Validation of a system of classifying female substance abusers based on personality and motivational risk factors for substance abuse

Abstract

This study explored the validity of classifying a community-recruited sample of substance-abusing women (N = 293) according to 4 personality risk factors for substance abuse (anxiety sensitivity, introversion-hopelessness, sensation seeking, and impulsivity). Cluster analyses reliably identified 5 subtypes of women who demonstrated differential lifetime risk for various addictive and nonaddictive disorders. An anxiety-sensitive subtype demonstrated greater lifetime risk for anxiolytic dependence, somatization disorder, and simple phobia, whereas an introverted-hopeless subtype evidenced a greater lifetime risk for opioid dependence, social phobia, and panic and depressive disorders. Sensation seeking was associated with exclusive alcohol dependence, and impulsivity was associated with higher rates of antisocial personality disorder and cocaine and alcohol dependence. Finally, a low personality risk subtype demonstrated lower lifetime rates of substance dependence and psychopathology.

Full text

Psychology
of
Addictive
Behaviors
Copyright
2000
by the
Educational
Publishing
Foundation
2000,
Vol.
14, No. 3,
243-256
0893-164X/OW5.00
DOI:
10.1037//0893-164X.14.3.243
Validation
of a
System
of
Classifying
Female
Substance
Abusers
on the
Basis
of
Personality
and
Motivational
Risk
Factors
for
Substance Abuse
Patricia
J.
Conrod
Robert
O.
Pihl
State
University
of New
York
at
Stony
Brook
McGill
University
Sherry
H.
Stewart Maurice Dongier
Dalhousie
University
McGill
University-Douglas
Hospital
Alcohol
Research
Program
This study explored
the
validity
of
classifying
a
community-recruited
sample
of
substance-abusing
women
(N
=
293)
according
to 4
personality risk factors
for
substance abuse (anxiety sensitivity,
introversion-hopelessness,
sensation seeking,
and
impulsivity).
Cluster analyses
reliably
identified
5
subtypes
of
women
who
demonstrated differential lifetime
risk for
various addictive
and
nonaddictive
disorders.
An
anxiety-sensitive subtype demonstrated greater lifetime risk
for
anxiolytic
dependence,
somatization
disorder,
and
simple
phobia,
whereas
an
introverted-hopeless subtype evidenced
a
greater lifetime
risk for
opioid depen-
dence,
social
phobia,
and
panic
and
depressive
disorders. Sensation seeking
was
associated
with
exclusive alcohol dependence,
and
impulsivity
was
associated
with
higher rates
of
antisocial personality disorder
and
cocaine
and
alcohol dependence.
Finally,
a low
personality
risk
subtype demonstrated lower lifetime rates
of
sub-
stance dependence
and
psychopathology.
A
recent
approach
to
understanding
drug
ad-
cal
learning
model
of
alcoholism
maintains
that
diction
has
been
to
differentiate
substance
abus-
the
heterogeneity
of
alcoholism
is
best
captured
ers
according
to
their
degree
of
vulnerability
to by a
typology
that
distinguishes
alcoholics
on
experience
specific
drug-reinforcement
effects,
the
basis
of
early
versus
late
onset
of the
disor-
For
example,
Cloninger's
(1987)
neurobiologi-
der,
presence
of
neurotic
versus
impulsive
dis-
orders,
and
sensitivity
to
anxiety
reduction
ver-
sus
"perceptual
reactance"
reduction
from
alcohol.
Patricia
J.
Conrod,
Department
of
Psychology,
D
ite
i(s
popularity,
this
typology
has
been
State
Unrvers.ty
of
New
York
at
Stony Brook; Robert
^^
^
^^
wjm
to
reliability,
O.
Pihl,
Department
of
Psychology
and
Department
....
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...
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_
. ,
,
of
Psychiatry,
McGill
University,
Montreal, Quebec,
vahd
"y
<
Glenn
&
Nlxon
>
1996;
Penmck
et
al
-
Canada;
Sherry
H.
Stewart, Department
of
Psychol-
199
°)<
™*
clmlcal
utjllt
y
(Kadden,
1996).
One
ogy
and
Department
of
Psychiatry, Dalhousie Uni-
possible
explanation
for why
this
typology
fails
versity,
Halifax, Nova Scotia, Canada; Maurice
to
account
for the
heterogeneity
observed
in
Dongier,
Department
of
Psychiatry,
McGill
Uni-
alcoholic
samples
(e.g.,
Glenn
&
Nixon,
1996)
versity-Douglas
Hospital Alcohol Research
Pro-
is
that
it
does
not
consider
other
potential
gram,
Verdun,
Ouebec,
Canada.
sources
of
motivation
for
drug
use
that
are un-
This
study
was
supported
by the
National
Health
re
i
ate(
j
to
anxiety
or
reactivity
reduction.
Alco-
Research
and
Development
Program,
Health Canada.
hol
and
othef
d
of
abus£
^
j^^
to
affect
Correspondence
concerning
this
art,cle
should
h
functioning
within
brain
motivational
sys-
be
addressed
to
Patricia
J.
Conrod, Department
of ,
~.,,
...
. .
.
J
Psychology,
State University
of
New
York
at
tems
that
are
differentially
sensitive
to
various
Stony
Brook,
Stony
Brook,
New
York
11794-
stimuli
classes
(e.g.,
positive,
negative,
threat).
2500. Electronic
mail
may be
sent
to
pconrod@
As
such,
addictive
substances
are
often
classi-
ms.cc.sunysb.edu.
fied on the
basis
of the
manner
in
which they
243

