Both impulsive and compulsive behaviors are seen in alcohol dependence. It has been suggested that, alcohol-dependent behaviors located between; excessive preoccupation with substance in order to ensure the presence of the substance and to provide it and being uncontrolled in blocking the uptake of substance (1). Impulsivity is the state of having tendency to show fast and unplanned reactions to internal or external stimuli disregarding negative consequences, a failure to resist an impulse or stimulus. As a personality dimension, it is a situation that, the individual can not prevent the request of harming to himself or others (2). A strong association between alcoholism and impulsive behavior has been identified (3). Impulsivity in alcohol addicts is associated with comorbid personality disorders. Impulsivity is also more common in alcohol addicts without comorbid personality disorder (4). Impulsivity has been suggested to be associated with intense substance use (5) and relapse (6). It has been found that, impulsive boys had a risk for developing alcohol dependence with advancing age (7). It has been found that, impulsivity was effective in the process from behavior of alcohol use up to development of alcohol dependency (8) and proportional to onset of alcohol use at early age (4).
Difficulty in limiting drinking in addiction, to continue substance despite recurrent problems, emergence of dysphoric affect when substance was not taken and disappearance of this situation after substance uptake can be likened to the compulsion (9).
It has been reported that, impulsivity was more dominant in the early stages of addiction and compulsivity was more dominant in the later periods (9). In a study comparing impulsivity and compulsivity in alcohol addicts with controls, alcohol addicts were more impulsive, there was no difference between the two groups in terms of compulsivity but in contrast to the control group, compulsivity did not decrease in the study group with age which has been suggested to be associated with the use of alcohol (1).
In pathological gambling, a subtype of impulse control disorder (ICD), while thrill seeking and impulsivity are predominant (10), harm avoidance was determined in obsessive-compulsive disorder (OCD) (11).
Due to alcohol dependence had both impulsive and compulsive characteristics, it has been considered that, ICD and OCD, which have these characteristics, can be found together with alcohol dependence. In this study, it was planned to investigate the presence of comorbid OCD and ICD in the patient group with a diagnosis of alcohol dependence, alcohol use properties in the groups with or without these comorbid diseases and to compare the severity of alcoholism with impulsivity and compulsivity.
Our study is cross-sectional. Male inpatients or outpatients in the range 18-64 years, who were not under the influence of alcohol or withdrawal, were at least literate, diagnosed with alcohol dependence according to DSM-IV-TR diagnostic criteria, followed in the Izmir Ataturk Training and Research Hospital AMATEM (Alcohol and Drug Research, Treatment and Training Center) between March 2009 and July 2010, were included in the study. The patients with the additional diagnosis of bipolar disorder or psychotic disorders were excluded from the study, although they met these criteria. A total of 81 patients were enrolled. OCD was investigated with Structured Clinical Interview DSM-IV Axis I Disorders (SCID-I) in all cases. Subclinic OCD group with subthreshold symptoms diagnosed with OCD by SCID-I was named as ‘obsessive-compulsive features’ (OCF). ICD diagnosis of intermittent explosive disorder, kleptomania, pathological gambling, pyromania, trichotillomania and not otherwise specified (ICD-NOS) were performed according to DSM-IV criteria. The diagnosis of compulsive shopping, which is a ICD-NOS, was diagnosed according to the criteria of Mc Elroy et al. (12). This diagnosis, according to the criteria of which Turkish validity is not performed yet, was made taking into consideration the felt desire to do shopping, reduction in feelings of tension and feeling of pleasure after shopping, efforts to resist shopping, having intrusive thoughts in the level of clinical significance. Skin picking, compulsive sexual behavior and compulsive exercise were questioned with the Minnesota Impulsive Disorders Interview Scale (MIDI). Barratt Impulsivity Scale (BIS-11), the Maudsley Obsessive Compulsive Questionnaire (MOCQ), the Michigan Alcoholism Screening Test (MAST) were given to the patients. In the form of socio-demographic data, the presence of alcoholism in the family, history of substance use, age at the first try of alcohol and age of problematic use, the daily amount of alcohol were questioned. In our study, problematic use of alcohol means that the age alcohol-related problems were seen or the first age of onset of regular drinking. In the calculation of standard daily drinks, in accordance with the accepted values in previous studies, it was accepted that 1 standard drink contains 12-14 g of ethanol, and 330 mL of a small bottle of beer, 140 mL glass of wine, 40 mL of a single vodka, whiskey, gin, raki were 1 (one) standard drink (13). The study was approved by the local ethics committee. The patients in the study group were informed about study characteristics, the scales, which were to be applied, and the consent form was obtained from each patient concerning that they want to participate in the study.
