Alcohol & Alcoholism Vol. 41, No. 4, pp. 412–420, 2006
Advance Access publication 25 April 2006
BEHAVIOURAL ASPECTS OF IMPULSIVITY IN ALCOHOLICS WITH AND
WITHOUT A CLUSTER-B PERSONALITY DISORDER
GEERT DOM1*, BIEKE DE WILDE1, WOUTER HULSTIJN2, WIM VAN DEN BRINK3and BERNARD SABBE2
1Psychiatric Centre Alexian Brothers, Boechout, Belgium,2Collaborative Antwerp Psychiatric Research Institute (CAPRI), Antwerp, Belgium and
3Academic Medical Centre (AMC) and Amsterdam Institute for Addiction Research (AIAR), Amsterdam, The Netherlands
(Received 2 September 2005; first review notified 14 October 2005; in revised form 23 February 2006; accepted 13 March 2006;
advance access publication 25 April 2006)
Abstract — Aims: Studies have shown that alcoholics with a cluster-B personality disorder (cluster-B PD) are characterized by
high levels of impulsivity. However, impulsivity has mainly been studied as a broad concept without its different aspects being
considered. The present study compared abstinent alcoholic inpatients without any personality disorder (PD) and abstinent alcoholics
with cluster-B PD on different aspects of impulsivity, i.e. self-reported impulsivity and neuropsychological indicators such as
behaviouralcontroland delayofgratification.Methods:Fortyalcohol-dependentinpatientswithoutPDand22 alcohol-dependentinpa-
tients with a cluster-B PD were compared on two self-report impulsivity questionnaires (Barratt impulsiveness scale; sensation-seeking
scales) and three behavioural impulsivity tasks [Go/No-Go task; delay discounting task (DDT); Stroop colour word test]. Tests were
administered after stable abstinence of at least 3 weeks. Results: Self-report measures of impulsivity were higher in cluster-B alcoholics
than in alcoholics without PD. Behavioural tasks revealed a more differentiated pattern of impairments. On the Go/No-Go task, cluster-
B alcoholics were impaired in inhibitory control but not in reaction time compared with alcoholics without PD. In contrast, no signific-
ant differences on the DDT and the Stroop were observed. Conclusion: Alcohol-dependent patients with and without a cluster-B PD
differ in terms of behavioural inhibition but not in terms of activation or the ability to delay gratification. This finding may partly
account for their impulsive and (self-) destructive behaviours. Treatment planning should pay specific attention to these impairments
in behavioural control.
Research on substance use disorders (SUDs) has recently
taken great interest in the role of personality in the pathogen-
esis of addictive disorders. One of the personality traits that
have consistently been linked to substance abuse is impulsiv-
ity. Dawe et al. (2004) proposed that impulsivity was critically
involved in both the initiation and end-stage of addiction.
Similarly, Koob and Le Moal (2001) have suggested that
addiction is to be regarded as the progression from an
impulse-control disorder (i.e. high reward drive) to a compuls-
ive disorder in its end-stage (i.e. relapse after abstinence and
loss of control).
Impulsivity is now widely viewed as a multidimensional
construct consisting of different, related dimensions and
corresponding neuroanatomical pathways (Winstanley et al.,
2004). Specifically the anterior cingulate cortex (ACC) and
the orbitofrontal cortex have been reported to be critically
involved in impulsive behaviours (Rolls, 2004). It is note-
worthy that abnormalities in these brain regions have recently
been proposed to underlie both addictive processes and
cluster-B disorders, i.e. borderline and antisocial personality
disorders (PDs) (Lubman et al., 2004; Seguin, 2004; Berlin
et al., 2005; Dom et al., 2005; Kalivas and Volkow, 2005).
