C H A P T E R

28
Personality and Addiction Processes
Natalie Castellanos-Ryan, Patricia J. Conrod
Université de Montréal, Montreal, QC, Canada

O U T L I N E

Personality Traits Implicated in Addiction 272 The Negative Affect Regulation Pathway 275
Inhibited Domain 272 The Stress-Dampening Pathway 276
Negative Affect and Hopelessness 272 The Poor Response Inhibition Pathway 276
Anxiety Sensitivity 273 The Reward (and Positive Reinforcing Properties of
Disinhibited Domain 273 Substances) Pathway 278
Impulsivity 274
Summary and Implications 278
Sensation Seeking 275
Causal Pathways to Addiction 275

The emphasis placed on the role and significance of with anxiety and pessimism). Type 2, on the other
personality in the development and course of addiction hand, was characterized by an early age of onset, dis-
has varied substantially through the past few centuries. playing antisocial tendencies and behaviors, and high
While early models of addiction placed considerable scores on novelty seeking (a trait related to impulsivity).
emphasis on the role of personality, later more biological Other influential studies carried out by researchers
or pharmacological based models of addictions over- including Sher, Pihl, McGue, Stewart, Cooper, Conrod,
looked or disregarded personality as an etiological and their colleagues, to name a few, have also high-
factor for addiction. During the 1960s and 1970s, new lighted the important role different personality and/or
interest in the possibility of personality as a key factor temperamental traits have in the development and
in addictions arose, but was short-lived as, by the late maintenance of addiction. Among the personality
1970s, most of the studies carried out during this period factors most commonly cited in the literature as being
failed to identify one single personality trait that associated with alcohol and drug misuse, as well as
conferred risk for addiction. In more recent years, other addictions, are traits that fall within two main
however, models of addiction have placed a greater overarching personality domains of inhibited and disin-
emphasis on the reciprocal interplay between biological, hibited traits. Respectively and generally speaking,
psychological, and environmental factors, and the these two domains of personality correspond to a prone-
heterogeneity of the addictive processes and profiles, ness toward negative and positive affective states, and
identifying distinct pathways to addiction. One of the the two main action tendencies of behavior, avoidance
first and most influential of these models of addiction and approach, which are manifestations of the aversive
was proposed by Cloninger, who described two types and appetitive motivational tendencies in all humans.
of alcoholics. Type 1 was characterized by a relatively Within the inhibited domain, the personality dimen-
late onset, loss of control over drinking, experiencing sions that have been most consistently associated with
guilt because of one’s drinking, and high scores on the addictive behaviors are (1) negative emotionality, intro-
personality trait of harm avoidance (a trait associated version, or hopelessness; and (2) neuroticism, trait

Principles of Addiction, Volume 1

http://dx.doi.org/10.1016/B978-0-12-398336-7.00028-0 271 Copyright ! 2013 Elsevier Inc. All rights reserved.
272 28. PERSONALITY AND ADDICTION PROCESSES

