Answer & Explanation:Identify and discuss the two types of conduct disorder that are
commonly identified by therapists. Assess the similarities and
differences between the two. Discuss the prevalence of these disorders
amongst the general population and treatment options. Identify and
discuss the link to criminal behavior. the question should be between 500-1000 words A minimum of two references APA 6th edition citations and references
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Journal of Abnormal Psychology
1994, Vol. (03, No. 1.92-102
Copyright 1994 by the American Psychological Association, Inc.
0021-843X/94/S3.00
Personality and Disinhibitory Psychopathology:
Alcoholism and Antisocial Personality Disorder
Kenneth J. Sher and Timothy J. Trull
We discuss the relation between personality factors and two adult forms of disinhibitory psychopathology—alcohol abuse or dependence and antisocial personality disorder. First, we briefly review
various methodological issues relevant to research in this area. Next, we review empirical findings
relating three broad-band personality trait dimensions (neuroticism/emotionality, impuisivity/disinhibition, extroversion/sociability) to both alcohol abuse and dependence and antisocial personality
disorder. Finally, theoretical models of the relationship between personality and each of these two
disorders are presented. We conclude that although no single personality description is likely to be
both a sensitive and specific indicator of either alcoholism or antisocial personality disorder, personality variables are important components of etiological models of these disorders.
Disorders characterized by deficits in self-control such as alcoholism and antisocial personality disorder (APD) are both
relatively prevalent and extremely costly to society. In the Epidemiological Catchment Area (ECA) study, alcohol abuse or dependence, drug abuse or dependence, and APD were found to
be the most prevalent lifetime and 6-month diagnoses in men
(Meyers et al., 1984; Robins et al., 1984), and substance use
disorders were particularly prevalent among both men and
women in early adulthood and among men in midadulthood
(Meyers etal., 1984).
An understanding of the factors that contribute to the development and maintenance of these prevalent disorders holds
promise for developing more effective prevention and treatment
interventions for these conditions. In this article, we address the
question of the relation between personality factors and disinhibitory psychopathology, such as alcohol abuse and dependence, APD, and related conditions. We consider both alcoholism and APD under the general rubric of disinhibitory psychopathology, a term used by Gorenstein and Newman (1980) to
refer to a range of conditions marked by a failure of self-control,
such as hyperactivity in children, antisocial behavior in adolescents, and psychopathy and primary alcoholism in adulthood.
The unifying themes across these phenotypically related yet distinct conditions include deficits in inhibition and excesses in
rule-breaking or norm-violating behavior. The assumption that
these disorders are related, perhaps at the level of personality, is
implicit in much clinical thinking and is explicit in some older
diagnostic schemes (such as the original Diagnostic and Statistical Manual of Mental Disorders; American Psychiatric Association [APA], 1952). In this review, we specifically focus on
alcoholism and APD because of the extensive history of personality-based research on each of these disorders, because some
influential theorists (e.g., Cloninger, 1987a, 1987b; Gorenstein
& Newman, 1980) have postulated a common underlying vulnerability to these two disorders, and because each of these two
disorders represents somewhat different research traditions and
approaches.
Despite the seemingly widespread acceptance of concepts
like the “addictive personality” among the general public, decades of empirical research, summarized in many comprehensive reviews, has repeatedly failed to identify a unique pattern
of personality traits characterizing alcoholics or other substance
abusers (e.g., Barnes, 1983; Cox, 1985; Lang, 1983; Nathan,
1988; Sutker & Allain, 1988; Syme, 1957). This is not to say
that personality factors are unrelated to disinhibitory psychopathology, only that there is no single constellation of traits that
is both a sensitive and specific indicator of addiction (and, presumably, other related disorders).
What constitutes personality? As noted by Nathan (1988),
“Investigators of the link between personality and alcohol and
drug abuse have defined personality in a variety of ways, with
unfortunate consequences for both the reliability and validity
of their efforts” (p. 183). Reviewing definitions of personality
proposed by Allport, Murray, Costello, Levy, and Klinger, Nathan highlighted the commonalities of these definitions and
went on to describe personality as consisting of traits that are
“internal, unique, enduring, active, causal, and integrating”
(Nathan, 1988, p. 183). Clearly, a number of individual-differences variables that have been related to alcoholism do not meet
all the criteria that have been proposed by various personality
theorists. For example, individually held alcohol-outcome expectancies have been shown to be relatively strong correlates
of both nonpathological and pathological alcohol involvement
(e.g., Goldman, Brown, & Christiansen, 1987) but do not
clearly serve an integrating function at the level of the person.
