To assess personality disorder (PD), emotional intelligence (EI), and locus of control of alcohol dependent (AD) patients and its comparison with normal controls.
Materials and Methods:
Based on purposive sampling technique, 33 AD patients were selected from the De-Addiction Ward of Ranchi Institute of Neuro-Psychiatry and Allied Sciences (RINPAS) and 33 matched normal subjects were selected from Ranchi and nearby places. Both the groups were matched on various sociodemographic parameters, that is, age, gender, and socioeconomic level. All participants were assessed with Millon Clinical Multiaxial Inventory-III, Mangal EI Inventory, and Locus of Control scale. Obtained responses were scored by using standard scoring procedures and subsequently statistically analyzed by using Chi-square test.
AD patients have more comorbid pathological personality traits and disorders in comparison to their normal counterparts. Depressive, narcissistic, and paranoid PDs were prominent among AD group; followed by schizotypal, antisocial, negativistic, dependent, schizoid, sadistic, masochistic, and borderline PD. In comparison to normal participants, AD patients were significantly deficient in almost all the areas of EI and their locus of control was externally oriented.
Patients with AD have significantly higher PDs, low EI, and an external orientation on the locus of control. Identification and management of these comorbid conditions are likely to improve the management and outcome of AD.
Alcohol dependence (AD) is a heterogeneous disorder and has been shown to have high rate of comorbidity with personality disorders (PDs).[1,2,3,4] The National Epidemiologic Survey on Alcohol and Related Conditions reported that 39.5% of the AD subjects have at least one of seven investigated PDs in comparison to 14.8% of controls. Higher rates of PDs are often reported from inpatient samples of AD subjects, where the frequency of at least one axis II diagnosis ranged between 25% and 93%. The types of PDs reported to be associated with AD in the literature are very variable and no clear pattern has emerged. The types of PDs most often reported include dependent; paranoid and antisocial (AS); AS and borderline; AS, histrionic, and dependent; borderline; narcissistic and avoidant; avoidant; and obsessive compulsive. The diagnostic disparity and inconsistency in the literature with regard to the number and types of PDs associated with AD are due to differences in sample characteristics, different criteria and diagnostic instruments employed for identification of PD, to the different type of alcohol use disorder considered (abuse or dependence) and to the different settings (inpatients or outpatients) in which patients were evaluated.[14,15]
Addiction not only affects the personality of addicts, it also impacts on emotional expression and level of Emotional Intelligence (EI) of addicts. EI has been proposed as the basis for success in life because it underpins a wide range of adaptive behavior in humans. Low EI, on the other hand, is said to be associated with personal and social problems at home and at work. Individuals with low EI have difficulty in managing their emotions and delaying gratification and are thus believed to be vulnerable to alcohol and substance abuse.[16,17,18]
An AD individual’s relapse to drinking is thought to be related to various interpersonal and intrapersonal factors. The locus of control is a construct that consists of factors that influence and contribute to a person’s belief concerning the extent and degree to which he or others can influence life event. Differences in perceived control can influence drinking behavior. An individual who perceives events as being a consequence of his or her own behavior has a belief in internal control. By contrast, individuals who perceive events as not being contingent upon personal actions, but rather influenced by luck, chance or by some other power are externally oriented. Assessment of locus of control in alcoholics has yielded inconsistent results. While some studies found that alcoholics exhibit an internal locus of control, many other studies have indicated that alcoholics have an external control orientation.[19,20,21] In view of the paucity of Indian studies in this area, the present study was undertaken to assess the prevalence of PD, level of EI, and locus of control of AD patients and its comparison with normal controls.
MATERIALS AND METHODS
This study was carried out at Ranchi Institute of Neuropsychiatry and Allied Sciences (RINPAS). This is a referral center for all acute psychiatric hospitalizations and outdoor patients within its catchment area which includes patients from states of Jharkhand and Bihar. The protocol for the study was approved by the Institutional Ethical Committee.