Clinical Interview Scale Configured for DSM-IV Axis I Disorders (SCID-I): SCID-I is a configured interview schedule practiced by clinicians for determination of Axis 1 diagnoses. SCID-I was translated to Turkish by Ozkurkcugil et al. (14) and the validity and reliability studies were performed.
Minnesota Impulsive Disorders Interview (MIDI): MIDI searches lifelong impulse control disorders (intermittent explosive disorder, pathological gambling, kleptomania, trichotillomania, pyromania, compulsive shopping, compulsive sexual behavior, compulsive exercise) according to DSM-IV criteria (15). The MIDI is a semi-configured interview form consisting of 36 items.
Barratt Impulsiveness Scale (BIS-11): BIS-11 is used for evaluating the impulsivity and filled by the patient (16). It consists of 30 items. Four different sub-scores are obtained in BIS-11. These are total score, motor impulsivity, attention impulsivity, non planning impulsivity. The patient’s impulsivity level directly proportional to the total BIS-11 score. Turkish validity and reliability study of the BIS-11 were made by Gulec et al. (17) .
Maudsley Obsessive Compulsive Queistionnaire (MOCQ): MOCQ is used to measure the type and prevalence of obsessive-compulsive symptoms. It has been developed by Hodgson and Rachman (18). Validity and reliability study of the Turkish version were made by Erol et al. (19). It has subscales of checking, cleaning, slowness, doubting. Rumination subscale was added to the Turkish version of the scale. Cut-off score was not calculated in the study conducted in Turkey. It is recommended for use in comparative studies.
Michigan Alcoholism Screening Test (MAST): MAST is used whether the individual confronts from alcohol use problems and to measure the level. It has been developed by Gibbs (20). When the cut-off score is taken between 5-9, it contains 25 questions quering drinking problem, help-seeking behavior and alcohol-related losses, distinguishing the individuals with or without alcohol dependence in the best way. The reliability and validity of the Turkish version were made by Coskunol et al. (21).
All statistical evaluations were performed by using SPSS for Windows 15.0 software. For comparing groups, chi-square test was used for categorical variables. For groups with and without ICD, with and without OCF, numeric variables were compared with One Way ANOVA, post hoc Tukey test was performed when p<0.05 was obtained. Multiple linear regression analysis was applied that MAST score measuring the level of alcohol use-related problems was taken as constant variable. In this model, impulsivity, compulsivity and age of problematic use were taken as an independent variable. According to the results obtained from the model, the regression coefficient of each variable, standardized regression coefficients and significance level were calculated. Statistical significance level was accepted as p<0.05.
Eighty-one male patients were included in the study. Patients’ demographic data, characteristics of alcohol use are given in Table 1. The mean age of patients is 48±9. Fourty patients (49.6%) were married, 41 patients (50.4%) were single, divorced or living separately. Fourty-three patients (53.1%) were primary school graduates, a history of alcoholism in first-degree relatives was detected in 31 of them (38.3%). The mean age for the first try of alcohol of the patients, the mean age of regular use of alcohol, the mean age of problematic use were found to be as 18.7±6.1, 28.2±9.6 and 37.7±10.2, respectively. The mean daily amount of standard drink is 23.9±11.5. Sixteen patients (19.8%) use regularly non-alcohol substance, and 3 (3.7%) have tried any substance, and have not used regularly.
