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Subtypes of Alcoholic Women

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Helene Moses Caplan

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Wt

SUBTYPES OF ALCOHOLIC WOMEN

By

Helene Moses Caplan

A DISSERTATION
Submitted to
Michigan State University
in partial fulfillment of the requirements
for the degree of

DOCTOR OF PHILOSOPHY

Department of Psychology

1996

ABSTRACT
SUBTYPES OF ALCOHOLIC WOMEN
By

Helene Moses Caplan

Efforts to typologize male alcoholics have been in place for the past century.
However, until the current generation, little research has focused on subtypes among
alcoholic women. This study identified three distinct types among a sample of 128
young, Caucasian, female alcoholics participating in the Michigan State University-
University of Michigan Longitudinal Study due to their being married to an alcoholic
husband and having a preschool-aged son.

The first type (n=41, 32% of sample), the Antisocial Alcoholic group, was
distinguished from the other two by the subjects’ strong histories of childhood conduct
problems and lifetime antisocial behavior. These women also exhibited the densest
family histories of alcoholism and depression, and the poorest current social adaptation.

The second type (11:26, 20%), the Negative Affect alcoholic group, was
distinguished from the others by its high levels of current and worst-ever depression.
This group represented a unique developmental trajectory that shared certain elements
with each of the other two: the women’s family histories resembled those of the
antisocial group while their current fimctioning was similar to the primary group,
described below. In other words, while the negative affect alcoholics shared the

antisocial alcoholics’ dense family history of psychopathology and childhood behavior

problems, and developed alcohol problems of a similar severity, their overall adult
adaptation was significantly better. Their educational attainment and current family
income were higher, and the variety and life invasiveness of problems related to their
alcoholism (such as problems at work and in relationships) were lower.

The third group (n=6l , 48%), the primary alcoholics, demonstrated the most
benign family histories and the best current adaptation. Their alcohol diagnoses were less
severe, and their psychosocial functioning was the highest in most areas.

These results supported the theory that alcoholic women, like men, can be
subtyped into groups that differ in terms of family history and current functioning. In
addition, the findings suggest that the risk factors cumulate and aggregate differently at
various periods in the life course. These conclusions are tempered by the retrospective
and cross-sectional nature of the current database. It remains for prospective,

longitudinal research to verify the hypotheses generated herein.

For all the families, including my own, who made this work possible.

iv

ACKNOWLEDGEMENTS

This work could not have been completed without the assistance and support of
the following people:

Dr. Robert A. Zucker, whose enthusiasm for this project never flagged through
almost two years of long-distance advising via phone calls, faxes, and express mail. His
acute understanding of this database and the entire field of alcoholism research helped to
shape and direct this project in ways I could not have envisioned on my own.

Dr. Hiram E. Fitzgerald, who has always helped me to improve my work by
asking the challenging questions, and then questioning my answers. By demanding
excellence and rigor, he helps to foster them.

Dr. Dozier Thornton, who perhaps asked the most important question: “Where are
you in this work?” My work with Dozier changed the course of my graduate school
career, and I will always be grateful.

Dr. Jacqueline Lerner, who provided a rare contribution: a positive role model of
a successful female academician.

Susan Refior, Bob Noll, Mike Klinger, Linda Sullivan, Gene Maguin, Betty
Laffan, Ray Bingharn, and the entire staff of the MSU-UM Longitudinal Study, past and

present, who collected and managed the rich database used here.

My friends, relatives, and colleagues, whose support and encouragement have
helped in immeasurable ways. Special thanks go to my husband, Morris, who provided
not only moral support, and an occasional kick in the pants, but also the administrative
support--printing, copyint, and faxing--that made this so much easier. I am also grateful
to Eleanor Lercher for smoothing my way from here. I share this accomplishment with

my Mom, who also graduates (with a BS.) this semester.

This work was supported in part by grants to RA. Zucker and HE. Fitzgerald

from the National Institute on Alcohol Abuse and Alcoholism (R01 AA07065) and from

the Michigan Department of Mental Health, Prevention Services Division.

vi

TABLE OF CONTENTS

LIST OF TABLES

INTRODUCTION

REVIEW OF THE LITERATURE

More than one alcoholism: An historical perspective
The beginnings of modern typology

Precursors to current typologies: Comorbidity studies
Typologies based on comorbidity and family history

Research on female alcoholics: Comparisons with male alcoholics, and
emerging typologies

Antisocial alcoholism in female samples

Current typologies: The Michigan State University-University of
Michigan Longitudinal Study

Summary: Can discrete subtypes be identified among alcoholic
women? ,

STATEMENT OF THE PROBLEM

HYPOTHESES

METHOD

Subjects

Procedure

vii

27

31

43

49

51

53

57

57

58

Measures 59

Verifying participants’ DSM-III-R alcohol diagnoses 59
Constructing subgroups of alcoholic women 59
Assessing biopsychosocial differences among the subgroups 61
Demographic variables 62
Alcohol-specific variables 63

Indices of antisociality 65

Indices of internalizing psychopathology 66

Indices of the rearing environment 67

Indices of religious and interpersonal involvement 67

RESULTS 69
Missing data and outliers 69
Demographic characteristics 69
Constructing groups of antisocial and nonantisocial alcoholic women 69
Assessing biopsychosocial differences between nonantisocial and 78

antisocial alcoholics

Constructing groups of primary and negative affect alcoholics 79
More than two alcoholisms? 80
DISCUSSION 95
Characteristics of the sample 97
The antisocial/nonantisocial distinction 98
More than two alcoholisms? 100
How many alcoholisms? Future directions 103

viii

Conclusions

APPENDICES

MANOVAs testing for differences between nonantisocial and antisocial

alcoholics

MAN OVAs testing for differences between primary and negative affect

alcoholics

REFERENCES

ix

105

108

109

118

126

LIST OF TABLES

1. Sociodemographic characteristics of the sample
2. DSM-III-R lifetime alcohol abuse/dependence diagnoses of the sample

3. Content differences between nonantisocial and antisocial alcoholic women on
the Antisocial Behavior Checklist

4. Sociodemographic characteristics of nonantisocial and antisocial alcoholic
women

5. DSM-III-R alcohol abuse/dependence diagnoses of nonantisocial and
antisocial alcoholic women

6. Content differences between primary and negative affect alcoholic women on
the Hamilton Rating Scale for Depression, Worst-Ever Score

7. Demographic characteristics of primary and negative affect alcoholic women

8. DSM-III-R alcohol use diagnoses of primary and negative affect alcoholic
women

9. Demographic differences between primary, negative affect, and antisocial
alcoholics

10. Differences between primary, negative affect, and antisocial alcoholics on
alcohol-specific variables

11. Differences between primary, negative affect, and antisocial alcoholics on
indices of antisociality

12. Differences between primary, negative affect, and antisocial alcoholics on
indices of internalizing psychopathology

13. Differences between primary, negative affect, and antisocial alcoholics in
rearing environment

70

72

73

76

77

81

82

83

87

88

89

92

93

14. Differences between primary, negative affect, and antisocial alcoholics in
religious and interpersonal environments

A1. Descriptive statistics of variables used in subsequent analyses
B1. Demographic differences between nonantisocial and antisocial alcoholics

BZ. Differences between nonantisocial and antisocial alcoholics on alcohol-
specific variables

B3. Differences between nonantisocial and antisocial alcoholics on indices of
antisociality

B4. Differences between nonantisocial and antisocial alcoholics on indices of
internalizing psychopathology

B5. Differences between nonantisocial and antisocial alcoholics in rearing
environment

B6. Differences between nonantisocial and antisocial alcoholics in religious and
interpersonal environments

C 1. Demographic differences between primary and negative affect alcoholics

C2. Differences between primary and negative affect alcoholics on alcohol-
specific variables

C3. Differences between primary and negative affect alcoholics on indices of
antisociality

C4. Differences between primary and negative affect alcoholics on indices of
internalizing psychopathology

C5. Differences between primary and negative affect alcoholics in rearing
environment

C6. Differences between primary and negative affect alcoholics in religious and
interpersonal environments

xi

94

108

110

111

112

113

116

117

120

121

122

123

124

125

INTRODUCTION

INTRODUCTION

A great deal of recent theoretical literature, as well as empirical research, has
strongly supported the idea that there is more than one "alcoholism." However, there is
considerable disagreement concerning what the different alcoholisms are, and what are
the best criteria by which to distinguish them. In the current vernacular, an "alcoholism"
is a discrete syndrome consisting of clinically significant alcohol-related difficulty, an
identifiable developmental trajectory, a specific group of etiologic risk factors, and a
somewhat predictable course and prognosis that are differentiable from other forms of the
disorder (Babor & Meyer, 1986).. Based on these conditions, two alcoholisms that have
received considerable attention in the literature are antisocial alcoholism, characterized by
a syndrome of sustained antisocial activity along with a dense family history of
alcoholism and relatively severe alcohol dependence, and a usually-unnamed second
alcoholism, in which there is little or no family history, and less-severe alcohol difficulty
with lower levels (or different kinds) of comorbidity (Zucker, 1994).

In addition to the widely accepted theory of multiple alcoholisms, other theories
hypothesize that female alcoholics may be different from male alcoholics. Much
additional research is needed to investigate whether similar or different biopsychosocial
pathways into alcoholism and its subtypes operate in women as in men, and whether

subtypes are identifiable among women.

The research reported herein emerges from this background, and represents an
effort to demonstrate that alcoholic subtypes, similar to those commonly observed among
men, also exist among women. This research investigated between-subtype variations in
family history, developmental history, and concurrent functioning and psychopathology.
and includes preliminary analyses pertaining to issues of course and outcome. More
specifically, the research identified three subtypes (Antisocial, Negative-Affect, and
Primary Alcoholics) within a sample of women participating in the Michigan State
University Longitudinal Study, and investigated the differences between them on a
variety of contextual measures. Once the diagnostic groups were established, they were
subjected to between-group comparisons to test for differences in the relative predictive
values of a variety of historical, contextual, and concurrent factors known to contribute to
the development of severe alcohol involvement as well as other psychopathology.

This study represents a contribution to knowledge in the field of alcoholism
research in two important ways: (1) by comparing and contrasting three distinct
alcoholisms on the bases of a wide variety of historical, contextual, and concurrent "risk"
factors, and (2) by identifying these patterns among women, it adds to a literature that has

heretofore focused very heavily on men.

REVIEW OF THE LITERATURE
More than One Alcoholism: An historical perspective
Efforts have been made since the mid-nineteenth century to classify and

typologize alcoholics. The purpose of such attempts at classification has generally been
to develop a language and system of knowledge that would help professionals and others
to anticipate the course of an alcoholic's problems, and to plan treatment strategies based
on current symptomatology, comorbidity, and putative etiology. According to Babor &
Lauerman's (1986) exhaustive review, most classifications of alcoholics have come out of
the United States, France, Germany, and England, and have accurately reflected the
contemporary social and political climates of each country's medical and intellectual
communities at the time of their inception. For example, French typologies at the end of
the 19th century were associated with the current temperance movement, and were
associated with the then-fashionable ideas of social Darwinism and inherited mental
degeneracy. Most types of alcoholics at that time were considered intractable because
heredity was equated with destiny, so individuals were sent to asylums for incarceration,
but not treatment. In contrast, in the days of Benjamin Rush and Dorothea Dix,
American typologies tended to focus mainly on psychological etiology, and there was a
great movement toward studying and treating alcoholics in relatively humane inebriate
asylums. In 19305 Germany, all intellectual pursuits were necessarily influenced by Nazi
dictates, and therefore alcoholics were classified as "constitutional," or "environmental."
As may be expected, in the interest of "racial hygiene," 30,000 "undisciplined, antisocial.

constitutional alcoholics," were denied admission to established treatment facilities,

sterilized to prevent procreation of others like them. and relegated to "secure custody" in
concentration camps. Clearly, these are extreme examples, but their most important
message is that classification of alcoholics can have very serious consequences in terms
of how they are viewed and treated by the medical community and society as a whole.
Irrespective of prevailing attitudes and policies, classification schemes have
generally shared a number of features in common. According to Babor & Meyer (1986).
a useful classification scheme should be characterized by homogeneity within categories;
heterogeneity between categories; stability; comprehensiveness and specificity;
multidimensionality; utility, and validity. Many past attempts at classification have failed
to gain wide acceptance and enduring credence because they have neglected to meet some
subset of the aforementioned criteria. For example, many of the systems reviewed by
Babor & Lauerman (1986), Morey & Skinner (1986), and Hesselbrock (1986), have
failed because they were too heavily based on ephemeral social mores, unidimensional
classification schemes, or too limited a population. As described by these authors, many
attempts at classification have included only hospitalized alcoholics, and the vast
majority have only looked at men (most commonly middle-aged Caucasian men in VA
hospitals), which clearly limits generalizability. Many schemes have relied solely on
dividing groups of alcoholics in terms of their MMPI profiles. This, too, is a faulty
method of classification, because it only relies on a single type of information from a
single source. Contemporary researchers now recognize the importance of basing
judgments on stable criteria, a wide and varied sample, and a range of information from

several sources.

The beginnings of modern typology

One of the earlier attempts at typology that is still studied today is that of Jellinek
(1960). Jellinek classified alcoholics into five types: alpha, beta, gamma, delta, and
epsilon. Alpha and Beta alcoholics engage in periodic heavy drinking with various
biopsychosocial consequences (often including antisocial behavior), but they do not
experience physical dependence. Thus they are comparable with the DSM-IV category of
alcohol abuse. Gamma, Delta, and Epsilon alcoholics do experience physical
dependence to varying degrees. Gammas can not control the amount they drink at a
given time, but can abstain for extended periods if they choose. Deltas can control their
individual drinking episodes, but are unable to abstain without withdrawal symptoms.
Epsilon alcoholics are binge drinkers who are unable both to control and abstain. To
apply more modern vernacular to J ellinek's typologies, the criteria for alpha and beta
alcoholics were similar to the DSM-III criteria for alcohol abuse, while the descriptions
of gamma and delta alcoholics conformed to the DSM-III criteria for alcohol dependence
(Hesselbrock, 1986).
Precursors to current typologies: comorbidity studies

Current researchers differentiate alcoholic subtypes on the basis of comorbid
psychopathology, as opposed to simply on individuals' drinking behaviors. A very early
example of typologizing alcoholics based on comorbid difficulty came from Knight
(1937), who distinguished essential versus reactive alcoholism. Essential alcoholism
was associated with childhood behavior problems, early onset of alcohol abuse, high

levels of antisocial behavior, and poor treatment prognosis. Reactive alcoholism, on the

7

other hand, was characterized by good psychosocial adjustment in childhood, late onset
of alcohol abuse, alcohol abuse limited to times of great psychosocial stress, higher levels
of social competence, and better treatment prognosis (Knight, 193 7).

In the half-century since Knight's theory emerged, much of the current work on
comorbidity-based typology has descended from general epidemiological studies that
provide information on the incidence and prevalence of disorders in various populations,
and the recognition that patterns of diagnoses tend to co-occur. When particular disorders
consistently appear at a higher rate in alcoholic samples than in the general population,
researchers become interested in the meaning of that comorbidity, and begin to
investigate what other characteristics the samples may share in common. For example, if
a sample is identified in which alcoholism and antisocial personality co-occur, as in
Knight's essential alcoholism, it is interesting to observe whether, in addition to having
both alcoholism and antisocial personality, the members of the sample also have similar
family histories, other psychopathology, concurrent medical problems, etc.

The main source of information for researchers interested in comorbidity has
come from studies of epidemiological catchment area (ECA) samples. In fact, the ECA is
one of the most comprehensive surveys to assess alcoholism as a disorder in a large
population using widely accepted diagnostic criteria, and to provide information about
the structure, frequency, and population distribution of alcoholism. It allows researchers
to examine associated risk factors and the relationship of alcoholism to the occurrence of

other psychiatric disorders (Helzer, Bumarn, & McEvoy, 1991).

8
In one recent study of the ECA data base, Helzer & Pryzbeck (1988) reported that

drug abuse/dependence, antisocial personality, phobic disorder, major depression, and
panic disorder, all appeared with significantly higher frequency among alcoholics than
among the general population in the catchment area under study. Similarly, Regier,
Farmer, Rae, Locke, Keith, Judd, & Goodwin (1990) interviewed 20,291 participants in
the ECA program, and found that, among persons having an alcohol disorder, 37% had a
comorbid mental disorder. The disorders that most commonly co-occurred with
alcoholism were anxiety disorders (19% of alcoholics also had anxiety disorders);
antisocial personality disorder (14.3%); affective disorders (13.4%), and schizophrenia
(3.9%). This information has led many researchers to view comorbid disorders as
possible syndromes. The constellation of alcoholic symptomatology and other
psychopathologic symptomatology may be considered an "alcoholism".

Helzer et a1. (1991) reported that, in recent studies of alcoholics among the ECA
samples, 47% had a second diagnosis. The comorbid diagnosis most highly associated
with alcoholism was abuse or dependence on other drugs, followed by antisocial
personality, mania, and schizophrenia. At every age group studied, at all five ECA sites,
antisocial personality was the psychiatric disorder most strongly related to alcoholism.
There was also a great deal of comorbid diagnosis with depression.

In addition to ECA studies, a great deal of other research regarding psychiatric
disorders co-occurring with alcoholism also takes place among hospital populations. In
one inpatient treatment study, Hesselbrock, Meyer, & Keener (1985) found the lifetime

prevalence rate for comorbid psychopathology among 321 patients with alcoholism to be

9

77%. With respect to specific diagnoses, 41% of the sample was diagnosed with
antisocial personality disorder, 38% with depression, and 54% with anxiety disorders or
schizoid personality disorders. Also using inpatient data, Powell, Penick, Othmer,
Bingham, & Rice (1982) found that 67% of a sample of 565 alcoholics in a VA hospital
qualified for other diagnoses, which included depression (42%); mania (20%); antisocial
personality (20%), and anxiety disorders (30%).
Typologies based on comorbidity and family history

About a decade afier Jellinek first proposed his five types, Winokur and his
colleagues (Winokur, Reich, & Rimmer, 1970; Winokur, Rimmer, & Reich, 1971) were
among the first to begin the prevailing trend of classifying alcoholics based on their
secondary psychiatric diagnoses. They identified three groups: primary alcoholics (who
had no other diagnoses predating the alcoholism), and depressed and sociopathic
alcoholics. The Winokur group found that alcoholics of all three types usually had
biological relatives who were also alcoholics. Also, "sociopathic and depressed
alcoholics were more likely to have a greater proportion of relatives with these
psychiatric diagnoses in their families than the primary alcoholics," (Alterman & Tarter,
1986). Clearly, because of its findings regarding familial antecedents, and its use of
concurrent psychopathology as a marker for classification, the work of Winokur et al.
(1970, 1971) set the stage for the comorbidity studies that continue today. Significantly,
another testament to the importance of the work of Winokur and his colleagues, is that

their subtypes, the sociopathic and depressed alcoholics, are still among the ones most

lO

commonly studied (i.e., Hesselbrock, 1991; Martin, Cloninger, & Guze, 1982;
Rounsaville, Dolinsky, Babor, & Meyer, 1987; Windle & Miller, 1989).

Cloninger and his colleagues (Bohman, Cloninger, Sigvardsson, and von
Knorring; Cloninger, 1987; Cloninger, Bohman, and Sigvardsson, 1981; Cloninger,
Sigvardsson, Gilligan, von Knorring, Reich, and Bowman, 1988) have proposed and
intensively studied two types of alcoholics, one of which is strongly reminiscent of
Winokur's sociopathic alcoholic and Knight's essential alcoholic. The Cloninger
typology is based on a large Scandinavian study using information gleaned from the
National Registers on the adoptive- and biological- families of male adoptees. The
Cloninger group compared information on the male adoptees' drinking records with those
of their adoptive and biological families, and each person studied was categorized as
having absent, mild, moderate, or severe alcohol abuse. The alcohol-specific information
was then compared with clusters of familial and environmental characteristics, and a
pattern emerged in which the contextual information was able to discriminate the groups.

This pattern "became the definitional basis for the familial alcoholism subtypes,"
(Penick, Powell, Nickel, Read, Gabrielli, & Liskow, 1990).