244
CONROD,
PIHL,
STEWART,
AND
DONGIER
interact with these brain systems
and the
type
of
reinforcement that they
produce.
In
addition
to
anxiolytic
and
stimulus reactivity-dampening
effects,
alcohol
and
certain
other addictive sub-
stances
are
known
to
have
analgesic
and
psy-
chostimulant
properties
(DiChiara,
Acquas,
&
Carboni,
1992;
Pihl
&
Peterson,
1995),
and
individuals
are
known
to
vary
in
their suscepti-
bility
to
such
effects
(Conrod,
Pihl,
&
Vassi-
leva,
1998).
In
the
present study
we
attempted
to
validate
a
system
of
classifying substance-abusing indi-
viduals
on the
basis
of
their
differential liability
to
seek
out
specific
reinforcing
effects
from
drugs
of
abuse.
Consistent with Cloninger's
(1987) original hypothesis, specific personality
risk
factors
for
substance
abuse
are
assumed
to
reflect
differences
in the
functioning
of
brain
motivational systems
and
differential suscepti-
bility
to
seek
out
specific drug-reinforcement
effects.
However,
the
current
classification
sys-
tem
will involve
an
expansion
of
Cloninger's
typology
to
focus
on
four
personality risk fac-
tors
and
corresponding motivational determi-
nants
of
drug
use and
abuse.
They
are
anxiety
sensitivity,
introversion-hopelessness, sensa-
tion
seeking,
and
impulsivity.
In the
sections
that follow
we
briefly
review converging liter-
atures suggesting that these factors
are
linked
to
specific
patterns
of
addictive
and
nonaddictive
psychopathology
by
means
of
their relationship
to
brain motivational systems that
are
specifi-
cally
affected
by
drugs
of
abuse.
Anxiety
sensitivity refers
to a
cognitive
or
personality style
that
involves
an
expectation
or
fear
that anxiety
and
physical arousal will lead
to
physical illness, social embarrassment, loss
of
mental control,
or
some combination
of
these
(Reiss, Peterson,
Gursky,
&
McNally,
1986).
As
such,
it is
associated
with
a five-fold in-
creased
risk for the
longer term development
of
panic-related anxiety disorders (Mailer
&
Reiss,
1992)
and
corresponds with self-reported rates
of
alcohol (Stewart,
Peterson,
&
Pihl, 1995)
and
anxiolytic
prescription drug
use
(Bruce,
Spei-
gel,
Gregg,
&
Nuzzarello, 1992). Furthermore,
this
personality style
is
associated with sensi-
tivity
to the
anxiety-reducing
effects
of
alcohol
and the
tendency
to
self-report motives
for al-
cohol
use
that
reflect
the
desire
to
self-medicate
negative emotions
(Conrod,
Pihl,
&
Vassileva,
1998; Stewart
&
Pihl,
1994).
It has
been
sug-
gested
that anxiety sensitivity
is a
personality
risk
factor
for
dependence
on
drugs that
posses
anxiolytic
properties
(such
as
alcohol
and
ben-
zodiazepines)
that
is due to a
need
to
escape
feared
symptoms
of
anxiety (Stewart, 1996).
Depression
may
also
be
considered
a
risk
factor
for
alcoholism
in
that
it is
predictive
of
later alcohol consumption
and the
development
of
alcohol problems, particularly
for
women
(Hartka
et
al.,
1991;
Helzer
&
Pryzbeck,
1988).
In
terms
of
personality factors that
are
common
to
both depression
and
alcoholism, primarily
depressed
alcoholics
have been shown
to
differ
from
nondepressed
and
secondarily depressed
alcoholics
on
measures
of
personality that
re-
flect
trait
anxiety
and
introversion (Epstein,
Ginsburg,
Hesselbrock,
&
Schwartz, 1994;
Martin
&
Sher,
1994).
Introversion
has
been
described
as
reflecting
a
sensitivity
to
punishment-
induced extinction
of
social
and
goal-oriented
behavior (e.g., Depue
&
Collins,
1999).
Pihl
and
Peterson
(1995) suggested that individuals
with
interpersonal sensitivity, punishment sen-
sitivity,
or
both appreciate
the
analgesic prop-
erties
of
alcohol
(at
certain doses)
and
certain
other
drugs
of
abuse (e.g.,
codeine)
because
analgesics suppress
the
inhibitory
effects
of
punishment
on
previously rewarded behavior
(Gray, 1982).
We
similarly hypothesized that
introverted,
depression-prone
substance abusers
are
particularly attracted
to
drugs
of
abuse that
possess analgesic properties
(e.g.,
opioids
and
alcohol).
Extraversion
and
novelty/sensation seeking
are two
additional personality characteristics
that
have been associated with elevated drug
use; however, they
are
more associated
with
a
tendency
to
drink
to
experience
the
euphoric
and
intoxicating
effects
of
alcohol (Conrod,
Peterson,
&
Pihl, 1997; Ohannessian
&
Hessel-
brock,
1994)
rather than
the
negatively reinforc-
ing
effects.
The
psychomotor stimulant theory
of
addiction suggests that
the
addictive proper-
ties
of
drugs
of
abuse
are
partially determined
by
their ability
to
increase
dopamine
in a
brain
system that causes intrinsically rewarding states
when
stimulated (Fibiger
&
Phillips, 1988;
Wise
&
Bozarth,
1987). Extraversion
and
sen-
sation seeking have been linked
to
specific
dopamine-related
biochemical mechanisms that
are
related
to the
functioning
of
this
incentive
reward
system (Depue
&
Collins,
1999).
There-

