.Addlcriw Behaviors. Vol. Il. pp. 359-366. Printed in the US.\.
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0306-1603192 $5.00 + .OO c‘ 1992 Psrgamon Press Ltd.
RELATIONSHIP OF DIAGNOSTIC, DEMOGRAPHIC, PERSONALITY VARIABLES TO SELF-REPORTED STIMULI FOR CHEMICAL USE
JOHN P. ALLEN, VIVIAN FADEN, and ROBERT RAWLINGS National
Institute on Alcohol Abuse and Alcoholism
Abstract - VVhile extensive research has been conducted to determine internal and external stimuli for drinking by alcoholics. the topic of how demographic, diagnostic. and personality variables may relate to these precipitants is largely unexplored. This study suggests that stimuli to use alcohol or drugs differ partly as a function of diagnosis (alcohol dependence vs. concurrent alcohol and drug dependence). Age. education. and gender do not appear related to the stimuli in either diagnostic group. Personality characteristics of cognitive reflectiveness. impulse control, sociability. and intrapunitiveness, however. seem to be associated with certain classes of high risk stimuli.
In recent years interest has focused on the stimuli to which alcoholics ascribe their drinking. Such studies are open to criticism since self-reported stimuli are of an attributional nature, and subjects may fail to fully understand or divulge them. Nevertheless, assessment of self-perceived stimuli is important since this information may help specify treatment strategies (Goldman & Klisz, 1982; Connors & Maisto. 1988) and may further understanding of the dynamics involved in alcoholic relapse (Marlatt. 1978). Despite heterogeneity in methodological approaches and content categories which surround investigations to taxonomize drinking stimuli, interesting clinical correlates of drinking stimuli have been found. First, problem drinkers seem to differ from social drinkers in ascribing greater saliency to drinking stimuli in general. and to negative emotional cues in particular (Deardorff, Melges, Hout, & Savage, 1975; Brown, Goldman, & Christiansen, 1985). Second, alcoholic patients who rate drinking stimuli as more likely to cause them to drink do, in fact, have higher rates of relapse than their treatment peers (Litman, Eiser, Rawson, & Oppenheim, 1979; Litman. Stapleton, Oppenheim, Peleg, &Jackson, 1983; Brown, 1985). [Expectancies for alcohol as a tension reducer may be especially associated with relapse (Brown, 1985).] Third, some evidence suggests that patients varying in levels of specific alcohol expectancies profit differentially, at least in terms of skill development, from interventions targeted.to these expectancies (Brown, Miller, & Possman, 1988). Finally, interventions focused on coping with drinking precipitants seem more effective in diminishing risk of relapse than do interventions of a more global nature (Chaney, O’Leary, & Marlatt, 1978; Annis & Davis, 1988). Despite extensive research to identify major classes of precipitants. the topic of how individual characteristics may relate to stimuli for drinking or use of drugs has been little explored. The present study was designed to further this area of research by assessing how demographic factors, personality characteristics, and drug dependence Correspondence concerning this article should be addressed to John Allen, Ph.D.. h1.P.A.. Chief. Treatment Research Branch, Division of Clinical and Prevention Research, National Institute on .Alcohol Abuse and Alcoholism. Room l4C-20. Parklawn Building, 5600 Fishers Lane. Rockville. hlD 20557. 359
concurrent use drugs.