According to the Cloninger group's system, which was initially based on adoption
and cross-fostering studies of the Swedish families, there exist two types of alcoholism.
Type I, milieu-limited alcoholism, was originally (Cloninger et. al, 1981) postulated to
be inherited through both male and female biological relatives. Current probands may
have mild or severe alcohol-specific symptoms, and their biological parents’ histories are

characterized by milder forms of alcoholism, little criminality, and later onset of drinking

11

(after age 25). In a later formulation (Cloninger et al., 1988), Type I alcoholics were also
described as having passive-dependent and anxious personality traits, rapid development
of tolerance and dependence on the “anxiety reducing” properties of alcohol, and
difficulty terminating binges once they are begun.

In contrast, Type 11, male limited alcoholism, was hypothesized to be inherited
only through male biological relatives; in Type 11 families in the Cloninger et al. studies,
the mothers rarely exhibited alcohol abuse or dependence. This type was characterized
by early onset of problem drinking, and was associated with antisocial acts and
criminality in the fathers. The probands themselves exhibit antisocial personality traits in
addition to moderately severe alcoholism, and seek alcohol for “euphoriant,” rather than
anxiety-reducing, effects (Cloninger et al., 1988). Type II alcoholics rapidly become
unable to abstain from alcohol, and tend to have alcohol-related arrests due to fighting
and other antisocial behaviors.

Cloninger's subtypes have received a great deal of attention; many subsequent
researchers have tested their reliability and validity in various settings, and have also
begun to investigate further implications of the two types. One such study (von
Knorring, von Knorring, Smigan, Lindberg, & Edholm, 1987) focused on a sample of
107 male alcoholics seeking treatment at a university hospital. This sample was divided
into Type I and Type II subgroups on the basis of age of onset and the presence or
absence of at least three alcohol-related complications such as job loss, arrest, drunk-
driving conviction, criminality, and illegal drug use. This assessment yielded 44 Type I

alcoholics and 63 Type 118. It should be noted that the von Knorring group did not use

12

family history as a means of dividing the sample. This was a departure from Cloninger in
that Cloninger’s Type I and Type II alcoholics were thought to be differentiable on the
basis of the degree and type of family history.

Following subtyping, all subjects in the von Knorring (1987) study were
administered the Karolinska Scales of Personality (KSP), which includes 135 questions
on 15 types of possible comorbid difficulties, including psychic anxiety, somatic anxiety,
muscular tension, social desirability, impulsiveness, monotony avoidance, detachment,
psychaesthenia, socialization, indirect aggression, verbal aggression, irritability,
suspicion, guilt, and inhibition of aggression. Family history was also studied with
regard to a variety of difficulties. Results indicated that Type II alcoholics had a higher
frequency of alcoholism and depression in their parents than Type I alcoholics. With
respect to the KSP, Type I and Type II alcoholics demonstrated significant differences
for all scales except social desirability and monotony avoidance. Specifically, Type II
alcoholics had higher scores on somatic anxiety and verbal aggression, and lower scores
on socialization and inhibition of aggression, as compared to Type Is. Clearly, the von
Knorring et a1. (1987) study lent credence to the reliability and validity of subtypes
similar to Cloninger's, and also provided additional information by demonstrating broad
personality differences between the two groups.

Irwin, Schuckit, & Smith (1990) advised readers to interpret von Knorring et al.'s
(1987) results cautiously. Because of the age of onset and personality effects that were
noted, Irwin et a1. argued that the von Knorring group's "Type II" alcoholics were not

primary alcoholics, but instead had antisocial personality disorder, "of which alcoholism

13

is only a part of the syndrome," (Irwin et al., 1990). In concluding their critique of the
von Knorring study, Irwin et a1. (1990) suggested that including subjects with primary
antisocial personality disorder may have erroneously led readers to believe that a subtype
of antisocial alcoholics had been isolated, when in fact the subjects' "alcoholism" was, in
Irwin’s estimation, merely a symptom of their antisocial personality disorder.

In a subsequent study designed to differentiate the effects of age-of-onset upon
Type I/Type II distinctions, Irwin et al. (1990) assessed 171 male alcoholics who were
consecutively admitted to the alcohol treatment program at the San Diego Veterans
Affairs Hospital. Only veterans who did not meet criteria for any other primary DSM-III
diagnosis (including antisocial personality disorder) were included in the study. Data
were collected with regard to each subject's age of onset of alcohol dependence, and
history of Type I and Type II characteristics. Analyses of the main- and interaction-
effects of age of onset and Type I/I‘ype 11 classification indicated that age of onset was by
far the more potent predictor of the severity of alcohol and drug abuse, and childhood
criminal history. Most notable was the fact that Type I/Type II classifications failed to
predict these characteristics even when age of onset was held constant in the statistical
analyses.

Penick, Powell, Nickel, Read, Gabrielli, & Liskow (1990) also tested Cloninger's
subtypes in a sample of inpatients. Subjects were 360 male alcoholics in VA hospitals.
In contrast to the von Knorring (1987) study, and similar to that of Irwin et a1. (1990),
Penick et a1. (1990) found Type I/Type II characteristics to be of little value in

comparison to age of onset. In fact, Penick et a1. (1990) found marked overlap between

14

the symptom-clusters used to define the two sub-types: 91% of this sample satisfied
criteria for both symptom clusters. Only when Penick et a1. (1990) divided their sample
on the basis of age of onset (> or < 25 years), did they observe clear distinctions between
Type Is and Type US. These results were similar to those reported by Irwin et al. (1990),
and they led to the authors’ conclusion that Cloninger's subtypes were merely indices of
age of onset when used to describe current alcohol-related difficulties. The authors
concluded by suggesting that use of the Cloninger subtypes should be limited to
classifying only the families of alcoholics, as per Cloninger's own original schema.

An important aspect of Cloninger's typology, which was not utilized in any of the
three studies described above, is family history. Hesselbrock, Hesselbrock, & Stabenau
(1985) reported that family history was an important means by which to characterize
alcoholics, and that a number of typologies have used it as the main distinguishing
variable. In their 1985 study, Hesselbrock et a1. sought to differentiate the effects of
current antisocial personality, and family history of alcoholism, in predicting the course
and explaining the consequences of young men's alcohol misuse. These researchers
randomly selected male patients from three Hartford-area alcoholism treatment centers at
intake. They excluded patients with organic or medical problems. All of the subjects met
DSM-III criteria for alcohol dependence, and 52% qualified for a concurrent diagnosis of
antisocial personality disorder. The patients were divided into three groups: a negative-
family-history group, a unilateral-family-history group, and a bilateral-family-history
group, thus providing information on the degree of family history, as opposed to merely

its presence or absence. The initial results of this study indicated that the bilateral-

15

family-history group demonstrated significantly more difficulty in the three
"consequence" areas under study: impaired control/physical problems; psychosocial
problems; and symptoms associated with prolonged use. However, since the subjects
with concurrent antisocial personality disorder were unevenly distributed among the
family history groups, it was important to also analyze the data with and without the
effects of antisocial personality held constant. Indeed, when the researchers controlled
for antisocial personality, the three family-history groups were similar in terms of
alcoholic course. However, when antisociality was allowed to vary, all indices of
alcoholic course, including age of first drunkenness, age of first regular drinking, age of
first intoxication, age of regular intoxication, and age of first recognition of alcohol
problems, were all reached earlier in the antisocial group than in the nonantisocial group.
It is important that, even though more subjects with antisocial personality fell into the
bilateral-family-history group than into either of the other two groups, there were no
statistical interactions between family history and antisociality. In view of this lack of
statistical interaction, combined with Irwin et al.'s (1990) caveat, described above, it is
difficult to discern whether these results suggest antisocial alcoholism, or are an artifact
of antisociality. The authors themselves cautioned the reader that their results might
overestimate the effects of antisocial personality because diagnoses were based on DIS
and DSM-III criteria, which were thought to be quite liberal, and because a high level of
antisocial behavior was to be expected in such a young sample (mean age=3 9).
Similarly, when Hesselbrock & Hesselbrock (1992) studied the relative effects of

antisociality and family history of alcoholism in a sample of 91 young non-alcoholic

16

men, they found that those men who had received a DSM-III diagnosis of antisocial
personality disorder scored higher than those without such diagnoses on measures of
impulsivity, sensation-seeking, psychopathy, and monotony-avoidance. However, the
presence or absence of a family history of alcoholism did not differentiate the sample on
any of those variables. This was an important finding because the behavior problems
under study are commonly viewed as predictive of later alcohol problems. Therefore, it
should be noted that the problems were more highly related to antisociality than to family
history in this sample: perhaps antisociality may thus be viewed as a marker for later
alcohol difficulty. However, these data must be viewed with the same caution
recommended in the Hesselbrocks' (1985) study. The subjects in this study were quite
young (21-25 years), and so the same cohort effect as described above may also be
operative here.

Schuckit (1984) is another researcher who has attempted to differentiate the
effects of family history, antisociality, and other factors in predicting alcoholic course
and outcome. In a series of studies (Schuckit, 1984 & 1985; Zisook & Schuckit, 1987),
he and his colleagues interviewed a large sample of men in VA alcohol-treatment
programs, and members of their families. In the 1984 study, Schuckit conducted
structured interviews with 453 men consecutively admitted to the alcohol treatment
program at the San Diego VA Hospital, and also with up to two resource persons for
each. The resource people were interviewed with regard to subjects' background and
family history. Data were collected on patients' demographic backgrounds, drinking

patterns and problems, early antisocial life problems, drug-related problems, and major

l7

depressive episodes. Only primary alcoholics were included to ensure that observed
effects would be attributable to actual alcoholism, as opposed to alcoholic effects of other
disorders (see description of Irwin et al., above). The subjects were divided into four
groups based on family history. The results indicated that alcoholics with two alcoholic
parents had the highest rate of adult psychiatric difficulties, the lowest age upon entering
treatment, the fewest years of living with the alcoholic father, and the highest rate of
antisocial problems early in life. By contrast, the group of alcoholics without alcoholic
parents had the lowest rate of antisocial behavior, the least pervasive early life problems,
and the fewest related current major life difficulties. No significant differences were
discerned between groups of alcoholics with father-only or mother-only family histories.
These results, like those reported by Hesselbrock et a1. (1985), indicated that the density
of family history had similar effects on alcoholic course as did early onset. Clearly, then,
age of onset and family history are both important factors to consider when subtyping
alcoholics.

In an attempt to further differentiate the alcoholics at the San Diego VA Hospital,
Schuckit (1985) included 432 of the primary alcoholics described above (group 1), as
well as 60 alcoholics with primary drug abuse (group 2), 40 alcoholics with primary
antisociality (group 3), and 9 alcoholics with primary affective disorder (group 4). The
goal of this study was to identify differences between the four groups at intake and at
one-year follow-up. Results indicated that group 3 was markedly different from group 1,
"a finding consistent with the conclusion that alcoholism and antisocial personality may

be two independent disorders with some overlapping symptoms," (Schuckit, 1985). This

18

was a very different conclusion than others have drawn from similar results. While
others have used similar findings as evidence for antisocial alcoholism, Schuckit
maintained that his results supported his earlier idea that alcoholism and antisociality are
separate disorders that have symptoms in common.

Another finding reported by Schuckit (1985) was that there were very few
differences between groups 2 and 3, but that both differed from group 1 in many of the
same ways. From this finding, Schuckit (1985) concluded that the main difference
between primary-drug-abuse-alcoholics and primary-antisocial-alcoholics is that the latter
group begins engaging in antisocial activities at an earlier age (<15 years old).
Notwithstanding that difference, the two groups were highly similar in terms of the
subjects’ ages and educational attainment at intake, and in that the subjects were more
likely to have reported secondary affective episodes, suicide attempts, and psychiatric
hospitalizations at follow-up.

It was notable that Schuckit's fourth group, the alcoholics with primary affective
disorder, did not demonstrate significant differences as compared to the other groups.
This was a surprising result in light of the fact that other researchers have identified
alcoholism-with-depression as a discernible subtype. The failure of Schuckit's (1985)
data to differentiate negative-affect alcoholics may be largely attributed to the small size
of group 4. Only 9 alcoholics in this sample had a primary diagnosis of affective
disorder. Schuckit commented that perhaps the diagnostic criteria for depression were
too stringent, or that patients with primary depression ended up on wards other than the

alcohol treatment unit. Another possible limitation was that the sample was entirely

19

male. According to earlier research, depression is often found to be more common in the
general population among women than among men. Therefore, the convergence of
depression and alcoholism among women may be expected to be more common than
among men. Also, many other studies have reported findings similar to those implied by
Schuckit's results: alcoholic men most commonly have concurrent antisociality, while
alcoholic women are often observed to have concurrent internalizing disorders (see
Helzer & Pryzbeck, 1988, described above).

Zisook & Schuckit's (1987) work may be viewed as a further attempt to identify
and describe a group of alcoholics with characteristics of affective disorder. For this
study, the researchers followed groups of primary alcoholics with and without family
histories of affective disorder. The subjects were not themselves selected on the basis of
primary affective disorder. Three hundred sixty-one men consecutively admitted to the
alcohol treatment program at the San Diego VA were interviewed and asked to name two
relatives who could provide background and family history information. The men were
initially divided into two groups. Group 1 (n=37) consisted of alcoholics who had first
degree relatives with histories of affective disorder. Group 2 members did not have a
family history of affective disorder. At intake, group 1 was more likely to have had
secondary depression for at least 2 weeks during the course of their heavy drinking, and
to have attempted suicide. At one-year follow-up, they tended to demonstrate greater
alcohol-related pathology, but these differences were only significant with respect to

"morning shakes" and withdrawal hallucinations.

20

Subsequently, Zisook & Schuckit (1987) conducted a second series of analyses to
ascertain whether there was primary affective disorder among the subjects (as Schuckit
had not reliably found in the 1985 study). Groups 1 and 2 were subdivided into
subgroups A and B for family history of alcoholism, so that interactions between the
histories of affective disorder and alcoholism could be observed. There were no within-
group differences between Group 1 A&B, or Group 2 A&B; nor were there significant
statistical interactions between family histories of affective disorder and alcoholism.
However, the researchers concluded that the fact that 10% of the sample were family-
history-positive for both alcoholism and affective disorder was itself an interesting
finding that alluded to the existence of an interaction between the two diagnostic groups.

In other recent typology research, Babor and his colleagues (Babor, Hofrnann,
DelBoca, Hesselbrock, Meyer, Dolinsky, & Rounsaville, 1992; Litt, Babor, DelBoca,
Kadden, & Cooney, 1992), have identified two types of alcoholics that are somewhat
similar to Cloninger's types. Type A alcoholics were characterized by later onset, fewer
childhood risk factors, less severe dependence, fewer alcohol-related problems, and less
psychopathological dysfunction. Type B alcoholics were characterized by more
childhood risk factors, a higher degree of familial alcoholism, early onset of alcohol-
related problems, greater severity of dependence, polydrug use, a more chronic treatment
history, greater psychopathological dysfunction, and more life stress.

The two types of alcoholisms were derived from cluster analyses of 17 "defining
characteristics," including premorbid risk factors; chronicity and consequences of

drinking; and pathological use of alcohol and other substances, in a sample of 321

21

alcoholics in residential treatment. F ollow-up evaluations of the study's subjects at 12
and 36 months revealed that the two types, in addition to initially discriminating among
subjects on the bases of the 17 defining characteristics, also provided a useful basis for
predicting course and treatment outcome. It was observed that the two groups differed in
regards to alcoholic recidivism, other psychopathology, and life stress at both the one-
and three- year follow-up studies. In all respects, the Type B alcoholics fared more
poorly than Type As on the follow-up measures.

In a second study (Litt et al, 1992), the Babor group sought to replicate the
construct validity and predictive validity of their typology, and further to test its utility in
matching patients to treatment modalities. Their analyses of assessment and treatment
data from 79 male alcoholics indicated that the typology not only "held together" in this
new sample, but also demonstrated its usefulness in treatment planning. It was observed
that Type A alcoholics fared better in interactional treatment and more poorly with
coping skills training, while the Type Bs did better with the coping skills program and
more poorly with interactional therapy. These differences were maintained for two years
following the beginning of random assignments to treatment. Litt et a1. (1992)
commented that the different treatment outcomes were probably attributable to an
important point of distinction between the two groups: sociopathy. Based on previous
information that described sociopaths as "impulsive, untrustworthy, unable to learn from
experience, incapable of anticipating the reactions of others, and insensitive to society's
expectations (Doren, 1987), Litt et al. (1992) concluded that it was not surprising to find

Type Bs responding poorly to interactional treatment. Because of their sociopathy, Type

22

Bs would be incapable of forming enough of a therapeutic alliance to engage in, and
benefit from, interactional treatment. Therefore, coping skills training, which is more
concrete and intellectualized than interactional treatment, is logically a better choice for
sociopaths. Conversely, Type A patients may have found the structured coping skills
approach too restrictive and unresponsive to their needs (Litt et al., 1992).

Hesselbrock, Hesselbrock, & Workman-Daniels (1986) took a different approach
to studying alcohol typologies. Rather than dividing alcoholics into two types based on
the presence or absence of symptoms and historical risk factors, these researchers
compared and contrasted two groups with entirely different patterns of comorbidity.
Because antisocial personality and depression are two disorders that co-occur with
alcoholism quite frequently, Hesselbrock et al. (1986) chose these two disorders as a
basis of comparison for one another. Results indicated that alcoholics with comorbid
antisocial personality had an earlier onset of alcohol difficulty than those without, but that
there was no such relationship between comorbid depression and alcoholic onset. The
one issue distinguishing depressive alcoholics was that these individuals were most likely
to drink to relieve depressive symptoms. Thus the researchers concluded that antisocial
personality is far more salient than depression with regard to onset of alcohol difficulty,
but that depression may be an important factor as regards alcoholic course.

In a further exploration of the relationship of alcoholism to comorbid
psychopathology, Epstein, Ginsburg, Hesselbrock, & Schwarz (1994) employed a
multidimensional approach to compare and contrast the characteristics of alcoholics with

antisociality, negative affect, and both syndromes. These researchers tested the

23

hypothesis that a construct measuring high (anxious/depressed) vs. low (novelty seeking)
arousal personality could be used to distinguish antisocial and negative-affect alcoholics,
as well as alcoholics with both comorbid diagnoses. The results indicated that the
arousal construct did differentiate the two unidimensional subtypes. In addition, when
the antisocial alcoholics were further subdivided based on the presence or absence of
primary or secondary depressive disorder, several other findings emerged. Antisocial
alcoholics with primary depression exhibited trait (as opposed to state) depression and
anxiety, as well as hypermasculine traits and undersocialization. Antisocial alcoholics
with secondary depression showed a “high arousal” pattern, with low depression &
anxiety and hypermasculinity. Antisocial alcoholics without comorbid depression did not
present with negative affect, undersocialization, or hypermasculinity.

In another study comparing distinct alcoholic comorbidities to one another,
Powell, Penick, Nickel, Liskow, Riesenmy, Carnpion, & Brown (1992) administered
structured clinical interviews to 360 inpatient alcoholic men, and subtyped the subjects
based on comorbid psychopathology. Twenty-seven percent of the sample was
diagnosable for alcohol dependence plus one additional disorder. The resultant subtypes
were an alcohol-only subtype, an alcohol/drug abuse subtype; an alcohol/antisocial
personality subtype, and an alcohol/depression subtype. Similarly to von Knorring's
(1987) test of Cloninger's subtypes, Powell et a1. (1992) compared their subjects on the
bases of personal characteristics at intake and at one-year follow-up. These researchers
found that the alcoholism-only subtype and the alcohol/depression subtype were

significantly older than the other subtypes. The four groups did not differ in intelligence,

24

but did differ in educational and occupational attainment. The alcohol/drug and the
alcohol/antisocial groups demonstrated the earliest onsets of abusive drinking and the
earliest age of residential treatment, while the alcohol/depression group reported the most
psychiatric hospitalizations not due primarily to drinking. The alcohol/antisocial group
had, by far, the most problems with legal authorities. Few of these differences were
maintained at one-year follow-up. All groups demonstrated significant improvement in
drinking and psychosocial functioning. The authors interpreted their results to suggest
that typologies may be far less useful for predicting drinking course and outcome than for
classifying etiology and history.
Another type of psychopathology that coexists frequently with alcoholism, but
that has yet to be discussed in this review, is anxiety. Kushner, Sher, & Beitrnan (1990)
comprehensively reviewed the literature on the co-occurrence of alcoholism and anxiety
disorders. The data from all the studies reviewed yielded prevalence rates for
comorbidity ranging from 22.6% to 68.7%. The prevalence rates for the additional
disorder were higher than expected whether the studies under discussion measured
anxiety in people hospitalized for alcoholism, or screened for alcoholism in people
seeking treatment for anxiety disorders. Most studies reviewed reported that anxiety
predated alcoholism in the majority of patients.
Most attention to the relationship between anxiety and alcoholism has focused

on the tension reduction hypothesis, which states that many people who develop
alcoholism begin drinking as a means by which to alleviate innate anxiety in stressful

situations. Indeed, a variety of studies has revealed comorbidity of alcoholism and

25

anxiety, and several studies that differentiated types of anxiety disorders have shown that
agoraphobia and social phobia are more likely to coexist with, and temporally precede
alcoholism, than simple phobias, panic disorder, or generalized anxiety disorder, possibly
because the former lend themselves more easily to tension reduction through drinking
than the latter. However, according to Schuckit & Monteiro (1988), the use of alcohol by
persons with agoraphobia or social phobia to ease social situations may actually suppress
their natural processes of disinhibition and further undermine their sense of self-efficacy
in such situations. This leads to increased need for alcohol, which can in turn result in
increased anxiety, and spiral downward into comorbidity of anxiety disorder and
alcoholism.