SUBTYPES
OF
SUBSTANCE
ABUSERS
245
fore,
among
a
number
of
possible
determinants
of
alcohol
use
(Sher,
1993),
one
important fac-
tor may
involve
a
specific
sensitivity
to in-
centive motivation
and the
psychostimulant
properties
of
alcohol (Conrod
et
al.,
1998).
Accordingly,
we
proposed
that
a
subtype
of
substance abuser,
defined
primarily
on the
basis
of
sensitivity
to
incentive motivation
(sensation
seeking),
will
be
associated
with
a
propensity toward
alcohol
abuse
in the ab-
sence
of
other
forms
of
psychopathology
and
personality
risk
factors.
Finally,
impulsive-disinhibited
personality
has
been linked
to
elevated
risk for
early-onset
alcohol
and
drug problems (e.g.,
Pulkkinen
&
Pitkanen,
1994).
This personality
profile
has
been
operationally
described
as an
insufficient
ability
to
anticipate
future
reinforcement
and
delay behavioral responses accordingly
(Pihl
&
Peterson, 1995; Spoont, 1992).
In
contrast
to the
traditional self-medication hypothesis,
or the
psychomotor stimulant theory,
a
self-regulation
deficit
might
be
more appropriate
for
explaining
the
motivational link between
impulsivity
and
drug abuse. That
is,
heavy
and
problematic drug
use may be
consequential
to a
lack
of
inhibition
in
the
face
of
negative consequences
associated
with
the use of
certain substances
if
such sub-
stances
are
immediately reinforcing. Accord-
ingly, impulsive substance abusers should dis-
criminate
from
a
sensation-seeking subtype
and
other subtypes
on the
basis
of
their propensity
toward
antisocial
behavior
and
patterns
of
drug
use
that involve
use of
illegal substances
and
severe negative consequences
of
such
use.
We
proposed that
subtypes
of
substance
abusers,
identified
on the
basis
of
specific
per-
sonality
profiles (proposed
to
reflect
specific
motivational
liabilities
for
drug abuse),
will
present with
specific
patterns
of
comorbid psy-
chopathology
and
substance dependence.
We
chose
to
validate this motivational model
of
substance abuse within
a
population polysub-
stance
abusing/dependent women because
of
the
relative paucity
of
research
on
substance
abuse
in
women
and to
allow
for the
identifica-
tion
of
factors
that
are
potentially gender spe-
cific.
This investigation
was
conducted
within
a
community-recruited sample,
rather
than
a
treatment
sample,
to
address
the
concerns about
the
representativeness
of
treatment samples
with
respect
to
polysubstance
abuse
and
comor-
bid
psychopathology (Nathan,
1987).
Method
Participants
Three
hundred non-treatment-seeking female
sub-
stance abusers were recruited between August
1995
and
September
1996
through advertisements featured
in
English
and
French entertainment
and
community
newspapers freely circulated
in the
greater Montreal
area.
In
total,
790
women responded
to the
advertise-
ments
and
were screened with
a
30-min
telephone
interview.
The
inclusion criteria
for the
study were
as
follows:
between
30 and 50
years
of age
(i.e.,
the age
range
at
which distributions
for the
abuse
of
alcohol,
prescription drugs,
and
other psychoactive
sub-
stances overlap
for
women)
and
dependence
on or
abuse
of
alcohol, prescription drugs,
or
both
(as a
means
of
oversampling
for
prescription drug
de-
pendence/abuse). Screening
for
alcohol
and
sub-
stance abuse involved
use of the
brief version
of the
Michigan Alcoholism Screening Test (Brief MAST;
Pokorny,
Miller,
&
Kaplan,
1972)
and the
Drag
Abuse
Screening Test
(DAST;
Skinner, 1982).
Par-
ticipants
who
scored above
10 on the
Brief MAST
(Fleming
&
Barry,
1989)'
and/or
12 on the
DAST
were considered
to be
abusing
a
substance (Skinner,
1982). Alcohol
and
drug dependencies were diag-
nosed
if
respondents
met
three
or
more
of the
seven
Diagnostic
and
Statistical Manual
of
Mental
Disor-
ders
(4th
ed.
[DSM-IV];
American Psychiatric Asso-
ciation,
1994)
criteria
indicating
substance depen-
dence within
the
previous
12
months.
To
increase
the
reliability
of the
self-report measures used
in the
present
investigation,
we
excluded participants
who
had
been diagnosed with
or
medicated
for a
psychotic
or
bipolar disorder
within
the
previous
2
years
and
those
who
currently
had a
serious medical condition
for
which alcohol
and
drug consumption were
con-
traindicated (e.g., pregnancy). Respondents were
not
excluded
if
they
concurrently
abused
or
were depen-
dent
on
other psychoactive substances
in
addition
to
alcohol
and/or
prescription drugs.
The
sample preva-
lences
for
current dependence
on
various psychoac-
tive
substances
are as
follows:
84.2%
for
alcohol,
26.7%
for
anxiolytics,
6.2%
for
opioids,
19.9%
for
1
Although
Pokorny's
original
study
suggests
a
cutoff
score
of 6 for the
Brief
MAST, more recent
studies suggest that
the
specificity
and
sensitivity
of
abbreviated
forms
of the
MAST
using
weighted
items
are
significantly
improved when
the
cutoff
score
for a
diagnosis
of
alcoholism
is
raised
from
5 to
10
(Fleming
&
Barry, 1989).

246
CONROD,
PIHL,
STEWART,
AND
DONGIER
cocaine,
and
9.9%
for
cannabis.
Sixty percent
of the
sample
met
criteria
for
dependence
on
only
one
sub-
stance, 28.2%
for two
substances,
and
11.1%
for
three
or
more substances.
The
polysubstance-abusing
nature
of the
sample permitted
us to
explore
the
validity
of the
motivational model
of
substance abuse
as it
pertains
to
female substance abusers
who are
using
and are
dependent
on a
variety
of
psychoactive
substances.
Procedure
Eligible respondents were scheduled
to
participate
in
a
full
day (5
hr)
of
psychological testing during
which
time they completed
a
number
of
psycholog-
ical tests
and
questionnaires
on
a
computer.
All
par-
ticipants were provided with
$35
Canadian
as
com-
pensation
for
their time.
Assessment
of
Motivational
Profiles
Table
1
lists
the
personality
and
symptom inven-
tories selected
to
measure variation
on
four
dimen-
sions
of
psychological
functioning
that
we
propose
differentially
motivate individuals
to
seek reinforce-
ment
from
drugs
of
abuse.
2
Because these measures
are
widely used
in
current research
on
psychopathol-
ogy,
and
evidence
for
their reliability
and
validity
has
been previously documented, they
are not
reviewed
here.
Assessment
of
Psychopathology
We
used
the
Computerized Diagnostic Interview
Schedule
(C-DIS;
C-DIS
Management Group, 1991)
to
assess lifetime diagnoses
of
psychiatric disorders
according
to
criteria
specified
by the
DSM—H1—R
(American
Psychiatric Association, 1987).
The
C-DIS provides
a
standardized
format
for
question-
ing
individuals about their symptoms while abiding
by
the
DSM-1II-R
decision rules
and
ensures ade-
quate coverage
of all
relevant criteria.
The
C-DIS
has
been shown
to
have adequate
test-retest
reliability
(Blouin,
Perez,
&
Blouin,
1988)
and a
sensitivity that
is
equivalent
to
that
of a
computer-prompted version
of
the
DIS
(Erdman
et
al.,
1992). Participants were
assessed
for all
mood,
anxiety,
and
psychoactive
substance-use
disorders
as
well
as for
antisocial per-
sonality
disorder, somatization disorder,
somatoform
pain disorder, anorexia
nervosa,
bulimia
nervosa,
and
pathological
gambling.
Measures
of
Alcohol
and
Substance
Use,
Dependence,
and
Abuse
Four
dimensions
of
drug-
and
alcohol-related
be-
havior
were assessed:
(a)
current alcohol
and
drug
abuse using
the
telephone-administered Brief MAST
(Pokorny
et
al.,
1972)
and the
DAST (Skinner, 1982),
(b)
current alcohol
and
drug
dependence according
to
DSM-IV
criteria (American Psychiatric Association,
1994),
(c)
average quantity-frequency estimates
and
special-occasion quantity-frequency estimates
of al-
cohol
and
substance
use
(obtained during
the
tele-
phone interview
and
during
a
structured interview
involving
the
Timeline
Follow
Back method devel-
oped
by
Sobell
&
Sobell,
1992),
and (d)
lifetime
alcohol
and
drug abuse
and
dependence using
the
Alcohol
and
Drug Dependence modules
of the
C-DIS.
Results
Demographic Characteristics
of
the
Sample
The
recruitment
procedure
resulted
in the se-
lection
of 300
women
for
participation
in the
study.
In
total,
293
women
(97.7%)
completed
the
full
assessment
battery;
70%
were
French
speaking.
Table
2
details
the
demographic
char-
acteristics
of the
sample.
Derivation
of
Personality
Risk
Profiles
We
performed
a
factor
analysis
on the
entire
battery
of
personality
and
symptom
inventories
(excluding
C-DIS
and
substance
use
information).
We
used
an
eigenvalue
> 1.0
criterion
for
factor
extraction;
four
factors
emerged
representing
Anxiety
Sensitivity,
Sensation
Seeking,
Impulsiv-
ity,
and
Introversion-Hopelessness,
which
to-
gether
accounted
for
69.3%
of the
variance
in the
data.
Table
1
presents
factor
loadings
after
vari-
max
rotation.
We
then
randomly
split
the
sample
into
two
subsamples
and
performed
similar
factor
analyses.
Pairwise
correlations
between
factor
loadings
for
each
factor
across
the two
subsamples
2
To
accommodate
the
bilingual
nature
of
this
Quebec
sample,
all
tests
and
measures were available
in
French
and
English. French translations were
per-
formed
by
employees
of our
research team
who
were
experienced
in
English-to-French
translation.
As a
verification
of
each translation,
they
were
then
back-
translated
by a
separate employee,
and
modifications
to the
original translation were made accordingly.