anxiety, and anxiety sensitivity. Within the disinhibited depression also has relevance for understanding how
personality domain, the two dimensions that have neurotic/inhibited traits represent risk factors for
been most consistently implicated are (1) impulsivity, addiction, but particularly for substance misuse. For
sometimes generally referred to as disinhibition; and example, while the higher-order factor of negative
(2) extraversion, including sociability and sensation affect or neuroticism seems to be inconsistently related
seeking. to risk for substance misuse, lower-order facets
However, it is important to note that the association of neuroticism associated with low positive affect
between personality and addiction is not simple or (e.g. hopelessness) and fear (e.g. anxiety sensitivity)
straightforward. Although these personality traits have have been consistently shown to have specific relation-
consistently been linked with addiction, even across ships to particular aspects of substance use and
different forms of addictive behaviors, findings differ misuse.
according to the methodology used and sample studied.
For example, the personality traits that have often been Negative Affect and Hopelessness
found to characterize children of alcoholics or adoles- Hopelessness has been defined, generally, as a set of
cent substance users are different from those that have negative expectations concerning self and future life,
been associated with clinical samples of substance and, more specifically, as a tendency to expect negative
misusers. Similarly, findings from cross-sectional things to occur, that nothing will improve negative
studies highlighting concurrent associations between circumstances, or, conversely, that highly desired out-
personality and addictions sometimes differ from the comes will not occur.
associations found in longitudinal studies. Differences In a number of cross-sectional studies, hopelessness
could be attributed to the fact that the strength of associ- or low positive affect has been associated with substance
ations between personality and addiction varies by use and misuse. For example, hopelessness has been
developmental stage and, especially when it comes to found to be associated with higher rates of alcohol abuse
substance misuse, at different stages in the course of and dependence, sedative (including analgesics) drug
the disorder, with severe or chronic substance misuse use, and self-report reasons for substance use linked to
possibly resulting in changes in personality, negative depression coping and the numbing of painful memo-
affectivity, and impulsivity. ries in samples of college and secondary school students.
This chapter will provide a selective review of the Similarly, compared with adolescents with low levels of
literature establishing personality factors as correlates hopelessness, those with high levels of hopelessness
of, as well as risk factors for, addiction. Although addic- have been shown to be at least twice as likely to report
tive processes are similar across modalities or “objects of smoking tobacco in the last month, drinking in the last
addiction,” and similar personality traits have been week, and using marijuana in the last month, as well
implicated in a different range of addictive behaviors, as six times as likely to report cocaine use in the last
it is important to mention that this chapter will mainly month. Longitudinal studies confirm that hopelessness
focus on findings related to addiction to substances is a risk factor for substance misuse, showing that
such as alcohol and drugs. First, evidence linking adolescents with high levels of hopelessness report
specific personality traits to substance use and other greater acceleration in their trajectories of tobacco use,
addictive processes will be reviewed. The chapter will alcohol use, and marijuana use compared with those
then review several causal pathways to addictive behav- with low levels of hopelessness. These findings have
iors, in which personality traits play an important role. now been replicated in American, Canadian, and British
Finally, implications for prevention and clinical practice samples of adolescents. The association between this
will be discussed. personality trait and addictive behaviors has also been
found in clinical samples and community-recruited
samples of adults. For example, Conrod and colleagues
found in a community-recruited sample of alcohol-
PERSONALITY TRAITS IMPLICATED
dependent women that a personality factor reflecting
IN ADDICTION
introversion and hopelessness was associated with
a substance misuse profile that involved higher rates
Inhibited Domain of dependence on analgesics and greater comorbidity
Research on the structure of neurotic symptoms with recurrent depression and social phobia. A study
and/or inhibited personality generally finds that nega- with college students also showed a greater likelihood
tive affect is common to all neurotic traits but that of using sedatives/analgesics in college in those with
they can be subdivided into two lower-order factors, increased hopelessness. The frequently reported finding
characterized by low positive affect and fear, respec- linking hopelessness with a series of a number of inter-
tively. This hierarchical model of anxiety and nalizing problems, led researchers and clinicians in the

