis. Compared with the LOAs, the EOAs were characterized by a higher severity of alcohol dependence and related problems. They had longer substance-abusing careers, more frequently had a current or lifetime history of polysubstance abuse, and had higher severity scores on the EuropASI drug and
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alcohol domains. Furthermore, the EOAs had a higher problem severity on all EuropASI domains with the exception of the vocational domain. In addition, more EOAs had a paternal family history of alcoholism compared to the LOA subjects. These findings corroborate other studies suggesting that the age at onset is a valid criterion to define two subgroups of alcohol-dependent subjects with distinct differences in the course and severity of their alcohol-use disorder (Fils-Aime et al., 1996; Irwin et al., 1990; Lykouras et al. 2004). The alcohol-dependent subjects with co-morbid nicotine dependence in our sample had higher levels of impulsivity than the non-smoking alcoholics. Furthermore, the number of daily smoked cigarettes correlated with the BIS-11 scores, specifically the non-planning impulsiveness subscale. These findings are consistent with a recent study demonstrating higher scores on the non-planning subscale of the BIS10 in alcoholic inpatients with concomitant nicotine dependence compared to those without (Skinner et al., 2004). Although the exact relationship between smoking and impulsivity in alcohol-dependent subjects remains to be explained, our findings suggest that smoking status should be taken into account when exploring impulsivity in alcohol-dependent populations. The differences between the EOAs and LOAs highlighted in this and earlier studies may have important clinical implications. First, highly impulsive traits are indicative of poor treatment retention and prognosis. In cocaine-dependent patients higher levels of pre-treatment impulsivity, aggression and sensation seeking were associated with poor treatment outcome and retention (Moeller et al., 2001; Patkar et al., 2004). Recently, impulsiveness, as measured with the BIS-11, and aggressiveness, as measured with the BDHI, were found to be important predictors of craving (Zilberman, Tavares, & elGuebaly, 2003). Craving is an important risk factor associated with relapse. In an earlier study subjects scoring high on self-report measures of aggression reported more situations that triggered their use of substances (McCormick & Smith, 1995). Furthermore, several studies suggest that the sensation-seeking trait could constitute a prognostic factor. A 6-month follow-up study showed that sensation-seeking differentiated abstinent alcoholics from those who relapsed (Marra et al., 1998). Second, evidence is accumulating that subgroups based on the age-at-onset criterion have a differentiated response to pharmacological treatment. In a recent study the EOAs treated with a serotonin reuptake inhibitor (SSRI) relapsed more frequently than the LOAs (Chick, Aschauer, & Hornik, 2004). These findings support earlier results (Kranzler, Burleson, Brown, & Babor, 1996). EOAs may better respond to ondansetron (a 5-HT3 receptor antagonist) than to SSRI treatment, whereas LOAs may present the reverse pattern. In EOAs ondansetron had a beneficial effect on the alcohol-use variables craving and mood disturbances (Johnson, Roache, Ait-Daoud, Zanca, & Velzquez, 2003; Johnson et al., 2000; Kranzler, Pierucci-Lagha, Feinn, & Hernandez-Avilla, 2003; Stoltenberg, 2003). Thus, combining behavioral (self-report) measures with clinical observations of impulsive, aggressive, and sensation-seeking behaviors may help therapists in the early identification of dpoor respondersT who might consequently benefit from additional or alternative treatment approaches. In this respect age at onset of alcohol dependence may be a valid and clinically useful criterion for use in clinical assessment, treatment planning and choice of pharmacological interventions (Bakken et al., 2004).
5. Conclusions Age at onset of alcohol dependence is a valid criterion to distinguish two subgroups of alcoholics that differ extensively on demographics, substance use severity, and personality traits of
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impulsivity, sensation seeking and aggression. It is recommended to actively screen for impulsive traits and to take age at onset into consideration when planning treatment and pharmacological interventions. Acknowledgements This research was supported by an internal research grant of the Psychiatric Centre, Brothers Alexians, Boechout, Belgium. Preparation of this article was also supported by VAGGA, Centre for Ambulatory Health Care, Antwerp, Belgium. References Allen, T., Moeller, F. G., Rhoades, H. M., & Cherek, D. R. (1998). Impulsivity and history of drug dependence. Drug and Alcohol Dependence, 50, 137 – 145. American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th edition). Washington, DC7 Author. Babor, T. F., De Hofmann, M. I., Boca, F. K., Hesselbrock, V., Meyer, R. E., Dolinsky, Z. S., et al. (1992). Types of alcoholics: I. Evidence for an empirically derived typology based on indicator of vulnerability and severity. Archives of General Psychiatry, 49, 599 – 608. Baker, F., Johnson, M. W., & Bickel, W. K. (2003). Delay discounting in current and never-before cigarette smokers: Similarities and differences across commodity, sign, and magnitude. Journal of Abnormal Psychology, 112(3), 382 – 392. Bakken, K., Landheim, A. S., & Vaglum, P. (2004). Early and late onset groups of substance misusers: Differences in primary and secondary psychiatric disorders. Journal of Substance Abuse Treatment, 9(5), 224 – 234. Bayle, F. J., Bourdel, M. C., Caci, H., Gorwood, P., Chignon, J. M., Ades, J., et al. (2000). Factor analysis of French translation of the Barratt Impulsiveness Scale (BIS-10). Canadian Journal of Psychiatry, 45, 156 – 165. Bickel, W. K., Odum, A. L., & Madden, G. J. (1999). Impulsivity and cigarette smoking: Delay discounting in current, never, and ex-smokers. Psychopharmacology, 146, 447 – 454. Buss, A. H., & Durkee, A. (1957). An inventory for assessing different kinds of hostility. Journal of Consulting Psychology, 21, 343 – 554. Buydens-Branchey, L., Branchey, M. H., & Noumair, D. (1989). Age of alcoholism onset: I. Relationship to psychopathology. Archives of General Psychiatry, 46, 225 – 231. Chick, J., Aschauer, H., & Hornik, K. (2004). Efficacy of fluvoxamine in preventing relapse in alcohol dependence: A one-year, double-blind, placebo-controlled multicentre study with analysis by typology. Drug and Alcohol Dependence, 74(1), 61 – 70. Cloninger, C. R., Bohman, M., & Sigvardsson, S. (1981). Inheritance of alcohol abuse. Cross-fostering analysis of adopted men. Archives of General Psychiatry, 38, 861 – 868. Dawe, S., Matthew, J. G., & Loxton, N. J. (2004). Reward drive and rash impulsiveness as dimensions of impulsivity: Implications for substance misuse. Addictive Behaviors, 29, 1389 – 1405. Dawes, M. A., Tarter, R. E., & Kirisci, L. (1997). Behavioral self-regulation: Correlates and 2-year follow-ups for boys at risk for substance abuse. Drug and alcohol Dependence, 45, 165 – 176. Dinn, W. M., Ayciceggis, A., & Harris, C. L. (2004). Cigarette smoking in a student sample: Neurocognitive and clinical correlates. Addictive Behaviors, 29, 107 – 126. Feij, J. A., Dekker, P. H., Koopmans, J. R., & Boomsma, D. I. (1997). Nieuwe normen en stabiliteitsgegevens voor de Spanningsbehoeftelijst (SBL). Nederlands Tijdschrift voor de Psychologie, 52, 131 – 134. Fils-Aime, M. L., Eckard, M. J., George, D. T., Brown, G. L., Mefford, I., & Linnoila, M. (1996). Early-onset alcoholics have lower cerebrospinal fluid 5-hydroxyindoleacetic acid levels than late-onset alcoholics. Archives of General Psychiatry, 53, 211 – 216. Fossati, A., Di Ceglie, A., Acquarini, E., & Barratt, E. S. (2001). Psychometric properties of an Italian version of the Barratt Impulsiveness Scale-11 (BIS-11) in nonclinical subjects. Journal of Clinical Psychology, 57, 815 – 828.