SUBTYPES
OF
SUBSTANCE ABUSERS
247
Table
1
Results
of
Factor
and
Cluster
Analyses:
Factor
Loadings
of
Personality
and
Symptom
Inventories
Onto
Four
Factors
and
Factor
Scores
of
Five
Clusters
of
Substance
Abusers
Following
Cluster
Analysis
Anxiety
Sensation
Impulsivity/
Introversion/
Personality
or
symptom inventory Sensitivity Seeking Hostility Hopelessness
Neuroticism
(NEO-FFI-N;
Costa
&
McCrae,
1992)
.62 .52
Trait anxiety
(STAI-T;
Spielberger,
Gorsuch,
Lushene,
Vagg,
&
Jacobs,
1983)
.64 .58
Anxiety
sensitivity
(ASI;
Peterson
&
Reiss, 1992)
.79
Anxious
cognitions
(CCL-Anx; Beck, Brown,
Eidelson,
Steer,
&
Riskind,
1987)
.75
PTSD
symptoms
(PSS-SR;
Foa et
al.,
1993)
.75
Depressive cognitions
(CCL-Dep;
Beck
et
al.,
1987)
.58 .63
Extroversion
(NEO-FFI-E;
Costa
&
McCrae, 1992) -.76
Depressive symptoms
(BDI;
Beck, Ward, Mendelson,
Mock,
&
Erbaugh,
1961)
.67 .52
Low
self-esteem (SES; Rosenberg, 1965)
.75
Hopelessness
(BHS; Beck,
Weissman,
Lester,
&
Trexler,
1974)
.69
Sensation
seeking (SSS;
Zuckerman,
1979)
.88
Venturesomeness (Eysenck
&
Eysenck, 1978)
.81
Openness
(NEO-FFI-O;
Costa
&
McCrae, 1992)
.68
-.46
Impulsiveness (Eysenck
&
Eysenck, 1978)
.75
Agreeableness
(NEO-FFI-A; Costa
&
McCrae, 1992) -.73
Conscientiousness
(NEO-FH-C;
Costa
&
McCrae,
1992) -.58
Clusters
of
female substance
abusers
Anxiety sensitive
(n
= 53)
M
SD
Introverted/hopeless
(n = 53)
M
SD
Sensation
seeking
(n
=
72)
M
SD
Impulsive
(n = 73)
M
SD
Low
personality
risk
(n
=
42)
M
SD
Factor scores
1.34
0.60
-0.00
0.84
-0.23
0.75
-0.68
0.60
-0.10
0.85
-0.25
0.84
-0.12
0.90
0.84
0.60
0.15
0.85
-1.22
0.65
0.67
0.72
-0.75
0.66
-0.65
0.58
1.00
0.65
-0.51
0.73
-0.20
0.84
1.24
0.75
-0.58
0.65
0.22
0.85
-0.69
0.56
Note.
NEO-FFI-N
=
NEO
Five-Factor
Inventory—Neuroticism
scale;
STAI-T
=
State-Trait
Anxiety
Inventory,
Trait scale;
ASI =
Anxiety
Sensitive Index; CCL-Anx
=
Cognition
Checklist—Anxiety
scale;
PTSD
=
posttraumatic
stress
disorder; PSS-SR
=
Posttraumatic
Stress Symptom
Scale—Self
Report;
CCL-Dep
=
CCL—Depression
scale;
NEO-FFI-E
=
NEO-FFI—Extroversion
scale;
BDI =
Beck Depres-
sion Inventory;
SES =
Self-Esteem
Scale;
BHS =
Beck Hopelessness Scale;
SSS =
Sensation-Seeking Scale
Form
V;
NEO-FFI-O
=
NEO-FFI—Openness
scale;
NEO-FFI-A
=
NEO-FFI—Agreeableness
scale;
NEO-FFI-C
=
NEO-FFI—Conscientiousness
scale.
were
very
high
(r
=
.94-98),
thus
demonstrating
the
previous
analysis.
The
percentage
change
the reliability of the
factor-analytic
findings.
3
in
agglomeration
coefficients
(sum
of the
We
then
performed
cluster
analyses
to
gain
a
perspective
on the
distribution
of
such
fac-
tors
in the
current
sample.
We
obtained
initial
3
Confirmatory
factor
analyses were
performed
to
clusters
using
Ward's
squared
Euclidean
dis- compare
the fit of
this
four-factor
model
relative
to
tance
method
using
factor
scores
yielded
from
2
three-factor models
(in
which
anxiety-
and

