Relapse may be defined as the resumption of alcohol drinking following a prolonged period of abstinence. Events that potently trigger relapse drinking fall into three general categories: exposure to small amounts of alcohol (i.e., alcohol induced priming), exposure to alcohol related (i.e., conditioned) cues or environmental contexts, and stress (1). Among treated patients with alcohol use disorders, estimated rates of relapse range between 20 to 60% within the first few months after treatment (2-4) and as high as 70 to 80% by the end of 1st year (4), depending on the severity of the disorder and the criteria for remission.
Relapse represents a major challenge to treatment efforts for people suffering from alcohol dependence (1). Studies suggest that among these individuals, more frequent and heavier alcohol consumption and more psychological and social drinking problems are associated with a more likelihood of relapse (5,6). Variables involved in relapse include the individual characteristics of the patient, the drug and environmental reinforcers (7,8). Among treated individuals, more severe alcohol-related problems, anxiety and depressive symptoms, lack of self-efficacy, poor coping skills and readiness for change have been associated with short-term relapse (8-13). Compared to individuals who obtain help, those who do not are less likely to achieve long term remission and subsequently are more likely to relapse (14). Nevertheless, relapse is a multi-factored phenomenon and most likely to result from a combination of various factors (7).
Defense mechanisms, a psychoanalytical concept, have been defined as an indicative of how individuals deal with conflict (15). They are known to lie along a continuum ranging from being immature or maladaptive (e.g., acting-out) to being mature or adaptive (e.g., humor) (16). Defense mechanisms are defined in the DSM-IV as “automatic psychological processes that protect the individual against anxiety and from the awareness of internal and external stressors” (17). In other words, defense mechanisms are involuntary cognitive operations that occur on an unconscious level in order to minimize sudden changes in internal and external environments by modifying the conscious experience of thought, feeling, and emotion (16,18). Function of these defenses are considered as to maintain homeostasis and prevent inordinate anxiety forcing its way into consciousness, whether the anxiety arises from conflict within the person or between the person and the environment (19). In the DSM-IV, defense mechanisms are considered almost equivalent to coping mechanisms (17,20). Some studies found a relationship between adaptive coping strategies and mature defenses, as well as between maladaptive coping strategies and immature defenses (21).
According to the early reports, substance dependent individuals use rationalization, projection, denial and suppression defenses more than healthy individuals (22,23). In Turkish substance dependents sublimation, pseudo-altruism, acting-out, isolation and autistic fantasy were found as predictors of patient group (24). In this study, using immature defenses were related with severity of dependency, dissociative experiences, and childhood trauma experiences (24). Also results of a recent study suggested that alcohol dependents are using maladaptive immature defenses more than healthy controls and immature defenses seems to be related with alexithymia (particularly DIF factor), low cooperativeness and high self-transcendence in alcohol dependents (25). Alcohol dependent patients who are using more immature defense styles may need alcohol as a way of coping with the anxiety caused by their conflicts, thus resulting in higher severity of dependence (24). These may suggest that these groups of patients are psychologically more problematic. Thus, for individuals being unable to achieve satisfactory or acceptable outcomes to stressful situation, drinking may become a predominant way of (avoidance) coping (26). In this regard, the use of “avoidant” coping styles has been found to be associated with greater levels of alcohol consumption (27), adverse consequences (28), and relapse (29).
The Temperament and Character Inventory (TCI) is an instrument to measure personality dimensionally, and it evaluates 4 basic temperament and 3 basic character dimensions (30). The psychobiological model assumes interactions between temperament and character scales, eliciting secondary emotions, which are important in the development of personality (31). Individual differences in personality structure and development have a strong influence on the risk of all forms of psychopathology, including alcohol abuse (32). The defense style is considered to be an important dimension of the individual’s structure of personality (33). Basiaux et al. (34) reported that the TCI data add to evidence concerning a higher probability of personality disorder in alcohol-dependent patients. Defense mechanisms are conceptually linked to psychological development, personality traits, and psychopathology (35,36). A previous study found that among temperament dimensions persistence makes a significant contribution to the prediction of latency to relapse following inpatient alcohol-dependence treatment (37). Similarly, the risk of relapse was higher in alcohol dependent patients with a low score in persistence (38).