Factor analyses of the various self-report instruments used
to measure impulsivity support a two-factor model to underlie
the trait (Dawe et al., 2004). In addition, animal and human
behavioural models of impulsivity discriminate at least two
dimensions (Winstanley et al., 2004). Dickman (1990) distin-
guished functional and dysfunctional impulsivity. Dawe and
Loxton (2004) argue for the two facets reward drive and rash
impulsiveness. De Wit and Richards (2004) identify two
behavioural processes. The first refers to the degree to which
immediate (rewarding) consequences have more control over
an individual’s behaviour than consequences that are delayed,
as measured in a delay discounting task (DDT). The second is
behavioural inhibition and denotes the ability of an individual
to appropriately inhibit thoughts or actions. Reflecting on the
relationship between personality and substance abuse,Verheul
(Verheul et al., 1999; Verheul, 2001) argues for a three-
pathway model with behavioural disinhibition, stress reactiv-
disinhibition pathway predicts that individuals scoring high
on traits such as antisocial behaviour and impulsiveness have
lower thresholds for deviant behaviours such as alcohol and
drug abuse (Verheul, 2001). Substance misuse like stimulant
abuse in individuals with an antisocial or borderline PD is
likely to develop along this pathway. It may be hypothesized
that specifically rash impulsiveness (or behavioural disinhibi-
tion) may be involved in this association. The stress-reduction
pathway to addiction predicts that individuals scoring high on
traits like stress reactivity typically respond to stress with
anxiety and mood instability, which in turn become a motive
for substance use as self-medication. Avoidant, dependent
and schizotypical PDs have been associated with this second
pathway. Finally, the reward-sensitivity pathway predicts
that individuals scoring high on traits such as novelty seeking
and reward seeking will be motivated to substance use for its
positive reinforcing properties, e.g. people with a histrionic,
antisocial or narcissistic PD. Specifically reward drive (cf.
delay discounting) may be involved in this developmental
Of the three proposed pathways, the disinhibition pathway
has been documented best. A high co-morbidity has indeed
been observed between SUDs and Axis-II disorders from the
impulse-control spectrum, i.e. cluster-B PDs such as the anti-
social and borderline syndromes (e.g. Bowden-Jones et al.,
2004). Furthermore, several longitudinal studies have shown
*Author to whom correspondence should be addressed: Psychiatric Centre
Alexian Brothers, Provinciesteenweg 408, Boechout, 2530, Belgium.
Tel.: +32 3 455 75 31; Fax: +32 3 454 20 84; E-mail: firstname.lastname@example.org
? The Author 2006. Published by Oxford University Press on behalf of the Medical Council on Alcohol. All rights reserved
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that childhood personality traits of behavioural disinhibition,
antisocial behaviour and low harm avoidance were associated
with an early engagement in substance use and subsequent
early development of SUDs in adolescence and young adult-
hood (Cloninger et al., 1988; Masse and Tremblay, 1997;
Tarter et al., 2003; Kirisci et al., 2004). Taken together,
evidence is accumulating that the behavioural-disinhibition
pathway may play an important role in subgroups of drug-
abusing populations and it is hypothesized that impulsivity,
especially its disinhibition dimension (or rash impulsiveness),
may be of particular relevance.
Various instruments have been developed to assess impuls-
ive behaviours. These can roughly be divided into subjective
self-report measures of personality that rely on an individual’s
self-perception of his or her behaviour, and objective behavi-
oural tasks that evaluate the subject’s performance patterns
in relation to specific dimensions of impulsivity. Research
on impulsivity has generally relied on self-reports or on meas-
urements or observations whose respective power to gauge
impulsivity is open to interpretation: the relationship between
how individuals behave and how they report they behave is an
ongoing topic of debate in personality research. The correla-
tion between the two techniques has been reported to be only
weak to moderate (Reynolds et al., 2006).
A limited number of studies have explored impulsive per-
sonality traits within different alcoholic subpopulations. Adult
early-onset alcoholics have been found to have higher levels
(Lykouras et al., 2004; Dom et al., 2006a). It is suggested
that in subtypes of alcoholics impulsivity-related personality
traits are not directly associated with alcohol abuse but rather
with elevated levelsof
(Whiteside and Lynam, 2003). This would support Verheul’s
disinhibition pathway, although none of the studies using
self-report measures of impulsivity to examine alcoholic
populations actually explored the association with co-morbid
Different operant behavioural tasks can be employed to
measure the two main dimensions of impulsivity, i.e. reward
drive and behavioural disinhibition (de Wit and Richards,
2004). The delay discounting paradigm has been studied
extensively in both animals and humans. It assesses the sub-
ject’s preference for a more immediate and more certain
reward relative to a delayed or uncertain reward (Mazur,
1987; Richards et al., 1999). Numerous studies have demon-
strated higher discount rates in non-clinical illicit-drug users
(Kollins, 2003) and in subjects dependent on heroin
(Madden et al., 1997, 1999; Kirby et al., 1999), cocaine
(Coffey et al., 2003; Kirby and Petry, 2004) and nicotine
(Bickel et al., 1999; Reynolds et al., 2004), all relative to the
rates found for healthy controls. However, studies investigat-
ing alcohol-dependent populations are scarce and results are
conflicting. Petry (2001) found higher discount rates in act-
ively using alcoholics than in alcoholics who were abstinent
at the time of testing and non-addicted controls. Kirby and
Petry (2004) could not find differences in discounting between
alcoholics and controls and although Bjork et al. (2004) did
report higher discount rates in alcoholics relative to controls,
they did not find any differences between Type-I and
Type-II alcoholics. In contrast, we demonstrated that
early-onset alcoholics had higher discount rates than
late-onset alcoholics (Dom et al., 2006b). Possibly, differ-
ences in co-morbid personality pathology may account for
these inconsistent findings.
