Department of Psychiatry, CB#7175, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC 25799-7160, USA
Received 2 November 1998; accepted 7 December 1998
ABSTRACT
This study evaluated the role of personality in the short-term outcome of alcohol/substance-use disorder patients. Detoxifying alcohol/substance-use disorder patients were administered the Myers Briggs Type Indicator (MBTI), the Tridimensional Personality Questionnaire (TPQ), the Michigan Alcohol Screening Test (MAST), the CAGE Questionnaire, and the Beck Depression Inventory (BDI). These patients were subsequently evaluated over a 1-month period for relapse and attendance at self-help group meetings. High TPQ Persistence scale scores predicted abstinence. When the Thinking and Feeling groups were considered separately, and when these two groups were combined into a single group, high scores for the individual groups and the combined group (i.e. Thinking and Feeling types together) predicted abstinence. High TPQ Persistence scale scores and low Shyness with Strangers and Fear of Uncertainty subscale scores predicted attendance at self-help group meetings. High MBTI Extroversion and high MBTI Thinking scores also predicted attendance at self-help group meetings. When the Extroverted and Introverted types and the Thinking and Feeling types respectively were combined, as with abstinence, high scores predicted attendance at self-help group meetings. Age, gender, CAGE, MAST, and BDI scores did not predict outcome. The above information suggests that specific personality variables may predict abstinence and attendance at self-help group meetings in recently detoxified alcoholics, and this may have prognostic and therapeutic significance.
INTRODUCTION
Overall, psychosocial programmes treating alcoholism and other substance-use disorders have had only modest success, especially if the goal of treatment is to maintain abstinence. Both out-patient and residential treatment programmes report significant relapse rates, generally averaging approximately 50% within 1 to 2 months of beginning treatment (Hunt et al., 1971; O'Malley et al., 1992
; Volpicelli et al., 1992
). The question of which factors predict relapse is therefore an important one, since by understanding what such factors are, strategies for minimizing their effects can be developed. Listed among the many predictors of whether or not alcoholism relapse will occur are life events, mood states, the existence of self-efficacy, coping behaviours, social support resources, readiness for change, commitment to abstinence, intention to avoid high-risk situations, and use of multiple drugs (see review by Cummings et al., 1980; Jones and McMahon, 1994; Brown et al., 1995; Miller et al., 1996; Isenhart, 1997).
In addition to the above variables, the relationship between alcoholism and personality has received some attention, as it relates to the prognosis of alcohol dependence. Personality disorders in general have been linked to poor treatment outcome in alcoholics, and antisocial personality disorder as such appears to be an especially good predictor of early relapse (Rounsaville et al., 1987; Poldrugo and Forti, 1988
).
Most studies exploring the relationship of underlying personality to outcome in alcoholics have utilized the scales of the Minnesota Multiphasic Personality Inventory (MMPI), and the identification of personality predictors of relapse has been inconsistent (Huber and Danahy, 1975; Krasnoff, 1977
; Knouse and Schneider, 1987
; Sheppard et al., 1988
). However, being introverted and having an external locus of control have generally been found to predict a poor prognosis (Tarnai and Young, 1983
; Canton et al., 1988
).
Sellman et al. (1997) recently explored the relationship between the components of Cloninger's tridimensional personality model of temperament, using the Tridimensional Personality Questionnaire (TPQ) (Cloninger, 1987) and The Structured Clinical Interview for DSM-III-R Personality Disorders (SCID-PQ) (Spitzer et at., 1987) to study relapse in alcoholic men. These authors studied alcoholics enrolled in a short-term substance-use disorder programme, and selected only those who were without antisocial personality disorder. Significantly, none of the expected dimensions of the SCID-PQ Cluster B Personality Category (i.e. antisocial, borderline, histrionic, and narcissistic personalities), or the Novelty Seeking factor of the TPQ were different in those who relapsed. When compared to those who did not relapse after 6 months of treatment, subjects who did relapse had lower TPQ Persistence scale scores and lower Obsessional scores. The TPQ Persistence scale score finding was observed only when informants were asked to rate the subjects, and not when the subjects rated themselves. In addition, the Obsessionality factor was no longer significant when multivariate logistic regression analysis was performed.