The question of which factors predict relapse is therefore an important one, since by understanding what such factors are, strategies for minimizing their effects can be developed. Listed among the many predictors of whether or not relapse to alcohol use will occur are life events, mood states, the existence of self-efficacy and coping behaviors (8,10,15). Thus, it is important to evaluate personality dimensions and defense styles as predictors of relapse in alcohol dependents. The aim of this study was to evaluate the clinical variables related with relapse to alcohol use during 12 months follow-up after inpatient treatment in male alcohol dependents.
This is a cohort study which was conducted in Bakirkoy Training and Research Hospital for Psychiatry, Neurology and Neurosurgery, AMATEM (Alcohol and Drug Research, Treatment and Training Center) between January 2010 and January 2011. The Ethical Committee of the hospital approved the study. Patients’ written informed consent was obtained after the study protocol was thoroughly explained.
Seventy consecutively admitted alcohol-dependent inpatients without history of any other substance abuse participated in the study. All participants fit the DSM-IV diagnostic criteria for alcohol dependence. Interviews with the study group were conducted after detoxification period, i.e. 4-6 weeks after the last day of alcohol use. One year later, each of these 70 participants were called with phone to interview. It was possible to reach 44 (62.9%) patients with telephone, among which 61.4% (n=27) relapsed during the 12 months.
All patients were assessed by using a semi-structured sociodemographic form both at baseline and at 12 month follow-up. The diagnosis of alcohol dependence in each participating patient based on the clinical examination, a screening interview based on the Structured Clinical Interview for DSM-IV (SCID-I) (39), Turkish version (40), conducted by trained interviewer (CE).
Temperament and Character Inventory
Evaluation of temperament and character traits was conducted by the Turkish version of the TCI, a 240-item, forced-choice, self-report scale (41,42). Dimensions of temperament were (a) HA, (b) novelty seeking (NS), (c) RD, and (d) persistence (P). Dimensions of character were (a) SD, (b) cooperativeness (C), and (c) ST. The reliability and validity of the Turkish version of the TCI were supported by its psychometric properties and construct validity (41).
Defense Style Questionnaire-40 (DSQ-40)
The defense mechanisms were evaluated by the Defense Style Questionnaire (DSQ) (43), a 40-question self-report questionnaire which was translated and recently validated into Turkish (44). The DSQ-40 assesses the defense strategies used by individuals to cope with stressful situations or events. Items are rated on a nine-point scale and measure the tendency of individuals to endorse specific defenses. The DSQ-40 comprises three factors (mature, neurotic and immature) and 20 defense mechanisms as originally described in the DSM-III-R. Each of the defenses is represented by two items on the DSQ-40. For example, ‘denial’ is measured by these statements: “People say I tend to ignore unpleasant facts as if they didn’t exist” and “I fear nothing”. The mature style consists of four defenses (sublimation, humor, anticipation and suppression), as does the neurotic style (undoing, pseudo-altruism, idealization and reaction formation). The immature style consists of twelve defenses (projection, passive-aggression, acting-out, isolation, devaluation, “autistic fantasy”, denial, displacement, dissociation, splitting, rationalization and somatization). Coefficient-alphas for defense styles are described as moderate (0.58) to high (0.80) (43).
The statistical package SPSS 17.0 for Windows was used for all the analyses. Categorical variables were compared with chi-square test. We used Mann-Whitney U test for independent samples to compare continuous variables. Taken relapse status as dependent variable, three Forward Logistic Regression models were performed. In the first model, age onset of regular alcohol use, main defense styles (mature, neurotic and immature) and temperament and character dimensions were independent variables. In the second model, age of onset of regular alcohol use, 12 immature defense styles and temperament and character dimensions were taken as independent variables. In the third model, current age was added to analysis as an independent variable to the independent variables used in the model 2. For all statistical analyses, p values were two-tailed and differences were considered significant at p<0.05.