with alcoholism might be associated with self-reported stimuli to drink or
E T H 0 D
Subjects for the project were patients admitted to a private. inpatient adult substance abuse treatment unit. Following interviews with them (and. where possible. with family members and employers) and clinical evaluations, 166 vvere diagnosed according to DSM III-R criteria as dependent only on alcohol and 17 1 as dependent on both alcohol and at least one other drug. The two diagnostic groups were quite similar in gender distribution, with 25 of the 166 alcohol only dependent patients and 22 of the 17 1 dually dependent cases being women. Similarly, the mean educational levels were almost identical with the average number of formal years of schooling completed being 1 1.90 years (s = 2.34) for the alcohol-only patients and 12.03 years (s = 1.62) for the dually dependent. The two groups did, hovvever, differ rather dramatically in age. The mean age for the alcohol only dependent group was 38.04 years (s = 10.32). The mean age for the sample dependent on both alcohol and drugs was 27.70 y-ears (s = 6.78) (t (335) = 10.90. p < .OO1). Clients ofthe treatment unit were primarily lower middle and middle class skilled workers employed in automobile manufacturing and other heavy industry. Approximately 90% were uhite. Subjects were administered a Chemical Use Survey (CUS) on the sixth day following admission. unless they were still being medically detoxified. in vvhich case assessment vvas deferred until they appeared able to complete it. The CUS consists of 23 items dealing vvith internal and external stimuli that may prompt the use ofdrug or alcohol. Seventeen ofthe items were derived from Miller and Mastria’s ( 1975) social learning model of putative antecedents for drinking. This schema attempts to tap five classes of stimuli: social, emotional, situational, cognitive, and physiological. These classes of stimuli are also the basis of Marlatt’s (1977) functional analysis of drinking behavior. Six additional items were included based on staff comments about other reasons for drinking or use of drugs that they reported they had commonly heard from patients, but vvhich vvere not in the Miller and Mastria set of stimuli. Items were written in a manner that would be applicable to either drugs or alcohol. At the same time, no items were included which referred to the specific effects of a particular drug such as inducement of hallucinations. Patients were instructed to employ a five-point Liken rating scale with 5 indicating that the stimulus was “very likely” to lead them to use drugs or alcohol and 1 indicating that the stimulus was “not at all likely” to have this effect. Concurrent with the CUS, the Personality Research Form (E) (PRF) (Jackson, 1984) was administered. The PRF is an objective personality measure designed to assess the classical trait taxonomy proposed by Henry Murray. Beyond its conceptual basis in personality theory, additional strengths of the measure are its multi-trait, multi-method approach to construct validity, the balancing of items keyed as true or false to control for the response styles of acquiescence and criticalness. the bipolar nature of the scales, the low reading level required, and the presence of validity scales for social desirability and atypical response patterns. The PRF has quite an extensive history of use in chemical dependency research projects, including investigations of risk factors of abuse. personality correlates of abuse, and treatment implications suggested by personality characteristics of chemically dependent patients (Allen, Fertig, & Mattson, 199 1). Data also were recorded for the presence or absence of coliateral drug dependence, gender, age, and education (in years of formal schooling completed).
Variables related to stimuli for chemical use
Scores on trait scales for the PRF were factor analyzed separately for the two groups. Principal components extraction followed by varimax rotation vvas employed. Various numbers of solutions from two to seven were considered. Based primarily on interpretability and comparability with previous factor analytic research on the PRF, the five factor solution was ultimately chosen for each group. The solutions accounted for 55.4% and 60.5% of the variances, with the lowest eigenvalues for the unrotated solutions being 1.27 and 1.22 for the alcohol only and dually-dependent groups, respectively. Despite slight variation in subscale loadings, the factors were remarkably similar for the two groups. Factor I seems to tap sociability with affiliation and dominance loading particularly high on it. Factor II is a bipolar dimension which appears to deal with cognitive control vs. impulsivity. Cognitive structure and order loaded heavily on one end of the factor and impulsivity and play on the other end. Factor III is a bipolar dimension which appears to involve hostility (e.g., aggression and defendence) vs. self blame (e.g., abasement). Factor IV, another bipolar dimension, seems to be capturing external influence on behavior vs. internal motivation. Social recognition received a high positive loading and autonomy a high negative loading. Finally, Factor V appears to gauge interiority or cognitive reflectiveness. Sentience and understanding defined this dimension. Means and standard deviations for CUS items are presented in Table 1. CUS itemby-item correlations were factored for the two groups separately. As with the PRF, the CUS was subjected to principal components extraction followed by varimax rotation. Considerations for interpretability led to selection of a rotated six-factor solution for Table I Means and standard deviations on the Chemical Use Survey subjects dependent on alcohol only or alcohol and drugs t\lcohol only
