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

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.

Full text

512 © 2020 Medical Journal of Dr. D.Y. Patil Vidyapeeth | Published by Wolters Kluwer - Medknow
 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.  This study aims to study the
prevalence and pattern of AIPD and personality prole in AUD and AIPD patients.
Materials and Methods: Consecutive sample of 100 patients with AUD fullling
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.  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.
 Alcohol use disorders, neuroticism, personality, psychosis,
psychoticism

 
Gowtham C. Reddy, P. S. Murthy, Suprakash Chaudhury1
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DOI:
10.4103/mjdrdypu.mjdrdypu_147_18
Address for correspondence: Dr. Suprakash Chaudhury,
Department of Psychiatry, Dr. DY Patil Medical College,
Hospital and Research Center, Dr. DY Patil University, Pimpri,
Pune ‑ 411 018, Maharashtra, India.
E‑mail: suprakashch@gmail.com
of vulnerability to develop alcohol dependence. In
general, there are two types of approach regarding
personality assessment. In the rst, personality
pathology is conceptualized within the context of
categorically dened personality disorders, with most


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
Department of Psychiatry,
Santhiram Medical College
and General Hospital,
Nandyala, Andhra Pradesh,
1Department of Psychiatry,
Dr. DY Patil Medical
College, Hospital and
Research Center, Dr. DY
Patil Vidyapeeth, Pune,
Maharashtra, India
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given and the new creaons are licensed under the idencal terms.
For reprints contact: reprints@medknow.com
How to cite this article: Reddy GC, Murthy PS, 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.

 06‑09‑2018,
20‑10‑2018,
 07‑07‑2020,
07‑09‑2020
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Reddy, et al.: Psychoses and personality prole in alcohol use disorder
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Medical Journal of Dr. D.Y. Patil Vidyapeeth ¦ Volume 13 ¦ Issue 5 ¦ September-October 2020
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
inuential personality models those of Eysenck,
Cloninger, and McCrae and Costa’s ve 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 proles and pattern of psychosis in AUD
patients.

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
fullling 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 <5 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.

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.
In this study, 9 patients who scored high lie score (>5)
were excluded from the assessment of personality
prole 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
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Reddy, et al.: Psychoses and personality prole in alcohol use disorder
514 Medical Journal of Dr. D.Y. Patil Vidyapeeth ¦ Volume 13 ¦ Issue 5 ¦ September-October 2020
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 signicantly higher psychoticism trait and
signicantly lower extraversion trait. Majority (66.7%)
of the individuals with signicant psychoticism were
severe AUD patients. This correlation between severity
of AUD and psychoticism trait was statistically
signicant (P < 0.05) [Figure 1] but not for extraversion
and neuroticism [Figures 2 and 3].

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 nding
is in agreement with an earlier Indian study.[9]
The most common psychotic symptom in the current
study was auditory hallucinations. This nding was
similar to an earlier Indian study.[10] Higher gures
were reported by a Malaysian study which found
that among the 34 subjects with alcohol‑induced
psychotic disorder (AIPD) 26 (76.5%) subjects had


 nnnnnn
Age (years)
21‑30 8 0 8
31‑40 24 0 24
41‑50 53 5 48
51‑60 15 4 11
Geographic area
Urban 21 0 21
Semiurban 30 1 29
Rural 49 8 41
Education
Illiterate 5 2 3
Primary 39 5 34
Secondary 31 2 29
Intermediate 15 0 15
Degree/postgraduate 10 0 10
Duration of alcohol intake (in years)
<5 8 0 8
6‑10 16 0 16
11‑15 24 1 23
>15 52 8 44
Severity of AUD
Mild 11 011
Moderate 37 0 37
Severe 52 9 43
Psychotic symptoms
None 91 0 91
Hallucinations 7 7 0
Both delusions and hallucinations 2 2 0
AUD: Alcohol use disorder, AIPD: Alcohol‑induced psychotic disorder
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Reddy, et al.: Psychoses and personality prole in alcohol use disorder
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Medical Journal of Dr. D.Y. Patil Vidyapeeth ¦ Volume 13 ¦ Issue 5 ¦ September-October 2020
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, ndings 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 ndings 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
nding 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 ndings 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]
Personality prole in alcohol‑induced psychotic
and alcohol use disorder
In the present study, the patients with AIP had
signicantly higher psychoticism and lower extraversion
n
 
