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ORIGINAL ARTICLE
Year : 2020  |  Volume : 13  |  Issue : 5  |  Page : 512-518  

Prevalence and pattern of alcohol-induced psychosis and personality profile of male alcohol use disorder patients: A hospital-based study


1 Department of Psychiatry, Santhiram Medical College and General Hospital, Nandyala, Andhra Pradesh, India
2 Department of Psychiatry, Dr. DY Patil Medical College, Hospital and Research Center, Dr. DY Patil Vidyapeeth, Pune, Maharashtra, India

Date of Submission06-Sep-2018
Date of Decision20-Oct-2018
Date of Acceptance07-Jul-2020
Date of Web Publication7-Sep-2020

Correspondence Address:
Suprakash Chaudhury
Department of Psychiatry, Dr. DY Patil Medical College, Hospital and Research Center, Dr. DY Patil University, Pimpri, Pune - 411 018, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/mjdrdypu.mjdrdypu_147_18

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  Abstract 


Background: There is a paucity of data on the prevalence and pattern of alcohol-induced psychotic disorder (AIPD) and the role of personality traits in alcohol use disorders (AUDs) and AIPD. Aim: This study aims to study the prevalence and pattern of AIPD and personality profile in AUD and AIPD patients. Materials and Methods: Consecutive sample of 100 patients with AUD fulfilling Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM 5) criteria and between 18 and 60 years old were included in the study with their informed consent. Psychotic symptoms were assessed in keeping with DSM 5 criteria for substance (alcohol)-induced psychosis. The Eysenck Personality Questionnaire (EPQ) was used to explore personality traits. Results: In the present study, middle class and lower middle class people were found to develop AUD. Early age of initiation of alcohol intake placed the individual at risk of developing severe AUD and psychotic symptoms. Psychotic symptoms were seen in 9% of the individuals. Persons with severe alcohol dependence and longer duration of alcohol use were at increased risk for developing psychotic features. The most common psychotic symptom was auditory hallucination. The EPQ showed that 65.93% of the individuals had psychoticism trait; 67.03% were extroverts. Persons with psychoticism trait were found to start taking alcohol at an early age and develop severe AUD. In the neurotic dimension, 54.95% were highly neurotic; 45.05% had average emotional stability. Conclusions: Psychotic symptoms were seen in 9% of patients with AUD. Psychosis in AUD was associated with severity of alcohol dependence, early initiation, longer duration of alcohol intake, and psychoticism personality trait. Psychoticism and extraversion personality traits were predominant in AUD compared to neuroticism trait.

Keywords: Alcohol use disorders, neuroticism, personality, psychosis, psychoticism


How to cite this article:
Reddy GC, Murthy P S, Chaudhury S. Prevalence and pattern of alcohol-induced psychosis and personality profile of male alcohol use disorder patients: A hospital-based study. Med J DY Patil Vidyapeeth 2020;13:512-8

How to cite this URL:
Reddy GC, Murthy P S, Chaudhury S. Prevalence and pattern of alcohol-induced psychosis and personality profile of male alcohol use disorder patients: A hospital-based study. Med J DY Patil Vidyapeeth [serial online] 2020 [cited 2020 Oct 23];13:512-8. Available from: https://www.mjdrdypv.org/text.asp?2020/13/5/512/294339




  Introduction Top


Alcohol abuse is a major public health problem all across the planet. Alcohol use disorder (AUD) has multifactorial causation and one among those factors is personality of the individual. Personality is one of the psychological factors most consistently associated with alcohol use. Interest in understanding the personality traits that are related to AUD have led to a variety of research studies in this area. There is increasing realization among substance use disorder specialists that personality and temperament are important determinants of vulnerability to develop alcohol dependence. In general, there are two types of approach regarding personality assessment. In the first, personality pathology is conceptualized within the context of categorically defined personality disorders, with most studies focusing on antisocial and borderline personality disorders (Diagnostic and Statistical Manual of Mental Disorders [DSM] cluster B personality disorders). In the second, a dimensional approach of normally distributed personality measures is used. Among the foremost influential personality models those of Eysenck, Cloninger, and McCrae and Costa's five factor model are especially relevant.[1] AIPD is a rare complication of alcohol dependence which should be discerned from alcohol-withdrawal delirium and schizophrenia, since the treatment and prognosis of those disorders differ from that of AIPD. A general population-based study of 8028 individuals reported that the lifetime prevalence for AIPS was 0.5% and was highest (1.8%) among men of working age. Risk of AIPS was related to younger age at onset of alcohol dependence, low socioeconomic status, father's mental state or alcohol problems, medical comorbidity, and multiple hospital treatments.[2] AIPD usually manifests acutely with auditory hallucinations, and less commonly with delusions and visual hallucinations, in the background of prolonged and excessive consumption of alcohol. The content of the auditory hallucinations is usually derogatory in nature or convey unpleasant messages. In contrast to delirium tremens sensorium is clear and withdrawal symptoms are mild or absent. The symptoms of AIPD usually resolve within a week, although they sometimes persist, especially in the presence of ongoing alcohol misuse. The recognized treatment for AIPD is antipsychotic medication. Abstinent patients usually do not require a long-term antipsychotic treatment and the prognosis is usually favorable, although 10%–20% may progress to schizophrenia.[3]