Feeling frustrated at self Feeling badly about life Feelings of loss Lacking hope Feeling ashamed Seeing others use Being where used before Being encouraged by others Remembering past enjoyable use Believing use was safe Using to reward self Feeling happy Liking taste/smell Using to relieve physical pain Feeling physical need to use Feeling guilty Using to feel calmer with others Wanting to hurt self Using to “get back” at others Feeling sexually frustrated Feeling tense for no reason Feeling bored Using to sleep
Drug and alcohol
3.16 3.83 3.42 2.70 2.78 2.39 2.96 2.27 3.07 2.45 2.58 2.70 3.28 2.46 3.10 2.92 2.89 I.53 1.75 2.08 3.05 3.20 2.48
I.50 I.45 I.61 1.57 I .50 I.50 I.53 1.38 I .49 I.51 I .43 I.55 I .67 I .60 I.61 1.58 I.51 1.12 I.27 I .44 I.56 I.55 I .62
3.32 3.81 3.31 2.87 2.72 2.99 3.24 2.69 3.14 2.24 2.8 I 2.84 3.30 2.37 3.09 2.78 2.69 1.55 I.81 2.14 3.01 3.36 2.45
1.45 I .36 I .65 I.55 I.61 I .47 I.45 1.47 I .49 1.45 1.47 1.58 I.58 I.61 1.64 I.58 I .49 I.18 1.30 1.68 I .46 I.50
solution for each group. The lowest eigenvalue for the unrotated six factor solution was 1.13 for the alcohol-only group and 1.10 for the dually dependent group. The six factors accounted for 54.3% of the variance in the alcohol-only patients and 56.4% of the variance in the alcohol and drug dependent group. Inspection of high loading items on the rotated factors suggested moderately high similarity in meaning across the two groups. In order to quantitatively assess the degree of similarity between factors for the two groups. scores on CUS items were standardized for the two groups combined. Two sets of six factor scores for each subject were then derived. The first set was computed by using the factor score coefficients from the unrotated factor solution for the group to which the patient actually belonged. The second set was computed by using the factor score coefficients from the unrotated factor solution derived from the group to which the patient did not belong. Correlations were then computed between the two sets of factor scores. (Under this approach it would thereby be possible to identify factors as similar. even though the specific item loading patterns might differ.) Scores on Factors I, II, and III correlated at .92, .92, and .79, respectively. Factor IV correlated only moderately at .56. Scores derived using the two sets of weights for the last two factors correlated so low that the factors could not be identified with each other. (It is unclear if this is because these latter factors actually measure different motives for alcohol-only use vs. drug and alcohol use or if these factors are simply weaker and thus correlate more poorly together than the other factors.) Results of the factor analysis of the CUS for the two groups are presented in Tables 2 and 3. Factor I seems to reflect depression and lack of self-esteem as a precipitant. Factor II is interpreted as peer pressure to use. Factor III seems to involve self-reinforc-
Feeling frustrated at self Feeling badly about life Feelings loss Lacking hope Feeling ash.rmed Seeing others use Being where used before Being encouraged by others Remembering past enjoyable use Believing use was safe Using to tward self Feeling happy Liking taste/smell Using to relieve physical pain Feeling physical need to use Feelingguilty Using to feel calmer \vith others Wanting to hurt self Using to “get back” at others Feeling sewally frustrated Feeling tense for no reason Feeling bored Using to sleep
38 js 77 2s -05 09 19 -01 OS -06 09 01 37 71 j3 05 -06 36
43 I’ I7 Factor
01 I? -19 -13 II
01 - 03 -30 -09 I2
21 16 27 21 -08
I5 I I 42 08 05
-07 -07 03 26 77
69 20 70 I7 -0-t 09 38 05 07 II 23 2s OS -17 -18 -IO 24 00
I3 19 07 60 71 j7 y 31 08 3-l 17 24 -02 01 18 08 -05 19
IS -06 -00 20 -06 36 3’ 1; 7;
-01 75 21 05 I3 2u 03 3 08 ‘6 - I9 -05 -07 -05 IO -7’ 30 -0s
-0; 07 I I -12 23 06 -01 -15 20 -12 13 -08 79 _sx j7 -09 -04 04
over .40 are underlined.
JI -01 36 03 05 09 2 57 ‘?
Table 3. Factor loadings of self-reported
related to stimuli for chemical
stimuli for substance abuse subjects dependent and drugs
on both alcohol
01 I3 -I4 II I8
IO 08 I1 27 28 04 22 I9 -08 34 08 03 -02 25 04 03 -12
Feeling frustrated at self Feeling badly about life Feelings of loss
79 74 js
-01 -04 IO
-04 I4 -00
Lacking hope Feeling ashamed
01 07 I5 I6 I6
Seeing others use Being where used before Being encouraged by others Remembering past enjoyable Belie\ ing use was safe
04 01 03 25 IO
3 I7 78 02 -12
I3 09 06 33 55
-10 03 -08 II 01
57 G 21 jl -27
;s 09 07 -04 25 62 -13 I5 39 I5 -I5 -02
72 63 72 IO 01 -07 25 -17 21 I5 I8 38 04
06 -00 I5 7j 31 I6 30 I6 -04 15 02 2s 80
:: 06 08 s 01 -06 23 IO -18 22 32 09
Using to reward self Feeling happy Liking taste/smell Using to relieve physical pain Feeling physical need to use
Feeling guilt) Using to feel calmer with others Wanting to hurt self Using to “get back” at others Feeling sexually frustrated Feeling tense for no reason Feeling bored Using to sleep Note: Decimal
points are removed.