248
CONROD,
PIHL,
STEWART,
AND
DONGIER
Table
2
Demographic
Characteristics
of
Five
Subtypes
of
Female
Substance
Abusers:
Subtype
and
Total
Sample
Percentages
or
Means
Variable
Age
M
SD
Marital status
(%)
Never married
Married, living
with
spouse
Common-law married
Married
but
separated
Widowed
Divorced
Living
situation
(%)
Living
alone
Living with spouse
Living
with
roommate
Living
with children only
Living
with parents
No. of
children
M
SD
Education (years)
M
SD
Level
of
education
(%)
High school incomplete
High school diploma
College
degree
1-4
years university
Postgraduate degree
Current
employment
(%)
Full time
Part time
Unemployed
Homemaker
Full-time student
Personal income
M
SD
Total
38.7
5.90
51.9
7.6
7.9
6.5
1.7
24.4
38.3
25.9
10.0
24.1
1.7
1.0
1.0
12.9
3.8
15.9
37.4
12.8
29.1
4.8
17.5
14.4
37.7
27.1
3.4
12,957
11,747
Anxiety
sensitive
38.3
5.9
46.2
13.5
5.8
9.6
5.8
19.2
40.4
32.7
5.8
21.2
0
1.1
1.1
11.8
3.7
23.1
40.4
11.5
23.1
1.9
24.5
7.5
22.6
41.5
3.8
13,479
13,375
Introverted/
hopeless
39.9
6.3
55.8
11.5
5.8
5.8
0
21.2
44.2
23.1
9.6
17.3
5.8
0.9
1.2
14.4
3.9
11.8
29.4
15.7
35.3
7.8
17.3
15.4
46.2
19.2
1.9
12,956
10,967
Sensation
seeking
38.6
5.8
56.9
1.4
11.1
8.3
0
22.2
37.5
22.2
12.5
26.4
1.4
1.0
1.0
13.9
3.7
12.5
27.8
8.3
44.4
6.9
23.6
16.7
33.3
23.6
2.8
14,354
10,465
Low
personality
Impulsive risk
37.8
5.4
58.9
5.5
6.8
4.1
1.4
23.3
30.1
27.4
12.3
28.8
1.4
1.0
0.9
12.0
3.3
18.1
45.8
11.1
20.8
4.2
5.5
17.8
45.2
26.0
5.5
11,092
13,322
39.5
6.4
33.3
9.5
9.5
4.8
2.4
40.5
43.9
24.4
7.3
24.4
0
1.1
1.2
12.0
3.5
14.3
45.2
21.4
16.7
2.4
19.0
11.9
40.5
26.2
2.4
13,150
9,799
squared
distances
between
clusters)
to
next
level
for 2 to 9
clusters,
respectively,
were
depression-relevant items were forced onto
one
fac-
tor
or
anxiety
and
depression
factors
were held sep-
arate
and
impulsivity
and
sensation-seeking items
were
forced
on one
factor)
and a
two-factor model
(in
which
anxiety-
and
depression-relevant items were
forced
onto
one
factor
and
impulsivity
and
sensation
seeking
were
forced
onto another). Results
of
these
analyses
are:
four-factor
model:
x*(92,
N =
243)
=
323.5, three-factor model:
^(88,
N =
243)
=
576.4,
and
^(87,
N =
243)
=
456.8,
two-factor,
^(86,
N =
243)
=
374.8,
and
indicate superiority
of
the
four-
factor
model relative
to the
alternative models.
15.9, 15.2, 13.1, 10.0, 10.0, 7.3, 6.6,
and
6.7.
The
scree
plot
method
for
determining
the
number
of
clusters
in a
data
set (as
suggested
by
Hair,
Anderson,
Tathames,
&
Black,
1995)
indicated
a five-cluster
solution
(i.e.,
the
point
at
which
the
slope
for
change
in
agglomera-
tion
coefficients
became
0). We
then
per-
formed
a
K-means
clustering
analysis,
con-
strained
to a five-cluster
solution,
on
factor
scores
using
cluster
centroids
from
the
hier-
archical
cluster
analysis.
Table
1
also
presents
mean
factor
scores
on
each
motivational
di-
mension
for the five
clusters
yielded
from
this
analysis.
We
then
repeated
this
procedure
on
the two
split-half
samples
to
assess
the
reli-