24.6% of patients with alcohol dependence have at least one ICD (NOS also when BTA) as an additional diagnosis. The most common ICD was found to be pathological gambling with 16%, second in frequency was intermittent explosive disorder with 6.1%, third in frequency was compulsive shopping with 3.7%. It has been determined OCD in 13.5% of the patients and subclinical OCD which was not as the level to diagnose OCD in 19.8% of them. In total, 33.3% were classified as ‘with obsessive-compulsive features’. ‘Obsessive compulsive features’ or one of the ICD or both were found in 46.9% of the patients.
Evaluation of groups with and without impulse control disorder (ICD), with or without obsessive-compulsive features (OCF) in terms of sociodemographic and clinical (BIS-11, MOCQ, MAST) variables
In a total of 81 alcohol-dependent patients, 9 patients with both OCF and ICD (group 1), 11 patients with only ICD (group 2), 18 patients with only OCF (group 3), 43 patients without OCF and ICD (group 4) were compared. There was no difference between the groups in terms of socio-demographic data (Table 2).
The groups were compared with one-way analysis of variance (ANOVA), the problematic use of age, MOCQ checking, MOCQ cleaning, MOCQ slowness, MOCQ doubting, MOCQ rumination and BIS attention scores were found to be significantly different. Followed by post hoc Tukey’s test, MOCQ cleaning and doubting scores were not found to be significantly different. The problematic use of age was significantly smaller in the group with both ICD and OCF than the group without ICD and OCF and the group with OCF, p(1.4)=0.03; p(1.3)=0.04. In the group without ICD and OCF, MOCQ checking p(4.1) = 0.02; slowness p(4.1)=0.04 and rumination p(4.1)≤0.001 was significantly lower than the group with ICD and OCF. MOCQ rumination was significantly higher only in the group with ICD compared to the group without ICD and OCF p(4.2)=0.03. BIS-11 attention score was significantly higher in the group with both ICD and OCF than the group without ICD and OCF and the group only with ICF p(1.4)<0.01 and p(3.1)<0.01 (Table 3).
Evaluation with the regression analysis of the factors thought to affect the increase in the level of problematic alcohol use assessed with MAST
There was a significant correlation between MAST score and early age of alcohol use problems (p≤0.001) (Table 4).
The most important result of this study is determining the additional diagnosis of ICD in one quarter of male patients diagnosed with alcohol dependence and showing that, OCD was found in one third of patients with the collection of OCD and subclinic OCD.
Core symptoms of dependence; to continue the behavior despite adverse consequences, loss of control, craving, dealing with the behavior in a compulsive manner. The discussion that, whether dependence is a compulsive or impulsive disease, continues (9).
In our study, at least one additional diagnosis of ICD was accompanied to 24.6% of the patients with a diagnosis of alcohol dependence. It has been reported in another study evaluating the frequency of ICD in psychiatric patients receiving inpatient treatment, ICD was found in 30% of patients and one in four of them was pathological gambling (22). In our study, the most common ICD was pathological gambling with 16%, the second and third ones were found to be intermittent explosive disorder and compulsive shopping with 6.1% and 3.7%, respectively. It has been determined in a study investigating the additional diagnosis of ICD in patients with depression, intermittent explosive disorder was in the first rank with of 31.3%, second and third ranks were pathological skin picking and compulsive shopping with 28% and 14%, respectively (23). Pathological gambling is suggested to be more common in those with substance use disorder (24). It has been reported in a study evaluating the additional diagnosis of alcohol and substance dependence in pathological gambling, this ratio was 63.3%, alcohol dependence formed the highest rate among dependence (25). It has been reported that, pathological gambling had overlapping features with dependencies and pathological gambling was a form of behavioral addictions (26).