Go/No-Go paradigms are widely used to test the
behavioural-disinhibition dimension of impulsivity. Since
successful performance requires prepotent behaviours to be
inhibited, the tasks provide a measure of behavioural control.
In drug addicts impairments in behavioural control have
frequently been reported (e.g. Hester and Garavan, 2004;
Moeller et al., 2004, 2005; Lee et al., 2005). A neuroimaging
study showed ACC hypo-activity in cocaine users during such
a behavioural suppression task (Kaufman et al., 2003). In their
recent fMRI study Forman et al. (2004) revealed attenuation
of the error signal in the ACC of opiate addicts and proposed
that this might play a role in the loss of control observed in
addictions and other forms of impulsive behaviours.
With respectto alcohol-use
inhibition paradigms have been mainly restricted to the study
of acute effects of alcohol priming in non-dependent, social
drinkers (e.g. Fillmore and Weafer, 2004). Studies examining
(stable abstinent) alcohol-dependent populations are limited.
Bjo ¨rk et al. (2004) found Type-II alcoholics to make more
errors on a behavioural-suppression task than Type-I alcohol-
ics but they failed to correct for co-morbid (antisocial) PDs,
which are known to be highly prevalent in Type-II alcoholics.
In conclusion, research relating personality traits to impuls-
ivity in particular mainly concerned drug-abusing populations
and the limited number of studies that did investigate alcohol-
dependent subjects did not examine the two aspects simult-
aneously. To amend for this lack, in the current study we
compared abstinent alcohol-dependent patients with and
without a co-morbid cluster-B PD. We tested the disinhibition
pathway as proposed by Verheul (2001) and its relation with
impulsivity. We hypothesized that for Verheul’s pathway to
be valid the alcoholics with cluster-B PD would need to score
higher on self-report measures of impulsivity and exhibit more
impairments on tasks measuring behavioural disinhibition
than alcoholics without co-morbid PDs.
Participants were DSM-IV alcohol-dependent adults recruited
from an inpatient treatment facility (see also Dom et al.,
2006a,b). During a period of 18 months (2003–2004) every
second patient admitted to the treatment unit was asked to par-
ticipate in the study (n = 147). Exclusion criteria were current
or lifetime history of psychotic disorders (n = 0), amnesic
disorders (n = 2), neurological disorders such as trauma capitis
or epilepsy (n = 2), and severe somatic disorders such as liver
cirrhosis, AIDS, thyroid disorders or visual problems that
could interfere with concentration during the interviews or
with task execution (n = 3). Ten patients refused participation
while another 30 patients continued their treatment on an out-
patient basis after detoxification. Eligible patients (n = 100)
were those patients who engaged in the clinic’s long-term
inpatient treatment after having been fully detoxified (and
whose abstinence could be monitored daily). Of this sample,
18 patients prematurely ceased treatment and in the course
IMPULSIVITY AND ALCOHOLISM413
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of the study 1 patient refused further participation. A trained
interviewer (MA in psychology) evaluated the remaining
81 participants for Axis-II PDs during a structured interview
(APA) 1994]. Forty patients had no co-morbid PD (49.5%),
22 were diagnosed with a cluster-B PD (27%), and 19
(23.5%) with a cluster-A and/or cluster-C PD. The participants
with a cluster-A or C PD were subsequently excluded.
Ultimately, the study sample comprised 62 patients: 40 alco-
holics without co-morbidity and 22 with a cluster-B PD.
In the cluster-B group 15 patients met criteria for borderline,
3 for antisocial, 2 for both borderline and antisocial, 0 for his-
trionic and 2 for narcissistic PD (Fig. 1).