In addition to questioning the apparent utility of alcohol use by persons with
anxiety disorder, Schuckit and colleagues (Schuckit, Irwin, & Brown, 1990) also called
into question the very coexistence of the two disorders. These researchers found that
98% of a sample of 171 alcoholics in a VA hospital had experienced at least one
symptom of anxiety during drinking and/or withdrawal, but that only 4% of their sample
fulfilled diagnostic criteria for generalized anxiety disorder after they had been dry for
three or more months. Based on this dramatic decrease, the researchers asserted that
studies reporting higher rates of comorbidity may not be controlling for anxiety that is
symptomatic of alcohol withdrawal, and may therefore be over-reporting true
comorbidity. This suspicion was previously described by Schuckit & Monteiro (1988),
who cautioned that an "abstinence syndrome," in which some symptoms of withdrawal,

including anxiety, may persist for several months in recovering alcoholics, may be

26

spuriously elevating the rates of comorbidity in treatment samples of alcoholics with
anxiety. Thus Schuckit et al. cautioned against premature dual diagnosis. This warning
countered Mullaney & Trippett's (1979) and Weiss & Rosenberg's (1985) conclusions
that the high frequency of alcoholism/anxiety comorbidity necessitates that clinicians
assess all patients, who are being seen for one of these disorders, for the other as well.
Their reasoning was that failure to treat anxious-alcoholics for anxiety following
detoxification sets the patients up for relapse. Unless such patients are given anxiolytic
medication, Mullaney & Trippett cautioned, they are left with a powerful risk factor for
alcoholism relapse.

Lending a further twist to the overdiagnosis vs. undertreatment argument
exemplified above are some thoughts about the paradoxes inherent in the anxiety-
reduction hypothesis. As reported by Schuckit et al. (1988, 1990), and Kushner et al.
(1990), several clinical studies have revealed that alcohol is no more effective than
placebo in relieving anxiety, and that it can serve to increase anxiety in the long run
(Stockwell, 1982).

Clearly, the relationship between anxiety and alcoholism is incompletely
understood, and requires further research. It is difficult to speculate what type of
"alcoholism" would be characterized by high levels of anxiety, and whether anxiety
might demonstrate relationships with family history of alcoholism, age of onset,
antisociality, and/or depression. Part of the answer to this question may be inferred from
the work on the anxiety reduction hypothesis. Perhaps people who drink to alleviate

social anxiety (as in social phobia), may be different in some important ways from those

27

with simple phobias or panic disorders, who may drink to alleviate generalized stress.
Perhaps differences in state vs. trait anxiety might also be useful in differentiating
alcoholics with anxiety. Kendler, Neale, Kessler, Heath, & Eaves (1992) reported that
anxiety and depression are so closely linked in women as to suggest inheritance via the
same genetic factors. Also, Brown, Svrakic, Pryzbeck, & Cloninger (1992) reported that
anxiety states seem independent of such personality traits as novelty seeking and harm
avoidance (which are associated with antisocial behavior), but more closely allied with
harm avoidance. It is thus unclear whether anxiety is more closely related to internalizing
or externalizing behavior, but it may be possible that, rather than being a hallmark of one
particular alcoholism, anxiety may operate differently in the etiology, course and
outcome of different alcoholisms.
Research on Female Alcoholics: Comparisons with Male Alcoholics, and Emerging
Typologies

Until about 15 years ago, few studies of alcoholism focused on women. In fact,
many earlier studies of mixed-gender groups dropped women from selected analyses, or
ignored them altogether. This apparent neglect of women in the alcoholism literature
may be attributed largely to the fact that alcoholism is a predominantly male disorder,
with a malezfemale ratio of over 5:1 (Helzer, Bumam, & McEvoy, 1991). However, it is
important to note Wilsnack & Wilsnack's (1990) prediction that public concern about
substance abuse in women is likely to increase greatly over the current decade. They
optimistically reported that, "researchers in the 1990s can use this momentum to break

away from the confines of cross-sectional, single-substance, individualistic research."

28

The Wilsnacks called for longitudinal research, and for an increased emphasis on
observing female alcoholics in social interactions, and for an increase in parallel research
on male and female substance users to clarify similarities and differences in the dynamics
of substance abuse.

Many studies have compared female alcoholics to males with respect to the same
criteria. Much of the data regarding sex differences has arisen out of the Epidemiological
Catchment Area studies. Helzer & Pryzbeck (1988) observed that female alcoholics were
far more likely than male alcoholics to have concurrent major depressive disorder.
Similar sex differences were also found for secondary phobic disorder, panic disorder,
somatization, and mania, but both male and female alcoholics were far more likely than
their nonalcoholic counterparts to have comorbid antisocial personality disorder. Sex
differences also emerged with respect to the temporal ordering of symptoms. Men with
dual diagnoses were likely to have developed alcoholism prior to their other disorders,
while women's alcoholism tended to have appeared secondarily to depression. Because
these data were based on retrospective self-reports, it is important not to infer causation
from this temporal relationship.

Helzer, Bumam, & McEvoy (1991) reported that comorbidity of alcoholism with
other disorders is more common in women than in men. Sixty-five percent of female
alcoholics, compared to 44% of men in the ECA study, had a comorbid diagnosis. With
respect to specific comorbidities, women were found to outnumber men in terms of
comorbid diagnoses of anxiety and affective disorders, with the exceptions of obsessive-

compulsive disorder and dysthymia. Male and female alcoholics both had their highest

29

comorbidity ratios with antisocial personality, drug abuse, mania, and schizophrenia.
Helzer et al. (1991) speculated that the differences were due in large part to the
overabundance of women diagnosable with depression and phobia in the general
population: because of this fact, women alcoholics would necessarily also demonstrate a
high prevalence of these disorders. However, a more important reason seems to be the
fact that alcoholism is far more deviant in women than men, and so it is not surprising
that women "deviant enough" to qualify for an alcohol diagnosis would also be
diagnosable with other disorders (Zucker & Gomberg, 1993).

Similar comparisons of male and female alcoholics have also been drawn among
treatment samples, and, again, both similarities and differences have emerged. In a large
sample of hospitalized alcoholics, Hesselbrock, Meyer, and Keener (1985) observed that
male alcoholics most often had comorbid other-drug abuse and antisocial personality,
while female alcoholics were more likely to have major depression and phobia. Although
the general patterns of comorbidity for men and women were different, the course of
alcohol difficulties was similar among both men and women of the same subtype. Thus,
both male and female alcoholics with antisocial personality had an accelerated course of
alcoholic difficulty. Similarly, Rounsaville, Dolinsky, Babor, and Meyer (1987) reported
that female and male antisocial alcoholics could be expected to have a poorer prognosis
than non-antisocial alcoholics of either sex. Again, the female antisocial alcoholics were
similar to their male counterparts.

The work of Windle and Miller (1989) also demonstrated that male and female

alcoholics of the same diagnostic category may be more similar to one another than to

30

same-sex alcoholics of different categories. In their sample of 461 convicted drunk
drivers (of whom 36 were female), Windle and Miller found that both males and females
who qualified for an alcohol-dependence diagnosis were appreciably more likely to be
depressed than those diagnosed with alcohol abuse. Both men and women diagnosable
with alcohol abuse were, in turn, only slightly more likely to be depressed than
individuals who did not qualify for any alcohol diagnosis. Windle and Miller’s data
analyses revealed an interaction between gender and alcohol-use severity such that,
among the subjects who were alcohol-dependent, women were more depressed than men.
Hesselbrock’s (1991) data also indicated that alcoholics may be subtyped based
on their symptom clusters, regardless of their sex. In a large group of hospitalized
alcoholics, she compared male and female alcoholics in terms of their family history of
alcoholism, percent of family members with antisocial personality disorder and
depression, and indices of course, consequences, and treatment outcome. Patients with
comorbid antisocial personality and depression reported more childhood behavior
problems and more current alcohol-related problems than did alcoholics with ASP-only,
depression only, or primary alcoholism. The alcoholics with both ASP and depression
also fared more poorly than the other groups in terms of treatment outcome. Among the
group of alcoholics with both types of comorbid psychopathology, there were no sex
differences in childhood behavior problems, current alcohol-related problems, or
treatment outcome. Again, female alcoholics were more similar to male alcoholics with

the same symptom cluster, than to other female alcoholics.

31

In addition to symptom profiles, male and female alcoholics have also been found
to be similar in terms of family history. Glenn and Parsons (1989) found that family
history Operates in similar fashion as a risk factor for alcoholism among both sexes. In
their study, both men and women with positive family histories for alcoholism (FH+)
demonstrated higher levels of childhood behavior problems, lower IQ scores, greater
anxiety and depression, and poorer peer relations and job stability, than did adults with
negative family history (F H-). Glenn and Parsons (1989) had expected sex differences to
emerge within the FH+ group such that, for example, females would exceed males in
terms of anxiety and depression and males would exceed females in childhood conduct
problems. However, these sex differences did not appear.

Antisocial alcoholism in female samples

All of the studies described above indicated that female alcoholics, like their male
counterparts, may be subtyped on the bases of comorbid symptomatology, family history,
and other characteristics. Therefore, it is reasonable to explore whether classification
schemes that were traditionally tested in specifically male samples may successfully be
applied to samples of women. Several such investigations were performed by the
Cloninger group.

Bohman, Sigvardsson, and Cloninger (1981) observed a preponderance of alcohol
abusers among the adopted daughters of Type I biological parents. These daughters
exhibited alcoholism when their mothers were alcoholic and, to a greater extent, when
both biological parents were alcoholic. If only the father was an alcoholic, however, the

daughter was not. Moreover, Type II alcoholic fathers did not have alcoholic daughters.

32

This led the researchers to further explore the observation that female alcoholism may be
partly accounted for by genetic factors, but that the patterns of heritability are different
from those observed among men. For example, the results demonstrated that Type I
familial alcoholism predicts alcoholism in both men and women, but Type II familial
alcoholism predicts alcoholism only in men. This finding suggested that the alcohol-
specific symptoms were heritable through both parents, but that antisociality was only
patrilineally heritable. Bohman et al. concluded their 1981 paper by hypothesizing that
the genotypic diathesis for alcoholism is passed by both parents to children of both sexes,
and characteristics of the uterine environment (i.e., fetal alcohol effects) affect both male
and female fetuses. However, the phenotypic differences observed in male and female
offspring may be attributable to different “sporadic” influences such as metabolic
differences, different sex-role expectations, and/or differences in the postnatal
environment.

In a subsequent cross-fostering study, Bohman, Cloninger, Sigvardsson, and von
Knorring (1987) found that female adoptees were more likely to develop alcoholism if
their biological fathers, but not their adoptive fathers, were alcoholic. This association
was only true if the biological fathers were Type I alcoholics; daughters of Type II
alcoholics tended instead to exhibit somatization symptoms. Alcoholism was even more
likely to appear in daughters of alcoholic biological mothers. Bohman et al. (1987) also
studied the biological extended families of these adopted-out women, and found that the
female relatives of Type II alcoholics, but not those of Type Is, tended to also be

somatizers. Among these women with somatization symptoms, there was a sub-group of

33

especially high-frequency somatizers. These women's male relatives were characterized
by prominent criminality and multiple incidences of alcohol-related difficulty. Thus,
three types of familial patterns were now identified: (1) families in which Type I men
and women had Type I male and female relatives; (2) families in which Type 11 men had
Type II alcoholic male relatives and nonalcoholic, low-frequency somatizing female
relatives; and (3) families in which particularly antisocial Type 11 men (who committed
violent crimes unrelated to their alcohol abuse) had "hypochondriacal" female relatives.
Thus, a phenomenon was observed in which male and female offspring with the same
biological family background (Type II fathers and somatizing mothers) exhibited
different symptom patterns: the sons were themselves Type 115 with varying degrees of
criminality, and the daughters were somatizers of various levels of severity. Again, as in
the 1981 paper, the researchers concluded that the different phenotypes observed among
males and females of the same alcohol-related genotype were due to different interactions
of genetic, social, and environmental circumstances (Bohman et al., 1987).

In another study of this Swedish cohort, Martin, Cloninger, and Guze (1985)
observed that the rate of antisocial personality disorder among convicted felons was
similar for males and females. Among a group of female felons, alcoholism was
associated with antisocial personality but not depression. The generalizability of these
results was unclear because the use of a sample of felons oversampled for antisociality.
However, taken together with the Cloninger group’s 1981 and 1987 findings, these
results indicate that, although men and women may not inherit alcoholism in the same

ways, there is evidence for the existence of a female alcoholic phenotype that strongly

34

resembles the Type II male in terms of the confluence of alcoholism, antisociality, and
criminality. However, this study did not account for family history or age of onset of
alcohol or antisocial symptoms, so it is difficult to discern the degree to which the males'
and females' pathways into their current situations were similar.

In contrast, Hill and Smith (1991) did test for genetic vs. environmental
transmission of female alcoholism via the same models (isocorrelational, environmental,
and independent) as the Cloninger group had previously applied to males. Their review
of twin- and adoption— studies showed that female and male alcoholisms are both
genetically mediated, but the researchers proposed that the mode of transmission is
different. Among alcoholic probands, Hill and Smith observed that there is greater
concordance among the families of female alcoholics than among male alcoholics,
suggesting that family history may be just as salient a predictor of female alcoholism as
for male alcoholism.

Babor et al. (1992) found among their female subjects a Type B subset that was
very similar to the male Type Bs. As compared to Type As of both sexes, both male and
female Type Bs exhibited more risky behavior, less control, a stronger history of
childhood aggression, a more extensive treatment history, lower occupational status,
greater relapse probability, and poorer prognosis. The only difference that Babor et al.
(1992) observed between male and female Type Bs was that females were less likely to
drink to self-medicate symptoms of anxiety and depression, and to use benzodiazapenes.

Kubicka, Csemy, and Kozeny (1992) studied many of the same phenomena

among their Czech sample as the Cloninger group has described in their Swedish

35

subjects. These researchers compared and contrasted a group of inpatient alcoholic
women, a group of inebriated women admitted to one-day detoxification, and a group of
randomly selected comparison women, on the basis of a variety of putative risk factors.
Irrespective of group membership, Kubicka et al. (1992) found that paternal alcoholism,
incomplete family of origin, conduct disorders in childhood and adolescence, and having
a heavy-drinking husband or best friend, were supported as risk factors of alcoholism. A
history of conduct disorder emerged as a risk factor, but a history of depression did not.
A factor analysis of these alcohol-related problems led to two dimensions (dependence
and disruptiveness), and consequently to four types of female alcoholics with different
patterns of risk factors. Except for the fact that early onset of drinking did not
differentiate the four groups of alcoholics, Kubicka et al. (1992) noted that the emergent
typologies closely resembled Cloninger's subtypes. In particular, the subjects from the
detoxification centers closely resembled Cloninger's Type IIs. A noteworthy feature of
this study is that it included a control group so that the sample was not unduly biased
toward antisociality, as was the case in the Martin et a1. (1985) study.

In contrast, Lex, Sholar, Bower, and Mendelson (1991) reported evidence
contrary to Bohman et al.'s (1987) findings that daughters of Type II alcoholic fathers
experience somatization as their primary symptom. Among a group of women arrested
and incarcerated for a third DUI offense, Lex et al. observed early onset of alcohol
problems, a strong history of antisocial behavior, and a 75% rate of family history of
alcoholism. This group of women closely resembled Cloninger’s Type 11 male alcoholics.

In an earlier study, Lex, Teoh, Lagomasino, Mello, and Mendelson (1990) studied the

36

personal characteristics of the first 20 women admitted for mandatory substance abuse
treatment following civil commitment by Massachusetts courts. The researchers first
diagnosed the women, and found that approximately two thirds were alcohol dependent,
and one third were polysubstance-dependent. Once diagnosed, each woman completed a
battery of questionnaires designed to elicit information about background characteristics,
overall health, alcohol and drug use histories, living situations, social and economic
circumstances, and legal infractions. They were also evaluated for physical, reproductive,
and psychological disorders. Overall, Lex et al. (1990) found that this more severely
substance abusing sample had problems of greater severity and variety than those
observed among female DUIL cases reported by other researchers. In addition, within
Lex’s sample, the women who were polydrug-involved had more variety and severity of
problems than women diagnosable with alcoholism only. Moreover, the polysubstance
abusing probands had the greatest density of alcoholism in their families, especially
among male relatives. Because Lex et al.'s subjects were recruited through the court
system, it was clearly a highly antisocial sample. On that basis, the generalizability of
these results may be limited by severity bias.

More recently, Lex, Goldberg, Mendelson, Lawler, and Bauer (1994) extended the
findings described in the above two studies. To further subdivide female antisocial
alcoholics, they administered the Substance Abuse, Somatofonn, Borderline, and
Antisocial sections of the SCID to 31 inpatients who met criteria of alcohol dependence.
The women were asked to complete the sections on personality disorders twice: once

with regard to their behavior when sober, and once with regard to their behavior when

37

drunk or hung-over; they were then divided into three groups for further analysis. Group
1 consisted of alcoholics with no antisocial behavior; group 2 was comprised of
alcoholics who behaved antisocially only when intoxicated; and group 3 contained
women who reported antisocial behavior regardless of alcohol use. Group 3 was
significantly different from the other two groups in that its members were the youngest,
took their first drink at the earliest age, had the earliest age of onset of alcohol
dependence, encountered legal problems the earliest, engaged in the earliest sexual
intercourse, and had the most borderline-like symptoms as well as the most antisocial
behavior both prior to and after age 15. Clearly, the women in Group 3 were different
both from non-antisocial alcoholics, and from those who may have used alcohol to help
them to be more assertive and uninhibited in social settings. Although Lex et al.’s (1990,
1991, 1994) findings were similar to Cloninger’s Type II and Babor’s Type B alcoholics,
they must be interpreted with caution because of low sample sizes.

Glenn and Nixon (1991) also attempted to apply Cloninger's subtypes to a sample
of women. These researchers found that, among their sample of 51 female inpatient
alcoholics, Cloninger's subtypes did not differentiate late-onset from early-onset
alcoholics. That is, women above and below the age of 25 were equally likely to endorse
Type I symptoms (such as guilt about drinking and attempts to limit drinking) as well as
Type 11 symptoms (including alcohol-related arrests and auto accidents). Because the
onset of alcohol symptoms was not a useful basis by which to split the sample, Glenn and
Nixon elected instead to divide them into groups of early and late symptom onset (any

alcohol-related symptom as opposed to a full-blown alcoholism syndrome). Based on

38

this division, the early-symptom-onset (BSD) and late-symptom-onset (LSO) groups
differed with respect to psychosocial and demographic variables, severity of alcohol
abuse, family history of alcohol abuse, psychopathologic characteristics including
comorbid depressive symptomatology and antisocial behavior; and history of substance
abuse other than alcoholism. For all of these differences, the ESO group demonstrated
greater severity of difficulty. Most significantly, ESOs more frequently reported paternal
alcoholism, paternal antisocial behavior, family density of alcoholism, current antisocial
behavior, subjective anxiety, and other-drug abuse. The two groups did not differ in
depressive symptomatology. These differences between female ESO and LSO alcoholics
were similar to the differences between Cloninger's types. However, because this
inpatient sample had an inherent severity bias, the results should be regarded with
caution. It would be useful to replicate this study with a larger group of women that
represented a greater variety and continuum of problems.