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Gerra, G., Angioni, L., Zaimovic, A., Moi, G., Bussandri, M., Bertacca, S., et al. (2004). Substance use among high-school students: Relationships with temperament, personality traits, and parental perception. Substance Use and Misuse, 39(2), 345 – 367. Henderson, M. J., & Galen, L. W. (2003). A classification of substance-dependent men on temperament and severity variables. Addictive Behaviors, 28, 741 – 760. Hendricks, V. M., Kaplan, C. D., Van-Limbeek, J., & Geerling, P. (1989). The addiction severity index: Reliability and validity in a dutch addict population. Journal of Substance Abuse Treatment, 6(2), 133 – 141. Irwin, M., Schuckit, M., & Smith, T. L. (1990). Clinical importance of age at onset in Type 1 and Type 2 primary alcoholics. Archives of General Psychiatry, 47, 320 – 324.1. Jaffe, L. T., & Archer, R. P. (1987). The prediction of drug use among college students from MMPI, MCMI and sensation seeking scales. Journal of Personality Assessment, 51, 243 – 253. Jaroni, J. L., Wright, S. M., Lerman, C., & Epstein, L. H. (2004). Relationship between education and delay discounting in smokers. Addictive Behaviors, 29, 1171 – 1175. Johnson, B. A., Roache, J. D., Ait-Daoud, N., Zanca, N. A., & Velzquez, M. (2003). Ondansetron reduces the craving of biologically predisposed alcoholics. Psychopharmacology (Berl), 160(4), 408 – 413. Johnson, B. A., Roache, J. D., Javors, M. A., DiClementi, C. C., Cloninger, C. R., Prihoda, T. J., et al. (2000). Ondansetron for reduction of drinking among biologically predisposed alcoholic patients: A randomised controlled trial. JAMA, 284(8), 963 – 971. Kranzler, H. R., Burleson, J. A., Brown, J., & Babor, T. F. (1996). Fluoxetine treatment seems to reduce the beneficial effects of cognitive-behavioural therapy in type B alcoholics. Alcoholism, Clinical and Experimental Research, 20(9), 1534 – 1541. Kranzler, H. R., Pierucci-Lagha, A., Feinn, R., & Hernandez-Avilla, C. (2003). Effects of ondansetron in early- versus late-onset alcoholics: A prospective, open-label study. Alcoholism, Clinical and Experimental Research, 27(7), 1150 – 1155. Lange, A., Pahlich, A., Sarucco, M., Smits, G., Dehghani, B., & Hanewald, G. (1995). Psychometric characteristics and validity of the Dutch adaptation of the Buss-Durkee Hostility Inventory (BDHI-D). Behaviour Research and Therapy, 33(2), 223 – 227. Lykouras, L., Moussas, G., & Botsis, A. (2004). Examination of type I/type II alcoholism typology in a Greek hospital treatment population. European Psychiatry, 19(4), 214 – 218. Mann, R. E., Sobell, L. C., & Sobell, M. B. (1985). Reliability of a family tree questionnaire for assessing family history of alcohol problems. Drug and Alcohol Dependence, 15, 61 – 67. Marra, D., Warot, D., Payan, C., Hispard, E., Dally, S., & Puech, A. J. (1998). Anhedonia and relapse in alcoholism. Psychiatric Research, 80, 187 – 196. Martin, C. A., Kelly, T. H., Rayens, M. K., Brogli, B., Brenzel, A., Smith, W. J., et al. (2003). Sensation seeking, puberty, and nicotine, alcohol, and marijuana use in adolescence. Journal of the American Academy of Child and Adolescent Psychiatry, 41(12), 1495 – 1502. McCormick, R. A., & Smith, M. (1995). Aggression and hostility in substance abusers: The relationship to abuse patterns, coping styles, and relapse triggers. Addictive Behaviors, 20(5), 555 – 562. Mitchell, S. H. (1999). Measures of impulsivity in cigarette smokers and non-smokers. Psychopharmacology, 146, 455 – 464. Moeller, F. G., Dougherty, D. M., Barratt, E. S., Oderine, V., Mathias, C. W., Harper, R. A., et al. (2002). Increased impulsivity in cocaine dependent subjects independent of antisocial personality disorder and aggression. Drug and Alcohol Dependence, 68(1), 105 – 111. Moeller, F. G., Dougherty, D. M., Barratt, E. S., Schmitz, J. M., Swann, A. C., & Grabowski, J. (2001). The impact of impulsivity on cocaine use and retention in treatment. Journal of Substance Abuse Treatment, 21(4), 193 – 198. Patkar, A. A., Murray, H. W., Manelli, P., Gottheil, E., Weinstein, S. P., & Vergare, M. J. (2004). Pre-treatment measures of impulsivity, aggression, and sensation seeking are associated with treatment outcome for African-American cocainedependent patients. Journal of Addictive Disorders, 23(2), 109 – 122. Patton, J. H., Stanford, M. S., & Barratt, E. S. (1995). Factor structure of the Barratt Impulsiveness Scale. Journal of Clinical Psychology, 51(6), 768 – 774. Petry, N. (2001). Substance abuse, pathological gambling, and impulsiveness. Drug and Alcohol Dependence, 63(1), 29 – 38. Reynolds, B., Richards, J. B., Horn, K., & Karraker, K. (2004). Delay discounting and probability discounting as related to cigarette smoking status in adults. Behavioural Processes, 65, 35 – 42. Skinner, M. D., Aubin, Henri-Jean, & Berlin, I. (2004). Impulsivity in smoking, non-smoking, and ex-smoking alcoholics. Addictive Behaviors, 29, 973 – 978.
