Alcohol abuse, personality disorders, and aggression: The quest for a common underlying mechanism
Introduction
Despite the high rates of co-occurrence (i.e., comorbidity; Lilienfeld, Waldman, & Israel, 1994) between alcohol abuse and personality disorders (PDs; Heramani Singh et al., 2005, Morgenstern et al., 1997, Trull et al., 2010), the literature on each has largely grown separately. A more comprehensive understanding of the co-occurrence of alcohol abuse and PDs seems needed for several reasons. For instance, treatments for each of these conditions are more likely to fail in the presence of the other (Horsfall et al., 2009, Stone, 2006). In other words, the presence of alcohol abuse may interfere with the treatment of PD patients, and the presence of a PD may similarly hinder the positive outcome of alcohol abuse treatments (Hasin et al., 2011, Krampe et al., 2006). The clinical picture is further complicated by the frequent association of both alcohol abuse and PDs with aggression and violent behavior. In turn, the presence of antisocial and aggressive acts makes it even more difficult to implement effective psychological treatments (Goldstein et al., 2010, Stone, 2006). The aim of the current review is to propose that common underlying mechanisms may help in explaining the occurrence of alcohol abuse, PDs, and aggression, as well as their co-occurrence. In line with this assumption, such shared antecedents could serve as useful targets for interventions, tailored to address the complex psychopathology characterized by the co-occurrence of these related domains. Thus, we review the literature linking alcohol abuse, PDs, and aggression, in an attempt to propose a comprehensive framework able to capture possible common etiological pathways and to provide new insights to improve currently available treatment programs.
A strong association between maladaptive personality features and alcohol misuse has repeatedly been reported, focusing both on basic personality traits (e.g., Creswell et al., 2015, Fairbairn et al., 2015, Few et al., 2013, Kotov et al., 2010, Malouff et al., 2007, Ruiz et al., 2008, Sher and Wood, 2005) and on DSM-based PDs (e.g., Creswell et al., 2016, Fernández-Montalvo et al., 2006, Hunter-Reel et al., 2014). Notably, the dimension of negative affectivity/neuroticism was consistently reported to increase the risk for alcohol misuse (Creswell et al., 2015, Few et al., 2013, Malouff et al., 2007). Furthermore, recent reviews and meta-analyses have shown that low agreeableness, low conscientiousness, and—to a lesser extent—high disinhibition were associated with alcohol misuse (Kotov et al., 2010, Malouff et al., 2007, Sharma et al., 2014). In addition, lack of constraint/impulsivity predicted solitary drinking in adolescence, above and beyond the influence of negative affectivity. This effect was both direct and indirect, through the partially mediating effect of the ability to resist drinking when experiencing negative emotions (Creswell et al., 2015). Finally, extraversion has also been theoretically linked to problematic drinking patterns, although empirical evidence has been mixed (Fairbairn et al., 2015, Few et al., 2013, Malouff et al., 2007, Sharma et al., 2014). Interestingly, recent findings revealed that this may be, in part, due to the contextual nature of this association, such that increased mood-enhancement from alcohol intake (i.e., increased alcohol-reward sensitivity) occurs among people high in extraversion primarily within social settings (Fairbairn et al., 2015).
Research investigating the association between alcohol abuse and selected PDs has historically been focused mainly on cluster B PDs, that is, the group of PDs characterized by impulsive, dramatic, emotional, and erratic traits (Jahng et al., 2011a, Tragesser et al., 2008, Tyrer et al., 1997). The cluster B includes four PDs: borderline, histrionic, antisocial, and narcissistic. In particular, the incidence of alcohol abuse is markedly high in patients with borderline PD (Fernández-Montalvo et al., 2006, Morgenstern et al., 1997, Trull et al., 2000). Indeed, the DSM–IV–TR (American Psychiatric Association [APA], 2000) criteria for borderline PD (which remained unchanged in the DSM–5 section II; APA, 2013) include substance/alcohol abuse as an example of the impulsive and potentially self-damaging behavior featured by borderline PD patients. Accordingly, a recent investigation in a sample representative of the United States, reported that alcohol use disorder (along with cocaine and opiate use) was uniquely related to borderline PD after controlling for relevant covariates and for the shared variance among different substance use disorders (Carpenter, Wood, & Trull, 2015).
