RISK FACTORS FOR ALCOHOL DEPENDENCE: A CASE-CONTROL STUDY

Kari Poikolainen*

Järvenpää Addiction Hospital, FIN-04480 Haarajoki, Finland and the Department of Mental Health and Alcohol Research, National Public Health Institute, Mannerheimintie 166, FIN-00300 Helsinki, Finland

Received 3 June 1999; in revised form 1 September 1999; accepted 15 September 1999


    ABSTRACT
 TOP
 FOOTNOTES
 ABSTRACT
 INTRODUCTION
 SUBJECTS AND METHODS
 RESULTS
 DISCUSSION
 ACKNOWLEDGEMENTS
 REFERENCES
 
Several possible risk factors for ICD-10 alcohol dependence were studied by comparing cases (117 men, 188 women) with controls (248 men, 300 women). Logistic regression analyses showed that parental alcohol problems and high trait anxiety were significantly related to high occurrence of alcohol dependence in both men and women. In women, high antisocial behaviour, high impulsivity, and high externality were also related to high occurrence of alcohol dependence. High facial flushing and high stimulation when intoxicated were related to low occurrence of alcohol dependence in both men and women. In men, this was also the case for high social support. Several interactions were observed. In contrast to earlier studies, there was no significant association between alcohol dependence and left-handedness.


    INTRODUCTION
 TOP
 FOOTNOTES
 ABSTRACT
 INTRODUCTION
 SUBJECTS AND METHODS
 RESULTS
 DISCUSSION
 ACKNOWLEDGEMENTS
 REFERENCES
 
Earlier research has revealed at least five risk factors for alcoholism: family history of alcohol problems, lack of facial flushing, low responsivity, antisocial behaviour, and cultural background. Much of the prospective evidence is based on studies with small numbers of alcoholics (McCord and McCord, 1960Go; Robins et al., 1962Go; Vaillant and Milofsky, 1982Go; Vaillant, 1984Go; Schuckit, 1994Go) and the interpretation of these findings is undermined by variation in the number of other factors controlled for in the analysis and the definition of the outcome and the diagnostic criteria. Several earlier studies have combined two diagnostic categories, alcohol dependence and alcohol abuse, into one overall outcome variable (Vaillant, 1984Go; Spak et al., 1997Go). This is problematic, because the diagnosis of alcohol dependence is fairly reliable, whereas that of alcohol abuse is not (Schuckit et al., 1994Go).

Thus firstly, it is known that alcoholism runs in families and is partly inherited (Vaillant, 1984Go; Merikangas et al., 1994Go; Cadoret et al., 1995Go). Recent research has shown that this is also true for DSM-III-R (American Psychiatric Association, 1987Go) alcohol dependence (Dawson et al., 1992Go; Kendler et al., 1995Go). It is not known what exactly is inherited (Gordis, 1996Go). Secondly, the risk of alcoholism is partly related to alcohol-induced facial flushing, in its strong form due to the deficiency and differences in the genotypes of aldehyde dehydrogenase among some Oriental subjects, but found also in a weaker form among some White subjects (Ward et al., 1994Go; Whitfield et al., 1998Go). Thirdly, low responsivity to alcohol has been found to predict the incidence of alcoholic outcome (alcohol abuse and alcohol dependence) in a follow-up study (Schuckit, 1994Go; Schuckit and Smith, 1996Go). Fourthly, pre-morbid antisocial behaviour has been found to predict alcoholism (McCord and McCord, 1960Go; Vaillant and Milofsky, 1982Go; Lewis and Bucholz, 1991Go; Miller, 1991Go; Cadoret et al., 1995Go). Fifthly, cultural background also has predictive power (Vaillant and Milofsky, 1982Go).

In addition to the known risk factors for alcoholism, there are several other possible candidates. Trait anxiety has been found to be associated with susceptibility to heavy alcohol use among adolescents (Colder and Chassin, 1993Go), with craving for alcohol among alcoholics (McCusker and Brown, 1991Go), and to predict alcohol dependence longitudinally (Heath et al., 1997Go). Moreover, anxiety disorder has been found to be a risk factor for alcohol dependence in a follow-up study (Kushner et al., 1999Go). Alcohol use has been found to be predicted by such personality variables as pre-delinquency, rebelliousness, impulsivity, and sensation seeking (Brook et al., 1995Go). High external control scores in adolescence have been found to predict heavy alcohol use in young adulthood for both males and females (Steele et al., 1995Go). Social support (Ohannessian and Hesselbrock, 1993Go), social desirability (Yoshino and Kato, 1995Go), and left-handedness (Bakan, 1973Go; McNamara et al., 1994Go) have also been found to be associated with problem drinking or alcoholism. The role of these factors in the aetiology of alcohol dependence remains to be clarified. The present case-control study aimed to examine which of the above correlates of heavy alcohol use, problem drinking or alcoholism remain(s) associated with alcohol dependence, defined by the ICD-10 criteria (World Health Organization, 1992Go) after controlling for the known risk factors in a culturally homogeneous population.