I3 -16 -03 I5 33 CC! 30 27 I5 24 s 39 22
63 I_! so -05 -17 -08
Factor loadings over .40 are underlined,
ing. hedonistic reasons for use. Factor IV appears to be characterized as “self-medicational” use to reduce physical or emotional stress. For the dually dependent, Factor V seems to involve social influences. Interestingly, the social influences appear to be of a somewhat passive nature since the item dealing with “seeing others use” loaded highly, while “being encouraged by others” yielded a rather low loading. The high loading for the “physical need” item suggests an additional component of physical dependency. For the alcohol-only group, Factor V seems to deal with stimuli associated with past use. Factor VI seems somewhat similar in meaning for both groups and appears to deal with using to punish oneself or others. Since requirements for normality of distribution of the predictor variables could not be met, and we were interested in treating gender, age, and educational level as covariates, analyses of variance rather than regression analyses were performed to determine relationships of the five personality factors, gender, age, and educational level on CUS scores. Granted the differences in factor solutions for the CUS, data for the two groups were treated separately in the analyses. For the alcohol-only dependent group the CUS factors of depression [F(8, 156, = 2.76, p = .0071)] and self medication [F(8, 156, = 2.74, p = .0075)] demonstrated significant overall effects. Adjustment of the alpha-level to .007, based on a Bonferroni correction, revealed that patients higher on the PRF factor ofcognitive control reported stimuli of depression as more likely to prompt them to use [F(S, 156 = 11.30, p = .OOlO)] than patients who were more behaviorally expressive. Patients higher in interiority or reflectiveness reported higher propensity to drug or alcohol use in
response to feelings ofanxiety [F(8, 156, = 8.45, p = .0042)] than did their low-scoring peers. Neither the other personality factors nor the demographic variables were significantly associated with these two CUS factors. Among patients dependent on both alcohol and drugs, the CUS factors of depression and passive social influence were significant [(F(8,159) = 2.273, p = 0249 and F(8,159) = 2.752, p = .007 I]. respectively. Patients higher on the PRF factor of internalizing blame reported greater proclivities to use drugs or alcohol in response to feelings of depression [F(X, 156) = 9.50, p = .0024]. Those higher on sociability reported being more likely to use substances due to passive social influences [F(8,159) = 8.79, p = .0032]. As with the alcohol only patients. the other personality factors and the demographic variables were not significantly associated with either of these CUS factors. DISCUSSION
This study suggests three generalizations about self-reported stimuli for substance use. First. several ofthe broad classes ofstimuli seem quite similar for inpatients dependent only on alcohol vs. those dependent on both alcohol and drugs. To the extent that stimuli for use are similar for both groups, it should be possible to develop a common assessment instrument and a common model for intervention based on modifying expectancies for chemical effects. Second, the fact that age, education, and gender are not significantly related to high risk stimuli for either alcoholic sample simplifies research in this area. On the other hand, since there were large sex imbalances in both samples. the failure to find a gender effect is slightly less compelling. Finally, interesting relationships between personality factors and reported high risk situation factors were found in the two groups. The small number ofstudies which have been conducted previously on this issue have employed college students as subjects, few ofwhom have likely diagnoses ofalcohol dependence (Leonard & Blane, 1988: Jackson & Matthews, 1988; Brown & Munson, 1987; Zuckerman. 1983). Hence, it is not possible to compare our results on older, diagnosed, alcohol-dependent patients with their findings. While the relationships between personality factors and perceived stimuli of use are intriguing, the reasons for these relationships are not as yet well understood. Alcoholonly dependent patients who tend toward cognitive reflection may thereby experience higher levels of stress and may find substance use a means of reducing it. It may also be that use of alcohol or drugs provides a desired respite from the worries which greater reflection might engender. A variety of techniques to reduce anxiety in recovering alcoholics have been proven helpful. These include stress management techniques such as biofeedback, systematic desensitization, and aerobic exercise (Miller & Hester. 