Among 44 alcohol dependent inpatients, 61.4% (n=27) were considered as relapsed to alcohol use. Current age was lower in the relapsed group. Age at regular alcohol use, duration of education and income did not differ between groups. Rate of history of self-mutilation and/or suicide attempt at baseline were higher in relapsed group. Rate of changing social environment during 12 months after inpatient treatment was lower in the relapsed group, whereas using drugs and spending time with substance using friends were higher in this group (Table 1). Mean scores of “acting out”, “devaluation” and “displacement” were higher in the relapsed group (Table 2). Immature defense style and SD predicted relapse in regression analysis, whereas among immature defense styles acting out, devaluation and displacement predicted relapse together with SD (Table 3). When current age was included in the analysis, being younger and high acting-out predicted relapse in alcohol dependents (Table 3).
Among those who were available for interview (n=44) at the end of 12 month, 27 (61.4%) were considered as relapsed to alcohol use during the 12 month follow-up. This rate is same with the previous study conducted in the same clinic, which found 61.8% relapse rate at the end of 1 year after treatment (45) and similar with studies conducted in other countries (57%) (46). A number of studies have identified predictors of alcohol relapse after discharge from an alcohol treatment program. These variables include biological markers, personality features, psychiatric disorders, social characteristics, patterns of substance use and abuse, such as length of drinking history and age of onset, and whether the patient had attempted suicide (47). Consistent with these in the present study, rates of history of self-mutilation and suicide attempt at baseline were higher in relapsed group. Also low SD score, which is an indicative of personality disorder, discriminated this group from those in remission. Nevertheless, the main finding of the present study is that immature defense style and lower scores on character dimension of SD are associated with relapse at the end of 1 year after inpatient treatment. Consistent with this, the results of the previous studies (48-50) suggested that the pre-treatment use of immature defenses predicts a poor outcome of treatment in psychiatric disorders. Finally, it has been postulated that persons with an immature defense style will respond less effectively to both pharmacological (49) and psychological (48,51,52) treatment. Lower scores on SD was also previously related with less response to treatment (53,54). Consistent with this, in a previous study SD was found to be lower in short-term abstinence patients who may be perceiving higher levels of stress and use non-adaptive coping strategies than long-term abstinence group (55).
Alcoholics experiencing highly threatening or chronic psychosocial stress following treatment are more likely to relapse than abstaining individuals not experiencing such stress, which is also called the stress-vulnerability model of relapse (10,56). Patients should develop strategies to cope with high-risk situations such as negative emotional states and interpersonal conflicts (57). The use of negative (e.g., “avoidant”) coping styles has been found to be associated with greater levels of alcohol consumption; the use of positive (e.g., “active”) coping styles, with lower levels of alcohol use and problems (27). The distorting and projective mechanisms that under function in alcohol dependence and are part of the defensive mechanism of avoidance might also be related to these associations. This may especially be the case when the age is younger. Higher rates of self mutilation and suicide attempt (58) and seeking treatment in early ages (59) may suggest that severity of psychopathology is higher in younger alcohol dependents and that they may also be using more pathological defense mechanisms (60). Relapse rates are generally greatest for the young, perhaps the younger abstainers are less likely to have voluntarily chosen abstinence as their mode of recovery (e.g., more likely to have become abstinent in response to legal requirements following a drunk driving or other legal offense) and consequently less committed to remaining abstinent. Possibly their initial dependence symptoms are mild enough in nature to make them think that they could safely resume drinking (4). In present study SD seems to be mediating the association between being younger and relapse.