    SUBJECTS AND METHODS
 TOP
 FOOTNOTES
 ABSTRACT
 INTRODUCTION
 SUBJECTS AND METHODS
 RESULTS
 DISCUSSION
 ACKNOWLEDGEMENTS
 REFERENCES
 
Sample
The case series was collected from the Järvenpää Addiction Hospital between April 1995 and March 1997. To be eligible, the patients had to meet the ICD-10 criteria for alcohol dependence (World Health Organization, 1992Go), and withdrawal treatment needed to have been completed before the patients were admitted for in-patient treatment. Of those meeting the criteria, 49% gave their informed consent and responded. The case series comprised 117 men and 188 women. Of the subjects, 33.3% of the men and 38.3% of the women were married. The mean age (SD) was 37.7 (8.6) years for men and 41.8 (8.9) years for women. The age range was 19–72 years. No misuse of substances other than alcohol was reported. The study was approved by the Ethics Committee of the A-Clinic Foundation.

The controls were household members aged 18 years or more from a sample stratified to represent Finnish households in January 1996. Sampling and characteristics of the subjects have been described earlier (Poikolainen, 1997Go). The response rate was 68–72%. The 66 subjects meeting the ICD-10 criteria for alcohol dependence were excluded from the control series. Thus, the control series comprised 248 men and 300 women. The percentage of married subjects was 59.7 among both males and females. The mean age (SD) was 43.2 (14.7) years for men and 44.7 (14.6) years for women. The age range was 19–81 years. One subject reported misuse of cannabis and another misuse of sedative drugs. Neither met the ICD-10 criteria for substance dependence.

Measures
Diagnosis of alcohol dependence. Questions used to operationalize the diagnosis of alcohol dependence according to both ICD-10 criteria have been described in detail earlier (Caetano and Tam, 1995Go). There were 10 questions altogether. These questions pertained to the previous 12 months.

Parental history and facial flushing. Parental history of drinking problems was assessed by asking whether the parents of the respondents had ever had drinking problems or had been in treatment because of these. The test–retest reliability for classification of first-degree relatives has been found to be good, while data for second-degree relatives is considerably less reliable (Worobec et al., 1990Go). Tendency to facial flushing was measured by one question on an 11-point scale.

Perceived effects of alcohol intoxication. The Anticipated Bisphasic Alcohol Effects Scale was used to measure perceived degree of alcohol-induced stimulation and sedation during the last recalled instance of alcohol intoxication. This scale was chosen to yield information on the level of response to alcohol, measured in earlier work by self-reports on the degree of intoxication after exposure to alcohol (Schuckit, 1994Go). The 11-point scale comprises two 7-item subscales, one on the stimulant effects of alcohol and another on its sedative effects. These subscales have been found to have high internal consistency during both the ascending and descending arms of the blood-alcohol curve (Martin et al., 1993Go).

Trait anxiety. The trait part of the State-Trait Anxiety Inventory was used to measure anxiety as a relatively stable behavioural predisposition (Spielberger et al., 1970Go). It has good psychometric validity and reliability (Bech et al., 1993Go).

Antisocial behaviour. Three subscales from the Karolinska Scales of Personality (Knorring et al., 1987Go), monotony avoidance, impulsiveness, and socialization, were used to map out antisocial personality styles. The socialization scale was inverted into the antisocialization scale. The scales are fairly independent of the state of the subject (Knorring et al., 1987Go). Factor analyses have suggested that scales of monotony avoidance, impulsiveness, and socialization combine into a common factor that has been called the impulsive sensation-seeking psychopathy factor (Knorring et al., 1987Go).

Locus of control. The scale for this measures the respondent's perception of who is in control: him- or herself (internal control) or others, or fate (external control). The 17-item version of the scale was used (Craig et al., 1984Go). It has been shown to have good psychometric properties (Haynes and Ayliffe, 1991Go).

Social support. Based on an earlier analysis of the types and sources of social support (House, 1981Go), the questionnaire asked how much social support the respondent would expect to receive from the spouse, relatives, and friends in case of a serious problem. The response options were (1) none at all, (2) a little, (3) average, (4) rather a lot, (5) a lot and (6) would not ask for help, or accept it. Similar questions have been used before in Finland (Vahtera, 1993Go).

Laterality. In line with earlier research (Dellatolas et al., 1990Go), laterality (handedness) was assessed by asking the preferred hand used for throwing, playing ball games and using a cooking pan, shaving or applying make-up, brushing teeth, slicing bread, hammering, turning a screwdriver, eating, combing hair, and writing. The answering options were ‘right hand always’, ‘right hand more often’, ‘both’, ‘left hand often’, and ‘left hand always’.

Social desirability. This refers to the respondent's tendency to deceive in order to create a good impression. To measure it, three items from the Personality Diagnostic Questionnaire were used (Hyler et al., 1990Go).