1986). Alcohol-only patients who overinhibit behavioral urges may experience greater depression due to failure to act spontaneously and may find drinking a means of reducing the depression. Depression in recovering alcoholics, especially in the initial phases of sobriety, is common. Fortunately, in most cases depression dissipates within a couple of weeks (Brown & Schukit, 1988). Techniques such as cognitive behavior therapy for depression or short-term, medically-monitored use of an antidepressant might reduce risk of relapse in those recovering patients in whom depression does not quickly remit. For the dually dependent, higher levels ofsociability seem associated with greater susceptibility to passive social influences to use substances. Research on assertion training
in the treatment of alcoholism has yielded generally promising results (Miller & Hester, 1986) and might be considered for dually-dependent patients vulnerable to such stimuli. Finally, while internalizing guilt may often be preferable to blaming and direct aggression against others, intrapunitiveness may place the dually-dependent patient at higher risk to use alcohol and drugs. Chemical use may alleviate the depression accompanying excessive self-blaming. Despite the attention given by alcoholism treatment programs to helping patients manage guilt feelings, little research seems to have been done on what specific interventions are actually effective. While certain personality variables were associated with some of the high risk chemical use factors, the overall contributions of personality factors to other stimuli for use were non-significant. Further, even for those high risk factors where significant relationships were found. most of the variance remained unexplained. The present study should be viewed primarily as an initial effort to understand possible relationships between personality factors and high risk drinking stimuli. Future projects might involve confirmatory factor analyses of high risk stimuli in populations differing from the present one. These might include individuals who abuse drugs only, patients in less intensive treatment or community settings, women, adolescents, and minorities. It would also be interesting to assess the long-term impact of techniques to reduce high risk stimuli. The Annis and Davis ( 1987) study noted above suggested considerable advantage for focusing interventions on high risk stimuli, but did not demonstrate which techniques were specifically helpful with the vaqing types of high risk stimuli. lnprovements in instrument selection to assess personality and high risk chemical use stimuli might well reveal relationships stronger than those found in this project. Nevertheless, one should bear in mind that factors prompting use of alcohol or drugs are probably influenced by a range of other non-personality phenomena such as modeling of drinking or drug use patterns, early experiences with alcohol or drugs, immediate situational variables, and biochemical factors. Ultimately, it is hoped that a comprehensive, highly explanatory model of chemical use relating this entire gamut of factors can be developed. REFERENCES J. P.. Fertig. J. B.. & Mattson. Xl. E. (1991). Personalir~Gxzsed s~tht~pcs ofc/ternicaNy dcye,tdent pn~icvtrs.hlanuscript submitted for publication. Annis, H. M.. & Davis. C. S. (1988). Assessment ofexpectancies in alcohol dependent clients. In D. hl. Donovan & G. A. Marlatt (Eds.). .&sessrnenr qfaddictiw behaviors. New York: Guilford Press, Brown. S. A. (1955). Reinforcement expectancies and alcoholism treatment outcome after a one-year followup. Jottrnal yfStttdies on .~lcohol. 46(4). 303-308. Brown, S. A.. Goldman. hl. S., & Christiansen, B. A. (1985). Do alcohol expectancies mediate drinking patterns of adults? Jottrnal of Consulring and Clinical Psychology, 33(4), 5 I 2-5 19. Brown, S. A.. Miller, A.. & Possman, L. (1988). Utilizing expectancies in alcoholism treatment. Psi,chologJ qf.dddictiw Bdtaviors. 2. 59-65. Brown, S. A., 6: Munson. E. (1987). Extroversion. anxiety and the perceived effects of alcohol. Jotrntal of Studies on .-llcohol. 48, 272-276. Brown, S. A.. & Schukit. M. A. (1988). Changes in depression among abstinent alcoholics. Jottrnal~f.Srtrdies on .Ilc0i101.49(4), 4 I 2-4 17, Chaney, E. F.. O’Leary, M. R., & Marlatt. G. A. (1978). Skill training with alcoholics. Journal ofConst&ing nnd Clinicui Psyholog?;, 46(5), IO97- I 104. Connors, G. J.. & Maisto, S. A. (1988). The alcohol expectancy construct: Overview and clinical application. Cognitire Therapj~mtd Research, 12(j), 487-504. Deardorff, C. hl.. Melges. F. T., Hout. C. N., & Savage, D. J. (1975). Situations related to drinking alcohol. Jottrnal of Sfttdirs on Akohol. 36(9). I l84- I 195. Allen,
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