There have been numerous research studies that have attempted to classify alcoholism or what is now termed an alcohol use disorder into different subtypes. One of the most famous is the typology developed by the biostatistician E.M. Jellinek that has received virtually no additional research support, but is still heavily referred to by members of the organization Alcoholics Anonymous. Other different researchers have developed models of alcohol use disorders that consist of two subtypes, three subtypes, four subtypes, etc.
The model referred to in this article came from a 2007 study published in the journal Drug and Alcohol Dependence. The researchers used data from 1,484 individuals who had participated in the National Epidemiological Survey on Alcohol Related Conditions and had been diagnosed with alcohol dependence according to the diagnostic criteria from the American Psychiatric Association’s (APA) DSM-IV. Both the diagnosis of alcohol dependence and the diagnostic scheme used in the DSM-IV are no longer considered valid since APA released the DSM-5 in 2013.
The researchers applied a sophisticated structural equation modeling technique known as latent class analysis to the data to develop a model of different subtypes of alcohol use disorders. In addition to information from the DSM-IV diagnostic profile, the researchers also used the following information:
- The estimated age that the individual started drinking and when they were diagnosed with alcohol dependence
- The individual’s psychiatric history, including any diagnosis of other substance use disorders or mental disorders
- Family history, including family history of substance use
- Other demographic information, such as the individual’s gender
Latent class analysis results in the development of multiple different models that divide the data into different types referred to as clusters. Researchers typically use statistical criteria to determine which model fits the data most appropriately. In the current study, the researchers determined that the five-cluster model or five-type model provided the best fit. The model produced five different subtypes of alcohol dependence (often referred to as alcoholism by laypeople but in clinical terms today, the term is an alcohol use disorder). One of the subtypes produced by the model was the young antisocial alcoholic subtype.
Characteristics of the Young Antisocial Alcoholic Subtype
According to the model, the characteristics of the young antisocial subtype of alcohol dependence include the following:
- The individuals are typically males in their mid-20s.
- About half of individuals in this subtype had a family history of a first-degree or second-degree relative with the diagnosis of alcoholism.
- These individuals typically started drinking in their mid to late teens.
- Three-quarters of these individuals smoke tobacco products, two-thirds met the criteria for cannabis abuse, about one-quarter used cocaine, and about one-fifth used opioids. The use of more than two drugs was common in this group.
- The individuals had a history of antisocial behavior.
This category was the second most common category generated by the model, with 21 percent of the sample being classified into this category. According to the data, about one-third of the individuals in this group sought treatment for their alcohol abuse on their own.
It should be pointed out that many sources mistakenly state that 21 percent of Americans are classified in this subtype based on this research. That is an invalid conclusion. The research cannot generalize to the American population, but any comments or observations made on the data are only restricted to the sample of participants used in the study. The research design does not allow for a broader generalization.
The Utility of These Findings
Unfortunately, many online sources refer to the study as if it is currently being used for diagnostic purposes. When the study was performed in 2007, the diagnostic manual used by APA was the DSM-IV. In 2013, APA revised their diagnostic criteria for mental disorders with the release of the DSM-5. There are significant differences in the diagnostic criteria for alcohol abuse from the DSM-IV to the DSM-5. These differences do not reflect the addition of any subtypes of alcoholism based on current research or any other research that has attempted to use statistical techniques or clinical data to develop different subtypes of alcohol use disorders.
The DSM-5 does allow for classification of an individual’s alcohol use disorder as either mild, moderate, or severe based on the number of symptoms they satisfy, but the numerous different statistical classifications made in research studies are not used for diagnostic purposes. The reason for this is that different studies produce different subtypes depending on the types of data they use to classify their participants. Moreover, reliability is often an issue with this type of research, such that different researchers using very similar criteria on a different sample will generate an entirely different model. (See Ioannidis 2005 for a discussion on issues with reliability in research using significance testing.)
Since there are so many different models, and different researchers develop different models based on similar criteria, the clinical utility of this research is very low. The research does have utility regarding observations about different presentations of alcohol use disorders that may need to be treated differently. The combination of alcohol abuse and a personality disorder, such as antisocial personality disorder, represents a particularly difficult treatment option.