Statistical analysis
Logistic regression was used to model relationships between alcohol dependence and suspected risk factors. First, all the risk factors were entered into the model as continuous variables whenever possible. Table 1Go lists the measures that were used to evaluate risk factors possibly involved in the development of alcohol dependence; in addition to these 11 risk factors, age and social desirability were included in the full model. Variables not significantly associating with the diagnosis of alcohol dependence were removed. After this, interactions were studied. Finally, the model was re-parameterized to describe interactions. The strength of associations was summarized as odds ratios (OR). OR approximates the risk ratio when the prevalence of the disease is low. To calculate ORs, potential risk factor variables were dichotomized. The cut-off points were based on either natural categories (e.g. parental alcohol problems vs no parental alcohol problems), the population prevalence (e.g. the prevalence of left-handedness was set at 13.5%), or on the 67th percentile point of the total population sample in the case of continuous variables, so that the group consisting of the approximately one-third of the cases with the highest values represents those that might belong to the high-risk part of the distribution (see Table 1Go for cut-off points). Because of a few missing cases and rounding the cut-off points to integers, the proportion of cases in the higher category is not always exactly 33%. Adjusted ORs and their 95% confidence intervals (95% CI), were calculated from the regression coefficients and their SEMs from the logistic models. Altogether, 3.7% of the responses were missing. Missing responses were replaced by the value for the reference category for the variable in question. Because of an emphasis on marital therapy in the hospital, women were over- represented in the clinical sample, and men and women were therefore analysed separately.


View this table:
[in this window]
[in a new window]
 
Table 1. Risk factors for ICD-10 alcohol dependence, crude odds ratios (OR), and their 95% confidence interval (95% CI)
 

    RESULTS
 TOP
 FOOTNOTES
 ABSTRACT
 INTRODUCTION
 SUBJECTS AND METHODS
 RESULTS
 DISCUSSION
 ACKNOWLEDGEMENTS
 REFERENCES
 
Among both men and women, significant positive associations were found between alcohol dependence and parental alcohol problems, with trait anxiety, high antisocial behaviour, high impulsivity, and high monotony avoidance (Table 1Go). Likewise, significant negative associations were found between alcohol dependence and high facial flushing score, high social support and becoming highly stimulated by alcohol intoxication (Table 1Go). There was no association between dependence and left-handedness. High external locus of control associated negatively with dependence was found only among men (Table 1Go).

Logistic regression analyses with continuous independent variables showed that not all bivariate associations remained significant in multivariate models and that there were several interactions between the significant independent variables. Therefore, the models were re-parameterized to describe interactions. For example, the trait anxiety–parental alcohol problems interaction was represented by the three new (0 or 1) dummy variables ‘high trait anxiety, parental alcohol problems', ‘high trait anxiety, no parental alcohol problems', and ‘low trait anxiety, parental alcohol problems' leaving ‘low trait anxiety, no parental alcohol problems' as the reference cateogry.

In the final logistic model for men (Table 2Go), both high trait anxiety and parental alcohol problems associated positively with alcohol dependence and interacted strongly. The OR for dependence was from two to three times higher among men with both high trait anxiety and parental alcohol problems than among men with only one of these two risk factors. Negative associations were found for high facial flushing, high stimulation when intoxicated by alcohol and high social support (Table 2Go).


View this table:
[in this window]
[in a new window]
 
Table 2. Risk factors for ICD-10 alcohol dependence by multiple logistic regression, adjusted odds ratios (OR), and their 95% confidence interval (95% CI) in 117 male cases and 248 male controls
 
In the final model for women (Table 3Go), high antisocial behaviour, high impulsivity, and high externality (measured on the locus of control scale) associated positively with alcohol dependence. Moreover, women with both high trait anxiety and low social support were more often dependent on alcohol than women with either low trait anxiety or high social support. The occurrence of alcohol dependence was increased among women with low facial flushing if they also had a history of parental alcohol problems. Decreased occurrence was found among women with high facial flushing irrespective of alcohol problems among their parents, and also among women who had reported high stimulation when intoxicated by alcohol (Table 3Go).


View this table:
[in this window]
[in a new window]
 
Table 3. Risk factors for ICD-10 alcohol dependence by multiple logistic regression, adjusted odds ratios (OR), and their 95% confidence interval (95% CI) in 188 female cases and 300 female controls
 

    DISCUSSION
 TOP
 FOOTNOTES
 ABSTRACT
 INTRODUCTION
 SUBJECTS AND METHODS
 RESULTS
 DISCUSSION
 ACKNOWLEDGEMENTS
 REFERENCES
 
Among men, increased occurrence of alcohol dependence was related to both high trait anxiety and parental alcohol problems. Decreased occurrence was related to high facial flushing, high stimulation when intoxicated by alcohol, and high social support. Among women, increased occurrence was related to high antisocial behaviour, high impulsivity, and high externality, to the joint presence of high trait anxiety and low social support, and to the joint presence of low facial flushing and parental alcohol problems. Decreased occurrence was related to high facial flushing and to high stimulation when intoxicated by alcohol. Some of the factors studied, for example facial flushing, can be seen as preventive factors, or contrariwise, the lack of the preventive category can be seen as a risk factor.

Approximately one-half of the consecutive hospital patients did not take part in the study. This was mainly due to the fact that patients who were judged to be too confused, chaotic or tired were not asked to take part. Thus, the present patient series may represent the less severe half of in-patients with alcohol dependence. Although this might weaken the observed associations, the statistical analysis based on categorized variables should be relatively insensitive to this possible bias.