Despite these limitations, it is undeniable that the appearance of Type II
alcoholics in the three female populations just described was an important finding in
terms of both research and intervention. Indeed, Zucker & Gomberg (1994), upon
reviewing the literature on antisociality in women alcoholics, commented that this area of
research constitutes a "hot spot," because female antisocial alcoholics were observed to
be similar to their male counterparts not only in current symptomatology, but also in
terms of developmental trajectory. As had previously been observed in the families of
origin of male antisocial alcoholics, the rearing environments of female antisocial

alcoholics tend to be characterized by poor social functioning; physical and sexual abuse

39

of women and children; strong histories of various psychological dysfunction; and dense
family history of alcoholism. Likewise, the current life situation of the female antisocial
alcoholic is typified by poor social functioning; abusive domestic partnerships;
concurrent psychological disturbance; and severe alcohol symptomatology and alcohol-
related psychosocial consequences. These observations led Zucker & Gomberg (1994) to
comment that the emergence of female antisocial alcoholics, with the concomitant risk-
taking behaviors of any antisocial individual, "will point overwhelmingly to the need for
considerably earlier intervention, involving multimodal, outreach based approaches that
would be more likely to successfully sustain contact with this heavily troubled set of
young women."

In addition to these comparisons of male and female alcoholics, and attempts to
subtype alcoholic women, there have also been a number of studies of the special
biopsychosocial issues particular to women alcoholics. Gomberg (1986) reviewed the
contributions of sex role conflict, specific precipitants, female sexuality, and cognitive
impairment, to the understanding of alcoholism in women of different age groups.
Among women in their forties, Gomberg (1986) observed that alcohol use was highly
related to sex-role dissatisfaction. For these women, "alcohol seems to be a way of
minimizing feelings of frustration and resentment...that the fantasies and dreams of
girlhood..might never be satisfied," (Gomberg, 1986). For women in their thirties,
difficulties arose in resolving conflictual feelings about traditional roles and new
opportunities available to them. Alcohol use may, for these women, be a way to avoid

conflicted feelings about sex-role-appropriate behaviors in the context of rapid social

40

change. For women in their twenties, Gomberg observed, "there are serious problems
with impulse control and the formation of adult identity. Relationships with the family of
origin are frequently strained and tense, and therapists would do well to help these young
women work out their relationships with their mothers and other women. " In addition to
these age-related observations, Gomberg (1986) also reported that depression, sexual
history (trauma, lack of fulfillment, etc.), and cognitive deficits, all figure prominently in
the development of alcoholism in women of all ages.

Similar to Gomberg (1986), the Wilsnacks and their colleagues (Wilsnack,
Wilsnack, & Klassen, 1984; Wilsnack & Wilsnack, 1990; Wilsnack & Wilsnack, 1991;
Wilsnack, Klassen, Schur, & Wilsnack, 1991) have also observed that social role is an
important factor in women's alcoholism. These researchers conducted a five-year
longitudinal study of women's problem drinking in which they followed-up problem
drinkers and non-problem drinkers in order to observe factors that might account for
stability and change. At the beginning of the study, they noted that the women who
drank differed from those who didn't in that they had less stable roles. For example,
women who drank at Time 1, were more likely than those who didn't, to be cohabitating,
single, separated, or divorced, and to work part-time. The heaviest drinkers at Time 1
also reported belligerence with their spouses, associations with heavy-drinking fiiends
and family, and incidences of drunk driving.

As this group of researchers followed their sample, they also noted a variety of
factors that appeared to contribute to stability and change in alcohol difficulty. For

instance, they reported that younger age, cohabitation, low self-esteem, history of

41

childhood sexual abuse, infertility problems, exposure to heavy-drinking fiiends and
family, and lifetime use of drugs other than alcohol, were all predictive of Time 2 alcohol
problems among women who had not been alcoholics at Time 1. In terms of stability,
women who were alcoholics at Time 1 were most likely to remain so at Time 2 if they
experienced sexual dysfunction, inconsistent work history, or depression, or if they had
never been married. In a 1990 comment on the future of research on female alcoholism,
Wilsnack & Wilsnack urged that investigators continue to study the role of personal
relationships, sexuality, and "companionate drinking," as each factor bears on the course
of alcohol difficulty.

Yandow (1989) observed that women's drinking was highly correlated with the
drinking behaviors of significant others in their lives, and problems with drinking often
centered around issues of shame and guilt pursuant to negative societal views toward
women's drinking. Yandow (1989) posited that one reason for the relatively low
incidence and prevalence of alcoholism among women was that it was simply under-
diagnosed. Women alcoholics have historically been loath to seek treatment because they
feared stigma, and health professionals may have been more likely to diagnose depression
or personality disorder, to the neglect of alcoholism, for the same reasons.

Another risk factor that has emerged several times in the research on women
alcoholics, but that has received very little attention in the men's literature, is the presence
of current domestic violence and/or a history of physical or sexual abuse. The
importance of interpersonal violence was alluded to in the Wilsnacks' work (described

above), but has been studied in greater depth by a group of researchers in Buffalo, New

4 2
York. Miller, Downs, & Gondoli (1989) administered the Conflict Tactics Scale to a

group of female alcoholics and to a randomly selected control group. Alcoholic women
were found to have experienced higher levels of negative verbal interaction, moderate
violence, and severe violence with their husbands, as compared to the comparison
women.

In a more recent study, Downs, Miller, Testa, & Panek (1992) examined the
relationships between childhood experiences of violence, current domestic violence, and
alcohol-related problems. They observed that mother-to-daughter violence was highly
predictive of current domestic violence, while father-to-daughter violence (especially
verbal aggression) predicted alcohol abuse. The researchers concluded that their findings
were likely connected to social roles. The mother-to-daughter violence may have taught
the daughters that violent behavior was an acceptable mode of problem solving, and an
appropriate way to assert power over others. Thus, the daughters may not have seen
domestic violence as abnormal, and may have even reciprocated it themselves. On the
other hand, the verbal aggression from the fathers may have served to decrease the
women's self-esteem, and led to current self-medication through alcohol abuse. As the
researchers also said in the 1989 study, it was more difficult to understand the
relationships between the current drinking and domestic violence. It may be that the
drinking was a means of escape from the violence, and/or that the violence came in
retaliation for the women's drinking. Equally likely, both events may have been caused
by a third variable, such as the level of marital conflict or dissatisfaction, or the partner's

own drinking behavior and/or history of abuse.

43

While the Buffalo group focused its research on women's histories of physical
abuse, Hurley (1991) concentrated on incest. She began her article by noting the
psychosocial parallels between alcoholic women and survivors of incest, and concluded
by discussing patterns that emerge when the two phenomena co-occur. According to
Hurley, the incidence of incest among alcoholic samples was at least twice the regular
population rate. In a review of studies of women in treatment for alcoholism, a wide
range was observed in which as many as 85% of the subjects report a history of sexual
abuse (Hurley, 1991).

In her review of studies comparing alcoholic incest survivors with non-alcoholic
survivors, Hurley noted that the subj ects' mothers tended to be unresponsive to the
fathers; that the families were conflictual; that the women experienced sexual
dysfunction; that the survivors tended to feel guilty; and that the women started drinking
at a young age as a means by which to decrease sexual inhibition. As compared to
nonalcoholic sexual abuse survivors, alcoholic survivors also-tended to report more life
trauma, a higher frequency of post-traumatic stress disorder, more turbulence in
adolescence, and a greater reliance on alcohol to "fit in" during social occasions and to
boost self-esteem.

Current typologies: The Michigan State University-University of Michigan
Longitudinal Study

Recent work with the Michigan State University-University of Michigan

Longitudinal Study's data set, of which the current study is a part, has also examined

alcohol typologies and their implications in terms of etiology, psychosocial functioning,

44

course, and outcome. The work on typology has its origins in the Four Alcoholisms
theory advanced by Zucker (1987). Zucker's four alcoholisms included two very familiar
groups, and two new types. Type 1, antisocial alcoholism, is characterized by early
onset of alcohol problems and early evidence of antisociality, with both disorders
exhibiting clinical severity and persisting from pre-adolescence into adulthood. This type
is most reminiscent of the alcoholism-with-sociopathy and alcoholism-with-antisocial
personality groups described above, such as Cloninger’s Type II and Babor’s Type B.
Type 2, developmentally cumulative alcoholism, differs from Type 1 in its later
onset, less dense family history, and lower incidence of antisocial behavior. In Zucker’s
(1987) scheme, “the notion of developmental cumulation implies that Type 23’ pattern of
risk is more closely tied to normal, culturally prescribed processes of drinking and
problem drinking than in antisocial alcoholism, but that the addictive process has, over
the life course, become sufficiently cumulative as to move along a different
developmental trajectory than if it were simply regulated by normative developmental
trends” (Zucker, 1987, p. 67). In other words, heavy drinking may begin in a culturally
normative pattern and time frame (i.e., weekend bingeing in college), but continues past
this period and often increases in severity. Zucker’s explanation for this phenomenon is
that Type 25 lack adequate methods for coping with the stresses inherent in the transition
to adulthood, such as job stress and marital stress, and therefore continue (and often
increase) their drinking as a means by which to mediate their emotional discomfort.
Type 3, developmentally limited alcoholism, has much in common with Type 2,

except that the developmental trajectory ends in early adulthood (developmental

45

discontinuity) rather than continuing to cumulate. For this group, frequent heavy
drinking usually drops off by the mid-twenties, likely in response to increased societal
expectations of responsibility and conventionality and decreased tolerance for deviance
and rebelliousness.

Type 4, negative affect alcoholism, is a type that has been frequently studied but
less well understood than types associated with antisociality. For individuals with this
symptom cluster, alcoholism is associated with depression, possible suicidal ideation,
and/or anxiety. In some studies, it has been more closely associated with women than
with men (Wilsnack, Wilsnack, & Klassen, 1969), and appears to be associated with
fewer pervasive life difficulties and less significant family history of alcoholism than is
seen among antisocial subtypes.

More recent work on the MSU-UM Longitudinal Study has attempted to
empirically support some of the alcohol typologies described above. Thus far, completed
work has focused heavily on antisocial alcoholism in men. Instead of comparing the
alcoholisms, one to another, current work is comparing alcoholics with comorbid
antisocial behavior (antisocial alcoholics, or AALs) to alcoholics without such
comorbidity (nonantisocial alcoholics, or NAALs). At the moment, few attempts have
been made to differentiate types of non-antisocial alcoholics beyond the extent to which
NAALs are different from AALs.

In the first of these studies, Zucker, Ellis, & Fitzgerald (1994), began by
classifying 102 male alcoholics based on Cloninger's subtypes. Subjects who met a

DSM-III abuse/dependence diagnosis, whose drinking had not incurred serious social

46

consequences (family arguments, violence while drinking, loss of job, other legal
difficulties), and who have suffered psychological distress as a result of their drinking,
were coded as Type I. Those who met DSM-III criteria, had an early onset of alcohol
trouble (< 25 years), and whose drinking has incurred the social consequences described
above, were coded as Type 11. Among this sample of 102 alcoholic men, 25 were
classified as Type I, while 60 were classified as Type 11.

Once these typologies were established, subjects in each group were compared
on the bases of family expression of alcoholism (FEA), the pervasiveness of alcohol
problems in subjects' lives, socioeconomic status, childhood and adult antisocial
behavior, and depression. The results of this study indicate that Type Is and IIs exhibit
different patterns of lifetime alcohol problems. Type 118 showed a positive and
significant relationship between biological risk (high F EA) and level of lifetime alcohol
problems, while Type Is showed a negative relationship. Also, a LISREL analysis
revealed that the path models predicting lifetime alcohol problems in the two groups were
distinct. For Type US, it appeared that antisocial behavior in childhood predicted
antisociality in adulthood, which in turn drove alcohol-related difficulty. Among Type Is,
by contrast, only worst-ever depression (Hamilton, 1960) was strongly associated with
adult alcoholism.

In a second, related study, Zucker et al. (1995) attempted a developmental
approach to subtyping, in which typological variation in adulthood was established by
way of a classification scheme utilizing history as well as current functioning. The

sample was divided into AAL and NAAL subtypes based on a median split of their child

4 7
and adult scores on the Antisocial Behavior Checklist (Zucker, 1991). Those with scores

of 24 or higher were classified as AALs; with this cut-off score, the instrument's
sensitivity is .85 and its specificity is .83 for a diagnosis of antisocial personality disorder
using DSM-III-R criteria (Zucker et al., 1995). This use of both childhood and adult
antisocial behavior scores helps to establish a developmental trajectory which is thought
to begin early in life, and to crystallize as antisocial alcoholism in adulthood. The results
of this study indicated that AALs had an earlier onset of problem drinking, a heavier load
of alcohol-related difficulty, and a greater variety of alcohol-related problems, as
compared to NAALs. In addition, AALs demonstrated lower occupational attainment
despite comparable family-of-origin socioeconomic status. Also, AALs had a greater
incidence of comorbid depression and other psychopathology. Among the NAALs, only
lifetime variation of depressive symptomatology was found to predict alcoholic outcome.
Finally, this study showed that the NAAL/AAL typologies were also useful for
differentiating early risk in the children of the alcoholic fathers. Variations in child
behavior (as measured by the Achenbach & Edelbrock Child Behavior Checklist
[CBCL]), were examined in relation to patterning among predictor variables in the
children of AALs, NAALs, and nonalcoholic comparison parents. Whereas heritable
factors appeared to play a role in the development of externalizing behavior problems for
children of AALs, this was not true for children of NAALs or nonalcoholic controls.
Moreover, the impact of being raised by an alcoholic parent appeared less salient to the
emergence of psychopathology among children of NAALs (Ellis, 1993). This

information about early childhood problems has very important implications for the

48

development, course, and intergenerational transmission of familial alcoholism. Because
it is known that childhood antisocial behavior is a high risk factor for adult antisocial
alcoholism, it is very significant to observe that the children of antisocial alcoholics
exhibit behavior problems as early as the preschool years.

As a follow-up to the important results described above, Zucker, Ellis, &
Fitzgerald (1995) continued their typological study with the general hypothesis that a
sustained history of high levels of antisocial involvement concurrent with alcoholism
yields a different type of alcoholism, both symptomatically and etiologically, than one
which does not share such developmental covariation. Zucker et al.'s (1995) specific
predictions were that there would be (1) a different pattern of alcoholic symptomatic
display; (2) a different pattern of life adaptation in adulthood; and (3) a different pattern
of causal process for these different subtypes. More specifically, the authors predicted
that AALs would have earlier onset and greater severity of alcohol related
symptomatology, and would show more indices of poor social adaptation in adulthood
than would the NAALs. In addition, they anticipated that evidence suggestive of a
greater contribution of genetic influences to etiology would be found among the AALs.

The results of the Zucker et al. (1995) study provided strong evidence that there
are two subsets of alcoholic men who differ in age of onset of alcohol troubles, severity
and life invasiveness of alcohol symptomatology, occupational attainment, type and
severity of comorbid psychopathology, and salience of family history load of alcoholism.

AALs and NAALs were also found to differ in "the manner in which these contributory

sources of variation inter-relate; the models which best characterize the causal sequence

49

implicate different mechanisms in predicting the phenotype of the profundity of alcoholic
disorder," (Zucker et a1, 1995).

In addition to these completed works from the MSU-UM Longitudinal Study, a
preliminary analysis of the women's data suggested similarities with the aforementioned
results, and with earlier studies of female alcoholics. More specifically, in a pilot sample
of 65 alcoholic women, it was observed that 15% also met diagnostic criteria for
depression, 18% for antisociality, and 34% for both concurrent disorders. Also, among
the antisocial alcoholic women, there existed a significant relationship with history of
physical and sexual abuse.

Summary: Can discrete subtypes be identified among alcoholic women?

Upon reviewing the relevant literature, it is clear that there is ample evidence for
the existence of at least two alcoholisms. Among men, alcoholisms may be distinguished
via age at onset of alcohol difficulties; age of onset of antisocial behavior; family history
of alcoholism; comorbid psychopathology, and a variety of other factors.

Among women, the evidence is somewhat less clear. There are conflicting reports
as to whether female alcoholism is similar to or different from male alcoholism, but an
emerging trend suggests that female antisocial alcoholism is more similar to male
antisocial alcoholism, than to other types of female alcoholism. These findings were
observed among severely antisocial samples of women (i.e. Lex et al., 1991); further
research is needed to determine whether such a subtype is identifiable elsewhere.

It is also becoming apparent that there are some variables that differentiate

subgroups of female alcoholics from one another, though they do not appear to

50

demonstrate much of an effect among male alcoholics. One such variable is a history of
parental physical (Downs et al., 1992) and sexual (Hurley, 1991) abuse, as well as current
domestic violence (Miller et al., 1989). Another is social role disorganization and/or
dissatisfaction (Gomberg, 1986; Wilsnack & Wilsnack, 1991).

The relationship of an alcoholic woman with her alcoholic spouse must also
receive additional attention. The ideas of drinking partnerships (Wilsnack & Wilsnack,
1991) and assortative mating (Jacob & Bremer, 1986) certainly merit attention, especially
in view of Jacob & Bremer's observation that 50% of all alcoholic women have an
alcoholic spouse, compared to only 10% of alcoholic men.

Clearly, future research on alcoholic women must pay attention to traditionally-
tested variables such as family history, comorbidity, and age of onset, and also to the

newly-recognized effects of abuse history, social role, and alcoholic friends and family.

5 1
STATEMENT OF THE PROBLEM

Based on the existing literature, it is clear that there is much support for the
existence of more than one alcoholism. Whether samples have been divided by age of
onset, family history, or comorbid psychopathology, many studies have shown that
alcoholics may be classified into at least two groups. There is also considerable
knowledge about the different developmental trajectories that culminate in these
alcoholisms. For example, we know that a dense family history of alcohol difficulty, an
early onset of drinking, and antisocial activity in both adolescence and adulthood tend to
co-occur and comprise one "alcoholism," variously known as essential, Type II, Type B,
sociopathic, or antisocial alcoholism, while the histories of other alcoholics tend to be
characterized by depressive and/or anxious symptomatology, later onset, and less dense
family history. Considerable research has also been devoted to the question of whether
male and female alcoholics are similar to or different from one another, and if they
demonstrate different symptom clusters and life courses. However, few existing studies
have focused specifically upon female alcoholics, and attempted to typologize them
according to classification schemes widely used among men.

The current study focused on the issue of alcoholic subtypes among women.
Within the limits of a currently cross-sectional, retrospective data set, it sought to
identify subtypes of alcoholic women based on their scores on checklists measuring
comorbid antisocial behavior and depression. On the basis of pilot work, it was
anticipated that these alcoholic women would be differentiable on the bases of the

following constructs and variables:

52

1. Demographic characteristics, including current and family-of-origin
socioeconomic status, current family income, educational attainment, and number of
children.

11. Alcohol-specific personal and contextual characteristics, including family
history of alcoholism, lifetime alcohol problems, DSM-III-R alcohol diagnosis, and
husband’s alcohol diagnosis.

III. Personal and contextual indices of antisociality, including childhood
conduct problems, husband’s antisocial behavior, husband-to-wife domestic violence, and
wife-to-husband domestic violence.

IV. Internalizing psychopathology, including self-reported depression, fears and
phobias, and family history of depression.

V. Indices of the subjects’ childhood rearing environment, including family
history of alcoholism and depression, family of origin SES, and childhood physical
punishment.

VI. Religious and interpersonal involvements, including a subjective measure
of religiosity, current and family-of-origin attendance at religious services, and perceived

instrumental and emotional social support.

5 3
HYPOTHESES

Among a sample of women diagnosed with DSM-III-R alcohol abuse or
dependence, two sub-groups, based on their levels of antisociality, will be
differentiable on the bases of family history; developmental history; concurrent
psychopathology; adaptation; and social functioning. More specifically, the
NAALs and AALs identified in this study will be shown to differ from one
another on the bases of the following constructs:

1. Demographic characteristics, including current and family-
of-origin socioeconomic status, current family income, educational attainment,
and number of children.