The DSQ 40 was shown to be a valid instrument for the assessment of defense mechanisms and change in these mechanisms after psychotherapy among those with personality disorder comorbidity (61). Several studies among patients with personality disorder reported positive associations between immature (maladaptive or nonadaptive) defenses and personality disorders and negative relations between mature (adaptive) defenses and personality pathology (48,62-64). Although both antisocial personality disorder (APD) and borderline personality disorder (BPD) are associated with primitive defenses, acting-out in particular (65), some findings have supported that BPD may demonstrate higher levels of maladaptive defenses, such as acting-out and passive-aggression, compared to other personality disorder groups (66). The DSQ’s acting-out predominantly assesses impulsivity and limited aggression, which may be more likely to be self-reported by individuals with BPD or APD (66). Comorbidities such as APD and BPD are common among substance dependents and appear to be negatively associated with treatment outcome (67). These are Cluster B personality disorders defined as impulsive personalities (68) and low SD is the core feature of these personality disorders (69). Thus, the results of the present study may reflect the personality pathology commonly found among alcohol dependents. Nevertheless since we did not evaluate the personality disorders in present study, this may be considered as one of the limitations.
In treated samples, women and older, married and better-educated individuals tend to experience better short-term outcomes (5,70,71). Nevertheless, a combination of various factors with different impact may cause relapse, and probably there may be no single factor (7). In the present study, sociodemographic factors other than being younger did not differ between groups, suggesting that other risk factors are more important in our sample. Our sample included only male patients and sociodemographic variables as risk factors may change across genders. Not only sociodemographic but also other risk factors may differ between genders, i.e. for initial post-treatment relapses, women were more likely to have negative affect relapses, and men were more likely to have social pressure relapses (72).
There are several limitations for our findings. First, we have not analysed biological markers (CDT or GGT) nor collected reports of collateral informants, but we consider that the patients’ self-reports and information from relatives are valid. All patients were personally interviewed and all patients were well known by the interviewer (S.Y.). Several studies have shown a high validity and high reliability of self-report data of alcohol-dependent patients in treatment compared to toxicologic analyses of blood or collateral informant reports (73,74). Other important limitation of the present study was that no scale were used to evaluate severity of anxiety and depressive symptoms, since they may be related with not only relapse (12,75,76), but also with HSM, HSA and defense styles. Since this study is a cross-sectional one, the longitudinal designs are required to clarify the causal relationship of relapse with defense styles and personality. Findings of previous studies suggest that the improvement in symptom severity is associated with greater use of mature defenses (48-52). The use of maladaptive defenses might be the consequence of alcohol dependency; during the active phase of the disorder, their capacity to use mature adaptive defenses may diminish and they may use more immature defense styles, but if they could stay sober for a long time, and, as the anxious and depressive symptoms remitted, their defensive style may return to a higher degree of maturity (77). Thus, the hypothesis that the use of maladaptive defenses is a state dependent phenomenon cannot be rejected (50,78,79). Future follow-up study should evaluate the changes in defense styles during sobriety period.
Notwithstanding these important limitations, these findings suggest that certain personality related factors, particularly a low level of SD, along with immature defense mechanisms, particularly acting-out, might make younger alcohol dependent individuals more vulnerable to relapse after inpatient treatment. It is possible that this group did not manage to activate strong primitive defense mechanisms during psychological development. It has been argued that no mental status or clinical formulation should be considered complete without an effort to identify the patient’s dominant defense mechanisms (80) and avoiding difficult feelings has been suggested to be common phenomenon in alcohol dependents (81), which may offer some explanation as to why the use of immature defenses are more frequent in alcohol dependents. The use of less mature defenses was suggested to be associated with the severity of symptoms, and the clinical improvement to be accompanied by a shift toward the use of more mature defenses in previous studies (78). From a clinical standpoint, this is important because it underscores the value of immature defense styles and lower SD in identifying and evaluating new treatment strategies that may be more effective in battling the problem of relapse, particularly among younger patients.