Despite the actual fact that AUD is a major public health problem in India, there is a paucity of studies especially focusing on the association of AIPD and personality factors. The present research aimed to study the personality profiles and pattern of psychosis in AUD patients.


  Materials and Methods Top


The study was conducted in the Department of Psychiatry, Santhiram Medical College and General Hospital, Nandyal, Andhra Pradesh. The proposal for the study was approved by the Institutional Ethical Committee of this institution vides their letter dated December 7, 2017. All the individuals were explained the purpose of the study and were included in the study after obtaining written informed consent.

Sample

The sample for the study consisted of a consecutive sample of 100 patients with AUD attending the psychiatry outpatient department/inpatient department in Santhiram General Hospital, Nandyal, Andhra Pradesh, from December 1, 2015, to June 31, 2017, and the sample was selected by purposive sampling. Patients fulfilling the DSM 5th Edition diagnostic criteria for AUDs were included in the study.[4] Patients having psychosis due to organic illness such as diabetic ketoacidosis, hypertensive encephalopathy, infections such as meningitis, meningoencephalitis, cerebral malaria, liver diseases, and electrolyte imbalance were excluded from the study. Data for personality assessment included only patients whose lie score was A on Eysenck Personality Questionnaire (EPQ).

Tools

Self-designed questionnaire was used to collect information about sociodemographic variables. Eysenck Personality Questionnaire.[5]

Statistics

The data were statistically analyzed by the SPSS (Statistical Package for the Social Sciences) software 20 version. (SPSS, IBM, Chicago, USA) Relationship between two variables was tested by Chi-square test.


  Results Top


In the present study, all the individuals were male. Majority (77%) of the individuals were in the age group of 30–50 years, hailing mostly from rural (49%) followed by semi-urban (30%) geographic areas. Majority (52%) of the individuals were consuming alcohol for more than 16 years. Psychotic symptoms were seen in 9% of the individuals. Patients with AIPD were older in age, mainly from rural area, less educated, and longer duration of alcohol intake. At the time of assessment during study, most of the individuals (64%) were in precontemplation stage of motivation [Table 1]. Most of the individuals (n = 7) had psychotic symptoms after alcohol intoxication, while some (n = 2) had psychotic symptoms during withdrawal. Of total 9 individuals with psychotic symptoms majority (78%) of the subjects had hallucinations and only 22% of the individuals had both delusions and hallucinations. Of 7 subjects who had hallucinations 6 (86%) individuals had auditory hallucinations and 1 (14%) individual had both auditory and visual hallucinations.
Table 1: Demographic and alcohol related characteristics of alcohol use disorder patients and alcohol use disorder patients with and without alcohol.induced psychotic disorde

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In this study, 9 patients who scored high lie score (>5) were excluded from the assessment of personality profile and remaining 91 individuals were only included. In the study group, in the psychoticism dimension majority (65.93%) of the individuals had high psychoticism trait while rest (34.07%) had low psychoticism (Psychoticism Fisher's Two-tailed: P = 0.0031; P < 0.01). In extraversion dimension, 67.03% were extrovert and 32.97% were ambiverts (Extraversion: Fisher's two-tailed: P = 0.0015; P < 0.01). In the neurotic dimension, 54.95% were highly neurotic, while 45.05% had average emotional stability (neuroticism two-tailed: P = 0.4018 ns (P < 0.10) [Table 2]. Comparison of AUD patients with and without AIPD revealed that patients with AIPD had significantly higher psychoticism trait and significantly lower extraversion trait. Majority (66.7%) of the individuals with significant psychoticism were severe AUD patients. This correlation between severity of AUD and psychoticism trait was statistically significant (P < 0.05) [Figure 1] but not for extraversion and neuroticism [Figure 2] and [Figure 3].
Table 2: Personality profile of the alcohol use disorder patients (n=91) on the Eysenck's Personality Questionnaire

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Figure 1: Severity of alcohol use disorder and psychoticism trait

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Figure 2: Severity of alcohol use disorder and extraversion trait

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Figure 3: Severity of alcohol use disorder and neuroticism trait