308
G. Dom et al. / Addictive Behaviors 31 (2006) 298–308
Sollof, P. H., Lynch, K. G., & Moss, H. B. (2000). Serotonin, impulsivity, and alcohol use disorders in the older adolescent: A psychobiological study. Alcoholism, Clinical and Experimental Research, 24(11), 1609 – 1619. Somey, T., Sakado, K., Seki, T., Kojima, M., Reist, C., Tang, S. W., et al. (2001). The Japanese version of the Barratt Impulsiveness Scale, 11th version (BIS-11): Its reliability and validity. Psychiatry and Clinical Neurosciences, 55, 111 – 114. Stephenson, M. T., Hoyle, R. H., Palmgreen, P., & Slater, M. D. (2003). Brief measures of sensation seeking for the screening and large-scale surveys. Drug and Alcohol Dependence, 72, 279 – 286. Stoltenberg, S. F. (2003). Serotonergic agents and alcoholism treatment: A simulation. Alcoholism, Clinical and Experimental Research, 27(12), 1853 – 1859. Tarter, R. E., Kirisci, L., Mezzich, A., Cornelius, J. R., Pajer, K., Vanyukov, M., et al. (2003). Neurobehavioral disinhibition in childhood predicts early age at onset of substance use disorder. American Journal of Psychiatry, 160, 1078 – 1085. Varma, V. K., Basu, D., Malhotra, A., Sharma, A., & Mattoo, S. K. (1994). Correlates of early- and late-onset alcohol dependence. Addictive Behaviors, 19, 609 – 619. Wagner, M. K. (2001). Behavioral characteristics related to substance abuse and risk-taking, sensation-seeking, anxiety sensitivity, and self-reinforcement. Addictive Behaviors, 26(1), 115 – 120. Windle, M., & Scheidt, D. M. (2004). Alcoholic subtypes: Are two sufficient? Addiction, 99, 1508 – 1519. Zilberman, M. L., Tavares, H., & el-Guebaly, N. (2003). Relationship between craving and personality in treatment-seeking women with substance-related disorders. BMC Psychiatry, 3(1). Zuckerman, M. (1984). Sensation seeking: A comparative approach to a human trait. Behavioral and Brain Sciences, 7, 414 – 447. Zuckerman, M., & Cloninger, C. R. (1996). Relationships between Cloninger’s, Zuckerman’s, and Eysenck’s dimensions of personality. Personality and Individual Differences, 21, 283 – 285. Zuckerman, M., Kolin, E. A., Price, L., & Zoob, I. (1964). Development of a sensation-seeking scale. Journal of Consulting and Clinical Psychology, 28, 477 – 482. Zuckerman, M., Kuhlman, D. M., Joireman, J., Teta, P., & Kraft, M. (1993). A comparison of the three structural models for personality: The big three, the big five, and the alternative five. Journal of Personality and Social Psychology, 65, 757 – 768.
Differences in impulsivity and sensation seeking between early- and late-onset alcoholics G. Doma,T, W. Hulstijnb, B. Sabbec a
Psychiatric Centre Brothers Alexians, Provinciesteenweg 408, 2530 Boechout, Belgium Nijmegen Institute for Cognition and Information (NICI), Nijmegen, The Netherlands, University of Antwerp, Belgium c Coordinator CAPRI (Collaborative Antwerp Psychiatric Research Institute), University of Antwerp, Belgium
b
Abstract The personality traits of impulsivity and sensation seeking have been proposed as important features of earlyonset alcoholism. Early-onset (EOA, n = 62) and late-onset (LOA, n = 68 ) alcoholic inpatients were compared as to the severity of their substance use and related problems, and self-report scales measuring impulsivity (Barratt Impulsiveness Scale, version 11), sensation seeking (Sensation Seeking Scale), and aggressiveness (Buss Durkee Hostility Inventory). The symptom severity of the EOAs’ alcohol-use disorder and related problems was higher than that of the LOAs. Furthermore, the EOAs had higher levels of impulsivity, sensation seeking, and aggression relative to the LOAs. The differences in impulsivity remained after an analysis controlling for the effect of aggressiveness. Finally, cigarette smoking was positively correlated with impulsiveness across alcoholic subgroups. Active screening for impulsive traits in treatment-seeking alcohol-abusing populations is recommended to improve treatment planning and prevent early drop-out. D 2005 Elsevier Ltd. All rights reserved. Keywords: Impulsivity; Sensation seeking; Early-onset alcoholism; Late-onset alcoholism
1. Introduction Impulsivity is intimately related to substance abuse (Dawe, Matthew, & Loxton, 2004). Longitudinal studies have identified impulsivity in children as a high-risk factor for early substance use and later substance abuse (Dawes, Tarter, & Kirisci, 1997; Tarter et al., 2003). Cross-sectional studies show higher T Corresponding author. Tel.: +32 34557531. E-mail address: [email protected] (G. Dom). 0306-4603/$ - see front matter D 2005 Elsevier Ltd. All rights reserved. doi:10.1016/j.addbeh.2005.05.009
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levels of impulsiveness to be associated with substance use and abuse in college students (e.g. Jaffe & Archer, 1987). Within clinical populations it has been demonstrated that illicit drug abusers score higher than controls on inventories of impulsivity (Allen, Moeller, Rhoades, & Cherek, 1998; Petry, 2001). Furthermore, impulsivity proved to be linked to the severity of drug abuse and poor treatment retention (Moeller et al., 2001; Patkar et al., 2004). High levels of impulsive traits have also been found within alcohol-dependent patients (Patton, Stanford, & Barratt, 1995). However, alcoholism is a very heterogeneous disorder and in the past different typologies have been proposed to distinguish more homogeneous subgroups (Henderson & Galen, 2003; Windle & Scheidt, 2004). High trait levels for impulsivity and sensation-seeking have been associated with specific subgroups within the different classification systems, i.e. type II alcoholism (Cloninger, Bohman, & Sigvardsson, 1981), Type B alcoholism (Babor et al., 1992), and early-onset alcoholism in the univariate classification based on the age of alcoholism onset (Buydens-Branchey, Branchey, & Noumair, 1989; Varma, Basu, Malhotra, Sharma, & Mattoo, 1994). Irwin, Schuckit, and Smith (1990) found age at onset to be a robust predictor of the severity of alcohol dependence and showed it to be associated with a sensationseeking and impulsive temperament. This is consistent with a recent study revealing age at onset to be a valid classification criterion in male alcohol-dependent patients (Lykouras, Moussas, & Botsis, 2004). It was reported that early-onset alcoholics (EOAs) had more familial alcoholism, higher levels of family and professional instability and more impulsive behaviors compared to the late-onset alcoholics (LOAs). Finally, an increasing body of research points to a relationship between impulsiveness and nicotine dependence. Studies using self-report measures of impulsivity (e.g. the Barratt Impulsiveness Scale) and those using behavioral tasks (e.g. delay-discounting) have consistently demonstrated higher levels of impulsiveness in smokers than in non-smoking subjects (Baker, Johnson, & Bickel, 2003; Bickel, Odum, & Madden, 1999; Dinn, Ayciceggi, & Harris, 2004; Jaroni, Wright, Lerman, & Epstein, 2004; Mitchell, 1999; Reynolds, Richards, Horn, & Karraker, 2004). Recently, Skinner, Aubin, Henri-Jean, and Berlin (2004) found smoking alcoholics to have higher levels of impulsivity than non-smoking alcoholics. In the present study we were interested in the differences between EOAs and LOAs as to their personality traits of impulsivity and sensation seeking. These traits were measured by two well-known selfreport scales: the Barratt Impulsiveness Scale (BIS 11; Patton et al., 1995) and the Sensation Seeking Scale (SSS; Zuckerman, Kolin, Price, & Zoob, 1964). Furthermore, since a recent study on cocaine-dependent patients demonstrated a high correlation between BIS scores and measures of aggressiveness (Moeller et al., 2002), we included the Buss Durkee Hostility Inventory (Buss & Durkee, 1957). The following hypotheses were put forward: (1) EOAs have higher trait levels of impulsivity and sensation seeking, (2) EOAs have a higher prevalence of paternal alcoholism, (3) EOAs were expected to have a more deteriorated pattern of alcohol and drug use as reflected by higher levels of social, family and legal problems compared to LOAs; and finally, (4) we anticipated higher impulsiveness in alcoholics with co-morbid nicotine dependence compared to those without.