Traits related to antisociality (e.g., a history of childhood conduct problems) have been repeatedly shown to be robust predictors of both alcoholism and APD but are not necessarily either causal or integrating. In large part, the importance of per-
Kenneth J. Sher and Timothy J. Trull, Department of Psychology,
University of Missouri—Columbia.
Preparation of this article was supported, in part, by Grant AA7231
from the National Institute on Alcohol Abuse and Alcoholism to Kenneth J. Sher.
Correspondence concerning this article should be addressed to Kenneth J. Sher, Department of Psychology, University of Missouri, 210
McAlester Hall, Columbia, Missouri 65211.
92
ALCOHOLISM AND ANTISOCIAL PERSONALITY
93
sonality in alcoholism and APD depends on the inclusiveness of
the definition of personality.
ating and moderating relationships, and we discuss these types
of models later.
Models of Personality and Disinhibitory
Psychopathology
General Methodological Concerns
There are a number of ways that personality can be related
to alcoholism and APD. Considering artifactual and spurious
relations first, correlations between personality variables and
diagnostic groupings can be obtained because of unrecognized
confounds at the measurement or design level. At the measurement level, purported personality scales often contain items
pertaining to diagnostic criteria for APD (e.g., childhood conduct problems) or alcoholism (e.g., drinking-related behavior).
Thus, obtained personality correlates of various disorders could
reflect little more than content overlap between the two constructs. Personality and disorder can also be spuriously related
because of “third variables.” For example, throughout the life
span, alcoholism and APD are more prevalent among men than
among women (Robins et al., 1984), and many personality variables are related to gender (e.g., Costa & McCrae, 1992). Consequently, personality correlates of disorder can spuriously result from confounds with gender.
Aside from artifactual and spurious relations, existing research suggests several models relating personality to disorder.
First, there are models that posit personality as a predisposing
factor. In these models, personality traits (either as main effects
or in interaction with other variables) are thought to provide the
primary motivational basis for substance use or for engaging in
antisocial behavior. Second, there are models that view personality characteristics as a consequence of disorder. Such models
assume that the psychosocial (e.g., life stress and demoralization) and biological (e.g., ethanol toxicity and brain insult) consequences of disorders result in personality changes. For example, in the area of alcoholism and personality, there is considerable evidence that the cross-sectional correlates of clinical
alcoholism differ from the prospective correlates of risk for alcoholism, leading to distinctions between prealcoholic and clinical alcoholic personalities (Barnes, 1983). Further support for
the distinction between prealcoholic and clinical alcoholic traits
comes from studies comparing changes in personality traits in
alcoholics over an extended period of abstinence; some traits
appear relatively stable (especially those related to psychopathic
traits) whereas others appear to normalize (especially those related to anxiety and depression; Barnes, 1983).
Relation of Personality to Other Causal Variables
A large, multidisciplinary literature demonstrates that
multiple factors at varying levels of biopsychosocial organization contribute to the development of both alcoholism and
APD. Typically, theorists and researchers deal with the issue of
multifactorial causation either by ignoring other domains of explanatory variables or by creating atheoretical additive models
that include both personality and other types of variables but
do not specify ways in which they are related. A number of
models in the area of addiction, however, place personality variables into the nexus of other etiological constructs. In these
models, personality variables are viewed in the context of medi-
There are numerous methodological issues to consider in research on personality and alcoholism and APD. Several of the
most crucial issues bear on the nature of the types of inferences
that can be drawn from a given study and are briefly noted in
the following paragraphs.
Diagnostic Subtypes
A critical methodological issue concerns the heterogeneity of
membership within diagnostic categories such as alcoholism
and APD. For example, there is ample reason to suspect that
there are etiologically distinct subtypes of alcoholism and APD
(see discussion in later sections). To the extent that these various
subtypes differ in their personality correlates, failure to consider
subtyping will obscure possible relations. Furthermore, theorists have long proposed subtypes based on personality variables
(e.g., Blackburn, 1975;Morey&Blashfield, 1981), and personality differences among groups differentiated on the basis of personality data run the risk of becoming tautological.