SUBTYPES
OF
SUBSTANCE
ABUSERS
249
ability
of the findings. The
scree
plot
method
and
Mojena's
(1977) rules
for
determining
the
number
of
clusters
in a
data
set
suggested
five-cluster
solutions
for
both
samples.
Chi-
square
analysis indicated
a
highly significant
rate
of
agreement (86%) between cluster
as-
signments
based
on the
full
and
split-half
sample solutions,
x*(\6,
N =
293)
=
786.4,
p
<
.00001.
Analysis
of
cluster group
effects
on the
demographic variables
(Table
2)
indicated
cluster effects
on
total number
of
years
of
education
completed,
F(4,
288)
=
6.04,
p <
.01; level
of
education,
*
2
(16,
N =
293)
=
26.19,
p <
.06;
and
current employment sta-
tus,
x
2
(16,
N =
293)
=
26.34,
p <
.08.
Post
hoc
chi-square
analyses exploring these
ef-
fects
indicated
that
(a)
introverted-hopeless
and
sensation-seeking women were
more
likely
to
achieve postsecondary levels
of ed-
ucation
(p <
.01),
(b)
impulsive women were
underrepresented
in the
full-time
employment
category
(p <
.05),
and (c)
anxiety-sensitive
women
more
often
indicated
homemaking
as
their
full-time
employment
(p <
.05).
Validation
of
Clusters
Differential
vulnerability
to
DSM-III-R
life-
time
psychiatric disorders. Lifetime preva-
lences
for
DSM-Hl-R
nonaddictive
disorders
for
this sample
and
self-report mean
age of
onset
of first
symptom
for
each disorder
ap-
pear
in
Table
3 . We
assessed
group
differ-
ences
in
risk
for
each lifetime diagnosis using
chi-square analyses
on
rates
of
diagnosis
in
each group relative
to the
rate
of
diagnosis
across
the
entire sample. Results indicated
significant
cluster main effects
for
lifetime
diagnoses
of
major
depressive
episode,
j^(4,
N
=
284)
=
10.43,
p <
.01;
recurrent major
depression,
^(4,
N =
284)
=
4.48,
p <
.05;
panic
disorder,
)f(4,
N =
284)
=
5.92,
p <
.05;
social
phobia,
^(4,
N =
284)
=
9.66,
p <
.01;
simple
phobia,
^(4,
N =
284)
=
5.30,
p <
.05; somatization,
/(4,
N =
284)
=
19.08,
p <
.001;
and
antisocial personality disorder,
x
i
(4,
N
=
284)
=
6.57,
p
<.05. Also presented
in
Table
3 are
odds ratios representing lifetime
risk
for
various
C-DIS
diagnoses
for
each cluster
group
relative
to
lifetime
risk for the
remaining
sample. Chi-square analyses were also used
to
Table
3
Sample
Prevalences,
Age of
Onset
of
First
Symptom,
and
Subtype
Risk
for
Lifetime
DSM-III-R
Mood,
Anxiety, Personality,
and
Substance Dependence Diagnoses
Age
of
onset
of
firiil
Relative risk
of
lifetime diagnosis
(odds ratios)
by
cluster
Prevalence symptom
Diagnosis
Antisocial
personality
Recurrent depression
Major
depressive episode
Panic
and/or
agoraphobia
Social phobia
Simple phobia
Somatization
Generalized anxiety
Alcohol dependence
Anxiolytic
dependence
Cocaine dependence
Cannabis
dependence
Opioid dependence
in
full
sample
9.7
37.5
46.2
31.9
29.2
33.0
7.6
21.2
81.6
22.9
28.5
17.7
9.7
M
7.6
29.2
29.7
25.5
19.3
14.9
13.7
23.3
24.3
28.8
27.5
19.2
25.5
SD
2.0
10.8
11.03
10.5
12.3
11.1
5.5
15.3
8.4
9.7
6.9
6.0
6.7
Anxiety
Introverted-
sensitive
1.4
1.8
1.1
1.5
1.7
2.1*
5.8***
1.9*
0.5
3.0***
1.5
0.5
1.3
hopeless
0.5
1.9*
2.7**
2.1*
2.6**
1.0
1.6
1.5
1.2
1.7
0.5
0.5
2.9*
Sensation
seeking
0.5
0.9
0.8
0.8
0.5
0.9
0.4
1.0
4J**
0.6
1.2
2.0
1.1
Low
personality
Impulsive
2.8**
0.4
0.7
0.6
0.9
0.9
0.1
0.3
2.7*
0.3
1.8*
1.1
0.2
risk
0.5
0.7
0.5
0.7
0.5
0.7
0.3
1.0
0.3
0.7
0.5
1.0
0.4
Note.
Boldface values indicate
significant
effects.
Odds ratios
refer
to risk for a
DSM-IH-R
diagnosis
in an
individual
subtype relative
to risk
within
the
remaining sample.
Significant
odds
ratios
(tested using Pearson
chi-square values)
are
indicated with asterisks (i.e.,
the
impulsive group demonstrated
2.8
times greater
risk
for
antisocial personality disorder relative
to
risk estimated across
the
other
four
subtypes,
p <
.01).
DSM-Hl-R
=
Diagnostic
and
Statistical Manual
of
Mental Disorders
(3rd ed.,
rev.).
*p<.05.
**/><.01.
***p<.001.

250
CONROD,
PIHL,
STEWART,
AND
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SUBTYPES
OF
SUBSTANCE
ABUSERS
251
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Cells
with
asterisks
indica
sensitive
subtype
is
represented
i
distribution).
MAST
=
Michigan
sensation
seeking;
I =
impulsive:
"
Due to
missing
values, degrees
*p<.05.
**p<.01.
***p