n (%)

n

n

Fishers P
Psychoticism trait
Signicant 60 (65.93) 9 46 0.0254 <0.05 (S)
Insignicant 31 (34.07) 0 36
Extraversion trait
Extrovert 61 (67.03) 1 60 0.0005 <0.05 (S)
Ambivert 30 (32.97) 8 22
Neuroticism trait
Neurotic 50 (54.95) 7 41 0.1636 >0.05 (NS)
Average emotional stability 41 (45.05) 2 41
S: Signicant, NS: Not signicant, AUD: Alcohol use disorder, AIPD: Alcohol‑induced psychotic disorder
0
11
(35.5%)
20
(33.3%) 15
(48.4%)
40
(66.7%)
5
(16.1%)
0
5
10
15
20
25
30
35
40
45
> 4 (Significant)≤ 4 (Insignificant)
Personality Profile (Psychoticism trait)
Mild
Moderate
Severe
 Severity of alcohol use disorder and psychoticism trait
5
(10.3%)
6
(14%)
20
(41.7%)
15
(35%)
23
(48%)22
(51%)
0
5
10
15
20
25
≥14(Highly neurotic)13 to 5(Average emotional stability)
Personality Profile (Neuroticism trait)
Mild
Moderate
Severe
: Severity of alcohol use disorder and neuroticism trait
4
(9.1%)
7
(15%)
16
(36.4%)
19
(40.4%)
24
(54.5%)21
(44.6%)
0
5
10
15
20
25
30
≥ 17 (Extrovert)16 –8 (Ambivert)
Personality Profile (Extraversion trait)
Mild
Moderate
Severe
Figure 2: Severity of alcohol use disorder and extraversion trait
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Reddy, et al.: Psychoses and personality prole in alcohol use disorder
516 Medical Journal of Dr. D.Y. Patil Vidyapeeth ¦ Volume 13 ¦ Issue 5 ¦ September-October 2020
trait as compared to AUD patients without AIP.
Neuroticism trait though higher in AIP patients was not
signicantly different from the AUD groups.
In this study, it has been observed that high psychoticism
and high extraversion traits were signicantly
associated with AUD. Although AUD subjects had
high neuroticism, it was not statistically signicant. 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 high P level are
signicantly 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
reection 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 signicantly higher levels
of psychoticism and extraversion. Neuroticism was
also high in AUD patients but not signicant. These
ndings are in agreement with the nding 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.[16‑18]
This nding is consistent with the suggestion that
impulsivity measured by the psychoticism part of
EPQ was more associated with substance use.[19‑21]
Neuroticism appears to correlate positively with alcohol
consumption specically among those with clinically
signicant 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 ndings 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
reect psychoticism and neuroticism than nonpsychiatric
controls.[25]
The results in the current study correlated with a
meta‑analysis to quantify the relationship between the
ve‑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 nding
suggests that signicantly higher number of ambiverts
were susceptible to AUDs than extroverts and introverts.
The results of the current study were in contrast to
the ndings 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 benets 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, afliate 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
11
00
37
00
43
7
2
0
5
10
15
20
25
30
35
40
45
50
None Hallucinations Both delusions &
hallucinations
Psychotic Symptoms
Mild
Moderate
Severe
 Severity of alcohol use disorder and psychotic symptoms
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Reddy, et al.: Psychoses and personality prole in alcohol use disorder
517
Medical Journal of Dr. D.Y. Patil Vidyapeeth ¦ Volume 13 ¦ Issue 5 ¦ September-October 2020
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 prole 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
difculty 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 ndings 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.

Alcohol‑induced psychosis was found in small but
signicant 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.
Conicts of interest
There are no conicts of interest.

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