In the current study, we have evaluated a variety of personality variables in 62 detoxifying alcohol/ substance-use disorder patients, and followed 42 of these over a period of 1 month post-detoxification to see if underlying personality is related to short-term relapse and attendance at self-help group meetings.
SUBJECTS AND METHODS
Subjects
The overall study group consisted of 62 detoxifying substance-dependent patients. Patients were recruited from Freedom House, a residential non-medical social setting detoxification programme located in Chapel Hill, NC, USA, utilized primarily for alcohol and/or cocaine detoxification. All subjects were dependent on substances of abuse, and were usually detoxified over a period of 3 to 7 days. Approximately 70% abused or were dependent on both alcohol and cocaine, with the remainder being equally divided in using only alcohol or cocaine. Of the patients 50% also used marijuana. The majority of the subjects studied were unemployed, and most, if they worked, had worked at low socio-economic level jobs. The age range of the subjects varied from 20 to 50 years (mean 32.5 years). Thirty-eight of the subjects were male and 24 were female, 60% were Caucasian and 40% were African American. Although the patients were not formally diagnosed using DSM-III-R criteria, they were considered to be alcohol- or other drug-dependent on the basis of the histories obtained at admission, the fact that they came to Freedom House for detoxification from a specific substance of abuse (i.e. alcohol and/or cocaine), and because of their high scores on the Michigan Alcohol Screening Test (MAST) and CAGE surveys (see Table 1). The Institutional Review Committee of the University of North Carolina at Chapel Hill School of Medicine approved the study, and all subjects provided written informed consent.
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The MBTI is a 166-item self-report scale widely used in business, education, general counselling, and vocational counselling to evaluate personality. The MBTI divides subjects into four dichotomous personality dimensions. There are thus eight categorical personality types: Introverted or Extroverted, Sensing or Intuitive, Thinking or Feeling, and Judging or Perceiving (I or E, S or N, T or F, or J or P respectively). Combinations of each of these categories yield 16 possible four-factor personality types [i.e. ExtrovertedIntuitiveFeelingPerceiving (ENFP)].
Extroverted individuals tend to relate to the outside world of people, whereas Introverted individuals enjoy relating to their own inner thoughts. Extroverts are sociable, interactive, externally oriented, enjoy multiple relationships, and are gregarious, whereas Introverts are internally oriented, intensive, territorial, enjoy limited numbers of relationships, are reflective, and are energy conservative. Sensing individuals deal with the concrete and the here and now, whereas Intuitive individuals tend to look toward future possibilities. Sensing individuals tend to rely on experience, are realistic, hard-working, actually oriented, down to earth, factual, practical, and sensible. Intuitive individuals are future-oriented, trust hunches, are speculative, inspirational, ingenious, imaginative, fantasize, and are creative. Thinking individuals prefer to use their cognitive processes to engage in decision-making, whereas Feeling individuals relate to their relationships with others. Thinking individuals are objective, policy-oriented, legalistic, firm, impersonal, justice-oriented, analytical, and adhere to standards. Feeling individuals are subjective, intimate, use persuasion, are personable, humane, harmony-oriented, sympathetic, and devoted. Judging individuals enjoy coming to judgements and decisions rapidly. Perceiving individuals like to keep things open. Thus, Judgers are settled, decided, fixed, like to plan ahead, believe in deadlines, and enjoy closure. Perceivers adapt as they go, like to keep their options open, are open-minded, tentative, dislike deadlines, and have a wait and see attitude (Myers and McCaulley, 1985).
The MBTI individual categorical dimensions (Extroversion or Introversion) can be represented on a continuum (i.e. the range from the most Extroverted to the most Introverted), and continuum scores generated (Myers and McCaulley, 1985). In addition, the degree of an individual's single factor type (i.e. how extreme was a given Extrovert's or Introvert's degree of Introversion or Extroversion respectively a preference score) can be derived, as can a preference score for a given dichotomy (i.e. an overall preference score for all Extroverts and all Introverts in a given dichotomy) (Myers and McCaulley, 1985
).
The TPQ is a 100-item self-report survey which generates four temperament scales. These scales are Novelty Seeking, Harm Avoidance, Reward Dependence, and Persistence (previously a subscale of Reward Dependence). In addition, each of these temperament scales has associated subscales. For purposes of data analysis, our study considered Reward Dependence as including Persistence, and also considered Persistence as a separate scale (Cloninger, 1987; Cloninger et al., 1993
, 1994
).