2. Method 2.1. Participants All alcohol-dependent participants were recruited from an inpatient addiction treatment facility. During a period of 18 months (2003–2004) every second patient hospitalized for treatment of his/her
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alcohol problem was invited to participate in the present study. Abstinence on the ward was monitored by regular, randomized controls on alcohol, medication and illicit drug use. DSM-IV diagnosis (American Psychiatric Association, 1994) of alcohol dependence was made during a psychiatric interview and supplemented by collateral information (family), data from the European version of the Addiction Severity Index (EuropASI), and laboratory tests (blood and urine analysis). Patients with a current or lifetime history of psychotic disorders, amnesic disorders, brain disorders (e.g. trauma, epilepsy), or severe somatic disorders (liver cirrhosis, AIDS, thyroid disorders, visual problems) were excluded. Furthermore, patients who could not read or did not possess the required intellectual, social or educational level to respond to the questionnaires were excluded. Ultimately 130 alcohol-dependent subjects participated in this study. Sixty-two were classified as early-onset and 68 as late-onset alcoholics. EOAs were defined as having severe alcohol-use-related problems and symptoms of alcohol dependence before the age of 25 years. LOAs were defined as having symptoms of alcohol abuse or dependence after age 25. Age at onset was assessed during a clinical interview using the time-line method and complemented with data from the EuropASI interview and, if possible, collateral information. Family history of alcohol dependence was assessed by means of a clinical interview using a family-tree method (Mann, Sobell, & Sobell, 1985) and completed with the data from the EuropASI interview and, if possible, with additional collateral information (family, spouse). Paternal family history (PFH) and maternal family history (MFH) were defined as positive if the biological father or mother of the participant was diagnosed as (lifetime) alcohol dependent. Nicotine dependence was defined as the current and past year daily use of 10 or more cigarettes. The mean number of cigarettes used daily across all smoking alcoholics in the current sample was 26.8 (standard deviation 11.5). All participants gave their written informed consent as required by the Helsinki declaration. The study was approved by the clinic’s Medical Ethics Committee. 2.2. Assessments In the following sections a brief description of the measures the alcoholic patients completed during the first 2 weeks after admission is given. 2.2.1. EuropASI The patients completed the Belgian adaptation of the Dutch version of the Addiction Severity Index, European version (EuropASI; Hendricks, Kaplan, Van-Limbeek, & Geerling, 1989). This structured interview provides reliable, valid and sensitive measures of problem severity in seven domains for the 30-day period preceding the interview, with higher scores reflecting more severe problems. All subjects were interviewed by a certificated ASI trained interviewer. 2.2.2. Barratt Impulsiveness Scale The Barratt Impulsiveness Scale (BIS-11; Patton et al., 1995) is a self-report scale that is structured to assess long-term patterns of behavior by asking the respondents to answer questions about the ways they act and think without reference to any specific period and is thus frequently used as a trait measure of impulsivity. The BIS-11 has a total score (BIS_T) and contains three subscales related to impulsiveness. The first scale measures motor impulsiveness and lack of perseverance (BIS_M; sample item: bI am restless at the theatre or lecturesQ), the second measures cognitive impulsivity (BIS_C) by assessing inattention and
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cognitive instability (sample item: bI have racing thoughtsQ), and the third scale evaluates non-planning impulsivity (BIS_NP) by scoring lack of self-control and intolerance of cognitive complexity (sample item: bI plan tasks carefullyQ). The reliability and validity of the BIS has repeatedly been shown in a variety of languages (Bayle et al., 2000; Fossati, Di Ceglie, Acquarini, & Barratt, 2001; Patton et al., 1995; Somey et al., 2001). 2.2.3. Buss Durkee Hostility Inventory The Buss Durkee Hostility Inventory (BDHI; Buss & Durkee, 1957) is a widely used true–false questionnaire. The Dutch version (BDHI_D) consists of three subscales: direct aggression, indirect aggression, and social likeability. The psychometric properties of the BDHI-D are well examined and show good reliability and validity (Lange et al., 1995). 2.2.4. Sensation Seeking Scale The Zuckerman Sensation Seeking Scale (SSS; Zuckerman et al., 1964) was developed to evaluate sensation-seeking constructs that have been linked to impulsivity (Zuckerman, 1984). The questionnaire contains five subscales: General Sensation Seeking (SSS_G; sample item: bI like to explore a strange city or section of town by my myself, even if it means getting lostQ), Thrill and Adventure Seeking (SSS_TAS; bI enjoy many of the rides at amusement parksQ), Experience Seeking (SSS_ES; bI would like to hitchhike across the countryQ), Disinhibition (SSS_DIS; bI like wild, uninhibited partiesQ), and Boredom Susceptibility (SSS_BS; bI get bored seeing the same old facesQ). Substance-abusing participants were asked to fill out the Dutch version of the Sensation Seeking Scale (SSS_D). The SSS_D has been tested in a Dutch population showing good reliability and validity. Norm scores for different age groups are available (Feij, Dekker, Koopmans, & Boomsma, 1997). 2.3. Statistical analysis Student t-tests were used for continuous variables and Chi-square tests for dichotomous variables. Comparisons of the self-report scores between early- and late-onset alcoholic subjects were made using a GLM multivariate analysis. Since age inversely correlated with impulsivity measures, all subsequent analyses included age as a covariate, except for the analysis of the SSS where the scores were normalized for age. Furthermore, because gender differences have been reported, we also controlled for this factor. Pearson correlation analyses were performed to assess the relationship between the impulsivity and aggression measures. To control for the effect of aggression on impulsivity, in a second analysis the BDHI scores for direct and indirect aggression were included as covariates. Pearson correlation analysis was performed to evaluate the relationship between age at onset, the BIS11 total score and the SSS total score.