252
CONROD,
PIHL,
STEWART,
AND
DONGffiR
determine whether
the
odds
of a
diagnosis
in a
particular
subtype
were
significantly
greater
than
those
for the
remaining
four
subtypes (e.g,.
impulsive
vs. all
nonimpulsive subtypes). Sig-
nificant
effects
showed that
the
introverted-
hopeless group evidenced
a
significantly
ele-
vated relative
risk
for
lifetime
diagnoses
of
major
depressive
episode,
recurrent
major
de-
pression,
panic
disorder,
and
social phobia.
By
contrast,
the
anxiety-sensitive group demon-
strated
an
elevated lifetime
risk for
simple pho-
bia,
somatization,
and
generalized
anxiety
dis-
orders,
and the
impulsive group demonstrated
an
elevated lifetime risk
for a
diagnosis
of an-
tisocial
personality
disorder.
The
sensation-
seeking
and
low-personality-risk groups
did not
show
elevated
risks for any of the
psychiatric
disorders
assessed.
Differential
vulnerability
to
lifetime
DSM-
III—R
psychoactive
substance dependence.
Similar chi-square analyses were used
to ex-
plore subtype differences
in
lifetime rates
of
DSM-III-R
psychoactive substance dependen-
cies (see
Table
3).
Analyses indicated
signifi-
cant subtype
differences
for
alcohol,
^(4,
N —
284)
=
22.3,
p <
.001;
anxiolytic,
;f
(4,
N =
284)
=
19.42,
p <
.001; cocaine,
;f(4,
N =
284)
=
8.9,
p <
.01;
and
opioid dependence,
X
2
(4,
N
=
284)
=
10.3,
p <
.01.
The
groups
did
not
differ
in
lifetime rates
of
cannabis
depen-
dence,
x*(4,
N =
284)
=
6.90,
ns,
and
heroin
and
inhalant substance dependence were
too
uncommon
to
test
for
group
differences
in
prev-
alence rates. Table
3
also contains odds ratios
reflecting
risk
within each subtype
for
lifetime
dependence
on a
particular substance relative
to
rates
of
diagnosis calculated
for the
remain-
ing
subtypes.
As
indicated
in the
table,
the
sensation-seeking
group
was
more than
four
times,
and the
impulsive
group
was two
times,
more likely
to be
diagnosed
with
alcohol depen-
dence
relative
to the
other groups.
The
anxiety-
sensitive subtype demonstrated
a
threefold
in-
creased
risk for
anxiolytic
dependence,
and the
introverted-hopeless
subtype demonstrated
a
threefold
increased
risk for
opioid dependence.
Differential
use
of
alcohol
and
drugs. Table
4
presents group means
and
standard deviations
for
variables representing quantity-frequency
of
current alcohol
and
drug consumption.
Whenever
possible,
we
performed one-way
analyses
of
variance
on the
data
to
establish
whether group differences existed. Variables
such
as
quantity
of
anxiolytic, opioid, cannabis,
or
cocaine consumption
per
month were
not
normally
distributed
and
were thus converted
to
categorical variables
and
analyzed with chi-
squares.
These variables included three catego-
ries
representing
(a)
those
who
reported
no use
at
all,
(b)
those
who
reported infrequent use,
and
(c)
those
who
reported regular
or
heavy
use.
4
Analyses indicated higher rates
of
anxiolytic
substance use, abuse,
and
dependence among
the
anxiety-sensitive-subtype participants
and
higher rates
of
cocaine use, abuse,
and
depen-
dence among
the
impulsive-subtype partici-
pants. Despite equivalent dependence scores,
the
impulsive-subtype participants also reported
a
greater number
of
negative consequences
as-
sociated with
alcohol
use
(i.e.,
higher MAST
scores)
and
self-reported consuming greater
quantities
of
alcohol, cocaine,
and
cannabis
on a
monthly
basis.
Drug
of
choice
by
cluster.
To
test
the hy-
pothesis that
the
identified subtypes would dem-
onstrate preferential
use of
substances with spe-
cific
reinforcing properties,
we
categorized
participants
according
to
whether they demon-
strated
one of the
following current drug depen-
dence patterns:
alcohol
only,
stimulant drugs
only
(with
or
without alcohol dependence),
an-
xiolytic
drugs only
(with
or
without alcohol
dependence),
and
opioid drugs
only
(with
or
without
alcohol dependence). Chi-square
anal-
yses
indicated
that
a
significantly
larger propor-
tion
of the
sensation-seeking group (76.4%)
and
a
significantly
smaller proportion
of the
anxiety-sensitive
group (26.4%)
reported
de-
pendence
on
alcohol exclusively relative
to the
rate
of
alcohol dependence
across
the
remain-
ing
groups (52%),
x*(4,
N
=
284)
=
32.00,
p <
.001.
As
hypothesized,
a
significantly
larger
proportion
of the
impulsive
group (23%)
re-
ported
exclusive stimulant dependence
(10%),
X
2
(4,
N =
284)
=
13.69,
p
<.001,
and a
sig-
4
Because
of the
small
rate
of
cocaine
and
canna-
bis use in
this
sample,
heavy
drug
use was
deter-
mined
on the
basis
of the
cutoff
for the top 15% of
cocaine
(>2 g per
month)
and
cannabis
(>2 g per
month)
users.
Because
anxiolytic
use was
more
fre-
quent,
heavy
use was
denned
on
the
basis
of
the
cutoff
for the top 25% of
users
(>90
mg
of
loraz-
epam
equivalents).

SUBTYPES
OF
SUBSTANCE
ABUSERS
253
nificantly
larger proportion
of the
anxiety-
sensitive
group (34%)
reported
exclusive
anxi-
olytic
dependence relative
to the
other groups
(16%),
;p(4,
AT
=
284)
=
20.56,
p <
.001.
Finally, although
the
prevalence
of
exclusive
opiate
dependence
was
elevated
for the
introverted-hopeless
subtype (5.7%
vs.
1.7%),
differences
did not
reach significance.
Discussion
We
tested
a
series
of
hypotheses linking dis-
tinct personality profiles
with
specific patterns
of
drug dependency
and
comorbid
psychopa-
thology.
The first
step
in
this investigation
was
to
test
the
validity
of
categorizing
a
variety
of
personality risk factors
for
substance abuse
along four hypothesized motivational dimen-
sions.
Factor
analysis indicated that
four
sepa-
rate factors were reliably
delineated:
Anxiety
Sensitivity,
Introversion-Hopelessness,
Sensa-
tion
Seeking,
and
Impulsivity.
These results
are
not
interpreted
as
reflecting
the
structure
of
per-
sonality,
per se, as
this study focused only
on
aspects
of
psychological
functioning
that
are
known
to be
associated with
risk for
substance
abuse. Nevertheless,
the
present results yield-
ing
four
personality factors
are
consistent with
numerous
other
reports
suggesting
that
neu-
roticism,
extroversion-sociability, experience
seeking-venturesomeness,
and
impulsivity rep-
resent separate dimensions
of
personality (e.g.,
Costa
&
McCrae, 1992; Eysenck
&
Eysenck,
1978;
Zuckerman,
1994).
We
further
hypothesized that substance
abusers classified
on the
basis
of
different
personality/motivational
profiles
for
sub-
stance
abuse would manifest
different
pat-
terns
of
substance abuse
and
comorbid psy-
chopathology.
Our
hypotheses were generally
confirmed,
in
that
five
specific
personality
configurations
were reliably
identified
from
cluster
analyses
on two
(split-half) sub-
samples randomly selected from
the
original
sample.
Our
claim
that
these
four
personality
dimensions
reflect
motivation
for
substance
abuse
was
partially supported
by the finding
that
a
cluster
of
women
classified
on the
basis
of
relatively
low
scores
on all
dimensions
of
personality
also
demonstrated
the
lowest life-
time
rates
of
psychopathology
and
polysub-
stance abuse. Nevertheless, this group still
met
criteria
for
substance abuse
or
depen-
dence, indicating that additional
unidentified
vulnerability
factors
for
drug abuse might
be
relevant
to
this group.
Anxiety
Sensitivity
as a
Motivational
Link
Between
Anxiety
and
Substance-Use
Disorders
Stewart
(1996)
previously suggested that
the
overlap between alcoholism
and
anxiety
disor-
ders
can be
explained
by the
fact
that anxiety
sensitivity
is
common
to
both classes
of
disor-
ders.
The
present results
further
support this
claim
in
that anxiety-sensitive women
in the
present sample evidenced
a
preferential
use of
substances
with
anxiolytic
properties
and the
highest rates
of
anxiolytic drug
dependence,
somatization
(23%),
and
simple phobia
(49%).
Although this group
did
demonstrate
elevated
rates
of
panic disorder (39%) relative
to all
clusters other than
the
introverted-hopeless
group (25%),
it was the
introverted-hopeless
subtype that evidenced
the
highest
rates
of
panic-related anxiety disorders (45%).
This
finding
stands
in
contrast
to
previous reports
of
a
strong relationship between anxiety sensitivity
and
panic disorder (Mailer
&
Reiss, 1992),
yet
it
might
be
explained
by the
fact
that approxi-
mately
50% of the
anxiety-sensitive women
were consuming anxiolytic medication daily,
which
likely resulted
in the
dampening
of
panic
symptoms.
Anxiolytic substance dependence
and
anxiety symptoms
may
represent alterna-
tive
manifestations
of a
similar underlying
mechanism,
namely anxiety sensitivity. Fur-
thermore,
the
finding
that
the
anxiety-sensitive
subtype
demonstrated
the
most severe
use/
abuse
of
anxiolytics,
but not
necessarily
the
highest
rates
of
panic-related
anxiety
disorders,
occludes
interpretation
of the
relationship
be-
tween
anxiolytic substance abuse
and
anxiety
disorders
as
reflecting
an
influence
of
anxiolytic
use on
anxiety
sensitivity
and
related symp-
toms.
The
fact
that
the
mean
age of
onset
of first
symptom
of any
anxiety disorder preceded
the
onset
of
anxiolytic substance abuse also chal-
lenges this alternative hypothesis. Finally,
it is
worthwhile
to
mention that
the
most robust
finding
with
respect
to
rates
of
psychopathology
in
the
anxiety-sensitive group
was a
higher
prevalence
of
somatization disorder (23.5%).