The BDI is a self-evaluation depression rating scale which measures depressed mood (Beck et al., 1961). This scale has been widely used in psychiatric research (Beck et al., 1961
). The CAGE (Ewing, 1984
) and MAST (Selzer et al., 1975
) are well known alcoholism survey instruments, used to screen for alcoholism.
Follow-up measures
Forty-two of the patients' sobriety status and self-help group meeting attendance was followed-up for 1 month after discharge from Freedom House. Patients were contacted at 2 weeks and at 1 month post-discharge, or as close as possible to these target dates, via telephone by a substance-use disorder counsellor (author A.B.) who had served as a therapist for the subjects during their detoxification phase. If the patients could not be contacted directly, a significant other or a close family member was contacted to serve as an alternative informant. Each subject was asked whether or not he or she had resumed drinking/drug use, and whether or not such use had rapidly (i.e. within 1 to 2 days) stopped. Each was also asked whether or not they had attended one or more self-help group meetings, such as Alcoholics Anonymous (AA) or Narcotics Anonymous since discharge. Attendance of at least one AA meeting, and/or other self-help group meeting was considered to be a positive self-help group attendance. Consistent drinking and/or other drug use for two or more days was considered to be a relapse.
If a patient had resumed drinking at the 2-week evaluation point, and could not be found at the 1-month post-discharge time point, he or she was considered to have relapsed. If a patient was not drinking at the 2-week time point and was lost to the 1-month follow-up, he/she was not considered in the major data analysis at 1 month. Cases not located at 2 weeks, but found and interviewed at 4 weeks, were retrospectively interviewed for the first 2-week interval, and were included in the data analysis. All 42 subjects who were followed-up had completed the MBTI while being detoxified. Thirty-seven subjects completed the TPQ, 39 completed the CAGE, 32 completed the MAST, and 35 completed the BDI. Of the 42 subjects who were followed-up, eight abused alcohol, five abused cocaine, and 29 abused cocaine and alcohol. Twenty-three also abused marijuana, and two also abused heroin. All subjects who abused marijuana or heroin also abused alcohol, cocaine or both.
Statistics
Means ± SEM for the TPQ and its subscales, the CAGE, the MAST, and the BDI were calculated to profile the patient group. These data were compared with normative data and/or accepted cut-off points for the diagnosis of alcoholism and for depression. For the MBTI data, we used the Center for Applications of Psychological Type (CAPT) Selective Ratio Type Table (Granade et al., 1987). This computer program takes MBTI distributions for a given group (i.e. our patient group) and compares these with data from normative or other populations, using
2 and Fisher exact tests. For the purposes of this paper, the eight single-factor types (i.e. Extroverted, Introverted, Sensing, Intuitive, Thinking, Feeling, Judging, and Perceiving) and the 16 four-factor types (i.e. Extroverted/Sensing/ Thinking/ Judging,Introverted/Intuitive/Feeling/ Perceiving etc.) were compared with normative distributions derived from a database of 55 309 individuals (Macdaid et al., 1986
). To determine if differences existed between those subjects who relapsed and those who remained abstinent respectively, and those who attended at least one self-help group meeting and those who attended none, we used t-tests. We compared differences between groups for the MBTI continuum and preference scores, the four TPQ scales and associated subscales, the CAGE, the MAST, and the BDI. We also used Spearman correlation coefficients to determine the relationship of MBTI continuum scores to TPQ scale and subscale scores. Because of the exploratory nature of this study, a Bonferroni correction for the number of analyses was not applied. Similarly, all statistical tests were non-directional (two-tailed), with level of significance set at
= 0.1.
RESULTS
Table 1 describes the TPQ, BDI, CAGE, and MAST scores of the patient group which was tracked post-detoxification. The patient group scored very high on the CAGE and MAST alcoholism inventories, compared to accepted scores for non-alcoholics (Selzer et al., 1975
; Ewing, 1984
). The group also scored as low moderately depressed on the BDI (Beck et al., 1961
). The patient group also demonstrated an obvious elevation in the TPQ Novelty Seeking and Harm Avoidance scales as compared to normative data (Cloninger et al., 1994; Tables 5 and 7
).