11. Alcohol-specific personal and contextual characteristics,
including family history of alcoholism, lifetime alcohol problems, DSM-III-R
alcohol diagnosis, and husband’s alcohol diagnosis.

111. Personal and contextual indices of antisociality, including
childhood conduct problems, husband’s antisocial behavior, husband-to-wife
domestic violence, and wife-to-husband domestic violence.

IV. Internalizing psychopathology, including self-reported
depression, fears and phobias, and family history of depression.

V. Indices of the subjects’ childhood rearing environment,
including family history of alcoholism and depression, family of origin SES, and

childhood physical punishment.

54

VI. Religious and interpersonal involvements, including a
subjective measure of religiosity, current and family-of-origin attendance at
religious services, and perceived instrumental and emotional social support.

The direction of these differences will appear as follows:

a. AALs will score lower than NAALs on the demographic indices. In
addition, it will be observed that AALs demonstrate a downward shift in socioeconomic
status such that their current family SES will be appreciably lower than their family-of-
origin SES.

b. The AALs will exceed the NAALs in their reporting of all of the alcohol-
specific indices. They will report denser family histories of alcoholism, will themselves
attain higher Lifetime Alcohol Problems Scores and more severe DSM-III-R alcohol
diagnoses, and will more likely be married to men with severe alcohol diagnoses.

c. The AALs will exceed the NAALs in all indices of antisociality. They will
report a higher level of childhood conduct problems, they will more likely be married to
an antisocial spouse, and there will be higher levels of domestic violence in their marital
relationships.

(I. The NAALs will endorse more symptoms of internalizing psychopathology
including depressive affect, fears and phobias. The two groups will be approximately
equal in their reporting of family history of depression.

6. The rearing environment of AALs will be observed to be more pathological

than that of NAALs. AALs will report denser family history of alcoholism, lower

55

family—of-origin SES, and more physical punishment during childhood. The two groups
will report family history of depression to a similar degree.

f. The NAALs will exceed the AALs in their experience of religious and
interpersonal involvement. NAALs will report more frequent attendance at religious
service, stronger subjective feelings of religiosity, and more significant emotional and
instrumental social support.

2. Within the group of NAALs, those with concurrent negative affect (NAs) will
report poorer adaptation than primary alcoholics (PAS) such that:

a. Negative affect alcoholics will report lower SES, family income, and
educational attainment than primary alcoholics. They will also demonstrate a greater
degree of downward shifting in which their current family SES is appreciably lower than
that of their family of origin.

b. Negative affect alcoholics will exceed primary alcoholics on all alcohol-
specific measures. Their Lifetime Alcohol Problems Scores and DSM-III-R diagnoses
will be more severe, they will report denser family histories of alcoholism, and will more
likely be married to alcoholic spouses.

c. By definition, a lower overall level of antisociality will be found among both
subgroups of NAALs (NAs and PAS), as compared to the groups of AALs. However, it
is hypothesized that NAs will report somewhat more lifetime and childhood antisociality,

and will more likely be married to alcoholic men and experience domestic violence.

56

(1. Also by definition, the NA group will exceed the PA group on all measures of
intemallizing psychopathology: subjective depression', fears and phobias, and family
history of depression.

e. The NA group will surpass the PA group in all measures of trouble in their
rearing environments. They will report denser family histories of alcoholism and
depression, lower family-of-origin SES, and more childhood physical punishment.

f. Finally, the NA group will report less social connectedness and more isolation
than the PA group. They will report less religious attendance and subjective religiosity,
and lower levels of perceived social support.

3. When all three groups (AALs, NAs, and PAs) are compared to each other on the
six major constructs and their component variables, differences will be observed among
all three groups. For each construct, the difference of greatest magnitude will be
observed between the AAL and PA groups, with the NA mean falling between the two.
The only exception is that, among the group of internalizing variables, the greatest
difference will appear between the PA and NA groups, with AAL falling between the

two.

5 7
METHOD

SUBJECTS

The women in this study were drawn from the 314 families participating in the
Michigan State University-University of Michigan (MSU-UM) Longitudinal Study
(Zucker, 1987; Zucker, Fitzgerald, & Noll, 1986). Of these families, one subset was
accessed for study as a result of the man's being convicted of drunk driving, while the
remaining subset was accessed via canvasses of the neighborhoods in which the court-
referred families resided. Of the canvassed families, one subset included families in
which one or both parents qualified for an alcohol- or drug-use diagnosis, but had not
come to the attention of the courts or any treatment program. In the remaining subset of
the families, neither parent qualified for an alcohol- or drug-use diagnosis. For a more
complete description of these sampling and recruitment procedures, the reader is referred
to Zucker (1987), Zucker, Ellis, Fitzgerald, Bingham, & Sanford (in press), and
Fitzgerald, Zucker, & Yang (1995).

For the purposes of this study, all of the women out of this sampling base who
met DSM—III-R criteria for Alcohol Abuse or Dependence (N=128) were included.
Because of the sampling methods employed in this study, and because it has been
observed (Jacob & Bremer, 1986; Wilsnack & Wilsnack, 1991) that alcoholic women are
often married to alcoholic men, it was expected that the proportion of alcoholic women in
these groups would far exceed typical population estimates.

While it is clear that our recruitment methods oversampled alcoholic women, it

should also be noted that this is a more heterogeneous group than many alcoholism

58

studies employ. Very few of these women had sought treatment for alcohol-related
problems at the time of the larger study’s initial contact, which decreases the severity bias
inherent in many other studies. This study may thus be regarded as including earlier-
stage alcoholics than many others. Also, by virtue of the sampling techniques employed,
it was likely that the subjects would represent a broad range of alcohol-use severity and
comorbidity. For example, because the court-referred families in our study demonstrate a
very high rate of antisocial personality disorder among the men, our knowledge of
assortative mating (Jacob & Bremer, 1986) suggested that we should observe a higher-
than—usual rate of antisocial behavior among the women as well. In contrast, we expected
the non-court-referred families to be experiencing somewhat less distress, and, if
comorbidity did exist, we expected it to be of a more internalizing nature.
PROCEDURE

Each participating family provided information through questionnaires, direct
observation sessions, and interviews (Zucker, Noll, & Fitzgerald, 1986). The data were
collected during the course of a nine-session contact schedule which included
approximately 20 hours of contact with project personnel. The majority of the data were
collected in the families’ homes. The families came to the MSU campus once for
videotaping of a structured interaction task, and once for the child to participate in a one-
to-one interaction with a project staff member. Data were collected by a trained team of
graduate and undergraduate students who were blind to each family's level of risk status.
Each of these families will continue to participate in this data-collection procedure once

every three years until the target child reaches adulthood. Families receive financial

59

compensation for their participation. Currently the amount of compensation is $250.00
for each wave of data collection.
MEASURES
I. Verifying participants’ DSM-III-R alcohol diagnoses

DSM-III-R diagnoses were made by an intensive review of all alcohol- and drug-
use items on the Diagnostic Interview Schedule (DIS, Robins,Helzer, Croughan, &
Ratliff, 1981), the Short Michigan Alcoholism Screening Test (SMAST, Selzer, 1975),
and the Drinking and Drug History (DDH, Zucker & Noll, 1980; Zucker, Noll, &
Fitzgerald, 1986). The DDH instrument consists of items proven in a variety of survey
and clinical settings (Johnston, Bachman, & O'Malley, 1979; Cahalan, Cisin, & Crossley,
1969; Schuckit, 1978), including information about quantity, frequency, and variability of
alcohol use, as well as variety and extent of drug use and extent of substance-related
trouble or consequences.
II. Constructing sub-groups of alcoholic women

A. Distinguishing antisocial (AAL) vs. nonantisocial (NAAL) alcoholic
women

The Diagnostic Interview Schedule (DIS; Robins et al., 1985) and the Total Score
of the Antisocial Behavior Checklist (ASB, Zucker & Noll, 1980; Zucker, Noll, Ham,
Sullivan, & Fitzgerald, 1994) were used to assess antisocial behavior as a means by
which to divide the sample into AAL and NAAL subgroups. The DIS is an extensive
clinical interview aimed at attaining diagnoses for a wide variety of psychological

disorders. It was orally administered to each participant by a trained graduate student in

60

clinical psychology, counseling, or social work. Diagnoses were arrived at using DSM-
III-R criteria for required symptoms and minimal numbers of additional symptoms.

The Antisocial Behavior Checklist (ASB, Zucker & Noll, 1980; Zucker, Noll,
Ham, Sullivan, & Fitzgerald, 1994) is a 46-item inventory that measures the frequency of
the respondent’s participation in a variety of delinquent, criminal, and antisocial activities
in childhood, adolescence, and adulthood. The scores for childhood and adult antisocial
behavior were summed to obtain a lifetime index of antisociality for the purpose of
classifying the subjects in this study. For the purposes of this study, a cut-off score of 17
was used to divide the sample into antisocial and non-antisocial sub-groups. A more
complete description of this procedure can be found in the Results section, below.

A series of reliability and validity studies with samples ranging from male and
female college students to state prison inmates has shown that the instrument has
adequate test-retest reliability (.91 over four weeks), and internal consistency (coefficient
alpha=.93) (Zucker, Noll, Ham, Sullivan, & Fitzgerald, 1994). It has also been shown to
differentiate between groups with major histories of antisocial behavior (prison inmates),
versus individuals with minor offenses in district court, versus university students
(Zucker, Noll, Ham, Sullivan, & Fitzgerald, 1994).

B. Distinguishing between negative-affect (NA) and primary (PA) alcoholic
women

The Worst-Ever score on the Hamilton Rating Scale for Depression (Hamilton,
1960) was used to sub-classify the group of NAALs into primary alcoholic (PA) and

negative affect alcoholic (NA) subgroups. The Hamilton scale is a clinically focused

61

index of depression, which covers a variety of behavioral, affective, somatic, and
psychological dimensions associated with depression. Each item on the scale was scored
twice: once as an index of current symptomatology (current score), and once to describe
the subject’s worst experience of depression in her lifetime (worst-ever score). The
current and worst-ever scores for each item was then summed to provide total Current
and Worst-Ever scores.

The Hamilton scales were rated by the DIS administrators upon completion of the
interview. The scores were based on the subjects’ responses to the DIS items measuring
depression, in which respondents were asked to describe their first, most recent/current,
and worst-ever experiences of depressive symtoms. Published interrater reliabilities with
the Hamilton scales have ranged from .80 to .90 (Hamilton, 1969). In a reliability
evaluation involving sixteen subjects in the MSU-UM study, interrater reliabilities were
measured at .78 for current depression and .80 for worst-ever depression.

For the purposes of this study, a worst-ever score of 18 was used to divide the
sample of non-antisocial alcoholics into primary and negative-affect sub-groups. A more
complete description of this procedure follows in the Results section, below.

111. Assessing biopsychosocial differences among the subgroups

Once the NAAL and AAL subgroups were established, and again when the

NAALs were subdivided into PA and NA groups, the groups were compared and

contrasted with one another on a variety of constructs and variables, as described below.

62

A. Demographic variables

The subgroups of alcoholic women were compared on the bases of the following
five demographic measures:

1 & 2: Current and family-of-origin SES

Both of these items were measured using the Revised Duncan Socioeconomic Index
(Stevens & Featherman, 1981), an index of occupational attainment. The Duncan index
was chosen on the basis of work by sociologists suggesting that occupation-based measures
represent a more contemporary indicator of SES (as opposed to measures based solely on
income), that is sensitive to changes in occupational attainment (F eatherman & Hauser,
1977; Mueller & Parcel, 1981; Nock & Rossi, 1979. Both current and family-of-origin SES
were defined in this study as the average of both spouses' codes when both parents work;
the working spouse's code when only one spouse works; and a minimal code when neither
parent works.

In this study, current and family-of-origin SES were considered separately. The
family-of-origin score was viewed as a childhood contextual factor that influenced later
development, while the current family score was thought of as an index of current adaptive
functioning.

3. Current family income is simply each family’s gross annual income in dollars.
This information was reported by respondents on the same form as current- and family-of-
origin SES. The subjects responded to a lO-point scale in which a score of 1 represented
income less than $4,000; 2=$4,000-$7,000; 3=$7,001-$10,000; 4=$]0,001-$13,000;

5=$l 3,001-$ 1 6,000; 6=$ 16,001-$20,000; 7=$20,001-$30,000; 8=$30,001-$50,000;

6 3
=$50,001-$75,000; 10=over $75,000. For all subsequent analyses, these scale scores were

transformed to midpoints. For example, a scale score of 3 was coded as $8500.

4&5, Number of children and Years of education, were also reported by
respondents on the same form as SES and Income.

B. Alcohol-specific variables

1. Family history of alcoholism

Each participant in the study reported her family history of a variety of medical and
psychological diagnoses and problems by way of a genogram interview conducted by a
senior level mental health professional. Data were reported for each woman's mother,
father, siblings, grandparents, aunts, uncles, and first cousins. Using genogram data, a
Family Alcoholism Liability (F AL; Zucker, Ellis, & Fitzgerald, 1994) score was computed
as follows: First, a weight equivalent to the coefficient of relationship value for each
alcoholic family member was assigned. The weights were .5 for first degree relatives, .25
for second degree relatives, etc. FAL scores were then computed as follows: (1) within
each generation, the weightings for all alcoholic relatives were summed; (2) the sum
computed in step 1 was multiplied by the ratio of alcoholics to total number of relatives in
that generation; and (3) the subscores across generations were summed. Thus, the F AL
score reflected the density of alcoholism in the subject's extended family as well as the
degree of relatedness of these family members to herself (Zucker et al., 1994).

2. Lifetime Alcohol Problems Score (LAPS, Zucker, 1991) provided a global

picture of the role of alcohol and its related difficulties in an individual's life, and was

64

therefore an excellent way of measuring the total effects that one's "alcoholism" and its
component parts have had on her life.

The LAPS incorporated information on the primacy (onset), variety, and life
invasiveness of problems associated with drinking based upon data from two different
interview measures. The LAPS score consists of three component subscores: (a) the
primacy component, which is the squared inverse of the age at which the respondent
reported first drinking enough to get drunk; (b) the variety component, which is the number
of areas in which drinking problems are reported, adjusted for current age; and (c) the life
percent component, which is the interval between the earliest and most recent drinking
problems, again adjusted for cunent age. Scores were standardized separately for males and
females within the larger project sample. This measure has been shown to be a valid
indicator of difficulties in long-term severity of drinking difficulty in a wide variety of
areas, regardless of the individual's current drinking status (Zucker, 1991). Thus, the LAPS
provided different, and often more substantial, information about the role of alcohol in an
individual's history, as compared to using a DSM-III-R diagnosis alone.

3. DSM-III-R alcohol use diagnosis

As described above, for inclusion in this study, each participant was given an
alcohol use diagnosis based on her responses to the SMAST and DDH questionnaires. For
subsequent analyses, and for a basis of comparison among the sub-groups, the diagnoses
(alcohol abuse and mild, moderate, and severe dependence) were assigned numerical values

of one through four.

65

4. Husband’s alcohol diagnosis

To provide an index of assortative mating, and a picture of the density of alcohol
use in the respondent’s home, each woman’s husband’s DSM-III-R alcohol diagnosis was
used. This diagnosis was made in the same way as was the women’s diagnoses.

C. Indices of antisociality

1. Childhood conduct problems were used as a measure by which to test for
differences between NAALs and AALs. The DIS, as described above, contains groups of
questions addressing both childhood and adult antisocial behavior. The childhood items
include behaviors such as school difficulties, truancy, nmning away from home, fighting,
and stealing from parents and others. Each subject’s DIS responses were coded 0 or 1 for
the absence or presence of clinically significant childhood antisociality (above the
prescribed DIS cutoff).

2. Husband’s antisocial behavior

The participants’ husbands’ total score on the Antisocial Behavior Checklist,
described above, was used to index both assortative mating and density of antisociality in
the subject’s home.

3 & 4. Husband-to-wife and wife-to—husband domestic violence were measured
using the Conflict Tactics Scale (CTS; Straus, Gelles, & Steinmetz, 1980). The CTS
measures spousal aggression, parental aggression toward children, child aggression toward
parents, sibling violence, and history of child physical and sexual abuse.

The domestic violence scores used here were Cumulative Intensity Ratings (Reider,

1989), which were derived by assigning weighted severity scores to each type of conflict

66

resolution strategy, multiplying this score by the behavior's frequency, and summing across
all of the behaviors endorsed. The conflict resolution strategies included such items as
discussing issues calmly, having verbal arguments, insulting the other person, and hitting,
kicking, biting, punching, beating, or using a weapon on the other person.

Based on a pilot study of 385 couples (Straus, 1979), the mean item-total correlation
was .87 for the Husband-to-Wife Violence Index, and .88 for the Wife-to-Husband
Violence Index. The alpha coefficients for the national sample were .83 and .82 for the
same indices, respectively.

For this study, both the husband-to-wife and wife-to—husband scores were used to
provide a more complete picture of the amount of violence that exists in the home.

D. Indices of internalizing psychopathology

1. Self-reported depression was measured using the short form of the Beck
Depression Inventory (Beck & Beck, 1972). This is a 13-item questionnaire that asks
respondents to what extent they are experiencing a variety of vegetative and affective
symptoms of depression, such as disturbances in appetite, sleep habits, mood, etc., on the
day of the interview. Scores on the short form of the Beck Depression Inventory have been
found to correlate between .89 and .97 (Beck, Steer, & Garbin, 1988) with the long form,
whose mean coefficient alpha has been measured at .81 for nonpsychiatric samples.

2. Fears and phobias were measured via the FEARS questionnaire (Zucker, 1993).

This measure was used to assess the lifetime incidence of a variety of specific fears, and the

severity of each one. For use in these analyses, the total FEARS score was derived by

67

summing the number of fears that the respondent acknowledged experiencing during her
lifetime

3. Family history of depression was calculated in the same way as was family
history of alcoholism. The score was derived fiom the same genogram data, and calculated
in the same manner, but here the coding was based upon the presence of depression in
family members.

E. Indices of the rearing environment

1 & 2, Family history of alcoholism and depression, were derived from genogram
data, as described in sections B1 and D3, above.

3. Family of origin SES:see section A2, above.

4. Childhood physical punishment was measured using the Conflict Tactics Scale
(CTS; Straus, Gelles, & Steinmetz, 1980), as described in C3 and 4, above. For the section
on childhood physical punishment, the respondents were asked whether they had ever
experienced physical and/or sexual abuse, and were asked to describe the severity,
frequency, and duration of the abuse. Physical punishment scores were computed by way
of the Cumulative Intensity Rating (Reider, 1989), in which the raters assigned a severity
weight to each type of punishment reported, multiplied the weighted scores by the
frequency of the events, and summed across types of events.

F. Indices of Religious and Interpersonal Involvement

1. Religiosity is a self-reported, subjective measure. On a questionnaire that asked
about various demographic information, subjects were also asked to rate how religious they

considered themselves to be on a 5-point Likert-type scale.

68

2 & 3, Current- and childhood religious attendance were reported on the same
demographic questionnaire. Respondents were asked to rate, on a 5-point scale, the
frequency with which their family of origin and their current family attended religious
services.

4. Perceived social support was measured using an expanded version (Weil &
Zucker, 1985) of the Norbeck Social Support Questionnaire (N SSQ; Norbeck, Lindsey, &
Carrieri, 1981). This questionnaire was designed to evaluate multiple dimensions of social
support; the expanded version used here measured network density, interpersonal similarity,
and organizational support. A total score, including both emotional and instrumental forms
of support, was used here.

The NSSQ has demonstrated a test-retest reliability of .85-.92, and internal

consistency above .85 (coefficient alpha).