The present study was based on self-reports. These may be inaccurate. However, scales were applied that have been found earlier to have good psychometric validity and good reliability. The tendency to give socially desirable answers was controlled for in the multivariate analyses. Responses to some scales in this study might have been sensitive to possible influence of recent withdrawal symptoms. To control for this, alcohol dependence cases who met the withdrawal criterion were compared with those who did not fulfil this criterion. There were no differences between these groups in the scores of trait anxiety, antisocial behaviour, impulsivity, or monotony avoidance scales. There is no reason to suspect any serious bias in the present data. Any lack of reliability in the scales applied is likely to decrease correlations, and the actual associations are therefore probably stronger than those observed. In contrast to many earlier studies that have combined alcohol dependence and alcohol abuse into the category of alcoholism, the outcome variable in the present study was alcohol dependence. The latter diagnosis has been found to be reliable, whereas alcohol abuse has not (Schuckit et al., 1994Go). The reliability of the diagnosis of alcoholism in earlier studies and its correspondence to the present ICD-10 and DSM-IV criteria may vary and undermine comparability between studies.

Trait anxiety is a relatively stable behavioural predisposition, thought to reflect the degree of arousal brought about by adverse stimuli (Andrews, 1991Go), and has been found to be determined partly by environmental and partly by genetic factors (Gustavsson et al., 1996Go). Strong correlations have been found between trait anxiety and autonomic nervous system activity, both at rest and under stress (Zahn et al., 1991Go). The present results support the view that trait anxiety is an important risk factor for alcohol dependence. This view is also supported by observational and experimental studies. In the rat, anti-anxiety actions of ethanol seem to be important reinforcers of voluntary ethanol consumption (Möller et al., 1997Go). Men with strong cardiovascular reactions to signalled shock have been found to drink more alcoholic drinks when asked to rate the flavour of these drinks, and to have more frequent histories of alcoholism than control men (Pihl et al., 1994Go). Cross-sectionally, high trait anxiety has been found to associate with susceptibility to heavy alcohol use among adolescents (Colder and Chassin, 1993Go) and with craving for alcohol among alcoholics (McCusker and Brown, 1991Go). Longitudinally, trait anxiety has been found to predict alcohol dependence (Heath et al., 1997Go) and anxiety disorder has been found to be a risk factor for alcohol dependence (Kushner et al., 1999Go).

Part of the association between high trait anxiety and alcohol dependence could result from an opposite causal pathway. Heavy alcohol use can induce anxiety in the short term (Kushner et al., 1990Go; Brown et al., 1991Go; Schuckit and Hesselbrock, 1994Go). However, this is unlikely to materially influence the results for several reasons. First, the questionnaires were filled in later than the first week of hospital treatment. Secondly, the instruction to the trait anxiety questions stresses that the respondent should think about how he or she has generally felt in the past, not about the present state. Thirdly, trait anxiety scores did not differ between the alcohol dependence cases who met the diagnostic withdrawal symptom criterion and those who did not fulfil this criterion. Earlier, trait anxiety measured at admission to withdrawal treatment has been found to correlate closely with that measured 4 weeks later (r = 0.91) or 8 weeks later (r = 0.76) (Ward and Hemsley, 1982Go). The present results are in line with a Swedish cohort study of almost 50 000 male conscripts, which found that both poor emotional control based on standardized tests and self-report of often feeling anxious predicted subsequent higher incidence of admission to psychiatric in-patient care because of alcoholism over a 15-year follow-up period (Andréasson et al., 1993Go).

In line with a host of earlier studies, parental alcohol problems were clearly related to an increased occurrence of alcohol dependence (Dawson et al., 1992Go; Kendler et al., 1995Go; Kranzler et al., 1997Go). Among men, there was a strong interaction between high trait anxiety and parental alcohol problems. Compared with men with low trait anxiety and no parental alcohol problems, the men with either one of these risk factors had an 11–13-fold OR for alcohol dependence, whereas men with both these risk factors had a 28-fold OR. The strong interaction between high trait anxiety and parental alcohol problems may go unnoticed if the emphasis is on the typology of alcoholics. For example, the typology of Cloninger (Cloninger et al., 1988Go; Sigvardsson et al., 1996Go) divides alcoholics into two types. The type 2 alcoholic has early onset, familial alcohol problems, low reward dependence, low harm avoidance, and high novelty seeking. The type 1 alcoholic exhibits late onset, high reward dependence, high harm avoidance, and low novelty seeking. Harm avoidance and reward dependence correlate with trait anxiety and some of their features are similar to those of trait anxiety. Moreover, type 1 alcoholics are postulated to drink to relieve anxiety (Sigvardsson et al., 1996Go). In terms of this typology, the cases with high trait anxiety might fall into the type 1 category and those with parental alcohol problems into the type 2 category. There would, however, be no clear place for the cases who have both these risk factors.