3. Results 3.1. Demographic characteristics The EOAs were younger, had longer substance-abusing careers and lower educational levels than the LOAs (see Table 1). As can be seen in Table 2, the EOA group also contained more males (marginally
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Table 1 Main demographic characteristics and differences between the early-onset alcoholics (EOA) and the late-onset alcoholics (LOA) Mean
EOA (n = 62)
LOA (n = 68)
t ( p)
Age Number of years at day-school Age at onset Years of alcohol abuse Daily cigarette use of smoking participants
37.53 12.29 17.69 19.84 28.7
45.47 13.67 33.57 11.90 25.2
4.995 (b 0.001) 2.704 (0.008) 15.765 (b 0.001) 5.310 (b0.001) ns
(9.43) (3.18) (3.20) (9.61) (12.5)
(8.69) (2.61) (7.35) (7.38) (10.4)
significant), a higher proportion of smokers and more participants with a positive paternal family history of alcohol dependence (PFH+) than the LOAs. Finally, polysubstance abuse, defined as lifetime or current abuse or dependence of at least one illicit drug in association with the current alcohol dependence (DSM-IV criteria; APA, 1994) was more prevalent in the EOAs. 3.2. Self-report questionnaires 3.2.1. Differences between EOA and LOA Overall, the results of the GLM multivariate analysis including all scales (BIS, SSS, BDHI) and all EuropASI items was significant for Group (EOA v. LOA; F(18,81) = 2.968; p b 0.001). The GLM multivariate analysis with both Gender and Group as fixed factors and Age as covariate revealed that the EOAs had higher scores on all BIS, BDHI, SSS scales and subscales as compared to the LOAs, except for the SSS_TAS subscale (see Table 3). Gender differences were not significant, with the exception of the BIS_C subscale (mean score for men = 16.97, F 5.72; women = 20.85, F 3.60; F(1,112) = 4.375; p = 0.039). 3.2.2. Effect of nicotine dependence A GLM multivariate analysis with Age as covariate and both Group and Nicotine (Y/N) as fixed factors did not change the statistical significance of the differences found between the EOAs and LOAs on the BIS, BDHI, and SSS scales. There was a marginally significant effect of smoking, showing nicotine-dependent alcoholics to have higher scores on the BIS_NP subscale than the non-smoking alcoholics ( F(1,112) = 3.442; p = 0.066). Within the smoking alcoholics (controlled for age) the number of daily cigarettes correlated positively with BIS_NP (r = 0.2283; p = 0.047), BIS_T (r = 0.2455; p = 0.033) and SSS_BS (r = 0.254; p = 0.023). Table 2 Gender distribution, number of nicotine-dependent participants, number of polysubstance abusers, and number of participants with a positive paternal (PFH+) or maternal (MFH+) family history of alcohol dependence for the early-onset alcoholics (EOA) and late-onset alcoholics (LOA) Men Smokers Polysubstance abusers PFH+ MFH+
EOA (%)
LOA (%)
v 2(1) ( p)
77 92.5 61 49 20
62 71 10 30 15
3.731 (0.053) 8.747 (0.003) 37.264 (b 0.001) 4.794 (0.029) ns
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Table 3 Differences between the early-onset alcoholics (EOA) and the late-onset alcoholics (LOA) for (1) the Barratt Impulsiveness Scale (BIS): cognitive impulsiveness (BIS_C), motor impulsiveness (BIS_M), non-planning impulsiveness (BIS_NP), and the total BIS score (BIS_T), (2) the Sensation Seeking Scale (SSS): thrill and adventure seeking (SSS_TAS), experience seeking (SSS_ES), boredom susceptibility (SSS_BS), disinhibition (SSS_DIS), and the general sensation seeking score (SSS_G), and (3) the subscales of the Buss Durkey Hostility Inventory (BDHI): Direct Aggression (BDHI_DA), Indirect Aggression (BDHI_IA), and Social Likeability (BDHI_SL) BIS_C BIS_M BIS_NP BIS_T SSS_TAS SSS_ES SSS_BS SSS_DIS SSS_G BDHI_DA BDHI_IA BDHI_SL
EOA Mean (sd)
LOA Mean (sd)
F( p) Group
17.98 19.30 23.82 61.10 5.75 7.56 6.37 8.00 7.44 9.64 11.04 1.70
14.84 13.17 17.92 45.94 5.90 6.34 5.23 7.02 6.44 5.92 8.27 2.29
6.285 (0.014) 17.400 (b0.001) 17.951 (b0.001) 25.182 (b0.001) ns 8.589 (0.004) 7.088 (0.009) 10.209 (0.002) 8.543 (0.004) 14.048 (b0.001) 9.253 (0.003) ns
(5.49) (7.84) (7.29) (15.37) (2.90) (2.58) (2.73) (2.23) (2.33) (3.29) (4.71) (1.43)
(5.88) (5.82) (8.06) (14.70) (2.92) (2.86) (2.96) (2.45) (2.66) (3.79) (4.09) (1.45)
3.2.3. Correlations Pearson correlation analysis showed that there was a significant, negative relationship between the age at onset of alcohol abuse and both the total BIS score (r = 0.365; p b 0.001) and the General SSS score (r = 0.230; p = 0.013). Furthermore, the total BIS-11 score correlated positively with the BDHI direct aggression subscale (BDHI_DA; r = 0.362; p b 0.001) and the BDHI indirect aggression subscale (BDHI_IA; r = 0.563; p b 0.001). 3.2.4. Effect of aggression as a covariate To control for aggression, a GLM multivariate analysis with the BDHI_DA and BDHI_IA scores as covariates was conducted to examine group differences in impulsivity. The results showed that the group difference for the BIS-11 total scores (BIS_T) remained significant ( F(1,112) = 8.655; p = 0.004).