I. THE NATURE OF ADDICTION

 PERSONALITY TRAITS IMPLICATED IN ADDICTION 273
1980s and 1990s to hypothesize that hopelessness or low is offered by O’Connor and colleagues who have shown
positive affect was associated with a particular suscepti- that alcohol and drug expectancies, especially those
bility to substance misuse patterns through a self-medi- related to tension reduction and cognitive and behav-
cation process involving analgesia-induced numbing of ioral impairment, are important moderators in the asso-
painful experiences and memories. Through varied ciation between AS and substance use but are not often
research, this hypothesis has been validated and has taken into account.
gained support as a specific pathway to addiction (see What has been consistently reported in the literature,
section “Casual Pathways to Addiction”). in both adolescent and adult samples, is the significant
association between AS and self-report motivations for
Anxiety Sensitivity substance use that reflect self-medication of anxiety
Another inhibited trait is anxiety sensitivity (AS), symptoms or drinking to cope with emotional distress.
described as a fear of anxiety-related physical sensations Many have also demonstrated that AS is associated
due to an unrealistic expectation that they could lead to with a pharmacological sensitivity to the arousal damp-
“catastrophic” consequences such as loss of physical or ening properties of alcohol and benzodiazepines.
mental control, among others. Like hopelessness, AS Indeed, as AS has often been conceptualized as an
has also been shown to be associated with high drinking “arousal-accelerator,” it is not surprising that the
levels and drinking problems, as well as with misuse of evidence does not support AS as a risk factor for adoles-
a variety of substances in adults, such as heroin, alcohol, cent onset substance use, but rather indicates that AS
nicotine, and anxiolytics. However, some of the findings represents a specific risk profile predicting who will
linking AS and heavy alcohol use in community samples use substances to cope with stressors that produce
have been mixed and a number of studies have shown physiologic arousal, such as drug withdrawal, trauma,
that AS is not associated with the use of marijuana, severe negative life circumstances, and, particularly in
hashish, or stimulants. Other studies have shown younger samples, those normative experiences such
increased levels of AS in individuals receiving treatment as social pressure to conform to peers’ substance use
for substance use disorders, and Zvolenski and patterns. It is important to note here, that there is
colleagues have shown that AS is associated with some literature suggesting that high AS men are at
heightened reactivity to nicotine withdrawal and the greater risk for self-medication drinking than high AS
tendency to rapidly return to smoking during quit women, especially when tension reduction expectan-
attempts. cies are increased, and that, in more general terms,
Although there is some prospective evidence that drinking for coping with negative affect (also related
anxiety symptoms in childhood or adolescence often to hopelessness) is a stronger motivation for men than
precede substance use and misuse, very few prospective for women.
studies on the association between AS and addiction
have been undertaken. Of those that have, findings are
mixed or suggest some developmental and gender spec-
Disinhibited Domain
ificity. For example, one study carried out in Finland Disinhibition is often referred to a general failure to
found that anxiety/shyness assessed at the age of 8 pre- plan, control, or regulate behavior, especially behavior
dicted increased alcohol and other drug use 20 years that can be unduly risky or can sometimes result in
later in women, but predicted reduced substance use negative consequences. Recent research on the structure
in men. In contrast, another study carried out in New of disinhibited behavior and personality also supports
Zealand by Caspi, Moffitt, and colleagues showed that a hierarchical structure of disinhibited or externalizing
inhibited boys, described as fearful, anxious, and shy, disorder symptoms and traits, indicating that while
were more likely to present alcohol-related problems. they are all correlated with each other and share
However, studies assessing AS in early adolescence common variance, subfactors exist that capture the
and its association with the onset of or increased unique variance of some disinhibited behaviors and
substance use across adolescence have not been able to traits. Certainly, disinhibited tendencies have been
confirm a prospective relationship between AS and referred to in a number of ways in the personality,
early onset or higher severity of substance use across behavioral and psychopathology literatures, from
this period. However, the prospective link between AS “acting without premeditation,” “lack of planning,”
and development of alcohol use disorders, becomes “excitement seeking,” “low tolerance to boredom,”
clearer in young adulthood, with studies carried out “behavioral undercontrol,” and impulsivity, among
by Schmidt and colleagues, as well as Stewart and others. Consequently, measures labeled “disinhibition”
colleagues, showing that AS assessed at ages 18–20 or “impulsivity” may measure different constructs
predict alcohol use disorders a couple of years later. A from each other. Indeed, although general factor models
possible reason for the inconsistencies in this literature of personality typically identify only one factor for