6 9
RESULTS

Missing Data and Outliers

Before beginning analyses, all variable files were screened for missing data and
outliers. Missing data were estimated via mean substitutions based on the existing data. No
more than five percent, and usually less than one percent, of the values were estimated in
this manner for any of the variables. Outliers were defined as non-adj acent values falling
outside a normal curve superimposed on the frequency distribution histogram for each
variable. Each outlying value was assigned a new value adjacent to the closest non-outlying
value while maintaining the rank order of subjects within each variable. No more than two
outliers were transformed in this way for any variable.
Demographic Characteristics

Table 1 presents the sociodemographic characteristics of the women in this sample.
The measure of socioeconomic status (SES) that is used here is the Revised Duncan
Socioeconomic Index (TSEIZ, Stevens & Featherman, 1981), described above. In this
sample, the mean occupational attainment scores for the subjects' current family and family
of origin were 27.7 and 35.0, respectively. These scores are reflective of skilled blue collar
occupations (e.g., a semi-skilled worker in manufacturing trades), and lower level white
collar occupations such as a skilled clerical worker. Scores ranged from 13.0 (unemployed)
to 88.5 (physician).
Constructing Groups of Antisocial (AAL) and Nonantisocial (NAAL) Alcoholics

Of the 314 women participating in the MSU-UM Longitudinal Study, 128 (41%)
qualified for a lifetime DSM-III-R alcohol use classification of abuse or some level of

dependence. The specific alcohol diagnoses of these 128 women are shown in Table 2.

7O

 

 

Table l
S . I I. :1 . . [I S l ill-1128:
VARIABLE MEAN STANDARD DEVIATION
Age (Years) 30.80 4.51 ‘
Education (Years) 13.20 2.08
Current Family SESa 27.74 16.14
Family Of Origin 5135' 35.09 19.03
3153 Changeb -7.36 21.14
Family Income (8) 32,440 16,840
Number Of Children 2.34 .88

 

 

'Drmcan TSEIZ (Stevens & Featherman, 1981)
l’Change=Current-Family of Origin SES

71

When DSM-III-R criteria for antisocial personality disorder were applied to the DIS
data for the alcoholic subsample, only one of the 128 women qualified for a formal
diagnosis. Thus, in order to approach the issue of potential differences in antisociality
among the women, it was necessary to employ a less stringent set of criteria. As was the
case in several earlier analyses of the parent study data (i.e., Zucker, Ellis, & Fitzgerald,
1994), the Antisocial Behavior Checklist (ASB, Zucker et al., 1994) was used as a tool for
dividing the sample into sub-groups of AALs and NAALs. For these purposes, a total score
of 17 on the Antisocial Behavior Checklist was used as a cut-off to distinguish the two
groups. Total scores were computed by summing the scores for each of the 46 items, which
were rated “0” if the woman had never participated in the activity described; “1” for once or
twice in her life; “2” for 3-9 times in life, and “3” for more than 10 times. Subjects who
received a score of 17 or less were classified as NAALs, while those who scored 18 or
higher were designated AALs. This cut-off falls at the 67th percentile (approximately one
standard deviation above the mean), and was thought to provide a level of antisociality that
closely approximated antisocial personality disorder, yet also provided sufficient statistical
power for subsequent analyses.

Table 3 provides a more detailed description of the antisocial attributes of the high
and low antisocial subsarnples, and indicates that the two groups differed substantially on a
number of markers related to the diagnosis of antisocial personality disorder. As shown in
the table, approximately 60% of the items on the Antisocial Behavior Checklist
distinguished the two groups. For no item was the mean score for NAALs significantly

higher than that for AALs.

72

 

 

Table 2
9 U- - ‘_It‘é HO 6|,.".'01’IO'I.'.-..°JIO' 0 .I‘ gun'k- I
DIAGNOSISa n PERCENT
Abuse 48 38
Dependence-Mild 30 23
Dependence-Moderate 36 28
Dependence-Severe 14 1 1

 

'In all analyses, alcohol diagnosis is rated on a 4-point scale, in which Abuse=l, Dependence-Mild=2,
Dependence-Moderate=3, and Dependence-Severe=4; Sample mean (SD)=2.13 (1.04).

73

 

 

Table 3
0|“! Di‘r'u ' g'la‘x‘lk'tetho.‘\$é 1": c.1951...» 3: I“
i] 1].!!! 1!. 'IEI . C111.
ITEM NAALs (n=87) AALs (n=41) E
MEAN SD MEAN SD
1. Skipped school without a legitimate excuse .74 .93 2.22 .33 66.61 "
for more than 5 days in one school year.
2. Been suspended or expelled from school for .01 .11 .24 .70 9.1 l”
fighting.
3. Been suspended or expelled from school for .08 .28 .68 .79 40.1 1"
reasons other than fighting.
4. Lied to a teacher or principal. .73 .68 1.59 .92 34.67”
5. Cursed at a teacher or principal. .06 .23 .46 .74 19.72“
6. Hit a teacher or principal. .03 .24 .02 .16 .07
7. Repeated a grade in school. .07 .26 .15 .36 1.90
8. Taken part in a gang fight. .01 .1 1 .05 .22 1.66
9. Beaten up another person. .26 .49 .59 .74 8.91"
10. Broke street lights, car windows, or car .00 .00 .02 .16 2.12
antennas just for the fun of it.
11. Gone for a ride in a car someone else stole. .01 .1 l .12 .40 5.72.
12. Teased or killed an animal just for the fun .08 .41 .17 .44 1.25
of it.
13. Defied your parents' authority (to their 1.02 .84 1.98 .91 33.78”
face).
14. Hit your parents. .02 .15 .39 .59 29.36“
15. Cursed at your parents (to their face). .49 .65 1.24 .99 25.77”

Table continues

74

Table 3, Continued

16. Stayed out overnight without your parents’ .45 .57 1.54 1.0 60.58"
permrssron.

17. Run away from home for more than 24 .12 .32 .76 .94 31.50“
hours.

13. Lied to your parents. 1.61 .71 2.46 .74 33.64“
19. Snatchedawoman’s purse. .00 .00 .05 .22 4.30’
20. Rolled drunks just for the fun of it. .02 .22 .07 .35 .97
21. ShOplifted merchandise valued over $25. .04 .19 .41 .31 17.1 1“
22. Shoplifted merchandise valued under $25. .45 .55 1.24 .97 34.30“
23. Received a speeding ticket. .76 .75 .88 .84 .58
24. Been questioned by the police. .34 .52 .73 .59 14.03”
25. Taken part in a robbery. .00 .00 .02 .16 2.09
26. Taken part in a robbery involving physical .00 .00 .00 .00 «~-
force or a weapon.

27. Been arrested for a felony. .01 .l l .02 .16 .28
23. Resisted arrest. .00 .00 .05 .22 4.29‘
29. Been arrested for any other non-traffic .06 .24 .17 .44 3.43
police offenses.

30. Been convicted of any non-traffic police .01 .l l .12 .40 5.64.
offense.

31. Defaulted on a debt. .19 .45 .56 .59 15.33”
32. Passed bad checks for the fun of it. .01 .11 .02 .16 .28
33. Ever used an alias. .00 .00 .20 .51 12.51”
34. Gone AWOL from the military. .00 .00 .00 .00 ---

Table continues

Table 3, Continued

35. Received a bad conduct or undesirable
discharge from the military.

36. Performed sexual acts for money.
37. Engaged in homosexual acts.

38. Had intercourse with more than one person
in a single day.

39. “Fooled around” with other women/men
after you were married.

40. Hit your spouse during an argument.
41. Lied to your spouse.

42. Spent six months without any job or
permanent home.

43. Been fired for excessive absenteeism.
44. Been fired for poor job performance.
45. Changed jobs more than 3 times in 1 year.

46. Lied to your boss.

75

.00

.01

.00

.09

.ll

.55

.72

.14

.02

.08

.09

.51

.00

.63

.59

.47

.15

.28

.29

.57

.00

.02

.00

.17

.46

1.07

1.37

.56

.17

.17

.37

.98

.00

.16

.00

.38

.71

.79

.70

.90

.38

.38

.62

.65

.28

1.34

12.10"

16.25”
29.57“

1 1.99”

9.53
2.19
11.13”

17.11"

 

'p<.05, "p<.01

76

 

 

Table 4
o OJ‘IIO'JIQOI 1215. ‘t' o tor-.10 4. he; o—I 2.1.5.
I! !I —IIJ!1 1 I'll!
VARIABLE NAALs (n=37) AALs (nu: 1) F
MEAN $12 MEAN 512
Age (Years) 31.33 4.19 29.69 5.00 3.55
Education (Years) 13.59 2.15 12.37 1.67 10.23"
Current Family 5133' 29.07 17.53 24.91 12.42 1.36
Family of Origin 3133‘ 34.37 17.57 35.57 22.03 .033
SES Change" -593 20.73 -10.66 21.33 1.43
Family Income (3) 35,450 16,250 26,040 16,470 9.23"
Number ofChildren 2.36 .86 2.29 .93 .144

 

73.05, "p<.01
'Duncan TSEIZ (Stevens & Featherman, 1981)
bChange=Current-Family of Origin SES

77

 

 

Table 5
111- 4.; on don“t-[1971; lam. ' o nor-.104. has I—: in
i . .liiil _”:!l 1 1.1!:
DIAGNOSIS NAALs AALs E
Abuse 38 (44%) 10 (24%)
Dependence-Mild 23 (26%) 7 (17%)
Dependence-Moderate 21 (24%) 15 (3 7%)
Dependence-Severe 5 (6%) 9 (22%) ..
Sample Mean (SD) 1.92 (.96) 2.56 (1.10) l 1.42

 

‘E<.05, "p<.01

78

Based on the division of the sample at a total score of 17, 87 of the women (the lower 67%)
were classified as non-antisocial alcoholics (NAALs), and 41 (the upper 33%) as antisocial
alcoholics (AALs). The demographic characteristics of the NAALs and AALs are shown in
Table 4, and the results of a MANOVA testing for group differences in the set of
demographic variables are presented in Appendix B, Table B1. The women’s DSM-IH-R
alcohol diagnoses appear in Table 5.

Assessing Biopsychosocial Differences Between NAALs and AALs

Once this sample was divided into NAALs and AALs, the next step was to
determine whether meaningful differences existed between the two groups on measures of
family history, developmental history, and comorbid psychopathology. The descriptive
statistics for these variables are shown in Appendix A, Table A1.

The variables were divided into six groups on the basis of domain similarity. The
first group contained demographic variables; the second contained alcohol-specific
variables; the third was comprised of measures of antisociality; the fourth contained
variables measuring internalizing psychopathology; the fifth included measures of the
rearing environment, and the sixth contained measures of interpersonal and religious
involvements. Correlations were measured among the variables in each group; no two
variables in any group were found to correlate by more than r=.4. Each group of variables
was then subjected to a multivariate analysis of variance (MAN OVAs) to test the
assumptions listed in Hypothesis 1, above.

As can be seen in Appendix B, Tables B1 through B6, these assumptions were

largely supported. As compared to NAALs, the AALs reported a greater degree of alcohol-

79

specific problems, childhood conduct problems, family history of alcoholism and
depression and a lesser degree of perceived social support and current attendance at
religious services. AALs also reported less educational attaimnent, and lower current
income. Appendix B contains a more complete description of the results of these
MANOVAs.

Constructing Groups of Primary (PA) and Negative Affect (NA) Alcoholics

Because the series of MANOVAs described above did demonstrate that there were
meaningful differences between the NAALs and AALs, there was interest in determining
whether there might actually be evidence for more than those two "alcoholisms." To
accomplish this, the NAALs were further sub-divided in order to assess whether additional
differences might be observed among NAALs with and without comorbid depression.
These groups were theoretically based on Zucker's (1987, 1994) Negative Affect and
Primary Alcoholism subtypes. Thus, they will heretofore be referred to as Negative Affect
(N As) and Primary Alcoholics (PAs), respectively.

The procedure by which PAs and NAs were differentiated was similar to the way in
which the NAALs and AALs were distinguished from one another. The sample of NAALs
(N=87) was split at the 67th percentile of the distribution of total Worst-Ever scores on the
Hamilton Rating Scale for Depression, such that individuals who scored at or below the
67th percentile (Hamilton Worst-Ever score=18) were placed in the Primary Alcoholic (PA)
group, while those who scored above the 67th percentile were placed in the Negative Affect

(NA) group. Thus, PAs were distinguished from NAs at the same percentile that was used

8 0
to split the full sample into NAAL and AAL groups based on their Antisocial Behavior

Checklist scores.

The Hamilton Worst-Ever score was rated by clinicians based on the respondents’
answers to questions about worst-ever depressive experience as reported on the DIS, and
represents the level of depression during the worst episode in the individual’s lifetime.

Each item is given a score of 0-4 to describe the degree to which the statement describes the
subject. Table 6 shows the differences between the NA and PA groups on the 24 items that
comprise the scale. As can be seen, all but two items distinguished the PA and NA group,
and for no item was the mean score for Primary alcoholics higher than that for Negative
Affect alcoholics.

The sociodemographic characteristics of the resultant NAs (n=26) and PAs (n=81)
are shown in Table 7, and the results of a MANOVA testing for group differences in the set
of demographic variables can be seen in Appendix C, Table C 1. Table 8 contains the DSM-
III-R alcohol use diagnoses of the PA and NA groups. As can be seen in the table, the
severity of alcohol use is significantly greater in the negative affect group.

More than Two Alcoholisms?

To assess the differences between negative affect and primary alcoholics (N As and
PAs), and to test the assumptions of Hypothesis 2, a series of six MANOVAs was
conducted using the same variables that had been used to distinguish non—antisocial from
antisocial alcoholics (NAALs and AALs) in the previous section. Results indicated a
substantial number of areas of difference. As shown in Tables C 1 to C6 of Appendix C,

the Negative Affect Alcoholics reported more antisociality; more severe alcohol-specific

81

 

 

Table 6
H 1.5 I - h '1'011-1 0'. 1‘0 0.1"" .5 It; -
o on start”. 0 u N 1° 9'0 H 0 -
ITEM NA E
MEAN SD MEAN SD
1. Depressed mood 1.27 .93 2.35 .61 62.93“
2. Guilt feelings and delusions .31 .56 1.50 1.03 47.52”
3. Suicidal ideation .19 .63 1.40 1.19 37.24“
4. Initial insomnia .27 .53 .96 .92 17.57“
5. Middle insomnia .03 .23 .96 .92 45.09"
6. Delayed insomnia .05 .29 .31 .90 34.43”
7. Work and interests .39 .64 2.19 1.06 93 .46”
8. Psychomotor retardation .24 .47 1.19 .94 39.35”
9. Psychomotor agitation .29 .53 1.12 1.23 13.06“
10. Psychic anxiety .73 .35 2.23 1.13 44.30"
1 1. Somatic anxiety .95 1.02 2.62 .93 49.29“
12. Appetite .10 .31 1.04 .37 52.37"
13. Somatic energy .59 .70 1.72 .54 51.32“
14. Libido .46 .60 1.04 .77 13.97”
15. Hypochondriasis .19 .44 1.03 .39 37.63"
16. Loss of insight .10 .30 .50 .65 14.96“
17a. Weight loss, by history .05 .29 1.03 .93 59.03“
17b. Weight loss, as measured .00 .00 .00 .00 --
18a Diurnal mood variation, worse in AM .00 .00 .22 .52 9.67"
18h. Diurnal mood variation, worse in PM .07 .33 .22 .52 2.22
19. Depersonalization & derealization .07 .31 1.04 1.15 36.48”
20. Paranoid symptoms .19 .51 .54 .90 5.06.
21. Obsessional & compulsive symptoms 12 .33 .35 .49 6.43”
22. Helplessness .46 .73 1.73 .87 48.79“
23. Hopelessness .42 .72 2.23 .76 103.64“
24. Worthlessness .24 .54 1.35 .33 107.51”

 

'p<.05, "p<.01

82

 

 

Table 7
.'OIO‘JI’2OI 1.1:...‘0‘11 0 inn-1"; 1"- -.HL‘°-._ ‘ai- It; 1‘0
Alcoholicflomen
VARIABLE PAs (n=61) NAs (n=26) E
MEAN SD MEAN SD
Age (Years) 30.35 4.11 32.36 3.94 2.53
Education (Years) 13.62 1.96 13.50 2.53 4.67
Current Family SES' 23.72 15.97 29.33 21.07 .54
Family of Origin SES' 35.77 17.75 32.75 17.27 .54
SES Change” -7.04 20.46 -2.37 21.43 .74
Income 35,330 15,360 35,630 13,510 .01
Number ofChildren 2.23 .73 2.65 .93 4.60'

 

fip<.05, wp<.01
'Duncan TSEIZ (Stevens & Featherman, 1981)
bDifference between Current and Family of Origin SES

 

83

 

 

Table 8
. \lf'i. JO. ‘.e.'J." . .IIlet ‘.5 fl—' v.” \'°el i' ‘K .-
Almholicflomen
DIAGNOSIS PAS (n=61) NAS (n=26) E
Abuse 30 (49%) 8 (31%)
Dependence-Mild 17 (28%) 6 (23%)
Dependence-Moderate 12 (20%) 9 (35%)
Dependence-Severe 2 (3%) 3 (11%) .
Sample Mean (SD) 1.77 (.88) 2.27 (1.04) 5.22
'p<.05, "p<.01

 

 

84

problems; more husband-to-wife domestic violence; denser family history of alcoholism;
and more self-reported depression and anxiety. A more complete discussion of the results
of these MANOVAS appears in Appendix C.

On these grounds, a more general question was posed: given that Antisocial
Alcoholics (AALS) are different fi'om Nonantisocial Alcoholics (NAALs), and, within
NAALS, Negative Affect Alcoholics (NAs) are different from Primary Alcoholics (PAS), to
what degree are these groups all differentiable from one another? That is, are AALS, NAS,
and PAS all identifiable as discrete “alcoholisms”? To answer this question, and to test
Hypothesis 3, a new series of MANOVAs was conducted utilizing a three-way model,
comparing AALS, NAS, and PAS. Next, within each MANOVA, the variables whose
univariate E tests were significant were subjected to mean comparisons using Bonferroni
tests of significance. The first of these more finely grained summary analyses is Shown in
Table 9, which contains the 3-way MANOVA results for the demographic variables. The
overall MANOVA was again significant [Multivariate E (10,244)=2.17,p<.05], with
univariate E tests for Income and Educational Attainment also significant. In both
instances, the mean for the PA group was highest, followed by NA and AAL. Thus, as
expected, the AALS fared the least well in this measure of social adaptation. For Table 9,
the values that were Shown by the Bonferroni tests to be significantly different are presented
in caption below the table. As can be seen, both Income and Educational Attainment
differed between the PA and AAL groups. The NA group, whose mean fell between the

others, was not significantly different from PA or AAL. However, upon visual inspection

85

of the data, it may be seen that the NA group means for both income and educational
attainment far more closely resembled the PA means than the AAL means.

Table 10 contains the 3-way MAN OVA data for the alcohol-specific variables. As
can be seen in the table and in the caption below, the 3-way MANOVA was significant
[Multivariate E (8,244)=3.47,p<.01], as were the univariate E tests for Family History of
Alcoholism (F AL), Lifetime Alcohol Problems Score (LAPS), and DSM-III-R Alcohol
Diagnosis (ALCDX). For FAL, the mean was highest in the AAL group, followed by NA
and PA; differences occurred between the PA and AAL group, and between the PA and NA
group, but not between NA and AAL. This was the expected result: the AALS and NAS
both reported dense family histories of alcoholism. Their histories did not differ
significantly fi'om each other, but both were significantly different fi'om the primary
alcoholics.

For LAPS, the mean was again highest in the AAL group, followed by NA and PA,
with a difference existing only between PA and AAL. The mean LAPS score for the NA
group was almost equidistant from the AAL and PA groups, indicating that, for negative
affect alcoholics, the primacy, variety, and degree of life invasiveness of drinking problems
falls almost exactly between those of antisocial and primary alcoholics.

The results for ALCDX were somewhat similar: the mean was highest for AALS,
followed by the NA and PA means. The significant difference was observed between the
antisocial and primary groups. Though not significant, there was a clear trend to suggest
that negative affect alcoholics were more similar to antisocial alcoholics, than to primary

alcoholics, in terms of their DSM-III-R alcohol diagnoses. The group means suggest that

 

86

the average AAL or NA carried a diagnosis of mild-to-moderate alcohol dependence, while
the PA mean fell between the scores for alcohol abuse and dependence-mild.

The three groups did not differ in terms of their husbands’ alcohol diagnosis. The
data show that all three groups of women tend to be married to alcoholic men who carry
diagnoses of mild-to-moderate dependence.