Diagnoses of alcohol dependence and co-morbid illicit-drug
abuse or dependence based on DSM-IV criteria (APA, 1994)
were made during a clinical psychiatric interview, supplemen-
ted with the data from the European version of the addiction
severity index (EuropASI), and, if possible, collateral
information (spouse, family). The patient’s family history of
alcoholism was determined using the information obtained
by a clinical interview using the family-tree method (Mann
et al., 1985) and completed with the data from the EuropASI
interview, and, if possible, collateral information.
The alcoholics without PD and those with a cluster-B PD
did not significantly differ in terms of sex (71% male), age
(mean 42.1 years; SD 9.5), years of education (mean 13.0;
SD 2.5), years of alcohol dependence (mean 15.8; SD 8.9),
days of abstinence before testing (mean 34.0; SD 15.3), IQ
(mean Full IQ 96.3; SD 12.5), and paternal or maternal family
history of alcoholism (positive history in 40 and 13% of the
participants, respectively). In contrast, the cluster-B parti-
cipants’ age-at-onset of alcohol dependence was significantly
lower (23 years; SD 9) than that of the alcoholics without PD
(28 years; SD 9) [t(60) = –2.095; P = 0.040]. Also, more
cluster-B alcoholics had a history of co-morbid illicit-drug
abuse or dependence and nicotine dependence (see Table 1).
The patients in our clinical sample received usual care, i.e.
they participated in the centre’s regular treatment programme
comprising both psychosocial and pharmacological interven-
tions. Of the total sample, 58% received pharmacological
treatment including antidepressants (50%), anti-psychotics
(14%) and mood-stabilizing anticonvulsants (5%). None of
the participants were taking anti-alcohol drugs (e.g. disulfiram
or acamprosate) at the time of testing (if indicated, these drugs
were started at the end of their inpatient treatment).
All patients gave their written and informed consent. The
study was approved by the medical ethics committee of the
Brothers of Charity psychiatric hospitals, Belgium.
In order to prevent contamination of the current levels of
psychopathology with symptoms of chronic intoxication or
withdrawal, patients were only interviewed and tested after
full detoxification, i.e. after at least 3 weeks of controlled
Instruments for sample description
European addiction severity index. The Belgian adaptation of
the Dutch version of the EuropASI (Raes, 1996) is widelyused
in addiction research and has been tested for reliability and
validity (Kokkevi and Hartgers, 1995). It provides problem-
severity scores in seven domains (medical, work, alcohol,
illicit-drug, legal, psychiatric and social) for the preceding
30-day period, with higher scores reflecting greater problems.
Structured clinical interview for DSM-IV Axis-II PDs. The
SCID-II (First et al., 1997) is a semi-structured diagnostic
interview developed to measure the 10 DSM-IV (APA,
1994) Axis-II PDs. We used the Dutch version (Weertman
et al., 1999).
Wechsler adult intelligence scale. The Wechsler adult intelli-
gence scale (WAIS-III) (Dutch version; 2000) consists of an
individually administered battery of tests designed to measure
verbal and performance intelligence. An overall measure of
Assessed for eligibility
Failing inclusion criteria
Refusing to participate
Treatment drop-outs (n=18)
Other reasons (n= 19)
[participants with a cluster
A or C personality disorder]
Allocated to full research protocol
[abstinent alcohol-dependent inpatients
without Axis II personality disorders]
Allocated to full research protocol
[abstinent alcohol-dependent inpatients
with a Cluster B personality disorder]
Fig. 1. The Consort E-flowchart.
414G. DOM et al.
by guest on June 3, 2013
intelligence, combining the two scores, is indicated as full-
The Beck depression inventory. For the Dutch version of the
Beck depression inventory (BDI) that was administered in
this study (Beck et al., 1961; Bouman et al., 1985) sufficient
reliability and validity have been established (Bosscher et al.,
Buss–Durkee hostility inventory. The Buss–Durkee hostility
inventory (BDHI) (Buss and Durkee, 1957) is a widely used
true–false questionnaire. The Dutch version (BDHI-D) com-
prises 40 items and its psychometric properties have been
well examined and show good reliability and validity (Lange
et al., 1995a,b). We used its direct-aggression subscale to
Instruments assessing aspects of impulsivity
Self-report questionnaires. Barratt impulsiveness scale: The
Dutch adaptation of the Barratt impulsiveness scale (BIS-11)
(Patton et al., 1995) is a 30-item self-report questionnaire
with a total score (BIS_T) and three subscales assessing differ-
ent aspects of impulsiveness: non-planning (BIS_NP), motor
(BIS_M) and cognitive impulsiveness (BIS_C).