Comorbidity
The issue of heterogeneity extends to the frequent phenomenon of comorbidity between alcoholism and APD, as well as
between each of these disorders and other Axis I and II disorders. Alcohol use disorders are highly comorbid with both APD
and drug use disorders in clinical (e.g., Hesselbrock, Meyer, &
Keener, 1985), criminal (e.g., Lewis, Cloninger, & Pais, 1983),
and general-population (e.g., Helzer & Pryzbeck, 1988) samples, and these associations persist even when overlap in diagnostic criteria is eliminated (e.g., Lewis, 1984). Furthermore,
alcoholism and APD are associated with increased likelihood
of anxiety, affective, and schizophrenic disorders (e.g., Koenigsberg, Kaplan, Gilmore, & Cooper, 1985; Regier et al., 1990)
as well as with non-APD personality disorders (e.g., Drake &
Vaillant, 1985). This comorbidity, especially if unassessed, reduces researchers’ ability to unambiguously attribute a personality characteristic to a specific disorder. Certainly, the extremely high rate of lifetime substance use disorders among
prisoners diagnosed with APD (90% in the ECA prison sample;
Regier et al., 1990) or with psychopathy (Smith & Newman,
1990) argues for careful assessment of confounding substance
use in studies of APD.
Research Design
Although the implications of different research designs for
studying the personality correlates of psychopathology are well
known, they nonetheless warrant brief comment. First, crosssectional designs, the most frequently used research designs in
personality and psychopathology research, fail to resolve the
temporal relation between personality and diagnostic status.
Prospective designs, although used relatively infrequently, are
much more useful in resolving temporal precedence. Nevertheless, it needs to be emphasized that the establishment of a pro-
94
KENNETH J. SHER AND TIMOTHY J. TRULL
spective relation between personality and disorder does not establish a causal relation, and third-variable alternative explanations need to be considered in evaluating this research.
Furthermore, both alcoholism and APD have a protracted and
insidious onset, with behavioral antecedents (e.g., oppositionality and conduct problems) appearing in childhood and adolescence. That is, prodromal aspects of APD and (at least earlyonset forms of) alcoholism are evident early in development;
ideally, prospective studies should evaluate whether various personality traits predict over and above these early behavioral
manifestations of disorder. Because of the limitations of crosssectional studies and the cost and difficulty of conducting prospective studies, there has been a dramatic increase in the use of
cross-sectional high-risk designs in recent years to study alcoholism (and to a lesser extent other forms of disinhibitory psychopathology). Although the high-risk method has the potential
to discover predisposing factors prior to the ultimate development of the disorder, high-risk versus low-risk differences on a
variable can only suggest but do not establish etiological relevance.
Sampling
Much of the personality research on alcoholism and APD is
based on samples ascertained on the basis of their status as patients in treatment facilities or as inmates in penal institutions.
Given that only some proportion of individuals with a given disorder are likely to receive treatment or become incarcerated
(and treatment status appears to relate to potential confounds
such as comorbidity), the generalizability of findings based on
clinical and institutionalized samples is always an issue (cf. Cohen & Cohen, 1984). Although nonclinical samples are frequently used in studies of alcohol abuse and occasionally in
studies of psychopathy, all too frequently these nonclinical samples are based on convenience or are not systematically ascertained, limiting our ability to generalize to known populations.
In addition, the contexts associated with various settings from
which subjects are selected may have important effects on the
assessment of personality itself (Eysenck & Gudjonsson, 1989).