Table 4 Differences (mean, standard deviation) between the early-onset alcoholics (EOA) and late-onset alcoholics (LOA) on the different domains of the European version of the Addiction Severity Index (EuropASI) EOA Health Vocational Alcohol Drugs Legal Social Psychiatric
2.82 3.05 7.30 5.37 4.35 5.63 6.46
LOA (1.80) (2.21) (12.54) (12.91) (12.90) (12.80) (12.62)
Higher scores are indicative of a higher problem severity.
2.15 2.77 6.02 1.46 1.21 3.08 4.57
F( p) (1.80) (1.88) (1.38) (1.81) (1.52) (1.44) (2.25)
4.503 (0.036) ns 3.469 (0.065) 11.717 (0.001) 7.545 (0.007) 7.720 (0.006) 5.801 (0.018)
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3.3. EuropASI severity scores A multivariate GLM analysis with Gender and Group as fixed factors revealed that the EOAs had significantly higher severity scores on all EuropASI domains, with the exception of the vocational domain (see Table 4). Gender differences were prominent. The female alcoholics had significantly higher severity scores on Vocational ( F(1,117) = 4.567; p = 0.035), Alcohol ( F(1,117) = 4.096; p = 0.045), Drug ( F(1,117) = 6.738; p = 0.011), Social ( F(1,117) = 7.023; p = 0.009), and Psychiatric ( F(1,17) = 8.469; p = 0.004) domains.
4. Discussion The criterion of age at onset of alcohol dependence generated two alcoholic subgroups that differed substantially with respect to their demographic characteristics, personality traits of impulsivity, aggressiveness and sensation seeking, and substance use severity and related problems. Furthermore, in accordance with our hypothesis, more EOAs had a positive paternal family history of alcoholism. Finally, the alcoholic inpatients with co-morbid nicotine dependence were more impulsive than those without. The EOAs had higher levels of impulsivity as measured with the BIS-11 than the LOAs. This difference was independent of concomitant aggressiveness traits. Furthermore, age at onset correlated inversely with the BIS scores, a finding that has been documented before for cocaine-dependent patients (Moeller et al., 2002). In addition, the sensation-seeking scores of the EOAs were higher than those of the LOAs. Sensation seeking is similar to the dimensions related to impulsivity in Eysenck’s and Cloninger’s personality models (Zuckerman & Cloninger, 1996; Zuckerman, Kuhlman, Joireman, Teta, & Kraft, 1993). The trait has been associated with a variety of illegal and/or risky behaviors such as the use of illicit drugs, smoking and alcohol use (Stephenson, Hoyle, Palmgreen, & Slater, 2003). In a recent study both higher sensation-seeking levels on the SSS and higher direct-aggressiveness scores on the BDHI were associated with concomitant illicit drug and alcohol abuse (polysubstance abuse; Gerra et al., 2004). It is of interest that, in line with our present findings, a recent study by Bakken, Landheim, and Vaglum (2004) also reported a high prevalence of polysubstance abusers in early-onset alcoholic populations. Taken together, both impulsivity and sensation-seeking traits are highly prevalent in early-onset alcoholics. Although these findings do not allow us to separate cause from consequence, a growing body of research suggests that high levels for these two traits in children and adolescents are associated with an early start of substance use and an increased risk of substance abuse later in life (Martin et al., 2003; Sollof, Lynch, & Moss, 2000; Wagner, 2001). Possibly, sensation seeking and impulsivity may have a differentiated impact on substance use and the development of abuse or dependence. A high level of sensation seeking may be a powerful incentive to start experimenting with alcohol or illicit drugs at an early age, while impulsive traits may be more involved in the subsequent loss of control and the development of abuse or dependence. However, further longitudinal research is needed to confirm this hypothesis. Compared with the LOAs, the EOAs were characterized by a higher severity of alcohol dependence and related problems. They had longer substance-abusing careers, more frequently had a current or lifetime history of polysubstance abuse, and had higher severity scores on the EuropASI drug and
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alcohol domains. Furthermore, the EOAs had a higher problem severity on all EuropASI domains with the exception of the vocational domain. In addition, more EOAs had a paternal family history of alcoholism compared to the LOA subjects. These findings corroborate other studies suggesting that the age at onset is a valid criterion to define two subgroups of alcohol-dependent subjects with distinct differences in the course and severity of their alcohol-use disorder (Fils-Aime et al., 1996; Irwin et al., 1990; Lykouras et al. 2004). The alcohol-dependent subjects with co-morbid nicotine dependence in our sample had higher levels of impulsivity than the non-smoking alcoholics. Furthermore, the number of daily smoked cigarettes correlated with the BIS-11 scores, specifically the non-planning impulsiveness subscale. These findings are consistent with a recent study demonstrating higher scores on the non-planning subscale of the BIS10 in alcoholic inpatients with concomitant nicotine dependence compared to those without (Skinner et al., 2004). Although the exact relationship between smoking and impulsivity in alcohol-dependent subjects remains to be explained, our findings suggest that smoking status should be taken into account when exploring impulsivity in alcohol-dependent populations. The differences between the EOAs and LOAs highlighted in this and earlier studies may have important clinical implications. First, highly impulsive traits are indicative of poor treatment retention and prognosis. In cocaine-dependent patients higher levels of pre-treatment impulsivity, aggression and sensation seeking were associated with poor treatment outcome and retention (Moeller et al., 2001; Patkar et al., 2004). Recently, impulsiveness, as measured with the BIS-11, and aggressiveness, as measured with the BDHI, were found to be important predictors of craving (Zilberman, Tavares, & elGuebaly, 2003). Craving is an important risk factor associated with relapse. In an earlier study subjects scoring high on self-report measures of aggression reported more situations that triggered their use of substances (McCormick & Smith, 1995). Furthermore, several studies suggest that the sensation-seeking trait could constitute a prognostic factor. A 6-month follow-up study showed that sensation-seeking differentiated abstinent alcoholics from those who relapsed (Marra et al., 1998). Second, evidence is accumulating that subgroups based on the age-at-onset criterion have a differentiated response to pharmacological treatment. In a recent study the EOAs treated with a serotonin reuptake inhibitor (SSRI) relapsed more frequently than the LOAs (Chick, Aschauer, & Hornik, 2004). These findings support earlier results (Kranzler, Burleson, Brown, & Babor, 1996). EOAs may better respond to ondansetron (a 5-HT3 receptor antagonist) than to SSRI treatment, whereas LOAs may present the reverse pattern. In EOAs ondansetron had a beneficial effect on the alcohol-use variables craving and mood disturbances (Johnson, Roache, Ait-Daoud, Zanca, & Velzquez, 2003; Johnson et al., 2000; Kranzler, Pierucci-Lagha, Feinn, & Hernandez-Avilla, 2003; Stoltenberg, 2003). Thus, combining behavioral (self-report) measures with clinical observations of impulsive, aggressive, and sensation-seeking behaviors may help therapists in the early identification of dpoor respondersT who might consequently benefit from additional or alternative treatment approaches. In this respect age at onset of alcohol dependence may be a valid and clinically useful criterion for use in clinical assessment, treatment planning and choice of pharmacological interventions (Bakken et al., 2004).