Sensation-seeking scale: The Dutch adaptation sensation-
seeking scale (SSS-D) is based on earlier versions of
Zuckerman’s Sensation-Seeking Scale (Zuckerman et al.,
1964). It was tested in a Dutch population and showed good
reliability and validity. Norm scores for different age groups
are available (Feij et al., 1997). The 67-item, self-report
questionnaire provides a general score (SSS_G) as well as
scores on four subscales assessing disinhibition (SSS_DIS),
thrill and adventure seeking (SSS_TAS), experience seeking
(SSS_ES) and boredom susceptibility (SSS_BS).
Behavioural tasks. Go/No-Go task: A classical Go/No-Go
paradigm was presented in a computerized design. The materi-
als and software used are described in De Jong et al. (1996).
Participants were seated in a quiet room at a table on which
a computer screen and writing tablet were mounted. They
were asked to move a screen cursor (yellow dot), controlled
by displacements executed with an electronic pen, as fast
and as accurately as possible into a newly presented target
circle if this was coloured dark blue (Go trial) and to withhold
a reaction if the target was light blue (No-Go trial; see Fig. 2).
Participants were presented with four series each comprising
56 trials (ratio Go/No-Go was 1/8).
The dependent variables were the number of errors (Error)
in the No-Go trials and the reaction (RT) and movement times
(MT) in the Go trials. An error on a No-Go signal was defined
as any movement away from the start circle. RT was defined
as the time between the appearance of a new target circle
and response initiation, and MT as the interval from response
initiation until the target circle was reached.
Stroop colour word test: The Stroop colour word test
(Stroop, 1935) is a behavioural task traditionally employed
to measure attentional bias. We opted for this test as it is espe-
cially useful at assessing whether stimuli are differentially
attended to by participants. It determines to what extent the
lexical information processing of the stimulus word overrules
the perception of the colour in which the word is printed. The
interference effect (defined as the time to read card series
3 minus the time to read card series 2) is hypothesized to be
a behavioural measure of response inhibition (Lezak, 1995).
The Stroop colour word test has frequently been used to
investigate behavioural inhibition within drug- and alcohol-
dependent populations (see e.g. Tedstone and Coyle, 2004;
Fishbein et al., 2005).
Delay discounting task: Delay discounting provides an
index of the relative value of immediate vs delayed rewards
(Mazur, 1987). A classical DDT design, using hypothetical
reward money, was presented on a computer screen (see also
Dom et al., 2006b). The test consisted of ?110 questions
Fig. 2. The Go/No-Go task with the left-hand panel illustrating a No-Go trial
and the right-hand panel a Go trial
Table 1. Differences between the alcoholics without PDs and those with a cluster-B PD on the EuropASI severity scores, the BDHI direct-aggression subscale
(BDHI_DA), the BDI, the percentages of cigarette-dependent alcoholics (Smokers), alcoholics with co-morbid illicit-drug abuse or dependence (Drug) and
alcoholics undergoing pharmacotherapy on the day of behavioural testing
EuropASI severity Alcoholics without any PDAlcoholics with Cluster-Bt(P)
2.657 (P < 0.05)
2.365 (P < 0.05)
2.543 (P < 0.05)
2.416 (P < 0.05)
–3.838 (P < 0.001)
x2(1) = 3.064 (ns)
x2(1) = 4.992 (P<0.05)
x2(1) = 0.170 (ns)
*ns = non-significant (a = 0.05).
IMPULSIVITY AND ALCOHOLISM415
by guest on June 3, 2013
(trials), an example of which reads: ‘Which do you prefer:
d10, 30 days from now, or d2 now?’ The questions are
presented according to an adjusting-amount procedure
(Richards et al., 1999), in which the amount of immediate cer-
tain money is adjusted across successive questions until an
amount is reached that the participant judges to be equivalent
to the delayed d10 reward. This amount thus provides a quant-
itative measure of the subjective value of the delayed rewards.
The points of subjective equality are called indifference
points, which were determined for three amounts, i.e. 10, 30
and d100, and for five different delays: 2, 30, 180, 365 and
730 days, respectively. On delay trials, participants could
choose between varying amounts of instant money and
between 10, 30 and d100 becoming available after a delay.
The indifference points obtained at each of the delays were
plotted and discount functions were derived through curve-
fitting analysis (Matlab, version 5.3). Previous research has
shown that an individual’s discount curves are best described
by a hyperbolic discount function (Mazur, 1987): V = A/
(1 + kD).