Antisocial personality styles, central in the vulnerability-severity typology of Babor et al. (1992) were examined by the monotony avoidance, impulsiveness, and antisocial behaviour scales. Finnish alcoholic offenders with antisocial personality disorder have earlier been found to differ significantly from normal controls with respect to these three scales (Virkkunen et al., 1994Go). Also in the present study, cases with alcohol dependence had higher scores of monotony avoidance, impulsiveness, and antisocial behaviour than controls in bivariate analysis. In multivariate analysis, however, only impulsivity and antisocial behaviour in women remained significant, although the distributions of these three variables included high scores also among men, and alcohol-dependent men had significantly higher mean scores for both antisocial behaviour and impulsivity than the control men (data not shown). High antisocial behaviour implies early conduct problems, since 13 of the 20 scale items pertain to childhood and adolescence. Thus, early antisocial problems seem to be a risk factor for alcohol dependence in women. Surprisingly, this was not true for men. One possible explanation is that, among men, parental alcohol problems may be, in addition to being an indicator of genetic susceptibility to alcohol dependence, also an indicator of antisocial behaviour tendencies. The alcoholic parent is not likely to be deeply involved with bringing up children and this might bring about difficulties in learning social behaviour patterns, especially among boys. This is supported by both epidemiological follow-up studies and animal experiments. In adolescents, parental substance abuse disorder predicts a decrease in family attachment and increases in both life events and drug use (Hoffman and Su, 1998Go). A 33-year follow-up study of adolescent boys found that, after parental alcoholism was controlled for, unstable relationship with the father and low familial cohesion no longer explained alcohol dependence (Vaillant, 1984Go). Experimental studies in the rhesus monkey suggest that peer rearing, a model for human parental neglect, is related to impaired social functioning, disruptive social behaviours, excessive alcohol intake and low serotonin turnover rate, patterns similar to those in early onset alcoholism among humans (Higley et al., 1996Go; Heinz et al., 1998Go). The present data are also consistent with this view, since alcohol-dependent men who reported parental alcohol problems had significantly higher mean scores for antisocial behaviour than the dependent men with no parental alcohol problems (data not shown).

High external control of behaviour was a risk factor for alcohol dependence in women. Subjects with high external control think that their behaviour is determined mainly by chance or by other people. This implies lack of both self-control, self-efficacy and personal autonomy. Earlier, high external control scores in adolescence have been found to predict heavy alcohol use in young adulthood for both males and females (Steele et al., 1995Go).

Several factors being studied were found to associate negatively with alcohol dependence, suggesting a preventive influence. Social support was important among both men and women. Among women, a buffering effect against high trait anxiety was suggested by the interaction observed. High stimulation when intoxicated by alcohol was related to a decreased occurrence of alcohol dependence both among men and women. This agrees with findings implying that low responsivity to alcohol (low level of intoxication after ingesting 0.75 to 1.1 ml/kg of ethanol) increases the risk of alcohol dependence (Schuckit and Smith, 1996Go; Volavka et al., 1996Go). High scores of facial flushing also showed a negative association with alcohol dependence. This is a new finding in a White population and interesting, because alcohol-induced facial flushing is relatively weak or absent among White subjects, in contrast to Oriental subjects (Ward et al., 1994Go). However, unpleasant reactions to alcohol at least occasionally have been reported by approximately one-quarter of the men and one-half of the women among subjects of European descent (Whitfield and Martin, 1996Go). These reactions are not solely explained by the deficiency of aldehyde dehydrogenase 2 causing the alcohol flush reaction (Whitfield and Martin, 1996Go). Metabolic, allergic or other immunologic causes may play a role. The present results suggest that unpleasant reactions to alcohol also have some preventive effect among White subjects.

Left-handedness has earlier been found to be more common among problem drinkers and alcoholics, than among healthy control subjects (Bakan, 1973Go; McNamara et al., 1994Go). These studies have been based on small samples. The present study did not find any significant association between left-handedness and alcohol dependence. There are two possible explanations. Either left-handedness is not a risk factor for alcohol dependence, or the effect is a minor one. The present results indicate that a larger than twofold increase in OR can be excluded with 95% confidence. If the suspected risk factor is a weak one, then larger samples yielding risk estimates with high precision are needed to show more definitely that there is no difference.

To sum up, the present results stress the multifactorial nature of the aetiology of alcohol dependence, differences between men and women and interactions between several risk factors. The findings suggest that parental alcohol problems and high trait anxiety strongly increase the risk of alcohol dependence. Moreover, high antisocial behaviour, impulsivity, and externality are important among women. Risk factors that seem to decrease risk include facial flushing, high stimulation when intoxicated by alcohol and high social support. Follow-up studies are needed to examine more closely the multitude of risk factors for alcohol dependence.


    ACKNOWLEDGEMENTS
 TOP
 FOOTNOTES
 ABSTRACT
 INTRODUCTION
 SUBJECTS AND METHODS
 RESULTS
 DISCUSSION
 ACKNOWLEDGEMENTS
 REFERENCES
 
This research was supported by the Järvenpää Addiction Hospital (of the A-Clinic Foundation), the Department of Mental Health and Alcohol Research at the National Public Health Institute (KTL) in Finland, and partly with a grant from the Yrjö Jahnsson Foundation.