Between Group research design was used for the study. Patients diagnosed with AD were compared with an age and sex-matched normal control group on Millon Clinical Multiaxial Inventory III ((MCMI-III), Mangal EI Inventory (MEII), and Locus of Control Scale (LCS).
Sample for this study consisted of 33 AD patients and 33 normal control subjects from the general population. All patients were taken from De-Addiction Ward of RINPAS. All the participants of the normal control group were selected from Ranchi and nearby areas. AD patients fulfilling International Classification of Diseases-10 diagnostic criteria for research, and currently abstinent, in protected environment (10–14 days) were included. Patients were in the age range of 20–50 years and educated at least up to standard VIII. AD patients having any other comorbid psychiatric disorder (apart from PD) and organic and neurological disorders were excluded. Co-operative normal participants matched with the patients for age and education was included in the control sample. Normal participants with a history of organic mental disorder, head injury, and other neurological disorders were excluded. An informed consent was taken from all the participants.
Sociodemographic and clinical data sheet
This semi-structured proforma was specially drafted for the study. It contained information about the sociodemographic variables such as age, sex, education, marital status, religion, socioeconomic status, and domicile of the patients. It also included information about the history of alcohol or substance use, family history of mental illness, any history of significant head injury, seizure, mental retardation any other significant physical or psychiatric illness.
Millon Clinical Multiaxial Inventory-III
The MCMI-III consists of 175 items scored true or false by the respondent, and it is especially designed to measure personzality traits and disorder. The scales are clustered into two groups: 14 PD scales and 10 Clinical Syndrome scales. It also has Social Desirability Scale (Scale Y), a Debasement Scale (Scale Z), and a Validity Scale (Scale V) which include 3 bizarre or highly improbable items to see if responses are consistent throughout. The MCMI-III uses base rate (BR) scores to provide diagnostic clinical cut-offs to indicate presence and prominence of the various personality traits and clinical syndromes. Traditionally, BR scores of 75–84 indicate the presence of clinically significant traits. BR scores of 85 or higher indicate the high probability of clinical diagnosis. BR under 75 are not considered clinically significant and are not to be interpreted. Internal consistency of the scales was estimated to be between 0.67 and 0.90 using Cronbach’s alpha, and test-re-test stability was estimated to be between 0.84 and 0.96 over a period of 5–14 days.[22,23]
Mangal Emotional Intelligence Inventory
The MEII was used to measures the Emotional Intelligence of the persons. It contains a total 100 items, 25 each from the four areas or aspects of EI namely, intrapersonal awareness, interpersonal awareness, intrapersonal management, and inter-personal management. The subject has to respond either “yes” or “no” in each item. Reliability of test is 0.92 (test-re-test method) and validity of this test are 0.71 from the inter-validity formula.
Locus of Control Scale
The LCS was used for determining externally and internally controlled subjects. The scale comprised 41 items having 18 positive items and 23 negative items. It is a three-point scale and the Ss have to respond in terms of “always.” “Sometime” and “never,” respectively. The scoring of negative items is done on reverse order. The highest score on the scale is 72 and lowest is zero. The higher the score on the scale, the more internally oriented the individual will be. The scale is highly reliable and valid having reliability coefficient 0.55 and coefficient of temporal stability 0.75.
Based on between group research design, hospitalized AD patients were screened according to inclusion and exclusion criteria, and samples were selected for this study. Normal subjects were drawn from Ranchi and nearby areas. Sociodemographic and clinical data sheet was filled after taking informed consent of the subjects. Following the standard administration procedure, MCMI-III, MEII, and LCS were administered to all the subjects included in the study. After test administration, all protocols were scored and analyzed according to standard scoring procedure. The obtained responses were compared and analyzed by using the Chi-square test.
The sociodemographic characteristics of the sample are given in Table 1. There was no significant difference found between both the groups on different sociodemographic variables.