This yields a parameter k, where V is the present value of the
delayed reward A at delay D in days. As k increases, the person
discounts the future reward more steeply. Therefore, k can be
regarded as an impulsiveness parameter, with higher values
corresponding to higher levels of impulsiveness (for details,
see Richards et al., 1999).
For the comparison of group mean scores Student t-tests for
independent groups were used, whereas c2tests were used
for dichotomous variables.
If not specified otherwise, general linear model (GLM) pro-
cedures were used. Group was a fixed factor with two levels:
alcoholics with cluster-B PD and alcoholics without PD. A
GLM repeated measures analysis was used to analyse the
DDT results. Because the discount rates had a positively
skewed distribution statistical analyses were performed on
the natural logarithmic transformation of these values:
ln(k + 0.001). The DDT variable ‘amount’ had three levels
(d10, d30 and d100; see also Dom et al., 2006b).
To control for potential confounding we ran an additional
analysis on the behavioural data to adjust for factors that might
have influenced motor performance, i.e. the current use of
psychiatric medication (Y/N)[fixed factor], age and BDI
depression scores [covariates].
Pearson correlations (with Bonferoni correction for mul-
tiple comparisons) were used to identify correlations between
the self-report and behavioural measures of impulsivity.
All analyses were performed using SPSS-11 statistical
Baseline patient characteristics are presented in Table 1.
Relative to the alcoholics without PD the alcoholics with a
cluster-B PD had significantly higher EuropASI problem-
severity scores on the domains work, illicit-drug, legal, social
and psychiatric as well as significantly higher depression
(BDI) and direct-aggression (BDHI-DA) scores and a higher
incidence of nicotine dependence and lifetime history of
illicit-drug abuse or dependence.
Measures of impulsivity
Self-report measures The results of the self-report question-
naires are presented in Table 2. Alcoholics with a cluster-B
PD had significantly higher scores on all BIS-11 subscales
than those without PD and they also scored significantly
higher on the SSS_ES. The two groups did not significantly
differ in their scores on the other SSS subscales.
Behavioural tasks The cluster-B alcoholics made more errors
on the No-Go trials than the alcoholics without PD. On the
Go trials, however, the two patient groups had similar RTs
and MTs. The Stroop and the DDT did not reveal any signific-
ant group differences (see Table 3).
After current use of psychiatric medication (Y/N), age and
depression scores (BDI) had been controlled for the group dif-
ference with respect to error remained significant (P = 0.024)
and the between-subjects effects of the Go/No-Go task (RT
and MT), Stroop and DDT remained non-significant.
Correlations Results of the correlation (Pearson) analysis are
presented in Table 4. Correlations were generally weak
(ranging from 0.01 to 0.32) and after Bonferoni correction
Table 2. Differences between the alcoholics without PDs and those with a
cluster-B PD on the subscales of the two self-report questionnaires, i.e. the
BIS (BIS_C = cognitive, BIS_M = motor, BIS_NP = non-planning,
BIS_T = total score) and the SSS (SSS_TAS = thrill and adventure
seeking, SSS_ES = experience seeking, SSS_BS = boredom susceptibility,
SSS_DIS = disinhibition, SSS_G = general sensation seeking)
any PD (n = 40)
cluster-B (n = 22)F(P)
4.440 (P < 0.05)
4.244 (P < 0.05)
4.128 (P < 0.05)
7.095 (P < 0.01)
4.669 (P < 0.05)
*ns = non-significant (a = 0.05).
Table 3. Differences between the alcoholics without PDs and those with a
cluster-B PD on the selected behavioural tasks: Go/No-Go task, Stroop
colour word task, and DDT
any PD (n = 40)
cluster-B (n = 22)F(P)
Number error No-Go
0.3179 (0.0343) 0.081 (ns*)
0.5012 (0.0458) 0.371 (ns)
0.0395 (0.0898) 0.285 (ns)
4.062 (P < 0.05)
Reaction (RT) and movement times (MT) and interference effect (IE) are
presented in seconds. The raw scores for the three discount rates (k10, k30
and k100) are presented (in the statistical analysis the natural log transforma-
tion Lnk was the repeated measure).
*ns = non-significant (a = 0.05).
416G. DOM et al.
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for multiple testing (P < 0.003 = 0.05/14) none of the correla-
tions between the self-report measures and behavioural meas-
ures of impulsivity proved statistically significant.