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Antisocial Personality Disorder and Substance Abuse
APA has specific diagnostic criteria that are used in the diagnosis of an alcohol use disorder. Only a trained clinician can formally diagnose an alcohol use disorder in anyone. In general, the diagnostic criteria for an alcohol use disorder consist of issues with:
- Controlling use of alcohol, such that its use results in negative consequences in numerous aspects of life
- Spending significant amounts of time using or trying to get alcohol or recovering from alcohol use
- Cravings for alcohol
- Using alcohol in dangerous or hazardous situations
- Developing the symptoms of physical dependence as a result of alcohol use (tolerance or both tolerance and withdrawal)
- Experiencing significant distress or dysfunction as a result of use of alcohol
APA also has specific diagnostic criteria for individuals who have antisocial personality disorder. The individual must be at least 18 years old, but has a history of violating the rights of others since the age of 15. They must also demonstrate at least three of the following:
- A history of failing to conform to social norms and breaking the law
- A history of deceitfulness
- A history of impulsivity
- A history of aggressiveness or extreme irritability
- A history of disregard for personal safety or the safety of others
- Is consistently irresponsible
- Demonstrates a lack of remorse or empathy
These individuals typically have histories of conduct disorder before they are 15 years old and have numerous issues with truancy at school, theft, fighting, lying to parents, etc. Research studies have found high rates of comorbidity for substance use disorders in individuals with a diagnosis of antisocial personality disorder.
Some studies indicate that the vast majority of individuals diagnosed with antisocial personality disorder (as much as 90 percent) have a comorbid (co-occurring) substance use disorder. The most common substances of abuse are alcohol, tobacco, and cannabis products.
Personality disorders are notoriously difficult to treat. An individual with an antisocial personality disorder by definition is an individual who is deceitful, attempts to bend the rules to meet their own needs, uses others to meet their own needs, and violates rules and regulations habitually. Interestingly, individuals with moderate to severe alcohol use disorders fit many of the same patterns of behavior. These individuals are not easy to treat.
According to information from the book A Guide to Treatments that Work, treatment goals should include:
- Decreasing the individual’s abuse of all substances
- Improving the individual’s ability to function in social situations
- Increasing positive feelings toward other people
There are no medications that are used specifically for the treatment of antisocial personality disorder, but medications can be used to treat certain symptoms, such as depression, cravings for alcohol, etc. The preferred form of treatment for individuals with antisocial personality disorder and co-occurring alcohol use disorder is the use of Cognitive Behavioral Therapy (CBT) with medications.
- In younger individuals, family therapy or group therapy may be useful in addressing destructive patterns of behavior and teaching new relationship skills.
- The cognitive component of CBT can be used to help the individual become more sensitive to the feelings and wishes of others.
- The behavioral component of CBT uses reinforcement for desired behaviors and punishments to eliminate unwanted behaviors.
- The use of Antabuse (disulfiram) can promote abstinence from alcohol.
- Drugs like ReVia (naltrexone) and Campral (acamprosate) can address cravings for alcohol.
- Treatment for co-occurring substance abuse issues should be included.
- The individual should be held accountable for their behavior and should be subject to random alcohol and drug screens to ensure abstinence.
- Treatment compliance is a major issue. Violations of abstinence and compliance with treatment should be met swiftly and effectively. These individuals often respond to sanctions on their personal freedoms.
Some medications like Antabuse can be administered by a healthcare professional to ensure compliance. Unfortunately, individuals with antisocial personality disorder have a guarded prognosis. Over time, many of their behaviors become less intense, but as one might expect, a good number of these individuals wind up incarcerated or worse.
Treatment must be focused, consistent, and monitored. The rules of the treatment must be explained completely so the individual understands the consequences for violating them. Any violations must be dealt with immediately and effectively. Due to the nature of antisocial personality disorder, treatment is often conducted in conjunction with monitoring by legal authorities, such as judges and parole officers.