254
CONROD,
PIHL,
STEWART,
AND
DONGIER
This latter
finding is
consistent
with
recent
re-
search suggesting that anxiety sensitivity
re-
flects not
only
a
fear
of
anxiety-related bodily
sensations (e.g., dizziness, rapid heartbeat) but,
more broadly,
a
fear
of any
unusual bodily
sensation
(e.g.,
rashes, headaches; Otto, Pol-
lack,
Sachs,
&
Rosenbaum,
1992).
Introversion-Hopelessness
as the
Motivational
Link
Between
Depression
and
Analgesic
Drug
Use
A
very interesting
and
novel rinding
of the
present investigation
was
that substance-abusing
women
who
manifested depressive
and
pessi-
mistic cognitions were prone
to
preferential
abuse
of
substances that possess analgesic prop-
erties
and
psychological
disorders
involving
so-
cial withdrawal
and
extinction
of
social behav-
iors (e.g.,
comorbid
depressive disorders
and
social phobia). Although pessimism
and
intro-
version
have previously been linked
to
vulner-
ability
to
panic disorder, social phobia,
and de-
pression (Ball, Otto,
&
Pollack,
1995),
the
rinding
of a
very
specific
relationship between
this
personality
profile
and
opioid dependence
is
rather original. Because
of the low
rates
of
opioid
use in
this sample, replication
of
these
findings
using
larger samples
of
prescription
drug
abusers will
be
necessary. Nevertheless,
this
personality profile
may
provide
the
missing
link
when attempting
to
understand
the
func-
tional
relation between depression
and
sub-
stance
abuse.
Sensation
Seeking
and
Alcohol
Abuse
As
hypothesized,
a
motivational
profile
in-
volving
high sensation seeking, openness
to ex-
perience,
and
extraversion
was
associated
with
a
preferential dependence
on
alcohol. This
find-
ing is
consistent
with
a
substantial body
of
theoretical
and
empirical
literature
suggesting
that
sensitivity
to
alcohol
reinforcement
consti-
tutes
a
pathway
to
alcoholism that
is
indepen-
dent
of
other personality-based vulnerability
pathways,
such
as a
negative-affect
or
deviance-
proneness
pathway
(Conrod,
Peterson,
&
Pihl,
1997;
Sher, 1993).
Impulsivity,
Self-Regulation,
and
Polysubstance
Abuse
As
hypothesized, women
who
were identi-
fied
on
the
basis
of
their
general tendency
to
react impulsively demonstrated antisocial
personality
traits
and an
unconstrained
pattern
of
drug abuse.
It is
interesting that this
im-
pulsive
subtype
was
significantly
more likely
to use or
abuse cocaine, alcohol,
and
cannabis—substances
that have been shown
to
affect
mesolimbic
dopaminergic
activity
(Chait
&
Zacny, 1992; DiChiara
et
al.,
1992).
This
finding
speaks
to our
original hypothesis
that such
a
personality
profile
would
be
asso-
ciated with deficits
in
regulating behaviors
in
the
presence
of
positive reinforcement.
An
alternative interpretation
of
these
findings
might
be
that chemical dependence causes
an
increase
in
impulsive
and
antisocial behavior.
However,
the
mean
age of
onset
of
conduct
problems
(7
years) preceded severe substance
abuse
in the
current sample, thus suggesting
that
at
least some aspect
of the
impulsive
personality
existed
before
the
substance
use
disorder.
Although
the
results
of
this study
may
loosely
parallel
Cloninger's
(1987)
Type
I-Type
II
or
Babor
et
al.'s
(1992)
Type
A-Type
B
typolo-
gies,
the
present
findings
also suggest that
a
two-cluster
structure
may not
adequately cap-
ture
the
true
heterogeneity
within
female
substance-abusing
populations.
For
example,
sensation
seeking (characteristic
of
Cloninger's
Type
II,
male-limited alcoholism) described
two
female
alcoholic subtypes
in the
present
study,
yet
only
one of
these appeared
to be
related
to
impulsivity, antisociality,
and
poly-
substance
abuse. Furthermore, distinguishing
between
anxiety
sensitivity
and
introversion-
hopelessness,
which
might
characterize Clon-
inger's
(1987) Type
I
alcoholic,
identified
two
subtypes
of
female
substance abusers
who
pre-
sented
with
distinct patterns
of
psychopathol-
ogy and
substance
dependence.
Future
investi-
gations
involving
clinical
populations
and
male
participants
will
be
required
to
further
explore
the
generalizability
of the
proposed
typology.
Nevertheless,
the
present
findings arc
very
promising
and
provide
insight
into
factors
that
should
be
targeted
in
subtype-specific
interventions.

SUBTYPES
OF
SUBSTANCE
ABUSERS
255
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Received
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14,
1999
Revision
received
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22,
1999
Accepted
January
4,
2000
•