    FOOTNOTES
 TOP
 FOOTNOTES
 ABSTRACT
 INTRODUCTION
 SUBJECTS AND METHODS
 RESULTS
 DISCUSSION
 ACKNOWLEDGEMENTS
 REFERENCES
 
* Address for correspondence: Järvenpää Addiction Hospital, FIN-04480 Haarajoki, Finland. Back


    REFERENCES
 TOP
 FOOTNOTES
 ABSTRACT
 INTRODUCTION
 SUBJECTS AND METHODS
 RESULTS
 DISCUSSION
 ACKNOWLEDGEMENTS
 REFERENCES
 
American Psychiatric Association (1987) Diagnostic and Statistical Manual of Mental Disorders, 3rd edn, revised. American Psychiatric Association, Washington, DC.

Andréasson, S., Allebeck, P. and Brandt, L. (1993) Predictors of alcoholism in young Swedish men. American Journal of Public Health 83, 845–850.[Abstract]

Andrews, G. (1991) Anxiety, personality and anxiety disorders. International Review of Psychiatry 3, 293–302.

Babor, T. F., Hofmann, M., Delboca, F. K., Hesselbrock, M., Meyer, R. E., Dolinsky, Z. S. and Rounsaville, B. (1992) Types of alcoholics. I. Evidence for empirically derived typology based on indicators of vulnerability and severity. Archives of General Psychiatry 49, 599–608.[Abstract]

Bakan, P. (1973) Left-handedness and alcoholism. Perceptual and Motor Skills 36, 514.[ISI][Medline]

Bech, P., Malt, U. F., Dencker, S. J., Ahlfors, U. G., Elgen, K., Lewander, T., Lundell, A., Simpson, G. M. and Lingjærde, O. (eds) (1993) Scales for assessment of diagnosis and severity of mental disorders. Acta Psychiatria Scandinavica87,4–28.

Brook, J. S., Whiteman, M., Cohen, P., Shapiro, J. and Balka, E. (1995) Longitudinally predicting late adolescent and young adult drug use: childhood and adolescent precursors. Journal of the American Academy of Child and Adolescent Psychiatry 34, 1230–1238.[ISI][Medline]

Brown, S. A., Irwin, M. and Schuckit, M. A. (1991) Changes in anxiety among abstinent male alcoholics. Journal of Studies on Alcohol 52, 55–61.[ISI][Medline]

Cadoret, R. J., Yates, W. R., Troughton, E., Woodworth, G. and Stewart, M. A. (1995) Adoption study demonstrating two genetic pathways to drug abuse. Archives of General Psychiatry 52, 42–52.[Abstract]

Caetano, R. and Tam, T. W. (1995) Prevalence and correlates of DSM-IV and ICD-10 alcohol dependence: 1990 US National Alcohol Survey. Alcohol and Alcoholism 30, 177–186.[Abstract]

Cloninger, C. R., Sigvardsson, S. and Bohman, M. (1988) Childhood personality predicts alcohol abuse in young adults. Alcoholism: Clinical and Experimental Research 12, 494–505.[ISI][Medline]

Colder, C. R. and Chassin, L. (1993) The stress and negative affect model of adolescent alcohol use and the moderating effects of behavioral undercontrol. Journal of Studies on Alcohol 54, 326–333.[ISI][Medline]

Craig, A. R., Franklin, A. and Andrews, G. (1984) A scale to measure locus of control of behaviour. British Journal of Medical Psychology 57, 173–180.[ISI][Medline]

Dawson, D. A., Harford, T. C. and Grant, B. F. (1992) Family history as a predictor of alcohol dependence. Alcoholism: Clinical and Experimental Research 16, 572–575.[ISI][Medline]

Dellatolas, G., Annesi, I., Jallon, P., Chavance, M. and Lellouch, J. (1990) An epidemiological reconsideration of the Geschwind– Galaburda theory of cerebral lateralization. Archives of Neurology 47, 778–782.[Abstract]

Gordis, E. (1996) Alcohol research. At the cutting edge. Archives of General Psychiatry 53, 199–201.[ISI][Medline]

Gustavsson, J. P., Pedersen, N. L., Åsberg, M. and Sshalling, D. (1996) Origins of individual differences in anxiety proneness: a twin/adoption study of the anxiety-related scales from the Karolinska Scales of Personality (KSP). Acta Psychiatria Scandinavica 93, 460–469.[ISI][Medline]

Haynes, P. and Ayliffe, G. (1991) Locus of control of behaviour: is high externality associated with substance misuse? British Journal of Addiction 86, 1111–1117.[ISI][Medline]

Heath, A. C., Bucholz, K. K., Madden, P. A. F. et al. (1997) Genetic and environmental contributions to alcohol dependence risk in a national twin sample: consistency of findings in women and men. Psychological Medicine 27, 1381–1396.[ISI][Medline]

Heinz, A., Higley, J. D., Gorey, J. G., Saunders, R. C., Jones, D. W., Hommer, D., Zajicek, K., Suomi, S. J., Lesch, K.-P., Weinberger, D. R. and Linnoila, M. (1998) In vivo association between alcohol intoxication, aggression, and serotonin transporter availability in nonhuman primates. American Journal of Psychiatry 155, 1023–1028.[Abstract/Free Full Text]

Higley, J. D., Suomi, S. J. and Linnoila, M. (1996) A nonhuman primate model of type II alcoholism? Part 2. Diminished social competence and excessive aggression correlate with low cerebrospinal fluid 5-hydroxyindoleacetic acid concentrations. Alcoholism: Clinical and Experimental Research 20, 643–650.[ISI][Medline]

Hoffman, J. P. and Su, S. (1998) Parental substance use disorder, mediating variables and adolescent drug use: a non-recursive model. Addiction 93, 1351–1364.[ISI][Medline]

House, J. S. (1981) Work Stress and Social Support. Addison-Wesley, Reading, MA.