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At 2 weeks, decreased TPQ Persistence (t = 4.46, d.f. = 37, P < 0.0001) and total Reward Dependence (t = 1.81, d.f. = 35, P < 0.07) scale scores were noted in those patients who relapsed. In addition, the preference scores of the MBTI Thinking/Feeling (t = 1.75, d.f. = 43.0, P < 0.08) dichotomy and the Judging/Perceiving (t = 2.35, d.f. = 43, P < 0.03) dichotomy were significantly lower in those who relapsed at 2 weeks.
When ANCOVA analyses were conducted, using gender as a covariant, no gender related effects were noted.
DISCUSSION
The observation that increased TPQ Novelty Seeking exists in our patient group is consistent with the work of a number of authors (Cloninger et al., 1988, 1994
). The observation that our patients have increased TPQ Harm Avoidance is also consistent with the work of some authors, but not others (Cloninger et al., 1994
; Kampov-Polevoi et al., 1988). With respect to the single- and four-factor MBTI profiles of our patients, our results are generally consistent with those of other investigators (Roszell et al., 1983
; Emanuel and Harsham, 1989
; Dawes, 1991
). Also, when compared to normative data, none of the eight MBTI single-factor types in the current study differed in direction from the directions noted in 90 alcohol/ substance-dependent in-patients we have studied (described in our companion article in this issue). Also, compared to normative data, only two of 16 four-factor MBTI types observed in this study differed in direction from the directions noted in the above in-patient study.
The observations made in this study may have biological significance. MBTI scales correlate highly with those of the five-factor NEO-PI, another widely-used personality inventory (MacDonald et al., 1994). The NEO-PI has been shown in twin studies to have strong genetic relationships with respect to its Extroversion, Openness, and Conscientiousness scales (Pederson et al., 1988
; Bergeman et al., 1993
). Furthermore, the NEO-PI's Extroversion scale correlates significantly and highly with the MBTI Extroversion to Introversion continuum, and the NEO-PI's Openness scale correlates highly with the MBTI's Sensing to Intuitive continuum. The NEO-PI Agreeableness scale correlates moderately with the MBTI Thinking to Feeling continuum, and the NEO-PI Conscientiousness scale correlates moderately with the MBTI Judging to Perceiving continuum (MacDonald et al., 1994
). Thus, it is likely that at least some MBTI scales are also strongly influenced by heredity, especially the Extroversion to Introversion continuum and the Sensing to Intuitive continuum. In addition, as described above, we have found that TPQ scales and subscales correlate significantly with MBTI Extroversion to Introversion and Judging to Perceiving continuum scores. Thus, heredity could in part determine the observed MBTI and TPQ personality profiles we have noted in patients with alcohol/substance-use disorders who did and did not relapse and who did and did not attend self-help group meetings.
Our results suggest that several personality factors are significantly related to short-term relapse after detoxification, and to attendance at self-help group meetings. Specifically, we have demonstrated that low TPQ Persistence scale scores are related to short-term relapse. Likewise, low TPQ Persistence scale scores and high Harm Avoidance Shyness with Strangers and Fear of Uncertainty subscales are associated with lack of attendance at self-help group meetings. Our TPQ results are similar to those of Sellman et al. (1997), who found that alcoholics who relapsed had on average lower TPQ Persistence scale scores. However, our study differs from that of Sellman et al. (1997) in that the subjects in this latter study were all men, had been detoxified from 3 to 8 weeks prior to beginning the study, had been in a 3-week-long abstinence focused psychosocial programme, and were followed-up for 6 months. Subjects who relapsed in the Sellman et al. (1997) study had decreased TPQ Persistence scale scores, as reported by an informant, but this finding was not observed when self-reports by the patients were analysed. Our study began immediately after a short-term detoxification, did not involve a treatment programme, only measured outcome for 1 month after detoxification, was largely based on patient self-report, and utilized both men and women.
Our MBTI results show that a relationship exists between high preference scores on the Extroversion/ Introversion and Thinking/Feeling dichotomies and outcome. Significantly, there is a parallel in the MBTI literature to this finding. U-shaped preference score curves exist for the Extroversion/Introversion, Judging/Perceiving, and Thinking/Feeling dichotomies when academic ability is measured (Myers and McCaulley, 1985).