The present study was the first to examine different aspects of
impulsivity in abstinent alcohol-dependent patients with and
without a cluster-B PD. The results showed that (i) compared
with alcoholics without PDs, alcoholics with a cluster-B PD
are characterized by a higher self-reported impulsivity and a
weakened inhibitory control on the Go/No-Go task and (ii)
the ability to delay gratification did not differ between the
Disinhibited behaviour may arise from either a weakened
inhibitory-control system or a heightened activation system
(Fillmore and Weafer, 2004). The Go/No-Go paradigm
assesses behavioural control as the net effect of competing
activating and inhibiting processes. It allows the source of
impaired control to be identified by independently measuring
the subject’s ability to activate and to inhibit a response. Our
Go/No-Go findings indicate that the cluster-B alcoholics
primarily differed from the alcoholics without co-morbidity
in terms of reduced inhibition rather than in terms of any
over-activation or excessive drive.
In contrast with the disparities in behavioural control, the
DDT did not reveal any differences between our two alcoholic
subgroups. The DDT is thought to reflect the reward-
sensitivity dimensions of impulsivity and as such may be
hypothesized to be involved in Verheul’s reward-sensitivity
pathway and not the behavioural-disinhibition pathway. The
delay discounting paradigm has been extensively studied in
both clinical and non-clinical populations and showing
elevated levels of discounting in nicotine-, alcohol- and
illicit-drug-dependent individuals (e.g. Bickel et al., 1999;
Kirby and Petry, 2004; Dom et al., 2006b). With the exception
of studies into pathological gambling (Petry and Casarella,
1999), few studies explored this aspect of impulsivity in other
psychiatric disorders characterized by high levels of impulsiv-
ity (like impulse-control disorders or cluster-B PDs). Our
results suggest that discounting may be relatively unimpaired
in cluster-B syndromes. However, since both our samples con-
sisted of alcohol-dependent participants, i.e. a population that
is by definition characterized by a low capacity to postpone
gratification (ceiling effect), more research is needed that
explores delay discounting in subjects with a cluster-B dis-
order without co-morbid substance abuse.
Salo et al. (2002) showed illicit-drug abusers to have
increased interference, i.e. prolonged RTs, on a Stroop colour
word task compared with controls. Others (like Swick and
Jovanovic, 2002) propose longer RTs or higher error rates to
reflect inefficient inhibition of task-irrelevant responses,
response conflict and distractibility. The lack of differences
in interference between our two alcoholic subgroups may be
due to the Stroop’s insensitivity to mild cognitive impairment
(Bohnen et al., 1992). In the literature Stroop effects in
alcohol-dependent patients tend to be conflicting. More con-
sistent findings have been produced with an emotional or
alcohol-specific Stroop task (i.e. including alcohol-related
words), suggesting that specifically alcohol-related words are
distracting to alcoholics (Bauer and Cox, 1998; Lusher et al.,
That our cluster-B alcoholics had a higher subjective
(BIS-11) impulsivity than the alcoholics without co-
morbidity is in line with earlier studies reporting higher BIS
scores for borderline patients relative to controls (e.g.
Dougherty et al., 1999; Berlin et al., 2005). The BIS is a
widely used validated self-report measure of impulsivity and
Dawe et al. (2004) have proposed that it specifically taps
Together, our findings are in line with the behavioural-
disinhibition pathway as proposed by Verheul (2001) and
indicate that specifically rash impulsiveness may play a prom-
inent role in the co-morbidity of substance abuse and cluster-B
PDs (Casillas and Clark, 2002).
In line with earlier studies (see e.g. Kirby and Petry, 2004;
Reynolds et al., 2006), the correlations between the self-
report and behavioural measures of impulsivity in our samples
were weak (ranging from 0.01 to 0.3) and not statistically sig-
nificant. This implies that the two types of tools reflect differ-
ent aspects of the concept impulsivity. It is of interest in this
respect that several recent studies revealed that the impair-
ments on behavioural tasks and not the levels of self-
reported impulsivity predicted relapse in addictive behaviours
(Bowden-Jones et al., 2005; Marisssen et al., 2005; Goudriaan
A.E., Oosterlaan J., de Beurs E., van den Brink W., manuscript
submitted). These findings lend further support to the use of,
not directly observable, behavioural (endophenotypic) charac-
teristics in personality and addiction research and underscore
the limitations of the use of directly observable or subjective
clinical (phenotypic) traits (Dougerthy et al., 2005; Noe ¨l
et al., 2005; Ooteman et al., 2005).