Hyler, S., Skodol, A., Kellman, D., Oldham, J. and Rosnick, L. (1990) Validity of the Personality Diagnostic Questionnaire — Revised: comparison with two structured interviews. American Journal of Psychiatry 147, 1043–1048.[Abstract]

Kendler, K. S., Walters, E. E., Neale, M. C., Kessler, R. C., Heath, A. C. and Eaves, L. J. (1995) The structure of the genetic and environmental risk factors for six major psychiatric disorders in women. Archives of General Psychiatry 52, 374–383.[Abstract]

Knorring von, L., Knorring von, A-L., Smigan, L., Lindberg, U. and Edholm, M. (1987) Personality traits in subtypes of alcoholics. Journal of Studies on Alcohol 48, 523–527.[ISI][Medline]

Kranzler, H. R., Babor, T. F. and Moore, P. (1997) Alcohol use disorders. In Psychiatry, Tasman, A., Kay, J., Lieberman, J. A. eds, pp. 755–778. W. B. Saunders, Philadelphia, PA.

Kushner, M. G., Sher, K. J. and Beitman, B. D. (1990) The relation between alcohol problems and the anxiety disorders. American Journal of Psychiatry 147, 685–695.[Abstract]

Kushner, M. G., Sher, K. J., Erickson, K. J. and Darin, J. (1999) Prospective analysis of the relation between DSM-III anxiety disorders and alcohol use disorders. American Journal of Psychiatry 156, 723–732.[Abstract/Free Full Text]

Lewis, C. E. and Bucholz, K. K. (1991) Alcoholism, antisocial behaviour and family history. British Journal of Addiction 86, 177–194.[ISI][Medline]

Martin, C. S., Earleywine, M., Musty, R. E., Perrine, M. W. and Swift, R. M. (1993) Development and validation of the Biphasic Alcohol Effects Scale. Alcoholism: Clinical and Experimental Research 17, 140–146.[ISI][Medline]

McCord, W. and McCord, J. (1960) Origins of Alcoholism. Stanford University Press, Stanford, CA.

McCusker, C. G. and Brown, K. (1991) The cue-responsivity phenomenon in dependent drinkers: ‘personality’ vulnerability and anxiety as intervening variables. British Journal of Addiction 86, 905–912.[ISI][Medline]

McNamara, P., Blum, D., O'Quin, K. and Schachter, S. (1994) Markers of cerebral lateralization and alcoholism. Perceptual and Motor Skills 79, 1435–1440.[ISI][Medline]

Merikangas, K. R., Risch, N. J. and Weissman, M. M. (1994) Comorbidity and co-transmission of alcoholism, anxiety and depression. Psychological Medicine 24, 69–80.[ISI][Medline]

Miller, L. (1991) Predicting relapse and recovery in alcoholism and addiction: neuropsychology, personality, and cognitive style. Journal of Substance Abuse Treatment 8, 277–291.[ISI][Medline]

Möller, C., Wiklund, L., Thorsell, A., Hyytiä, P. and Heilig, M. (1997) Decreased measures of experimental anxiety in rats bred for high alcohol preference. Alcoholism: Clinical and Experimental Research 21, 656–660.[ISI][Medline]

Ohannessian, C. M. and Hesselbrock, V. M. (1993) The influence of perceived social support on the relationship between family history of alcoholism and drinking behaviors. Addiction 88, 1651–1658.[ISI][Medline]

Pihl, R. O., Giancola, P. R. and Peterson, J. B. (1994) Cardiovascular reactivity as a predictor of alcohol consumption in a taste test situation. Journal of Clinical Psychology 50, 280–286.[ISI][Medline]

Pohorecky, L. A. (1991) Stress and alcohol interaction: an update of human research. Alcoholism: Clinical and Experimental Research 15, 438–459.[ISI][Medline]

Poikolainen, K. (1997) Risk factors for alcohol dependence: a questionnaire survey. Alcoholism: Clinical and Experimental Research 21, 957–961.[ISI][Medline]

Robins, L. N., Bates, W. N. and O'Neal, P. (1962) Adult drinking patterns of former problem children. In Society, Culture and Drinking Patterns, Pitman, D. J. P. and Snyder, C. R., eds, pp. 395–412. Wiley, New York.