I. THE NATURE OF ADDICTION

274 28. PERSONALITY AND ADDICTION PROCESSES

disinhibition/impulsivity, extensive research has been impulsivity to substance misuse is bidirectional. This
carried out on the differentiation between different highlights the importance of assessing both measures
dimensions of disinhibited personality, which usually of impulsivity and substance use simultaneously across
results in between two and four subfactors of disinhibi- time, so that cross-lag or bidirectional effects can be eval-
tion. Using methodologies like factor analysis, recent uated. With this in mind, a recent study by Littlefield,
research in the field of personality has identified, as Sher, and Wood evaluated, using latent growth models,
many as four personality facets associated with impul- the extent to which changes in personality and changes
sive-like behavior: lack of planning, lack of persistence, in drinking behavior covary across early adulthood and
urgency (acting rashly when upset or anxious), and showed that changes in drinking behavior from 18 to 35
sensation seeking, but most studies in the field of years of age tend to co-occur with changes in impul-
personality as well as cognitive sciences, agree that at sivity (as well as neuroticism). While this analysis does
least two clear subdimensions of disinhibition exist: not provide direct evidence for causal effects between
one which is referred to as impulsivity in this chapter, these two factors, the findings suggest that the relation-
and another which is referred to as sensation seeking. ship between impulsivity and drinking behavior may be
more complex than a simple causal relation and may be
Impulsivity reflecting a mutually exacerbating relationship.
Impulsivity is generally associated with a deficit in There is now enough evidence – provided particu-
reflectiveness and planning, rapid decision-making larly by studies on children of alcoholics as well as by
and action, and a failure to inhibit a behavior that is studies on nonsubstance use–related addictions such
likely to result in negative consequences. It is clear as problem gambling, where the vulnerability mecha-
from the literature on substance misuse in adolescent nisms underlying addiction can be studied without
and adult samples that impulsive traits play a prominent the confounding effects of substance use – showing
role in addictive behavior. Impulsivity has often been that impulsivity is indeed a risk factor for addiction.
associated with substance misuse, specifically, quantity For example, studies on children of alcoholics, consid-
and frequency of drug use, and early experimentation ered to be at a higher risk for future alcohol problems
with drugs. Impulsivity has also been associated with due to genetic vulnerability, have found that many of
the consumption of a range of different drugs, such as these children exhibit high levels of impulsive person-
cannabis, ecstasy, and heroin use, and is the personality ality traits and behaviors, with some even showing
trait that has most consistently been associated with that disinhibited traits mediate the relationship
alcohol disorders in the literature. between family history of alcoholism and drinking
Longitudinal studies have also identified impul- behavior.
sivity/disinhibited traits as risk factors for future Studies on problem gambling have shown similar
substance misuse. For example, impulsivity in child- results than those in the substance use field, indicating
hood, as measured by either Eysenck’s psychoticism or that compared with nongambling controls, problem
Cloninger’s novelty seeking, has been found to predict gamblers demonstrate increased scores on a range of
substance misuse and alcohol-related problems in impulsivity-related measures. Similar to findings in the
adolescence and adulthood, with a study by Cloninger alcohol, and drug use literature, impulsivity scores
and colleagues showing those reporting high scores in have also been shown to predict gambling symptom
impulsivity to be 20 times more likely to report alco- severity in clinical samples of problem gamblers, as
holism in adulthood compared with those who do not well as community-recruited adolescents. Finally,
report high scores on this trait. Impulsivity measured several studies provide evidence for the hypothesis
by higher-order factors or super-factors like constraint that impulsivity is a common risk factor for (or associ-
(i.e. Multidimensional Personality Questionnaire or the ated with shared vulnerability to) gambling and
Minnesota Multiphasic Personality Questionnaire) or substance use problems, as well as other addictive
by lower-order, more specific measures of impulsivity behaviors and externalizing problems, such as antisocial
(e.g. Substance Use Risk Profile Scale) assessed in child- behavior.
hood or early adolescence, have also been prospectively Although there is some research showing that
associated with alcohol and drug use in late adolescence impulsivity (or undercontrol) assessed early in child-
and young adulthood. However, it is important to high- hood is associated with alcohol problems in early
light that some laboratory studies have shown that adulthood in men but not women, varied research
severe and persistent substance use can result in deficits has shown that men and women tend to report similar
in behavioral and/or cognitive measures of impulsivity, levels of impulsivity – this is not the case though if the
such as response inhibition and decision-making, and impulsivity measure includes “aggressive tendencies”
even in increased levels of self-report trait impulsivity, (such as the measure of constraint) on which
suggesting the possibility that the pathway from men score higher – and similar associations between