Table 4. Correlations[r (P)] between the numberof errors (Errors) in the NoGo trials, the reaction(RT) and movementtimes (MT)on the Gotrials, the natural
log transformation of the discount rate for d100 (Lnk100) and the interference effect (IE) on the Stroop task on the one hand and the scores on the impulsivity
subscales of the BIS [cognitive (BIS_C), motor (BIS_M), non-planning (BIS_NP) and total (BIS_T)], and the subscales thrill and adventure seeking
(SSS_TAS), experience seeking (SSS_ES), boredom susceptibility (SSS_BS), disinhibition (SSS_DIS) and general sensation seeking (SSS_G) of the
Sensation-Seeking Scale on the other
BIS_C BIS_M BIS_NPBIS_T SSS_TAS SSS_ES SSS_BS SSS_DISSSS_G
*Non-significant (Bonferoni corrected a = 0.003).
IMPULSIVITY AND ALCOHOLISM 417
by guest on June 3, 2013
It is of clinical importance that the EuropASI problem
severity of the alcoholics with cluster-B PD was higher in
four of the seven substance-use-related domains than that of
the alcoholics without co-morbidity. A similar relationship
has been documented extensively in substance abusers with
Axis-II co-morbidity. In addition, co-morbidity with Axis-II
PDs and specifically with antisocial and borderline PD within
drug-abusing or alcohol-dependent populations has been
related to poor pre-treatment characteristics, treatment com-
pliance and outcome (Verheul et al., 1998, 2000; Van Horn
and Frank, 1998; Thomas et al., 1999; Ross et al., 2003;
Haro et al., 2004; Wagner et al., 2004). Specifically high
levels of aggression and impulsivity, key characteristics of
our cluster-B alcoholics, were associated with poor treatment
outcome (Moeller et al., 2001). Clearly, more targeted phar-
macological and psychosocial interventions need to be
developed that address impulsive and self-destructive beha-
viours and enhance treatment compliance (Ball, 2005). In
alcoholics with a borderline personality, for instance, dialect-
ical behaviour therapy (Linehan, 1987) has proven effective
in reducing these behaviours (Linehan et al., 1999; van den
Bosch et al., 2002; Verheul et al., 2003).
For a proper interpretation of our results, it needs to be
taken into account that the samples in our study are only
representative of alcohol-dependent subjects with a high
problem severity on several life domains. Although one
might argue that alcoholics that have chosen to undergo
long-term inpatient therapy
motivated group, most of the alcoholics in our sample
remained in our clinic because of their problem severity and
a lack of sufficient social or family support. Consequently,
our sample may have been characterized by disproportionately
high levelsof co-morbidity
high number of participants with socially inappropriate
We did not test a non-substance-abusing control group
because the principal aim of the current study was to elucidate
the differences between two clinically relevant subgroups of
alcoholic inpatients. However, our findings merit corrobora-
tion in other populations and the different aspects of impulsiv-
ity warrant further scrutiny, both in healthy controls and in
patients afflicted by other psychiatric disorders.
Finally, since this is essentially a clinical-descriptive study,
it excludes any hypotheses about causes or consequences.
Nevertheless, an interesting detail is that the alcoholics with
a cluster-B disorder had an earlier age-of-onset than those
without co-morbidity, which is in line with the findings
Skodol et al. (1999) reported. This could either indicate that
people who eventually develop PDs have problems in adoles-
cence that tend to incite them to substance use at an early age
or that an earlier use of substances leads to psychosocial prob-
lems that come to be diagnosed as PDs. Several longitudinal
studies corroborated the first assumption by demonstrating
that childhood conduct problems and disinhibitory behaviours
were predictive of the development of both (cluster-B) PDs
and substance-use-related disorders later in life (Bernstein
et al., 1996; Masse and Tremblay, 1997; Tarter et al., 2004).
More prospective, longitudinal studies are recommended to
delineate the effects of different personality traits on the
development of alcohol dependence and other psychiatric
syndromes later in life.
might represent a highly
Alcohol-dependent patients with and without a cluster-B PD
differ in terms of behavioural inhibition and self-reported
(rash) impulsiveness but not in terms of activation or their
ability to delay gratification. Health professionals should
take these differences into account when planning the
psychosocial and pharmacological treatments of these two
types of patients.
Acknowledgements — This study was funded by an internal grant of the
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