Also, antisocial PD has often been linked with alcohol misuse (Compton et al., 2005, Eaton et al., 2012, Moeller and Dougherty, 2001, Morgenstern et al., 1997). Moreover, in a female incarcerated sample, antisocial PD—but not borderline PD—was associated with alcohol abuse, and after controlling for the influence of antisocial PD severity, borderline PD was no longer related to substance abuse in general (Chapman & Cellucci, 2007). In particular, the recklessness feature of antisocial PD explained unique variance in alcohol abuse (Chapman & Cellucci, 2007). This finding seemed to support the possibility that gender differences may affect the relation between alcohol abuse and PDs (e.g., Eaton et al., 2012, Landheim et al., 2003). For instance, among individuals with alcohol dependence, males more often reported cluster A PDs (i.e., paranoid, schizoid, schizotypal), whereas females were more affected by cluster C PDs (i.e., dependent, avoidant, obsessive-compulsive); on the other hand, among alcohol dependent individuals with poly-substance abuse, males were more likely to suffer from antisocial PD or cluster C PDs, while females presented with a higher likelihood of borderline PD (Landheim et al., 2003). Taken together, these findings broaden the possibility of an association between PDs and alcohol abuse beyond the role of cluster B PDs, which are explicitly characterized by impulsive and erratic behavioral tendencies. Cluster A PDs are defined by odd and eccentric thinking and behavior accompanied by restricted or inappropriate affectivity. Finally, cluster C PDs share a common anxious/fearful component.
In line with the possibility that alcohol abuse problems may extend to PDs besides those included in the cluster B, research has shown that alcohol abuse was also frequently present among individuals with avoidant (Dimaggio et al., 2015, Hunter-Reel et al., 2014), depressive (Hunter-Reel et al., 2014), schizotypal (Agrawal et al., 2013, Kroll and Ryan, 1983), and obsessive-compulsive PDs (Hunter-Reel et al., 2014). Furthermore, significantly higher rates of schizoid, sadistic, passive-aggressive, masochistic/self-defeating, as well as dependent PD traits have been reported among alcoholics, compared to healthy controls (Fernández-Montalvo et al., 2006, Hunter-Reel et al., 2014, Landheim et al., 2003). Finally, Agrawal et al. (2013) replicated these associations in a large community sample using a multimethod assessment of personality pathology (i.e., structured interview, self- and informant-report), and finding in addition a correlation between alcohol dependence and histrionic and narcissistic PD traits. However, they also found a negative association between alcohol dependence and both obsessive-compulsive and schizoid PD (Agrawal et al., 2013), contrasting findings obtained in other studies (e.g., Hunter-Reel et al., 2014).
Recent work has begun to examine the association between problematic alcohol use and the newly developed alternative model of personality pathology included in the DSM-5 Section III (APA, 2013). This alternative conceptualization defines PDs from a dimensional perspective and adopts a two-step diagnostic system. First, PDs are generally defined by a pervasive impairment in self (i.e., identity and self-directness) and interpersonal (i.e., empathy and intimacy) functioning, which can vary in severity. Second, PDs are characterized by specific constellations of maladaptive traits, broadly grouped into five domains: negative affect, detachment, disinhibition, antagonism, and psychoticism (APA, 2013). In an outpatient sample, Few et al. (2013) found that clinician-rated Disinhibition and self-reported Antagonism scores predicted problematic alcohol use scores. Based on these initial findings, Creswell et al. (2016) investigated the relationships between problematic alcohol use and both general personality pathology and specific maladaptive personality traits. Notably, both the general personality pathology index, and two personality traits domain (i.e., Antagonism and Disinhibition) were linked to problematic alcohol use. Further, two other domains (i.e., negative affectivity and psychoticism) were able to distinguish between hazardous (reporting greater levels of dysfunctional personality traits) and non-hazardous drinkers.
Section snippets
Alcohol abuse and the externalizing/internalizing spectra of psychopathology: Examining evidence on the alcohol-aggression link
Substantial evidence exists in support of the association between alcohol misuse and both externalizing and internalizing behavior and psychopathology (Kivimäki et al., 2014, Nicholls et al., 2014, Vanheusden et al., 2008). For instance, alcohol misuse has consistently been linked to anxiety and depression symptoms (Ellingson et al., 2015, Kivimäki et al., 2014) as well as to somatic complaints (Kivimäki et al., 2014). Furthermore, other authors have reported an association between suicidal
The quest for common underlying mechanisms: Emotion dysregulation and impulsivity
Prior research supports the role of behavioral control and affect regulation as possible underlying mechanisms in the observed comorbidity among alcohol abuse, PDs, and aggression (Agrawal et al., 2013, Creswell et al., 2016, Jahng et al., 2011a, Krueger et al., 2007, Lejuez et al., 2010, Littlefield and Sher, 2010). Furthermore, behavioral/impulsive dyscontrol and emotion dysregulation have also been linked to increased risk for aggression, particularly in association with either
Conclusions: Treatment implications
To summarize the above conceptual and empirical work, the purpose of the present review was to examine the literature on alcohol misuse, PDs, and aggression. Substantial evidence has indeed been reported linking personality pathology (either considering selected PDs or pathological personality traits) and increased risk for both alcohol abuse and violent behavior. Furthermore, the co-occurrence of alcohol abuse or PDs is likely to amplify the incidence of violent behavior, as compared to the
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