5. Conclusions Age at onset of alcohol dependence is a valid criterion to distinguish two subgroups of alcoholics that differ extensively on demographics, substance use severity, and personality traits of
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impulsivity, sensation seeking and aggression. It is recommended to actively screen for impulsive traits and to take age at onset into consideration when planning treatment and pharmacological interventions. Acknowledgements This research was supported by an internal research grant of the Psychiatric Centre, Brothers Alexians, Boechout, Belgium. Preparation of this article was also supported by VAGGA, Centre for Ambulatory Health Care, Antwerp, Belgium. References Allen, T., Moeller, F. G., Rhoades, H. M., & Cherek, D. R. (1998). Impulsivity and history of drug dependence. Drug and Alcohol Dependence, 50, 137 – 145. American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th edition). Washington, DC7 Author. Babor, T. F., De Hofmann, M. I., Boca, F. K., Hesselbrock, V., Meyer, R. E., Dolinsky, Z. S., et al. (1992). Types of alcoholics: I. Evidence for an empirically derived typology based on indicator of vulnerability and severity. Archives of General Psychiatry, 49, 599 – 608. Baker, F., Johnson, M. W., & Bickel, W. K. (2003). Delay discounting in current and never-before cigarette smokers: Similarities and differences across commodity, sign, and magnitude. Journal of Abnormal Psychology, 112(3), 382 – 392. Bakken, K., Landheim, A. S., & Vaglum, P. (2004). Early and late onset groups of substance misusers: Differences in primary and secondary psychiatric disorders. Journal of Substance Abuse Treatment, 9(5), 224 – 234. Bayle, F. J., Bourdel, M. C., Caci, H., Gorwood, P., Chignon, J. M., Ades, J., et al. (2000). Factor analysis of French translation of the Barratt Impulsiveness Scale (BIS-10). Canadian Journal of Psychiatry, 45, 156 – 165. Bickel, W. K., Odum, A. L., & Madden, G. J. (1999). Impulsivity and cigarette smoking: Delay discounting in current, never, and ex-smokers. Psychopharmacology, 146, 447 – 454. Buss, A. H., & Durkee, A. (1957). An inventory for assessing different kinds of hostility. Journal of Consulting Psychology, 21, 343 – 554. Buydens-Branchey, L., Branchey, M. H., & Noumair, D. (1989). Age of alcoholism onset: I. Relationship to psychopathology. Archives of General Psychiatry, 46, 225 – 231. Chick, J., Aschauer, H., & Hornik, K. (2004). Efficacy of fluvoxamine in preventing relapse in alcohol dependence: A one-year, double-blind, placebo-controlled multicentre study with analysis by typology. Drug and Alcohol Dependence, 74(1), 61 – 70. Cloninger, C. R., Bohman, M., & Sigvardsson, S. (1981). Inheritance of alcohol abuse. Cross-fostering analysis of adopted men. Archives of General Psychiatry, 38, 861 – 868. Dawe, S., Matthew, J. G., & Loxton, N. J. (2004). Reward drive and rash impulsiveness as dimensions of impulsivity: Implications for substance misuse. Addictive Behaviors, 29, 1389 – 1405. Dawes, M. A., Tarter, R. E., & Kirisci, L. (1997). Behavioral self-regulation: Correlates and 2-year follow-ups for boys at risk for substance abuse. Drug and alcohol Dependence, 45, 165 – 176. Dinn, W. M., Ayciceggis, A., & Harris, C. L. (2004). Cigarette smoking in a student sample: Neurocognitive and clinical correlates. Addictive Behaviors, 29, 107 – 126. Feij, J. A., Dekker, P. H., Koopmans, J. R., & Boomsma, D. I. (1997). Nieuwe normen en stabiliteitsgegevens voor de Spanningsbehoeftelijst (SBL). Nederlands Tijdschrift voor de Psychologie, 52, 131 – 134. Fils-Aime, M. L., Eckard, M. J., George, D. T., Brown, G. L., Mefford, I., & Linnoila, M. (1996). Early-onset alcoholics have lower cerebrospinal fluid 5-hydroxyindoleacetic acid levels than late-onset alcoholics. Archives of General Psychiatry, 53, 211 – 216. Fossati, A., Di Ceglie, A., Acquarini, E., & Barratt, E. S. (2001). Psychometric properties of an Italian version of the Barratt Impulsiveness Scale-11 (BIS-11) in nonclinical subjects. Journal of Clinical Psychology, 57, 815 – 828.