The results of the 3-way MANOVA for antisociality are presented in Table 11. As
can be seen in the table and its caption, the overall MANOVA was significant [Multivariate
E (8,244)=4.23,p<.0001]. The univariate E test for childhood conduct problems was
significant, with the mean for AALS far exceeding that of the PA group, which very
modestly exceeded the NA mean. The Bonferroni test revealed differences between AAL
and PA, and between AAL and NA, but not between PA and NA. In other words, the
antisocial alcoholics, as expected, reported by far the most childhood conduct problems.
The group means for the primary and negative affect alcoholics were very close to one
another, indicating that they experienced similarly low levels of childhood antisociality.

The univariate E test for husband-to—wife domestic violence was also significant; the
mean was highest among the NA group, followed closely by AAL and more distantly by
PA. The difference was between AAL and PA. This indicates that negative-affect and
antisocial alcoholics reported a similar degree of abuse by their husbands, while primary
alcoholics reported this phenomenon to a far lesser degree.

The univariate E test for husbands’ antisociality was nonsignificant, but mean

comparisons revealed that the AALS were significantly different fi'om the PAS, who were

 

87

 

 

 

Table 9
Pawns-1 'i‘ ‘1 ‘ =‘h“1 3111.1 I'd 1"1 \“el ‘ t i‘ k41= 1 10.,
1"];511—|1;1111'
[Multivariate F (10,244)=2.l7,p<.05]
W W AALlnfll.)

MEAN SD MEAN SD MEAN SD F
Family of 35.77 17.75 32.75 17.27 35.57 22.03 35
Origin SES
Current 23.72 15.97 29.33 21.07 24.91 12.42 -97
Family SES
Family 35,377‘ 15,353 35,634 13,506 26,037' 16,465 4-61
Income (3)
Number of 2.23 .73 2.65 .93 2.29 .93 2-23
Children
Education 1362‘ 1.96 13.50 2.53 12.37' 1.67 5-‘4
(YearS)
°p<.05, "p<.01

' Means labeled with the same superscript differ from one another at the p<.05 level of significance.

8 8
Table 10

D 5‘1‘1.‘ 3116.611 31114 C’; 1—1 run ‘65‘ Us; 1: 1 411611 11 .

 

[Multivariate F (3,244)=3.47,p<.01]
EAInEQD NAlnEZQ) AALmfll.)
MEAN SD MEAN SD MEAN SD F
Family 225“ 1.27 3.11' 1.73 3.24” 1.63 6.31”
History of
Alcoholism

Lifetime 10.99‘ 1.21 11.76 1.43 12.45. 2.01 1103"
Alcohol

Problem

Score

DSM-III-R 1.77‘ .33 2.27 1.04 2.56' 1.10 3.20“
Alcohol
Diagnosis

Husband’s 2.44 1.41 2.77 1.18 2.95 .97 2.17
Alcohol
Diagnosis

‘p<.05, “p<.01
8", Means labeled with the same superscript differ from one another at the p<.05 level of significance.

Table 11

‘\."1 5111-1

A
O

 

[Multivariate F (3,244)=4.23,p<.0001]

 

 

MEAN SD MEAN SD MEAN SD F ..
Childhood .15' .36 .12" .33 .49 '1" .51 10.42
Conduct
Problems
Husband’s 17.59 9.99 18.62 16.89 23.29 10.55 2.96
Antisocial
Behavior
Husband-to-Wife 89.89’ 207.34 249.96 381.96 236.71 ' 315.16 4.54.
Domestic
Violence
Wife-to-Husband 100.16 174.32 168.69 219.50 183.88 210.74 2.56
Domestic
Violence
'p<.05, “p<.01

8’ Means labeled with the same superscript differ fi'om one another at the p<.05 level of Significance.

90

similar to the NAS. This trend is suggestive of assortative mating in that the antisocial
alcoholics were more likely than the others to have married an antisocial spouse.

Table 12 contains the results of the 3-way MAN OVA for internalizing
psychopathology. The overall MANOVA in this case was significant [Multivariate E
(6,246)=2.86,p<.01], as were the univariate E tests for Self-Reported Depression and
Family History of Depression. For Self-Reported Depression, the NA mean was the
highest, followed by AAL and PA; significant differences occurred between PA and NA,
and between PA and AAL, but not between NA and AAL. This result indicated that
antisocial and negative-affect alcoholics were Similar to one another in terms of their
depressive symptoms, but both were different from primary alcoholics.

For Family History of Depression, the mean in the AAL group was greater than
NA, which in turn was greater than PA; the only significant difference was between PA and
AAL. This was an unexpected finding. While it had been anticipated that negative-affect
alcoholics would report the densest family histories of depression, the results indicated that
the NA group was actually more similar to the PA group. The only Significant difference
was that antisocial alcoholics reported much more family depression than the primary
alcoholics.

In Table 13, the results indicate that the overall MANOVA for rearing environment
was again significant [Multivariate E (8,244)=3.08,p<.001]. Significant univariate E tests
were also seen for Family History of Alcoholism and Family History of Depression. AS

discussed in the description of Table 10, above, the mean for Family History of Alcoholism

 

91

was greatest in the AAL group, followed by NA and by PA. Significant differences were
observed between PA and NA, and between PA and AAL, but not between NA and AAL.

For Family History of Depression, the mean for AALS was the highest, followed by
NA and PA. A Significant difference existed only between PA and AAL. A more complete
description of these difference appears in the discussion of Table 12. Although it had been
expected that childhood physical punishment would be higher in the AAL group than in the
others, this result was not observed.

Table 14 contains the results of the final three-way MANOVA, which compared the
PA, NA, and AAL groups in terms of their religious and interpersonal involvements. The
table Shows that the overall MANOVA was significant [Multivariate E (8,244)=2. 14,p<.05],
as was the univariate E test for Current Attendance at Religious Services. The mean for this
variable was highest in the AAL group, followed by NA and PA. The significant difference
exists between AAL and PA. This was a most unexpected finding. It had not been
anticipated that the AAL group would demonstrate a high level of interpersonal

connectedness on any measure.

92

 

 

 

 

Table 12
'3‘1'1; 3'1.“1’d111-.ul’; 1"1 \‘M. ' ‘ a 5‘ Cu; 1= 1 -.11 41. 1 '
[Multivariate F (6,246)=2.86,p<.01]
EAtnil.) NAlnEZlS.) AALLnflI)

MEAN SD MEAN SD MEAN SD F ..
Self-Reported 2.32“ 3.32 4.92' 3.31 4.71” 3.60 5.06
Depression
Fears 24.42 5.98 27.59 6.18 25.30 6.69 2.21
Family 1.52ll 1.07 1.92 1.16 2.24' 1.56 4.0].
History of
Depression
.p<.05, ”p<.01

a’ Means labeled with the same superscript differ from one another at the p<.05 level of significance.

9 3
Table 13

I 3‘1'1.‘ =‘§."1'1111a.nl'; 1‘1 \‘°-_1‘ai‘ It; 1: 1 1.1161. 1 '

I551 *112!111"E . E'

 

[Multivariate F (8,244)=3.08,p<.001]

 

BAlnflD NAinzZfi) AALlnflIi

MEAN SD MEAN SD MEAN SD F ..
Family History of 2.25 ‘b 1.27 3.11' 1.73 3.24b 1.63 6.31
Alcoholism
Family History of 1.52 ' 1.07 1.92 1.16 2.24 ' 1.56 4.01‘
Depression
Family of Origin 357.68 177.52 327.46 172.73 355.71 220.33 .25
SES
Childhood 32.61 67.34 70.96 215.92 100.07 239.40 1.91
Physical
Punishment

 

‘ <05, "p<.01
a’ Means labeled with the same superscript differ from one another at the p<.05 level of significance.

94

Table 14

 

 

[Multivariate F (8,244)=2. l4,p<.05]

 

 

EAinflI) NAflEZfi) MLlnfll)

MEAN SD MEAN SD MEAN SD F
Religiosity 2.90 .65 3.00 .63 2.33 .74 .5 1
Religious 3.43 ' 1.23 3.54 1.39 4.20' 1.12 4.52’
Attendance-Current
Religious 2.54 1.15 2.65 1.06 2.73 1.12 .37
Attendance-
Childhood
Perceived Social 7.35 .72 7.64 .62 7.52 .73 2.91
Support (Emotional
and Instrumental)
‘p<.05, “p<.01

a Means labeled with the same superscript differ from one another at the p<.05 level of significance.

9 5
DISCUSSION

Alcoholism typologies have existed for over a century. Their main purposes have
been to provide a common nomenclature for researchers and clinicians; to aid in
understanding the development, course, outcome, and transmission of alcoholism; and to
assist in treatment planning. In order to adequately serve these purposes, a typology must
demonstrate homogeneity within categories; heterogeneity between categories; stability;
comprehensiveness and specificity; multidimensionality; utility, and validity (Babor and
Meyer, 1986).

Although typologies have changed considerably over this time interval in terms of
their scope, specificity, and basis of differentiating the subtypes, one important element
has remained common among them. Most classification systems, whether grounded in
empirical or theoretical research, and based on drinking pattern, comorbidity, family
history, age of onset, MMPI profile, or primary/secondary distinction, have identified two
major subtypes. One of these is characterized by mild-to-moderate drinking that is
accompanied by physical and psychological dependence; antisocial behavior or
criminality; dense family history of alcoholism and/or other psychopathology; early
onset; childhood behavior problems; a higher probability of other-drug use and other
psychological difficulties; repeated treatments and relapses; and wide-ranging life
difficulties related to alcoholism, such as work/school problems, relationship problems,
and problems with finances and/or the law (Babor et al., 1992; Cadoret, Troughton, and

Widmer, 1984; Nace, 1989). This subtype is generally compared and contrasted with a

96

second group that may engage in moderate-to-severe drinking in the absence of
antisociality or other pervasive life difficulties.

Some well known classification systems that are based on this general distinction
include Knight’s (193 7) reactive and essential alcoholism; Jellinek’s (1960) alpha, beta,
gamma, delta, and epsilon; Cloninger’s (1981) Type I/Type II, and Babor’s (1992) Type
A/Type B alcoholisms. Several other schemas involve the antisocial/nonantisocial
distinction, and extend their scope to encompass other related types. These include
Winokur’s (1970, 1971) primary, depressed, and sociopathic alcoholisms; Schuckit’s
(1985) primary alcoholism and alcoholism secondary to drug abuse, antisocial
personality, and depression; and Zucker’s (1987, 1994) antisocial, negative-affect, and
primary (developmentally limited and developmentally cumulative) alcoholisms.

Few studies have focused Specifically on the antisocial/nonantisocial distinction,
or other typologies, among women alcoholics. However, several studies that have
concentrated in this area (i.e., Hesselbrock et al., 1985; Rounsaville et al., 1987; Glenn
and Parsons, 1989; Glenn and Nixon, 1991; Kubicka, Czemy, and Kozeny , 1992) have
demonstrated not only that antisocial alcoholism is identifiable among women, but also
that female antisocial alcoholics strongly resemble their male counterparts. In one such
study (Hesselbrock etal., 1985), antisocial alcoholics of both sexes experienced an
accelerated course of alcohol-specific difficulties as compared to nonantisocial alcoholics
of both sexes. In another (Rounsaville et al., 1987), both male and female antisocial
alcoholics demonstrated poorer treatment outcome and prognosis than nonantisocial

alcoholics of both sexes.

97

The purpose of the present study was to determine whether valid subtype
differences could be observed among the female participants of the Michigan State
University-University of Michigan Longitudinal Study.

Characteristics of the sample

Of the 311 women participating in the MSU-UM Longitudinal Study, 128
qualified for a DSM-III-R diagnosis of alcohol abuse or dependence. These were
predominantly working-class, high-school educated Caucasian women, with a mean age
of 31. They had been married an average of eight years, and the mean number of children
was two, including the 3-6-year-old male target child. Thus the generalizability of these
results is limited to similar young Caucasian women, and is constrained by the cross-
sectional design of the analyses reported herein.

Because of the particular way in which the women were accessed for study, the
present work has some advantages and some problems in its ability to describe the
population of alcoholic women as a whole. One advantage lies in the fact that the women
were included only by virtue of their being married to a man who met the study’s criteria
(see above). Because the subjects were not drawn from treatment samples or court
referrals of the women, this study may be regarded as including earlier-stage alcoholics
than many others. It is also likely that the subjects represent a broader range of alcohol-
use severity and comorbidity than would be found in a treatment sample. Had the
families instead been recruited on the basis of the women’s having come to the attention
of the courts or treatment facilities, it is likely that the results would have been quite

different. The levels of antisociality and other psychopathology would likely have been

98

higher, and higher levels of domestic violence may have been reported, such that the
women would have more closely resembled the subjects described by Lex et al. (1990).

However, the fact that most (90%) of the subjects in this study were married to
alcoholic men also presents certain problems. It is possible that the phenomena observed
here may have been strongly related to the women’s being married to alcoholic and/or
antisocial men in addition to, or perhaps instead of, being related to the women’s own
diagnostic group membership. In other words, it is diffith to discern whether the
characteristics ascribed to the alcoholic women in this study may be more appropriately
attributed to women married to alcoholic men. Such phenomena as assortative mating, or
codependency, may be operative in this sample, and may in fact have confounded the
results. The reader should bear these caveats in mind when interpreting the results of this
study.
The antisocial/nonantisocial distinction

Based on their scores on the Antisocial Behavior Checklist (Zucker, 1992), these
128 women were divided into antisocial (AAL, n=41) and nonantisocial (NAAL, n=87)
subgroups based on a cut-off at the 67th percentile for this sample. It should be borne in
mind that only one woman qualified for a formal DSM-III-R diagnosis of antisocial
personality disorder. In addition, the use of a “one-third/two-thirds” split of the sample
placed the cut-off for female AALS on the Antisocial Behavior Checklist lower than the
cut-off of 24 used for men by Zucker, Ellis, & Fitzgerald (1994). The fact that less

stringent criteria were used for classifying female AALS, as compared to the classification

99

of male AALS in the earlier study, means that comparisons between male and female
AALS should be interpreted with caution.

With this caveat in mind, the observed results still substantially support the
hypotheses. A series of multivariate analyses of variance revealed that the AAL and
NAAL groups differed significantly in terms of demographics, alcohol-specific
difficulties, various indices of antisociality, family history variables, rearing environment,
and religious involvement/social support. Specifically, as compared to NAALS, the
AALS reported less educational attainment and lower current income; more severe DSM-
III-R alcohol diagnoses and higher Lifetime Alcohol Problems Scores (Zucker, 1991); more
childhood conduct problems; greater antisociality on the part of their husbands; denser
family histories of both alcoholism and depression; and lower degrees of perceived social
support and current religious attendance. Antisocial alcoholics also demonstrated trends
(p<.10, one-tailed) toward greater husband-to-wife and wife-to-husband domestic violence,
and childhood physical punishment. The finding that religious attendance was greater
among AALS was surprising. Perhaps the women in this group participate in religious
services not as an avenue to interpersonal connectedness, but rather as a means by which to
seek help or forgiveness with regard to their alcohol abuse and antisocial behavior.

It was also unexpected that domestic violence and childhood physical punishment
were not more strongly related to the antisocial/nonantisocial distinction. As described
above, these results may have been different had the women been accessed through court or

treatment samples.

100

Clearly, these data indicate that two alcoholisms, an antisocial and a nonantisocial
subtype, exist among this sample. The two groups differed in many of the same respects
identified in prior literature concerning the antisocial/nonantisocial distinction. Thus,
Hypothesis 1 of this study was substantially supported.

More than two alcoholisms?

As a follow-up to these favorable results, further analyses were performed to
determine whether additional alcoholisms could also be identified. To test Hypothesis 2,
the nonantisocial alcoholics (NAALS, n=87) were further subdivided into primary alcoholic
(PA, n=61) and negative-affect alcoholic (NA, n=26) groups. These categories were based
on Zucker’s (1987, 1994) groups of the same names, and the groups were differentiated on
the basis of clinicians’ ratings of the subjects’ worst-ever depression (Hamilton, 1960). As
can be seen in Appendix C, multivariate analyses of variance did reveal some differences
between the two groups. As expected, the negative-affect alcoholics exceeded the primary
alcoholics in self-reported depression, fears and phobias. In addition, husband-to-wife
domestic violence was reported more fiequently among the negative-affect group, as was
family history of alcoholism. The negative-affect alcoholics also experienced more alcohol-
Specific problems, as evidenced by their higher Lifetime Alcohol Problems Scores and
more severe DSM-III-R alcohol diagnoses.

Again, it became clear that negative-affect alcoholics were substantially different
from primary alcoholics. Now that three groups had been identified, it was important to
determine whether each one was different from the other two. To this end, a series of three-

way MANOVAS (with follow-up univariate E tests and post-hoc mean comparisons) was

101

performed. AS can be seen in Tables 7-15, these results were somewhat equivocal in their
support of Hypothesis 3. None of the post-hoc Bonferroni tests distinguished all three
groups fi'om each other. For many of the variables, the post-hoc comparisons Showed
PA/AAL differences and/or PA/N A differences, but the only NA/AAL difference was in
childhood conduct problems.

Despite the fact that none of the post-hoc comparisons differentiated all three groups
from one another, some important findings did emerge from this set of analyses. First, for
almost every variable for which the univariate E test was significant, the primary alcoholic
group demonstrated better functioning than the negative affect and antisocial alcoholic
groups. Specifically, the PA group exhibited the greatest educational attainment, the least
family history of alcoholism and depression, the lowest Lifetime Alcohol Problems Scores
(LAPS), the least severe DSM-III-R alcohol diagnoses, the least childhood conduct
problems, the least self-reported depression, and the least husband-to-wife domestic
violence. The only exceptions were that primary alcoholics had the second-highest
occupational attainment and the lowest level of current religious attendance.

Similarly, the antisocial alcoholics demonstrated the poorest adaptation in most
areas. They reported the lowest income and educational attainment, and the highest family
history of alcoholism and depression, the highest LAPS scores, the most severe DSM-III-R
diagnoses, and the most childhood conduct problems. However, they reported only the
second-highest self-reported depression scores and the most religious attendance.

The role of the negative-affect (NA) group was less clear-cut and more variable: in

some cases the group mean for the NA group closely resembled the PA mean, and in others

102

it approximated the AAL mean. More specifically, the negative affect alcoholics resembled
the antisocial alcoholics in family history of alcoholism, DSM-III-R alcoholism diagnosis,
husband-to-wife domestic violence, and self-reported depression. They were more similar
to the primary alcoholism group in demographics, childhood conduct problems, husband’s
antisociality, and family history of depression.

A closer inspection of these results revealed that the pattern of group means was not
random, and may in fact provide important information about developmental trajectory.
Although negative affect alcoholics closely resembled antisocial alcoholics in terms of
genetic loading of psychopathology, the two groups were less similar in terms of current
adaptation. For example, the results indicated that negative affect alcoholics were quite
similar to antisocial alcoholics in terms of family history of alcoholism and depression.
Correspondingly, the NA group also resembled the AAL group in their DSM-III-R alcohol
diagnoses and self-reports of depression. However, the NAS and AALS differed more
vastly in terms of their childhood conduct problems and Lifetime Alcohol Problems Scores.

In other words, although the negative affect group shared a high genetic load for
alcoholism and depression with the AALS, and also appeared to have similar levels of
transmission of alcoholism and depression, the two groups differed in terms of their
childhood behavior, and in the primacy (onset), variety, and life invasiveness of problems
associated with drinking. Although the severity of the AALS’ and NAS’ alcohol use was
similar, the variety of problems associated with drinking, and the degree to which alcohol-

related problems disrupted the individuals’ lives, were different.

103

Similarly, although there were no significant differences among the three groups in
terms of the socioeconomic status of their families of origin, there were differences in
educational attainment and current family income. Although all three groups were reared in
demographically similar backgrounds, only the PA and NA groups maintained this
similarity into adulthood. As compared to both the PA and NA groups, the antisocial
alcoholics completed Significantly less schooling, and currently earn less money. Thus, we
again see that the negative-affect group more closely resembled the primary alcoholics than
the antisocial alcoholics in terms of social adaptation.

Based on the foregoing observations, then, it appears that negative affect alcoholics
may possess some coping mechanisms, or other characteristics, that render them somewhat
more resilient to the effects of their rearing environments, and less debilitated by their
symptoms of psychopathology, than antisocial alcoholics.