In 13.5% and 19.8% of 81 patient, OCD and sub-threshold symptoms of OCD were detected. The patients diagnosed with OCD and subclinical OCD were grouped as ‘with obsessive-compulsive features’. ‘With obsessive-compulsive features’, which is found in 33.3% of the patients, is quite high compared with the general population (1.0-5.7%) (27). In Epidemiologic Catchment Area study, lifetime alcohol use disorders has been identified in 24% of patients with a diagnosis of OCD (28). The presence of OCD comorbidity has been reported three times more common in alcohol addicts than in the general population (29). Early onset of OCD has been found to increase the likelihood of development in alcohol dependence ( 29). It has been proposed that, there was an interaction which may predispose to the development of each other between OCD and dependence (30). In OCD and dependence, inability to control the problematic behaviors although it is known to be false is a common feature (31).
The patient ratio that the additional diagnoses of OCF and ICD were seen together was 11.1%. As in our study, the coexistence of OCF and ICD are consistent with studies conducted in this regard (32,33). It was found in a study evaluating the additional diagnosis of ICD in OCD, ICD comorbidity accompanied in 35.5% of patients and alcohol use disorder was seen at the same time in 7 of 10 patients with both OCD and ICD (32). In a study evaluating the coexistence of intermittent explosive disorder and OCD, comorbidity was reported to be 22% ( 33). In our study, the intermittent explosive disorder and the compulsive shopping were detected in 18.5% and 11.1% of patients with additional diagnosis of OCF, respectively. The other ICD’s were less in number. In a study in South America similar results were found, the intermittent explosive disorder, compulsive shopping were determined as the most common ICD among the patients with OCD (34). Pathological skin picking was reported to be quite common in patients with OCD as an ICD (35). It was found in the comorbidity of ICD and OCD that, OCD started at an earlier age, the severity and unresponsiveness to treatment were higher in OCD (34).
In the group of ICD, compulsivity was found to be higher in the group without comorbidity in MOCQ rumination subscale. In a study conducted by Lawrence et al. comparing the patients diagnosed with alcohol dependence and pathological gambling to healthy controls, compulsivity was evaluated with the Padua Inventory (36) and being more pronounced in alcohol addicts, control subscale has been found more compulsive in patients with pathological gambling (37). It has been reported that, there were both impulsive and gambling-related obsessive thoughts in pathological gambling (38). It has been determined that, pathological gambling occured with the triggering of the distressing impulses in a compulsive manner (39) and compulsivity was seen at high rates compared to controls (40). It has been determined that, the severity of illness before the treatment was associated with impulsivity and compulsivity in pathological gambling and the scores of impulsivity and compulsivity significantly decreased after the treatment (41).
BIS-11 attention score in the group that, the additional diagnoses of ICD and OCF seen together, was significantly higher than the group without comorbidity and with only additional diagnosis of OCF. Other than this, impulsivity did not differ between groups. In the studies evaluating the impulsivity in patients with OCD, a positive correlation between impulsivity and compulsivity was detected (42,43) and cognitive impulsivity has been reported to be high (44). In another study, a relationship was determined between the presence of sexual and aggressive obsessions and high impulsivity in patients with OCD (45).
In the group that ICD and OCF comorbidity seen, the age of problematic use was significantly lower than the groups without comorbidity and with only OCF. This suggests that, an increase in the burden of psychopathology may lead to alcohol use at earlier ages.
Determination of significant relationship between MAST score measuring the level of alcohol use-related problems and problematic use at early age is consistent with studies on this subject (46,47).
The most important limitation of the study is that the sample is not large enough and only male alcohol addicts were included in the study. A study with similar pattern including both gender may allow us to compare the impulsivity and compulsivity. Men and women with heavy alcohol use were compared, impulsivity was found to be less in women than men due to higher behavioral inhibition and reward response in women (48). Although men report alcohol-related problems, that they are facing, lesser than women, compulsive drinking was reported to be higher in men alcohol addicts than women (49).
Impulsivity and compulsivity were evaluated in alcohol addicts and their relationship was assessed from multiple perspectives by investigating the diagnoses of OCD and ICD. Identification of the common characteristics of OCD, ICD and dependence will provide obtaining the sides overlapping in the prevention and treatment of these diseases. The follow-up study, which will be conducted on the patients with any of these mental diseases, can provide to determine that which one of them is premise, which one of them is a secondary disorder added to primary psychopathology and the common features of these disorders.
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