Table 2 presents the individual scores and comparison of both the groups on the personality subscales of MCMI-III. Findings suggest that AD patients showed a higher pathological personality traits and disorders as compared to the normal control subjects. In AD group the most pathological personality traits and disorders were found as depressive and narcissistic (21.2% each) followed by schizotypal, AS, negativistic, dependent (15.2% each) and schizoid (12.1%), sadistic (6.1%), masochistic, and borderline (3.0% each). In the normal control group, the most prevalent pathological personality trait and disorders were narcissistic (15.2%), followed by schizoid (9.1%), depressive, dependent, compulsive and negativistic (3.0% each).
On MEII, significant statistical difference was found in all subscales of EI such as intra personal awareness for own emotions (χ2 = 19.52, P < 0.01), interpersonal awareness for others emotions (χ2 = 17.45, P < 0.01), intra-personal management for own emotions (χ2 = 5.75, P < 0.05), inter-personal management for others emotions (χ2 = 9.32, P < 0.01), and aggregate emotional quotient (χ2 = 24.50, P < 0.01), in comparison to the normal control subjects [Table 3].
Table 4 shows a comparison of locus of control between patient with AD and normal controls. Twenty-four percent (24.24%) AD patients were externally oriented and 33.33% were internally oriented. Most of the normal controls (81.81%) were internally oriented. Overall there was significant difference between both groups (χ2 = 16.44, P < 0.01).
The major findings of the present study were that pathological personality traits and PDs were very common in AD individuals. This finding is consistent with previous studies, which have also reported that pathological personality traits and PDs were very common in individuals with AD.[1,2,3,4,8,26,27] PDs are considered to be an important contributing factor in the pathogenesis, persistence and treatment outcome of AD. According to previous studies, the prevalence of PDs in alcoholism ranges from as low as 22–40% to as high as 58–78%. The most common personality traits in AD patients were negativistic, depressive, and borderline, which is in agreement with earlier studies.[4,26,28]
With respect to the types of PDs, the most prevalent PD in the present study was depressive and narcissistic PD. In contrast to this many researchers found that PDs in alcoholics tended to be within the cluster A and B category, such as paranoid, schizoid, schizotypal, narcissistic, AS, and borderline. A recent analysis of data from the 2004/2005 National Epidemiological Survey of Alcohol and Related Conditions (n = 34,653) in USA revealed that individuals with PDs are significantly more likely to misuse alcohol. AS, borderline, histrionic, and narcissistic PDs display the strongest links with AD, and the relationships are strongest among the heaviest drinkers.
The association between PDs and the persistence of common substance use disorders (SUDs) was determined in a 3-year prospective study of individuals with AD (n = 1172). Persistent SUD was found among 30.1% of participants with AD. Antisocial personality disorder (ASPD), borderline PD, and schizotypal PD were significantly associated with persistent alcohol use disorders. Narcissistic, schizoid, and obsessive-compulsive PDs were less consistently associated with persistence of the alcohol use disorder.
A notable finding from our sample was that while the rate of ASPD in alcoholics (15.2% of total sample) but in the normal population rate of ASPD was 0%. However, in other studies 7% to 23% rate of ASPD was reported in clinical samples of AD patients.[9,11,13,31] This discrepancy may be due to small sample size and exclusion of other substance abuse patients in our study. The lack of consistency with earlier studies could be related to the sampling method or to the different assessment tools to diagnose a PD. However, further research is required to find out the prevalence of ASPD and borderline PD in Indian AD patients and normal subjects.