I. THE NATURE OF ADDICTION

 CAUSAL PATHWAYS TO ADDICTION 275
impulsivity and later substance use or other addictive situations, and finding it difficult to complete tasks they
behaviors. find boring – all characteristics used to describe sensation
seekers. However, although often hypothesized that by
Sensation Seeking their very nature sensation seekers should be more prone
Sensation seeking is generally defined as a strong to gamble, findings have been mixed. While several
need for stimulation, a low tolerance to boredom, and studies have reported high levels of sensation seeking in
a willingness to take risks for the sake of having novel adult pathological gamblers, particularly those who bet
and varied experiences. Findings on the association at race-tracks or casinos, this has not been the case in
between traits related to extraversion and substance younger problem gamblers or across all gambling activi-
misuse in clinical samples as well as community ties. In fact, one study by Coventry and Brown has found
samples of adults have been somewhat inconsistent, that those who bet exclusively in an off-course betting
with a number of studies indicating only modest associ- office scored lower on sensation seeking than non-
ations between extraversion and drinking onset as well gamblers and the general population. Findings like these
as increased levels of alcohol use. However, sensation highlight the fact that gambling, and addiction generally,
seeking, a trait related but not equivalent to extraver- can’t be viewed as a homogeneous activity or process
sion, has been shown to be more robustly and consis- and that different pathways to addiction as well as
tently related to substance misuse behaviors, especially different profiles of addiction can be identified.
binge drinking or heavy episodic drinking, particularly
in adolescents and young adults. Indeed, a recent study
has shown that in a sample of drinking college students,
CAUSAL PATHWAYS TO ADDICTION
sensation seeking explained a significant amount of
variance in alcohol-dependence symptoms, above and
The evidence reviewed above implicating personality
beyond that explained by the trait of extraversion as
as an important factor in addiction is but a few of the
measured by the Neuroticism Extroversion Openness
several longitudinal studies, familial aggregation
Five Factor Inventory (NEO-FFI). Research carried out
studies, as well as genetic and animal studies, which
by Cooper and colleagues and Stewart and colleagues
provide strong evidence for causal relationships
have consistently shown that sensation seeking is associ-
between personality and addictive behaviors. In line
ated with using substances for enhancement motives
with the four personality traits described above, the
rather than for social or negatively reinforcing motives.
available evidence suggests at least four different devel-
Longitudinal studies in North American as well as
opmental or causal pathways to addiction, in which the
European samples have shown that sensation seeking is
different personality factors play an important etiolog-
not only associated cross-sectionally with binge drinking
ical role. It is proposed that these causal pathways are
but can also predict drinking rates and growth in drinking
described as (1) the negative affect regulation pathway,
quantity by frequency during adolescence. Although
(2) the stress-dampening pathway, (3) the poor behav-
findings are not as consistent as with alcohol use, some
ioral inhibition and/or deviance proneness pathway,
studies have shown prospective association between
and (4) the reward sensitivity pathway.
this trait and marijuana, tobacco, and hallucinogen use
in adolescence. Most of the positive findings linking
sensation seeking and future substance use have been
found in adolescent or young adult samples, suggesting
The Negative Affect Regulation Pathway
that sensation seeking might be an important factor in Several studies have shown that many individuals
earlier stages of substance use initiation or experimenta- engage in heavy drinking or substance use, as well as
tion, rather than in the continuation or compulsive use. excessive gambling or eating, to regulate affect or
Although men tend to score higher on sensation emotional states. Also referred to as the “self-medica-
seeking measures than women (especially during adoles- tion” hypothesis, many individuals report that they
cence), most research shows that the association between use substances to regulate or cope with negative affect,
high Sensation Seeking and substance use is significant such as depressed mood or anxiety, and to forget about
for both men and women, with only a few studies sug- difficult situations. Although the negative affect regula-
gesting that the association between sensation seeking tion model is one of the most enduring etiological
and alcohol use outcomes may be stronger for adolescent perspectives on addiction, it has been shown that it is
boys than girls. highly dependent on intraindividual factors such as
A “need for intensity” and sensation seeking have also personality, as well as other factors such as expectancies,
been associated with problem gambling. Some studies genetics, and environmental factors.
have characterized pathological gamblers as having Inhibited traits have typically been implicated in
a low tolerance to boredom, being attracted to stimulating models of negative affect regulation of addictive