How many alcoholisms? Future Directions

The results of the three-way MANOVAS beg the question: how many alcoholisms
are discernible in this sample? AS they stand, the data here indicate that there are three.
The primary and antisocial alcoholic groups are indisputably different fi'om one another in
terms of both life history and current adaptation. The negative affect alcoholics were
unique in that they Shared certain characteristics with each of the other two groups, but
clearly a divergent developmental pathway. Although they resembled the antisocial
alcoholics in terms of their genetic load and basic symptomatology, they appeared more
resilient than the AALS in that their psychopathology was less invasive and pervasive in

their lives. Perhaps genetic, environmental, and/or temperamental differences cause the NA

104

women to internalize, rather than extemalize their negative feelings. Perhaps, as a group,
they have mastered more adaptive methods for coping with stressors. Some future analyses
of this data set may help to further clarify the distinctions among the three groups.

First, the same series of analyses reported here Should be repeated with larger and/or
more comparable sample sizes. The small size of the negative affect group may have
spuriously minimized the differences between this group and the others.

Second, age-of-onset data Should be examined with respect to the subjects’
development of symptoms of alcoholism, antisociality, and depression. This would help to
elucidate whether the phenomena observed here represent a primary/secondary distinction
or a comorbid/non-comorbid distinction. That is, if the age of onset for alcoholism were
found to differ from that of antisociality or depression, then the disorder with the earliest
onset would be primary, and the other(s) secondary. The primary vs. secondary alcoholism
groups could then be compared and contrasted on the dimensions used here. If the ages of
onset do not differ significantly, than the operative distinction may be that of alcoholics
with and without comorbid psychopathology. Two groups (alcoholism only vs. alcoholism
with any other psychopathology, could then be compared and contrasted.

Third, the findings reported here should be observed longitudinally. It will be
interesting to learn whether subtype membership is transitory or enduring. In addition, it
will be important to observe the ways in which subtype predicts treatment participation and
outcome, and the course of the women’s alcoholism and related psychopathology. The
validity of these subtypes is, to some degree, dependent upon whether the life course of

AALS, NAS, and PAS will remain parallel, or converge at some point.

1 0 5
Fourth, the analyses should be repeated with the inclusion of a fourth group: a

comparison group in which the women have no DSM-III-R alcohol use diagnosis. This
would provide an even broader spectrum of psychopathology and adaptive functioning, and
would further enhance understanding of the differences in the developmental trajectories of
antisociality and negative affect separate fi'om their alcoholism-specific characteristics.

Fourth, the results reported here provide an excellent foundation for a subsequent
study on the transmission of alcoholism and related psychopathology. The target children
in the larger MSU-UM Longitudinal Study Should be grouped based on the subtypes of
their mothers and/or fathers, and differences in their development observed. Such research
Should examine the ways in which maternal and paternal subtypes predict child behavior,
alcohol-use expectancies, school adjustment and achievement, and the development of
substance abuse and/or other psychopathology. Based on the body of literature that
suggests that antisocial alcoholics are likely to experience the most troubled life course, it
should follow that the children of antisocial alcoholics would themselve experience more
trouble than children of primary alcoholics. Studying the children of these women would
also provide very early information about the relationship of negative affect with the other
diagnostic groups. In terms of the developmental trajectory issues described above, it
would be useful to observe whether the children of NA women more closely resemble those
of AALS or PAS.
Conclusions

The results reported here unequivocally indicate that at least two subtypes exist

among this sample of alcoholic women. In testing the first hypothesis, unmistakable

106

differences were observed between antisocial and nonantisocial alcoholics in terms of
demographics, alcohol-specific difficulties, various indices of antisociality, family history
variables, rearing environment, and religious involvement/social support.

Within the subset of nonantisocial alcoholics, several of the same differences
appeared between negative-affect and primary alcoholics. Negative-affect alcoholics
were found to differ from primary alcoholics in terms of alcohol-specific difficulties,
antisocial behavior, domestic violence, and internalizing psychopathology, largely
supporting Hypothesis 2.

When all three groups were compared to one another, there emerged evidence to
suggest that there were actually three discernible alcoholisms represented in this sample.

The primary and antisocial alcoholics differed vastly from one another. The negative
affect group appeared to follow a developmental trajectory in which their risk load,
childhood functioning, and alcohol-Specific symptomatology were similar to AALS, but
the current functioning more closely resembled the primary alcoholism group.

Clearly, the results reported here are of considerable interest given the population-
based, multivariate nature of the sample, and the fact that the study is one of a very small
number focusing on subtypes among women. The results indicate that an
antisocial/nonantisocial distinction can be drawn among female alcoholics who are early
on in the disease process of alcoholism. Other studies that identified antisocial subgroups
among female alcoholics (i.e., Lex et al., 1990) used samples drawn from court referrals

and inpatient admissions rosters. This study is unique in that similar phenomena,

107

including differences in family history and current psychopathology, were observed
among young women who had not yet even been formally diagnosed as alcoholics.

Another unique feature of this study is that it is among the first to identify three
subtypes among women. While several previous studies compared antisocial and
nonantisocial groups, or depressed and non—depressed group, this study is rare in its
Simultaneous comparisons of three groups. The results provided empirical support for the
theories advanced by Zucker (1987, 1994).

Finally, in addition to their inherent interest and value, the findings reported
herein also provide a foundation for further subtype research. They also contain strong
implications for treatment matching, outcome studies, and investigations of the

transmission and developmental trajectory of alcoholism and related psychopathology.

APPENDIX A

108

 

Table A1
.‘.1M1‘,.-_1‘11 1 .1‘ -.1-_1‘ '11..1‘1._‘1 61-. ' It- 3
VARIABLE MEAN STANDARD DEVIATION

DSM-III-R ALCOHOL DIAGNOSIS 2.13 1.04
HUSBAND’S ALCOHOL DIAGNOSIS 2.67 1.25
LIFETIIVIE ALCOHOL PROBLEMS 1 1.62 1.67
SCORE
TOTAL ANT ISOCIAL BEHAVIOR 14.71 8.26
SCORE
HUSBAND’S TOTAL ANTISOCIAL 19.62 12.04
BEHAVIOR SCORE
CHILDHOOD CONDUCT PROBLEMS .25 .43
WIFE-TO-HUSBAND DOMESTIC 140.90 198.44
VIOLENCE
HUSBAND-TO-WIFE DOMESTIC 169.43 293.50
VIOLENCE
CHILDHOOD PHYSICAL 62.01 173.98
PUNISHMENT
FAMILY HISTORY OF ALCOHOLISM 2.74 1.55
FAMILY HISTORY OF DEPRESSION 1.83 1.30
FEARS AND PHOBIAS 25.39 6.31
FAMILY-OF-ORIGIN SES 35.09 19.04
CURRENT FAMILY SES 27.73 16.14
SES CHANGE. -7.36 21.14
SELF-REPORTED DEPRESSION 3.85 3.62
CLINICIAN-RATED CURRENT 7.60 7.20
DEPRESSION
CLINICIAN-RATED WORST-EVER 17.50 12.61
DEPRESSION
SELF-REPORTED RELIGIOSITY 2.90 .67
CURRENT ATTENDANCE TO 3.72 1.27
RELIGIOUS SERVICES
FAMILY-OF-ORIGIN ATTENDANCE 2.63 1.12
TO RELIGIOUS SERVICES
CURRENT FAMILY INCOME 6.84 2.07
NUMBER OF CHILDREN 2.34 .88
EDUCATIONAL ATTAINMENT 13.20 2.08

SOCIAL SUPPORT 7.70 .71

 

APPENDIX B

109

Uék. ; ”111° 1 Di--1;=-h.“1h11-111.- -_11 61.01.12 1111'
CNAALaandAALs)

The first MAN OVA tested for demographic differences between NAALS and AALS
(see Table B1). The results indicate that NAALS and AALS differed from one another on
the demographic variables as a whole (overall MANOVA), and also in terms of the
univariate E tests for individual variables representing current family income and
educational attainment. In all cases in which a significant difference was observed, the
NAALS showed higher levels of social adaptation.

The second MANOVA was performed to test whether NAALS differ fiom AALS in
terms of alcohol-specific variables. As shown in Table B2, the results indicate that NAALS
and AALS differed from one another on the group of alcohol-Specific variables as a whole
(overall MAN OVA), and also on each of the univariate E tests for individual variables
except the husband’s alcohol diagnosis. The data Show that AALS exceed NAALS in terms
of family history of alcoholism, lifetime alcohol problem score, and DSM-III-R alcohol
diagnosis.

Table B3 contains the results of the third MANOVA, which tested NAAL vs. AAL
differences in variables related to antisociality. The results indicate that AALS exceeded
NAALS in terms of the group of variables as a whole (overall MANOVA), as well as the
univariate E tests for the subjects’ childhood conduct problems and the husbands’ total
antisocial behavior scores; there were also trends (p<.10) to suggest that AALS exceed

NAALS in both husband-to-wife and wife-to-husband domestic violence.

110

 

 

Table B1
0x11191111 Di"1‘ 3‘h“1\11.-.11-._I\;.‘. 1‘: -.11111 a;
nflllAlcoholics
[Multivariate F (5,122)=3.23, p<.01]
WEE-.81) AALS—Ell
MEAN SD MEAN SD F.
Family of 34.87 17.57 35.57 22.03 .04
Origin SES
Current Family 29.07 17.53 24.91 12.42 1.86
SES
Income 35,450 16,250 26,037 16,465 9.28”
Number of 2.36 .86 2.29 .93 .14
Children
Education 13.59 2.15 12.37 1.67 10.28”
(Y earS)

 

‘p<.05, ”p<.01

111

 

 

Table B2
'131‘1.‘ 1'11."1\11.-_11i-. “a; 1il-1151.1a- :. 111
ll 1 l-S 'fi 1! '11
[Multivariate F (4,123)=4.83, p<.01]
NAALsInEfiZ) AALSJnflD
MEAN SD MEAN SD F
Family History of 2.51 1.47 3.24 1.63 6.42‘
Alcoholism
Lifetime Alcohol 1 1.22 1.32 12.45 2.01 17.14"
Problem Score
DSM-III-R 1.92 .96 2.56 1.10 11.42”
Alcohol Diagnosis
Husband’s 2.54 1.35 2.95 .97 3.06
Alcohol Diagnosis

 

‘p<.05, "p<.01

112

 

 

Table B3
'1 1. 3h“1\11-_1 1 Ike; 1—1‘ 1161 1 .6 1“ a
I 1. E 1 . . 1'
[Multivariate F (4,123)=7.65, p<.0001]
NAAL-Emil) AAL-“LIED
MEAN SD MEAN SD F
Childhood .14 .35 .49 .51 20.33"
Conduct Problems
Husband’s 17.89 12.36 23.29 10.55 6.66.
Antisocial
Behavior
Husband-to—Wife 137.72 278.99 236.71 315.16 2.87
Domestic
Violence
Wife-to-Husband 120.64 190.27 183.88 210.74 3.22
Domestic
Violence

 

°p<.05, “p<.01

113

 

 

Table B4
'161‘1 ‘ 3‘1131‘1 \11-11 11105;; 1‘: I -_11 51! 1 -_. a; 1“ a 111 '
[Multivariate F (3,124)=2.84, p<.05]
NAALs_(ni&Z) AAL-5.11131)

MEAN SD MEAN SD F
Self-Reported 3.45 3.59 4.71 3.60 3.43
Depression
Fears 6.93 7.35 9.01 6.73 .01
Family History of 1.64 1.1 1 2.24 1.56 6.21 ‘
Depression

 

’p<.05, "p<.01

1 1 4
AS Shown in Table B4, the fourth MANOVA was performed to test for differences

between NAALS and AALS in internalizing psychopathology not specifically related to
either alcohol use or antisociality. These included two measures of the subjects’ current
level of depression, a measure of the subjects’ family history of depression, and a measure
of fears and

phobias. As Table B4 indicates, this MANOVA was marginally Significant overall, with
AALS exceeding NAALS only in the univariate E test for family history of depression.

The fifth MANOVA, whose results appear in Table B5, was used to test for
differences in the rearing environments of NAALS and AALS. Specifically, the two groups
were compared in terms of family history of alcoholism, family history of depression, and
childhood physical punishment. The results of this MANOVA were Significant overall, and
AALS demonstrated denser family histories of both alcoholism and depression in the
univariate E tests. In addition, AALS also evidenced a trend toward a history of more
physical punishment than NAALS (one-tailed p=.09). A one-tailed test was used here
because the direction of these effects had been predicted on the basis of a very substantial
prior literature.

The sixth MANOVA measured differences between NAALS and AALS in their
religious and interpersonal involvements. The two groups were compared in terms of the
subjects’ perceptions of emotional and instrumental social support from others, their reports
of how religious they consider themselves to be, and the frequency of attendance to
religious services in their current family and family of origin. AS can be seen in Table B6,

the overall MANOVA was significant. In terms of univariate E tests for individual

115

variables, NAALS reported a higher fi'equency of current attendance to religious services,

and a higher degree of perceived social support.

116

 

 

Table B5
'5‘1‘1‘ 3‘1.“1\11.-.11-_.ké; 115-116111- a; —‘ a 111
. B . E .
[Multivariate F (4,123)=3.99, p<.01]
NAALsInfll) AALSIEAD
MEAN SD MEAN SD F
Family History of 2.51 1.47 3.24 1.63 6.42‘
Alcoholism
Family History of 1.64 1.11 2.24 1.56 6.21’
Depression
Family of Origin 34.37 17.57 35.57 22.03 .04
SES
Childhood 44.07 130.49 100.07 239.40 2.93
Physical
Punishment

 

‘p<.05, ”p<.01

117

 

 

Table B6
Ii‘ '1; 1'1.“1\11-.1'1 -.. “a; 1—I 11131111. 3;. 1“ a 111 '
. E 1' . 11 11 1
[Multivariate F (4,123)=3.53, p<.01]
NAALSLIEBJJ AALS-infill
MEAN SD MEAN SD F
Religiosity 2.93 .64 2.83 .74 .63
Religious 3.49 1.27 4.20 1.12 9.07”
Attendance-Current
Religious 2.57 1.12 2.73 1.12 .55
Attendance-
Childhood
Perceived Social 7.79 .69 7.52 .73 4.11‘
Support (Emotional
and Instrumental)

 

‘p<.05, ”p<.01

APPENDIX C

118

11410 1. ”119 1 Di“1 - =-1.'-1'111-..1l'a -.11. r1- ' - 11'. it;
Alcoholics

The results of the six MAN OVAS testing for differences between Primary (PA) and
Negative Affect (NA) alcoholics appear in Tables C1-C6. As can be seen in Table C1, the
MANOVA for demographic variables was nonsignificant overall and the only significant
univariate E test revealed that the mean number of children in the NA group was slightly
higher than in the PA group.

Table C2 contains the results of the MANOVA testing for PA vs. NA differences in
alcohol-specific problems. As Shown in the table, the overall MANOVA was significant,
with univariate E tests indicating that the NA group exceeded the PAS in family history of
alcoholism, lifetime alcohol problems score, and DSM-III-R alcohol diganosis, but not
husband’s alcohol dignaosis.

As shown in Table C3, the third in this series of MANOVAS tested for differences
in antisociality between the PA and NA groups. The overall MANOVA was
nonsignificant, but significant E tests showed that NA alcoholics had a higher mean
Antisocial Behavior score than Primary Alcoholics, and NA women reported a higher
degree of domestic violence fiom their partners.

The fourth MANOVA in this series tested for differences between the PA and NA
groups in measures of internalizing psychopathology. As Shown, the results indicate that
the two groups differed Significantly on the overall MANOVA, and also on two of the
univariate E tests. NAS were shown to exceed PAS in self-reported depression and fears,

but not in family history of depression (see Table C4). Table C5 contains the results of the

l 1 9
fifth MAN OVA, which tested for PA vs. NA differences in rearing environment. The

overall MANOVA was significant, and the univariate E tests indicated that the Negative
Affect group exceeded the Primary Alcoholics only in terms of their family history of
alcoholism.

The final MANOVA in this series tested for differences in religious and
interpersonal involvements. AS shown in Table C6, neither the overall MANOVA nor any

of the univariate E tests was significant.

120

 

 

Table C1

P11191411 .i'vl‘l ‘ 3‘11“1'111-.1I';1—1 -.11L'°-_1 .i‘ k; 1-1

1 1 1 1'

[Multivariate F(5,81)=1.1 l,ns]
Emu—fill NAS—(11326)
MEAN SD MEAN SD F

Family of Origin SES 357.68 177.52 327.46 172.73 .54
Current Family SES 287.24 159.69 298.77 210.71 .08
Income 35,380 15,360 35,630 18,510 .00
Number of Children 2.23 .73 2.65 .93 4.60‘
Education (Years) 13.62 1.96 13.50 2.58 .06

 

‘p<.05, "p<.01

121

 

 

Table C2
Di"1.‘ 3116111111111 ’6 1—1 -.11 \‘M. ' 61-1 k; 1: 1 a 111 ' 11
1 11 1 1-5 .51, .1]
[Multivariate F (4,82)=2.91, p<.05]
BASInEQD NASIIEZQ
MEAN SD MEAN SD F
Family History of 2.25 1.27 3.11 1.73 6.54"
Alcoholism
Lifetime Alcohol 10.99 1.21 1 1.76 1.43 6.55”
Problem Score
DSM-III-R 1.77 .33 2.27 1.04 5,22’
Alcohol Diagnosis
Husband’s 2.44 1.41 2.77 1.18 1.08
Alcohol Diagnosis

 

‘p<.05, “p<.01

122

 

 

Table C3
.i‘t‘1 ‘ 3‘1161‘1’111-‘0'; 1—1 r11 \‘°-.. ‘ 133'. It; 1: 1 1‘. .111 ' 11
[Multivariate F (5,81)=2.05,ns]
EASIniQD NAS—(11226)

MEAN SD MEAN SD F
Antisocial 9.45 3.49 1 1.46 3.43 6.03‘
Behavior (Total
Score)
Childhood .15 .36 .12 .33 .16
Conduct Problems
Husband’s 17.59 9.99 18.62 16.89 . 12
Antisocial
Behavior
Husband-to-Wife 89.89 207.34 249.96 381 .96 6.3 8'
Domestic
Violence
Wife-to-Husband 100.16 174.32 168.69 219.50 2.40
Domestic
Violence

 

‘p<.05, “p<.01

123

 

 

Table C4
01"1.‘ =‘h"1'1.11-_1 I" 1-1 -.11\‘°-..‘;i‘ k; 1—1 a 111 11
[Multivariate F (3,83)=2.92, p<.05]
WEED NAS—(DEE)
MEAN SD MEAN SD F

Self-Reported 2.32 3.32 4.92 3.31 6.69“
Depression

Fears 24.42 5.93 27.59 6.13 472'
Family History of 1.52 1.07 1.92 1.16 2.35
Depression

 

‘p<.05, “p<.01

124

 

 

Table C5
.i'r‘vn .‘ 1‘1.“1 3111-1 0'; 1—1 -11 \‘HI ' 55- It; 1: 1 e .111 '
B . E .
[Multivariate F (4,82)=2.60, p<.05]
mien Nth-201326)
MEAN SD MEAN SD F
Family History of 2.25 1.27 3.11 1.73 6.54“
Alcoholism
Family History of 1.52 1.07 1.92 1.16 2.35
Depression
Family of Origin 357.68 177.52 327.46 172.73 .54
SES
Childhood 32.61 67.34 70.96 215.92 1.59
Physical
Punishment

 

°p<.05, ”p<.01

125

 

 

Table C6
'1‘1‘1 .‘ 1'11“1 5111-1 I'; 11 -.11\'°-. ° ii Ck; 1= 1 a 111 '
B 1' . 11 11 1
[Multivariate F (4,82)=.79, ns]
PAM.) NASJIEZQ)

MEAN SD MEAN SD F
Religiosity 2.90 .65 3.00 .63 .42
Religious 3.48 1 .23 3.54 1.39 .04
Attendance- Current
Religious 2.54 1.15 2.65 1.06 .18
Attendance-
Childhood
Perceived Social 7.85 .72 7 .64 .62 1.76
Support (Emotional
and Instrumental)

 

’p<.05, ”p<.01

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126

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