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  Discussion Top


Sociodemographic variables

In the present study, 77% of the subjects belonged to the age group of 31–50 years. The large number in this group may be due to the emergence of alcohol-related problems and the need to seek help in that age group. The pressure from family members, peers, and superiors might force this group to attend the clinical setting more often than others. This is in concordance with earlier Indian studies in this area.[6],[7] A recent study also reported that majority of the patients of alcohol dependence belonged to the age group ranging from 30 to 50 years (76.6%).[8] All the patients with AIPD belonged to the 40–60 years of age group which is consistent with earlier literature.[3]

Prevalence and pattern of psychotic symptoms

In the present study, psychotic symptoms were seen in 9% of the subjects. All the patients had the psychotic symptoms either after acute alcohol intoxication (n = 7) or during withdrawal from alcohol (n = 2). This finding is in agreement with an earlier Indian study.[9]

The most common psychotic symptom in the current study was auditory hallucinations. This finding was similar to an earlier Indian study.[10] Higher figures were reported by a Malaysian study which found that among the 34 subjects with alcohol-induced psychotic disorder (AIPD) 26 (76.5%) subjects had auditory hallucinations, 3 (8.8%) subjects had visual hallucinations, and 16 (47%) subjects had delusions.[11] Similarly, a study from Nepal observed that 12.36% of the patients with alcohol dependence had AIPD.[12] However, findings of the present study markedly differ from a study among patients with alcohol dependence treated in psychiatric hospitals in Germany, in which it was found out that 0.6%–0.7% had alcohol-induced psychotic disorder.[13] This difference may be due to differences in the study sample, awareness of alcohol-related problems and better access to health-care facilities in Germany.

Duration of alcohol use and psychotic symptoms

In the present study, among the total subjects who experienced hallucinations 86% were consuming alcohol for more than 16 years whereas 14% were consuming for 11–15 years. In agreement with our findings a Malaysian study of alcohol dependents with AIPD reported a mean duration of drinking of 14.2 years.[11] This shows that subjects with a history of longer duration of alcohol intake were at risk of developing psychotic symptoms compared to those with less duration of alcohol intake.

Age of onset of alcohol intake and psychotic symptoms

In the current study, all the subjects who had psychotic symptoms such as delusions and hallucinations have started consuming alcohol between 16–25 years. This finding was in concordance with studies which found that younger age of onset of alcoholism was associated with alcoholic hallucinosis.[2],[14]

Severity of alcohol use disorder and psychotic symptoms

In the current study, all the persons who had psychotic symptoms were diagnosed with severe AUD [Figure 4]. The underlying mechanisms of alcohol-induced psychosis are complex involving the neurotoxicity of alcohol and its damage at the genetic, biochemical, and cellular levels leading to neurological pathology. The findings in the present study were in line with an earlier study which observed that alcohol-dependent subjects with psychotic features face more alcohol-related life problems. This indicates that a high degree of alcohol dependence may predispose an individual to develop psychotic features.[14]
Figure 4: Severity of alcohol use disorder and psychotic symptoms

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Personality profile in alcohol-induced psychotic and alcohol use disorder

In the present study, the patients with AIP had significantly higher psychoticism and lower extraversion trait as compared to AUD patients without AIP. Neuroticism trait though higher in AIP patients was not significantly different from the AUD groups.

In this study, it has been observed that high psychoticism and high extraversion traits were significantly associated with AUD. Although AUD subjects had high neuroticism, it was not statistically significant. In Eysenck's theory, psychoticism is anchored at one end by aggressiveness and out-of-the-box thinking and at the opposite end by empathy and caution. This trait is so named because individuals with a highPlevel are significantly more at risk of psychotic disorders. In agreement with the above all the AIP patients in the present study had high psychoticism levels [Table 2]. Extraversion is represented on a bipolar scale anchored at one end by sociability and stimulation-seeking, and at the opposite end by social reserve and avoidance of stimulation. N is anchored at one end by emotional instability and spontaneity and at the opposite end by reflection and deliberateness. Subjects with a high N score are more at risk of anxiety-based problems.[15] When individual traits were compared, it was found that individuals with AUD had significantly higher levels of psychoticism and extraversion. Neuroticism was also high in AUD patients but not significant. These findings are in agreement with the finding that higher psychoticism levels are strongly associated with alcohol consumption,[11] and several other studies have shown a link between higher extraversion levels and alcohol consumption in nonalcoholics and alcoholics alike.[16],[17],[18]

This finding is consistent with the suggestion that impulsivity measured by the psychoticism part of EPQ was more associated with substance use.[19],[20],[21] Neuroticism appears to correlate positively with alcohol consumption specifically among those with clinically significant alcohol problems.[22] Individuals who consume alcohol heavily may develop high levels of Neuroticism and anxiety to buffer the negative affect related to alcohol dependence.[23]