I. THE NATURE OF ADDICTION

276 28. PERSONALITY AND ADDICTION PROCESSES

behaviors. For example, hopelessness has been argued arousal-accelerating factor, AS seems to not only render
to reflect sensitivity to punishment and has been linked, individuals susceptible to high levels of arousal in
by researchers including Sher, Cooper, and colleagues, normal stressful situations, but also in response to acute
to the development of alcohol use by using its analgesic and chronic drug withdrawal, physiologic states that are
properties to suppress feelings of negative affect. Fitting easily dampened by the pharmacologic properties of
with this profile of addiction are numerous findings alcohol and benzodiazepines.
indicating that depression and negative affect and/or Several studies have found that individuals with
hopelessness generally precede addictive behaviors a family history of alcoholism often have an increased
(although it is important to note that extended substance sensitivity to the dampening effects of alcohol on stress
use and gambling can also result in increased depression response, with findings showing that personality factors
or feelings of hopelessness), and recent evidence that the related to anxiety and AS seem to play an important
link between hopelessness and future substance use is role. For example, individuals who are high on inhibited
mediated through the occurrence of depressive symp- traits like AS have been shown to display reduced electro-
toms, and motivations for drinking that include coping dermal activity to threat cues when moderate to high
with depression. levels of alcohol have been consumed. Similarly, Conrod
Anxiety sensitivity has also been associated with and colleagues found that men with higher self-reported
substance misuse for negative affect regulation, but levels of anxiety sensitivity experienced electrodermal
specifically to relieve feelings of anxiety. Consistent response and heart rate dampening effects to aversive
with this are studies by Kushner and colleagues and stimulation after alcohol administration, compared with
Stewart and colleagues showing that AS is associated low anxiety sensitive men. These findings were inter-
generally with coping motives for alcohol use, and preted as showing a pharmacologic sensitivity that is
studies showing that those high in AS use substances produced by an interaction between anxious personality
specifically to avoid or escape anxiety symptoms. and sedative drug effects to produce a highly negatively
Accordingly, this pathway to addiction has been asso- reinforcing fear reduction. This is further confirmed by
ciated with late onset, a greater tendency to engage in findings from O’Connor and colleagues showing that
addictive behaviors (i.e. use substances or gamble) in risk for alcohol misuse in men results from increased
solitary contexts, and, specific to substance use, a predi- scores on AS in combination with the belief that drinking
lection for alcohol, sedatives, and/or analgesics, as well alcohol can reduce tension (i.e. tension reduction alcohol
as reporting lower enhancement motives for use. expectancies). This combination of factors – high AS, the
belief that alcohol or drugs can reduce tension, and the
heightened sensitivity to their pharmacological effects –
The Stress-Dampening Pathway together with the fact that chronic substance use will,
Over the last 20 years, a large body of research has with time, dampen or reduce the “tension-reduction”
assessed individual differences in their response to the properties of the substance being used, leading to further
effects of alcohol and other drugs, which may put substance use, might explain why this pathway is associ-
certain individuals at higher risk for addiction. First ated with substance use dependence or problems, rather
proposed by Sher and colleagues, the pharmacological than with substance use onset.
vulnerability model of addiction proposes that indi-
viduals are at risk for substance misuse because they
The Poor Response Inhibition Pathway
are especially sensitive to the reinforcing effects
of substances and are therefore more likely to use This pathway to addiction posits that individuals
substances as they experience greater effects from the with high levels of impulsivity (or low levels of
substance. constraint) are more inclined to engage in deviant
Inhibited traits such as AS and low positive affect behaviors in general, including substance misuse and
have been implicated in differential psychopharmaco- other addictive behaviors. This pathway to addiction
logical effects of substances. AS has been associated has been frequently investigated and thus is well docu-
with experiencing increased withdrawal symptoms, mented. There have been a few models that have
particularly those related to tobacco, and thus poorer attempted to explain the link between impulsivity
cessation outcomes. Similarly, low positive affect has and/or poor response inhibition and deviant behaviors
been associated, even after controlling for depression as well as substance misuse. As early as the 1970s, Jessor
symptoms, with higher withdrawal symptoms in and Jessor, and other colleagues, believed that it was the
a sample of adults attending a smoking cessation clinic. interplay and interdependence of three systems of vari-
However, studies specifically assessing the stress ables – the behavior system, the personality system, and
response–dampening effects of alcohol, have implicated the perceived environmental system – which resulted in
AS as a determining factor. Often described as an the engagement in problem behaviors or level of