The identification of personality pathology and PD in AD patients may have clinical implications. The course of AD is less favorable in the presence of comorbid PD; this is reflected in more severe alcohol use disturbances, poor social functioning, low rates of treatment retention, and an increased risk of relapse. Psychotherapeutic approaches that provide significant benefits for AD include motivational interviewing, community reinforcement approach, cognitive-behavioral therapy, marital and family therapy, brief interventions, and coping skills training. Of these, only two psychotherapeutic techniques have been shown to be helpful for patients suffering from both addictive and personality problems: The dual focus schema therapy and the dialectical behavior therapy targeting substance abuse.[33,34] Obviously clinicians treating AD patients with comorbid PD need to be specially trained on psychotherapy of both PDs and addiction.
On the EI scale, the AD group scored significantly lower on every domain of EI as compared to the normal control group [Table 3]. These findings are consistent with the findings of the previous studies.[16,35,36,37] The results of EI scale indicate that subjects with AD lack competence in dealing with their own emotions as well as dealing with other’s emotion. This lack of effective capability might be a causal factor for the development of alcoholic behavior. This poor emotional competence may also lead to comorbid psychiatric conditions such as affective disorders, neurotic disorders, suicide as well. Poor emotional ability also results in the poor ability to handle the challenges in different spheres of life, professional growth, inability to attain the objective either in personal or professional life. EI has been credited with successful leadership performance in the workplace, academic achievement, effective communication, assertiveness, and positive relationship that can lead to effective coping. Lower EI scores are associated with problematic behavior related to increased use of alcohol and illegal substance. The present study also adds to the existing body of knowledge regarding EI and its correlation to alcohol use.
Emotional intelligence has also been linked to the reduction in the risk factors that have been traditionally associated with AD. Stress is a major risk factor for the development of AD and also continuity of use contributing to relapse of AD. An increase in stress is a major contributor to the onset of alcohol use in. Studies indicate that a high degree of EI is associated with lower stress levels and fewer psychological symptoms pertaining to traumatic experiences. In addition, subjects with high EI are better equipped to deal with and recover from stress and hence are less likely to fall sick or be vulnerable to the conditions brought upon by stress. Therefore, improving EI skills can serve as a protective force, lowering one’s susceptible risk to the factors that have traditionally predicted alcohol use and abuse.
Locus of control has been generated to assess one’s orientation of decision making (self-determine decisions of life or determine by the outer world). In the present study, AD individuals were significantly more externally oriented in their life’s decisions and events than normal controls [Table 4]. Findings of the present study are consistent with previous studies, which also reported that people with AD exhibit a greater external locus of control than the normal population.[19,20,41,42,43] According to the theory of LOC, a person with internal LOC perceives that consequences result from the personal action. In contrasts, a person who has external LOC perceives consequences as caused by external events, not by individual responsibility. When people believe that they have no control, they will remain passive, not exert themselves, and give up easily. It has been observed that in comparison to patients with AD, a patient in the remission stage tends to have internal LOC but might go back to external LOC once they resume drinking alcohol. It has also been reported that using the autogenic relaxation to facilitate the acquisition of self-control by biofeedback training, can increase personal responsibility and foster an internal locus of control in subjects undergoing treatment for AD. In view of the above and the findings of our study, it is likely that making an effort to produce control experiences and promote the internal locus of control for AD patients may improve outcome of treatment.
There are certain limitations of this research. The sample size was small and all participants were male. Furthermore, the data are cross-sectional, rather than longitudinal, and, therefore, the findings cannot be used to explain causal relationships. The diagnosis of PD was not based on structured clinical interviews. Future studies should include a larger sample, include both sexes and use structured clinical interviews for making the diagnoses.
From the present study, it can be concluded that personality pathology and disorders are significantly more common in AD patients. Individuals with AD have low EI and an external orientation on LOC. This information could be helpful in alerting the Clinician to understand and handle difficulties in the therapeutic process. Incorporation of EI enhancement program and steps to foster an internal LOC in the therapy of AD patients is likely to improve the outcome. Further research on the fundamental organization of PDs and the behavior modification implications of these disorders with comorbid conditions is needed.
Source of Support: Nil.
Conflict of Interest: None declared.