G. Dom et al. / Addictive Behaviors 31 (2006) 298–308
307
Gerra, G., Angioni, L., Zaimovic, A., Moi, G., Bussandri, M., Bertacca, S., et al. (2004). Substance use among high-school students: Relationships with temperament, personality traits, and parental perception. Substance Use and Misuse, 39(2), 345 – 367. Henderson, M. J., & Galen, L. W. (2003). A classification of substance-dependent men on temperament and severity variables. Addictive Behaviors, 28, 741 – 760. Hendricks, V. M., Kaplan, C. D., Van-Limbeek, J., & Geerling, P. (1989). The addiction severity index: Reliability and validity in a dutch addict population. Journal of Substance Abuse Treatment, 6(2), 133 – 141. Irwin, M., Schuckit, M., & Smith, T. L. (1990). Clinical importance of age at onset in Type 1 and Type 2 primary alcoholics. Archives of General Psychiatry, 47, 320 – 324.1. Jaffe, L. T., & Archer, R. P. (1987). The prediction of drug use among college students from MMPI, MCMI and sensation seeking scales. Journal of Personality Assessment, 51, 243 – 253. Jaroni, J. L., Wright, S. M., Lerman, C., & Epstein, L. H. (2004). Relationship between education and delay discounting in smokers. Addictive Behaviors, 29, 1171 – 1175. Johnson, B. A., Roache, J. D., Ait-Daoud, N., Zanca, N. A., & Velzquez, M. (2003). Ondansetron reduces the craving of biologically predisposed alcoholics. Psychopharmacology (Berl), 160(4), 408 – 413. Johnson, B. A., Roache, J. D., Javors, M. A., DiClementi, C. C., Cloninger, C. R., Prihoda, T. J., et al. (2000). Ondansetron for reduction of drinking among biologically predisposed alcoholic patients: A randomised controlled trial. JAMA, 284(8), 963 – 971. Kranzler, H. R., Burleson, J. A., Brown, J., & Babor, T. F. (1996). Fluoxetine treatment seems to reduce the beneficial effects of cognitive-behavioural therapy in type B alcoholics. Alcoholism, Clinical and Experimental Research, 20(9), 1534 – 1541. Kranzler, H. R., Pierucci-Lagha, A., Feinn, R., & Hernandez-Avilla, C. (2003). Effects of ondansetron in early- versus late-onset alcoholics: A prospective, open-label study. Alcoholism, Clinical and Experimental Research, 27(7), 1150 – 1155. Lange, A., Pahlich, A., Sarucco, M., Smits, G., Dehghani, B., & Hanewald, G. (1995). Psychometric characteristics and validity of the Dutch adaptation of the Buss-Durkee Hostility Inventory (BDHI-D). Behaviour Research and Therapy, 33(2), 223 – 227. Lykouras, L., Moussas, G., & Botsis, A. (2004). Examination of type I/type II alcoholism typology in a Greek hospital treatment population. European Psychiatry, 19(4), 214 – 218. Mann, R. E., Sobell, L. C., & Sobell, M. B. (1985). Reliability of a family tree questionnaire for assessing family history of alcohol problems. Drug and Alcohol Dependence, 15, 61 – 67. Marra, D., Warot, D., Payan, C., Hispard, E., Dally, S., & Puech, A. J. (1998). Anhedonia and relapse in alcoholism. Psychiatric Research, 80, 187 – 196. Martin, C. A., Kelly, T. H., Rayens, M. K., Brogli, B., Brenzel, A., Smith, W. J., et al. (2003). Sensation seeking, puberty, and nicotine, alcohol, and marijuana use in adolescence. Journal of the American Academy of Child and Adolescent Psychiatry, 41(12), 1495 – 1502. McCormick, R. A., & Smith, M. (1995). Aggression and hostility in substance abusers: The relationship to abuse patterns, coping styles, and relapse triggers. Addictive Behaviors, 20(5), 555 – 562. Mitchell, S. H. (1999). Measures of impulsivity in cigarette smokers and non-smokers. Psychopharmacology, 146, 455 – 464. Moeller, F. G., Dougherty, D. M., Barratt, E. S., Oderine, V., Mathias, C. W., Harper, R. A., et al. (2002). Increased impulsivity in cocaine dependent subjects independent of antisocial personality disorder and aggression. Drug and Alcohol Dependence, 68(1), 105 – 111. Moeller, F. G., Dougherty, D. M., Barratt, E. S., Schmitz, J. M., Swann, A. C., & Grabowski, J. (2001). The impact of impulsivity on cocaine use and retention in treatment. Journal of Substance Abuse Treatment, 21(4), 193 – 198. Patkar, A. A., Murray, H. W., Manelli, P., Gottheil, E., Weinstein, S. P., & Vergare, M. J. (2004). Pre-treatment measures of impulsivity, aggression, and sensation seeking are associated with treatment outcome for African-American cocainedependent patients. Journal of Addictive Disorders, 23(2), 109 – 122. Patton, J. H., Stanford, M. S., & Barratt, E. S. (1995). Factor structure of the Barratt Impulsiveness Scale. Journal of Clinical Psychology, 51(6), 768 – 774. Petry, N. (2001). Substance abuse, pathological gambling, and impulsiveness. Drug and Alcohol Dependence, 63(1), 29 – 38. Reynolds, B., Richards, J. B., Horn, K., & Karraker, K. (2004). Delay discounting and probability discounting as related to cigarette smoking status in adults. Behavioural Processes, 65, 35 – 42. Skinner, M. D., Aubin, Henri-Jean, & Berlin, I. (2004). Impulsivity in smoking, non-smoking, and ex-smoking alcoholics. Addictive Behaviors, 29, 973 – 978.
308
G. Dom et al. / Addictive Behaviors 31 (2006) 298–308
Sollof, P. H., Lynch, K. G., & Moss, H. B. (2000). Serotonin, impulsivity, and alcohol use disorders in the older adolescent: A psychobiological study. Alcoholism, Clinical and Experimental Research, 24(11), 1609 – 1619. Somey, T., Sakado, K., Seki, T., Kojima, M., Reist, C., Tang, S. W., et al. (2001). The Japanese version of the Barratt Impulsiveness Scale, 11th version (BIS-11): Its reliability and validity. Psychiatry and Clinical Neurosciences, 55, 111 – 114. Stephenson, M. T., Hoyle, R. H., Palmgreen, P., & Slater, M. D. (2003). Brief measures of sensation seeking for the screening and large-scale surveys. Drug and Alcohol Dependence, 72, 279 – 286. Stoltenberg, S. F. (2003). Serotonergic agents and alcoholism treatment: A simulation. Alcoholism, Clinical and Experimental Research, 27(12), 1853 – 1859. Tarter, R. E., Kirisci, L., Mezzich, A., Cornelius, J. R., Pajer, K., Vanyukov, M., et al. (2003). Neurobehavioral disinhibition in childhood predicts early age at onset of substance use disorder. American Journal of Psychiatry, 160, 1078 – 1085. Varma, V. K., Basu, D., Malhotra, A., Sharma, A., & Mattoo, S. K. (1994). Correlates of early- and late-onset alcohol dependence. Addictive Behaviors, 19, 609 – 619. Wagner, M. K. (2001). Behavioral characteristics related to substance abuse and risk-taking, sensation-seeking, anxiety sensitivity, and self-reinforcement. Addictive Behaviors, 26(1), 115 – 120. Windle, M., & Scheidt, D. M. (2004). Alcoholic subtypes: Are two sufficient? Addiction, 99, 1508 – 1519. Zilberman, M. L., Tavares, H., & el-Guebaly, N. (2003). Relationship between craving and personality in treatment-seeking women with substance-related disorders. BMC Psychiatry, 3(1). Zuckerman, M. (1984). Sensation seeking: A comparative approach to a human trait. Behavioral and Brain Sciences, 7, 414 – 447. Zuckerman, M., & Cloninger, C. R. (1996). Relationships between Cloninger’s, Zuckerman’s, and Eysenck’s dimensions of personality. Personality and Individual Differences, 21, 283 – 285. Zuckerman, M., Kolin, E. A., Price, L., & Zoob, I. (1964). Development of a sensation-seeking scale. Journal of Consulting and Clinical Psychology, 28, 477 – 482. Zuckerman, M., Kuhlman, D. M., Joireman, J., Teta, P., & Kraft, M. (1993). A comparison of the three structural models for personality: The big three, the big five, and the alternative five. Journal of Personality and Social Psychology, 65, 757 – 768.