I. THE NATURE OF ADDICTION

 CAUSAL PATHWAYS TO ADDICTION 277
behavioral deviance, of which substance use was a study by Khan and colleagues investigating the struc-
considered only an indicator. Although emphasis is ture of psychiatric disorders in adults also showed that
placed on deficient socialization as a major “instigator” impulsivity (i.e. novelty seeking), but no other person-
or risk factor, their model highlighted the role tempera- ality traits, accounted for a proportion of the comorbid-
ment and personality traits, particularly those related to ity between dependence to substances (alcohol and
impulsivity, had in socialization and developmental drug) and conduct disorder. These results, and the
processes. Two more recent models explicitly implicate high rate of co-occurrence between substance misuse
impulsivity or deficits in self-regulation as key in the and antisocial behaviors, lend support to the deviance
development of behavioral problems and substance proneness and the behavioral dysregulation models of
misuse, as well as their comorbidity: the social deviance substance misuse and also suggest that impulsivity,
model, proposed by Sher and colleagues, and the but not other personality traits, may play a key role in
psychological dysregulation theory, proposed by Tarter, these liability models.
Clark, and colleagues. Both highlight the interplay Recent studies which use behavioral or cognitive
between individual and environmental factors, and refer measures of inhibition, also provide support for this
to substance use as part of a more general deviant pathway to addiction, with findings consistently
pattern of behavior, which usually begins in childhood, showing that deficits in self-regulation, assessed by
and can be exacerbated by poor socialization. However, increased commission errors on go/no-go or stop tasks,
while the deviance proneness model is firmly based on are associated with a range of behavioral problems,
sociopsychological theory, and places greater emphasis including conduct disorder, hyperactivity, and sub-
on the role of poor socialization, the psychological dys- stance misuse. Moreover, Castellanos-Ryan and Conrod
regulation theory is based on psychobiological theory showed that poor response inhibition, as measured by
of human behavior, and places greater emphasis on increased commission errors in a STOP task, partially
genetic liability. Consistent with both these models, mediates the association between self-reported impul-
longitudinal studies assessing early onset alcohol prob- sivity and externalizing behaviors, including substance
lems show consistent associations between alcohol prob- misuse and conduct disorder symptoms. These results
lems and a history of childhood antisocial behavior, poor indicate that the link between impulsivity and substance
school achievement, poor interpersonal relationships, misuse is, at least in part, explained by a deficit in
heightened activity or attentional problems during response inhibition that makes impulsive individuals
childhood, and inadequate parenting. Furthermore, more prone to engage in externalizing behavior in
studies have shown that early “difficult temperament” general.
characterized by high levels of disinhibition or impul- Finally, further support for this pathway and
sivity, in combination with poor parenting, leads to a common genetic liability for deviant or externalizing
unsocialized behavior. Impulsivity has also been shown behaviors comes from several studies showing common
to be associated with substance misuse that is comorbid genetic liability for conduct disorder, substance use,
with antisocial behavior, while other disinhibited traits behavioral undercontrol, as well as studies by Iacono,
like sensation seeking have not. Recent findings, using McGue, and colleagues, as well as Slutske and
structural equation modeling which make it easier to colleagues showing common genetic liability between
assess the comorbidity between disorders, as well as early measures of social deviance and later externalizing
their longitudinal associations, have also provided disorders and substance misuse. Although it seems
support for this pathway to substance misuse. For likely that a large number of genetic variants are impli-
example, one study demonstrated that adolescents cated in externalizing and substance use behaviors,
high in impulsivity showed their susceptibility to several common variants have been implicated in these
increased alcohol use through conduct disorder symp- behaviors and their comorbidity, with some studies sug-
toms, whereas adolescents high in sensation seeking gesting that a significant portion of the genetic contribu-
showed a direct susceptibility to increased alcohol use tion to early onset problem drinking and other drug use
and were only susceptible to conduct disorder symp- is mediated by personality. For example, studies have
toms as a consequence of their increased alcohol use. shown that the serotonin transporter (5-HTT) and the
Furthermore, another study by Castellanos-Ryan and low variant of the monoamine oxidase A (MAOA) are
Conrod showed that while impulsivity was associated implicated in substance use disorders and other
with an externalizing behavior factor, which accounted problem behaviors, as well as being associated with
for the shared variance between measures of conduct the personality trait of impulsivity and, in the case of
disorder and substance misuse, as well as a specific MAOA, with neurocognitive measures of disinhibition.
conduct disorder factor, it was not associated with Other genes, such as the serotonin transporter polymor-
substance misuse that did not co-occur with other exter- phism (5-HTTLPR), the DRD2 polymorphism, and the
nalizing behavior problems in adolescence. Finally, D4 dopamine receptor (DRD4) have been shown to be