These findings are partly in agreement with the results of studies which found that alcoholic men have high neuroticism, high psychoticism, and low extraversion.[15],[24] Similarly, another study, using Cloninger's temperament and character inventory, observed that alcohol-dependent patients were characterized by higher novelty-seeking and lower self-directedness which reflect psychoticism and neuroticism than nonpsychiatric controls.[25]

The results in the current study correlated with a meta-analysis to quantify the relationship between the five-factor model of personality and alcohol involvement and to identify moderators of the relationship. The meta-analysis showed alcohol involvement was associated with low conscientiousness, low agreeableness, and high neuroticism.[26]

Similarly, two studies found high levels of neuroticism to be associated with increased level of drinking.[27],[28] Possible explanation for the high neuroticism in alcoholics is higher levels of depression and anxiety which in turn have been linked with alcohol abuse. Thus, for neurotic individuals, drinking is a means of coping with negative emotions.

The results in the current study were not in concordance with the results of an Indian study in which majority of the patients had ambivert personality (76.6%), while 20% were extroverts and 3.3% introverts.[6] This finding suggests that significantly higher number of ambiverts were susceptible to AUDs than extroverts and introverts. The results of the current study were in contrast to the findings of a study that found low psychoticism in alcohol-dependent individuals.[29]

Biological basis of neuroticism originates from the sensitivity of the limbic autonomic system, which determines reactivity to environmental and psychological stimuli. Highly reactive individuals are typically easily startled and agitated. These individuals may be expected to use addictive substances for their calming and rewarding effects. Addictive behaviors are adopted and utilized because they serve as useful function for individual. In other words, it can be interpreted as the nature of addictive behavior gives certain benefits to the user. Hence, that type of behavior is continued even though there may be unwanted or negative consequences.

An individual with relatively high levels of impulsivity/behavioral disinhibition could hypothetically: Display a range of externalizing behaviors during childhood that may overlap with personality through common genetic factors, affiliate with deviant peer groups that have access to alcohol during adolescence, subjectively enjoy drinking because the effects of alcohol are especially rewarding by reducing stress, become increasingly involved in a heavy drinking lifestyle that includes using alcohol to increase positive moods and/or decreases negative moods. The psychoticism dimension is linked with higher impulsivity and lower self-regulation. Psychoticism-related characteristics are impulsivity, under controlled temperament, antisocial characteristics, low agreeableness, proneness to school, and behavioral problems. Future alcohol problems can be predicted by traits related to behavioral disinhibition and to a lesser extent, neuroticism.

The results in the present study indicate the need for the routine assessment of personality profile in alcohol-dependent individuals. This will help in better understanding of the addictive behavior in the individual patient and facilitate the best strategy for tailoring standard interventions to the individual needs and requirements. Understanding why high psychoticism and neuroticism places persons at increased risk for alcoholism would help in better understanding and conceptualizing AUDs, which will lead to improved treatment and prevention. This has important implication in the psychological management as well. Integrated psychological interventions should be considered to reduce negative emotional state and bring balance in physiological response and to improve coping with stress. Interventions like counseling should be considered to decrease neuroticism and interventions ranging from cognitive skills programs to exercise regimes should be considered to increase self-regulation and therefore, to decrease impulsivity. Efforts must be directed toward educational intervention for quitting alcohol among lower middle class and middle class. As coping motives appear to be an important mediator of the personality and alcohol relation, treatments targeting coping skills may also result in reductions in alcohol problems. Family-related genetic and environmental factors in developing psychosis related to alcohol are important themes that warrant future studies. Making the distinction between alcohol-induced psychosis and primary psychotic illness is essential in broadening knowledge and understanding of alcohol-induced psychosis and planning appropriate treatment for patients.

Limitations

Sample for the study, having been taken from a hospital-based population, may represent the more severely alcohol-dependent patients. This leads to difficulty in generalizing the results of the study to the general population. The sample size was small and all participants were male. Furthermore, the data were cross-sectional, rather than longitudinal, and therefore, the findings cannot be used to explain causal relationships. There was no control group in the study. Personality of alcohol dependence subjects should have been compared with personality of healthy controls. As the investigator was not blind to the diagnosis, while administering the questionnaire and pro forma, the chances of observer bias creeping into assessment has to be considered.


  Conclusions Top


Alcohol-induced psychosis was found in small but significant proportion of hospitalized patients with alcohol dependence. The most common psychotic symptom was auditory hallucinations. The propensity to develop psychotic symptoms appears to increase with longer duration of alcohol use. Psychoticism and extraversion personality traits were predominant in AUD while psychoticism trait was associated with AIP.

Recommendations

Future studies should include a larger sample from multiple centers, and include both sexes.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]
 
 
    Tables

  [Table 1], [Table 2]



 

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