Little has been written about determinants of self-help group meeting attendance. Hohman and LeCroy (1996) noted that adolescents who affiliated with AA had a history of prior treatment, had friends who did not use drugs, had less parental involvement while they were in treatment, and had more feelings of hopelessness. Hohman and LeCroy (1996) also summarized the work of others who studied the determinants of AA affiliation. These authors summarized information indicating that AA affiliators are more often female, are older, have had fewer alcohol-related problems, have had a greater length of time in AA, have embraced the AA ideology, and are more authoritarian, religious, extroverted, concrete, concerned with acceptance, and affiliative and less tough-minded, emotional, socially ill at ease, isolated and lonely.
Our results are consistent with some of these observations. We found that our patients were more likely to attend self-help group meetings if they had low scores on the TPQ Harm Avoidance Shyness with Strangers subscale, a finding consistent with affiliators being more Extroverted, less socially ill at ease, and less isolated. However, in contrast to what one would intuitively think, our MBTI data also suggest that affiliation with self-help groups occurs in both Introverts and Extroverts if the degree of Introversion or Extroversion (i.e. dichotomy preference score) is high.
One might consider that an elevated TPQ Reward Dependence scale and associated subscales would predict AA affiliation, based on the Hohman and LeCroy (1996) article's observation that AA affiliators are concerned with acceptance. However, in our study, TPQ Reward Dependence as such did not appear to predict AA affiliation if the Persistence subscale (scale) was eliminated as a factor. A high preference score in individuals who had an MBTI Feeling personality type did not predict attendance at self-help groups; yet a high preference score in patients categorized as MBTI Thinkers predicted self-help group meeting attendance.
Our results do not support the observation that increased introversion as such predicts relapse (Tarnai and Young, 1983). Neither the TPQ Harm Avoidance Shyness with Strangers subscale, nor being on the Introversion pole of the MBTI Extroversion to Introversion continuum predicted relapse. Furthermore, a negative mood state (i.e. high BDI scores) at the time of detoxification did not predict relapse. Nevertheless, we did observe that relapse occurred more often when other drugs (i.e. cocaine), in addition to alcohol, were used, a result consistent with the work of Tarnai and Young (1983).
It is important to realize that our study involved the short-term follow-up of recently detoxified alcoholics and/or other drug-dependent patients. Our data were obtained during detoxification and at 2 and 4 weeks post-detoxification, and thus differ from virtually all other studies, where relapse usually is reported months following either treatment or detoxification. Factors which determine short-term relapse may not be the same as those which determine long-term relapse. However, it has been noted that the majority of patients who are going to relapse do so within the first 1 to 2 months following detoxification, thus adding relevance to our results (O'Malley et al., 1992; Volpicelli et al., 1992
).
The observations described in this paper may have clinical importance. There is an extensive popular literature focused on the MBTI, with books and articles describing approaches for dealing with individuals who have different single-, two, and four-factor personality constellations (Myers and Myers, 1980; Keirsey and Bates, 1984
; Kroeger and Thuesen, 1992
, 1993
). These books are generally written for lay audiences and focus on occupational, social, and marital relationships. Such information as exists in these books might be applicable in helping a therapist decide best how to interact with a specific substance-use disorder patient. Furthermore, the observation that increased TPQ Persistence scale scores are present more often in patients who stay abstinent may have therapeutic implications. Possibly, patients with low TPQ Persistence scale scores might have better outcomes if case managers were effectively utilized in their treatment. Conversely, patients with high Persistence scale scores might be more likely to be self-motivated and need less external monitoring and control. Similarly, with respect to self-help group attendance, individuals who score high on the TPQ Harm Avoidance Shyness with Strangers subscale may do better in a recovery focused one-to-one therapy situation, whereas less shy patients might be better helped by self-help groups.
Although our results suggest potential therapeutic usefulness, it is important to note that the sample size of our patient group was relatively small, and the results are, at this point, quite tentative. A number of findings had significance (P) of only <0.1, and these findings may or may not become more significant when this work is replicated, using a larger sample size. Nevertheless, the above results suggest simple ways to predict outcome and imply possible therapeutic interventions.
FOOTNOTES
* Author to who correspondence should be addressed.
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