Schuckit, M. A. (1994) Low level of response to alcohol as a predictor of future alcoholism. American Journal of Psychiatry 151, 184–189.[Abstract]

Schuckit, M. A. and Hesselbrock, V. (1994) Alcohol dependence and anxiety disorders: what is the relationship? American Journal of Psychiatry 151, 1723–1734.[Abstract]

Schuckit, M. A. and Smith, T. L. (1996) An 8-year follow-up of 450 sons of alcoholic and control subjects. Archives of General Psychiatry 53, 202–210.[Abstract]

Schuckit, M. A., Hesselbrock, V., Tipp, J., Anthenelli, R., Bucholz, K. and Radziminski, S. (1994) A comparison of DSM-III-R, DSM-IV and ICD-10 substance use disorders diagnoses in 1922 men and women subjects in the COGA study. Addiction 89, 1629–1638.[ISI][Medline]

Sigvardsson, S., Bohman, M. and Cloninger, R. (1996) Replication of the Stockholm adoption study of alcoholism: confirmatory cross-fostering analysis. Archives of General Psychiatry 53, 681–687.[Abstract]

Spak, L., Spak, F. and Allebeck, P. (1997) Factors in childhood and youth predicting alcohol dependence and abuse in Swedish women: findings from a general population study. Alcohol and Alcoholism 32, 267–274.[Abstract]

Spielberger, C. D., Gorsuch, R. L. and Lushene, R. E. (1970) STAI Manual for the State-trait Anxiety Inventory. Consulting Psychologists Press, Palo Alto, CA.

Steele, R. G., Forehand, R., Armistead, L. and Brody, G. (1995) Predicting alcohol and drug use in early adulthood: the role of internalizing and externalizing behavior problems in early adolescence. American Journal of Orthopsychiatry 65, 380–388.[ISI][Medline]

Vahtera, J. (1993) Työn hallinta, sosiaalinen tuki ja terveys. Työ ja ihminen 7, Suppl. 1.

Vaillant, G. E. (1984) The contribution of prospective studies to the understanding of etiologic factors in alcoholism. In Research Advances in Alcohol and Drug Problems, Smart, R. G., Cappell, H. D., Glaser, F. B., Israel, Y., Kalant, H., Popham, R. E., Schmidt, W., Sellers, E. M. eds., pp. 265–289. Addiction Research Foundation and University of Toronto, Toronto.

Vaillant, G. E. and Milofsky, E. S. (1982) The etiology of alcoholism. American Psychologist 37, 494–503.[ISI][Medline]

Virkkunen, M., Kallio, E., Rawlings, R., Tokola, R., Poland, R. E., Guidotti, A., Nemeroff, C., Bissette, G., Kalogeras, K., Karonen, S-L. and Linnoila, M. (1994) Personality profiles and state aggressiveness in Finnish alcoholic, violent offenders, fire setters, and healthy volunteers. Archives of General Psychiatry 51, 28–33.[Abstract]

Volavka, J., Czobor, P., Goodwin, D. W., Gabrielli, W. F. Jr, Penick, E. C., Mednick, S. A., Jensen, P., Knop, J. and Schulsinger, F. (1996) The electroencephalogram after alcohol administration in high-risk men and the development of alcohol use disorders 10 years later. Archives of General Psychiatry 53, 258–263.[Abstract]

Ward, E. S. and Hemsley, D. R. (1982) The stability of personality measures in drug abusers during withdrawal. International Journal of Addiction 17, 575–583.[ISI][Medline]

Ward, R. J., McPherson, A. J. S., Chow, C., Ealing, J., Sherman, D. I. N., Yoshida, A. and Peters, T. J. (1994) Identification and characterization of alcohol-induced flushing in Caucasian subjects. Alcohol and Alcoholism 29, 433–438.[Abstract]

Whitfield, J. B. and Martin, N. G. (1996) Alcohol reactions in subjects of European descent: effects on alcohol use and on physical and psychomotor responses to alcohol. Alcoholism: Clinical and Experimental Research 20, 81–87.[ISI][Medline]

Whitfield, J. B., Nightingale, B. N., Bucholz, K. K., Madden, P. A. F., Heath, A. C. and Martin, N. G. (1998) ADH genotypes and alcohol use and dependence in Europeans. Alcoholism: Clinical and Experimental Research 22, 1463–1469.[ISI][Medline]

World Health Organization (1992) International Classification of Diseases, 10th edn. World Health Organization, Geneva.

Worobec, T. G., Turner, W. M., O'Farrell, T. J., Cutter, H. S., Bayog, R. D. and Tsuand, M. T. (1990) Alcohol use by alcoholics with and without a history of parental alcoholism. Alcoholism: Clinical and Experimental Research 14, 887–892.[ISI][Medline]

Yoshino, A. and Kato, M. (1995) Influence of social desirability response set on self-report for assessing the outcome of treated alcoholics. Alcoholism: Clinical and Experimental Research 19, 1517–1519.[ISI][Medline]

Zahn, T. P., Nurnberger, J. I., Berrettini, W. H. and Robinson, T. N. (1991) Concordance between anxiety and autonomic nervous system activity in subjects at genetic risk for affective disorder. Psychiatry Research 36, 99–110.[ISI][Medline]