Personality, Alcoholism, and APD: Data and Theory
We now review various ways that personality appears to be
related to alcoholism and APD. Because of the immense size of
the relevant empirical literature, our review is necessarily selective. To provide a broad overview, we reduce our main discussion of personality dimensions to certain broad-band personality traits that consistently appear in the literature focusing on
alcoholism and APD: neuroticism/emotionality, impulsivity/
disinhibition, and extraversion/sociability. Empirical support
for this three-dimensional approach comes from a recent study
that factor analyzed 46 scales that purport to measure basic dimensions of personality (Zuckerman, Kuhlman, & Camac,
1988). We recognize that other schemes are also defensible. For
example, Tarter (1988) used Buss and Plomin’s (1984) influential HAS (emotionality, activity, and sociability) dimensions,
which are similar (though not identical) to the structure
adopted here, to conduct a similar review. In addition, there is
currently considerable support for the view that the five-factor
model of personality best subsumes the different dimensions of
personality descriptions embedded into the natural language
(Digman, 1990). Although we believe that the five-factor model
of personality has great potential for systematically organizing
many of the seemingly disparate and unrelated findings reported in the literature on personality and disinhibitory psychopathology (e.g., Martin & Sher, in press), the three-factor approach we adopted here provides a convenient structure for
summarizing the existing research. Because trait approaches to
studying the personality bases of psychopathology often seem
static and merely descriptive, and not explanatory, we also examined the role of personality in more complex etiologicaJ
models that integrate personality variables with important variables from other domains.
Alcoholism
Over the years several influential approaches to the diagnosis
and classification of pathological alcohol use have been proposed, and, at present, the most widely adopted criteria in
North America are those established in the revised third edition
of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-IH-R; APA, 1987). The DSM-III-R (and the soon to
be published DSM-IV; APA, 1993) proposes two major classifications of alcohol use disorders: alcohol abuse and alcohol dependence. The criteria for alcohol abuse focus more on alcoholrelated problems, and this diagnosis approximates the more
general term problem drinking; the criteria for alcohol dependence incorporate both traditional signs of physical dependence
(e.g., tolerance and withdrawal) and more psychological aspects
of dependence (e.g., salience or importance of drinking in one’s
life, craving, and inability to abstain). Although the distinction
between alcohol dependence (in varying severity) and alcohol
abuse may be important both clinically and theoretically, most
published research on the personality correlates of alcoholism
has not used this distinction, and the diagnostic methods of a
large proportion of studies are vague and poorly specified. Thus,
although the term alcoholic is often restricted to individuals
who manifest significant levels of alcohol dependence, in practice much of the relevant research on personality and alcoholism has used individuals with a range of severity of alcohol
problems and dependence symptoms. Consequently, the term
alcoholic is used in a general and somewhat imprecise way.
Subtypes
Not only is the concept of alcoholism somewhat broad with
imprecise boundaries, but there is consensus in the field that
alcoholism is an etiologically and clinically heterogeneous disorder. Over the years, numerous approaches to subtyping alcoholism have been proposed (e.g., Jellinek, 1960; Zucker, 1987).
A number of studies (e.g., Morey, Skinner, & Blashfield, 1984;
Partington & Johnson, 1969) have used cluster analytic techniques to empirically derive taxonomies of alcoholism. Although difficult to summarize, these cluster analytic studies
tend to provide consistent evidence for at least two clusters,
which can broadly be termed a personality disorder cluster and
a neurotic cluster (Morey & Blashfield, 1981). The basic distinction between a primarily personality-disordered form of al-
ALCOHOLISM AND ANTISOCIAL PERSONALITY
coholism and a primarily neurotic form of alcoholism was
made more than 50 years ago by Knight (1937) in his essential
versus reactive distinction and has recently regained prominence in Cloninger’s (1987a) Type 1 versus Type 2 distinction.
Comorbidity
The presence of one or more comorbid disorders can be considered another approach to subtyping. Furthermore, some researchers (e.g., Schuckit, 1985) have found it useful to distinguish primary alcoholism from secondary alcoholism. This distinction is typically made on the basis of the temporal ordering
of age of- onset for alcoholism and comorbid diagnoses. Although in practice it is often difficult to resolve the temporal
ordering of alcoholism and a comorbid diagnosis (e.g., Kushner,
Sher, & Beitman, 1990), the primary versus secondary distinction can be useful both clinically and theoretically when conceptualizing the nature of comorbidity.
Personality Characteristics of Prealcoholics and
Alcoholics
To varying degrees, each of the three broad-band dimensions
of personality (i.e., neuroticism/emotionality, impulsivity/disinhibition, and extraversion/sociability) have been found to be
correlates of concurrent alcoholism, future alcoholism, or risk
for alcoholism, and these findings are briefly summarized in the
following paragraphs. To cover the literature efficiently, we have
reli …
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