I. THE NATURE OF ADDICTION

278 28. PERSONALITY AND ADDICTION PROCESSES

associated with impulsivity or disinhibited personality association between sensation seeking and substance
and substance misuse. misuse is offered by Leyton and colleagues, who found,
Besides the high rates of co-occurrence or comorbid- in an exploratory study using positron emission tomog-
ity with other problem behaviors, such as antisocial raphy (PET), that sensation seeking (as measured by
traits and behavioral problems as mentioned above, “exploratory-excitability,” a subdimension of Clo-
this pathway to addiction has been characterized by ninger’s novelty seeking) was associated with greater
early onset, more severe levels of substance used (as amphetamine-induced dopamine release in the ventral
well as of gambling), as well as undefined motives of striatum and drug wanting. The authors suggested
substance use and a lack of specificity to substance or that amphetamine consumption elicits a dopamine-
addictive behavior of choice (i.e. impulsivity has been mediated appetitive state which is stronger for those
implicated in a wide range of addictive behaviors and high in sensation seeking.
substances). However, it is important to note that sensation
seeking has also been linked to risk-taking in general.
Accordingly, sensation seeking has been associated
The Reward (and Positive Reinforcing
with general or nonsubstance-related measures of
Properties of Substances) Pathway reward sensitivity/dependence, particularly in studies
This pathway to addiction posits that those individ- looking at gambling behavior. Moreover, a recent study
uals scoring high on sensation seeking or related traits, by Castellanos-Ryan and Conrod has shown that the
such as novelty seeking, extraversion, or reward association between sensation seeking and binge
seeking, will engage in addictive behaviors motivated drinking in adolescence was partially mediated by
by their positive reinforcing properties or to enhance reward sensitivity, as measured by a (monetary)
positive feelings or emotions. Supporting this pathway rewarded go-no-go task, while other measures of disin-
to addiction are several studies, including those by hibition, such as impulsivity, were not.
Pihl, Peterson, and colleagues, that show that height-
ened physiological sensitivity to substances, such as
accelerated heart rate after alcohol consumption, is asso- SUMMARY AND IMPLICATIONS
ciated with increased risk for alcoholism and substance
misuse. Similarly, compared with controls, men with The development of addictive behaviors seems to be
a family history of alcoholism have been shown to expe- multidetermined and multiple risk factors for addiction
rience a heightened subjective stimulant response to have been identified, such as genes, individual differ-
amphetamine. In another study, college students with ences in sensitivity to the reinforcing effects of
poor inhibitory control reported heavier drinking and substances, age of onset, and the presence of deviant
exhibited enhanced subjective stimulation during the peers, as well as conduct and emotional problems.
ascending limb of the blood alcohol curve. However, However, it is also clear that some individuals, some-
although disinhibited traits like impulsivity and sensa- times subjected to the same general risk factors, go on
tion seeking have both been associated with increased to develop an addiction and some do not. As reviewed,
and problematic substance use, only sensation seeking a number of research findings suggest that different
has consistently been associated with enhancement or pathways to addictions exist, where psychological
reward-related motives for substance misuse. The moti- factors such as personality traits, play an important
vation for positive reinforcement from substances has role. These different casual pathways to addiction
been shown to be founded on the neuropharmacological suggest that personality traits are related to substance
effect substances have on the brain centers involved in misuse, and possibly other addictive behaviors, through
basic reward mechanisms, that is, substances stimulate different motivational processes, and are associated
mesolimbic dopamine activity and increase activity in with different profiles and/or patterns of addiction.
brain opioid systems. Consistent with this, are studies For example, while findings support that anxiety sensi-
showing that individuals who are high on disinhibited tivity is associated with substance misuse through its
personality traits such as sensation seeking tend to be association with the anxiolytic or stress-dampening
more sensitive to drug-induced reward and to display effects of specific substances, sensation seeking is associ-
heightened heart rate response to alcohol, as well as ated with the initiation of substance use behaviors as
experience more positive feelings in general after well as substance misuse through the mediation of
alcohol intoxication. Thus, the link between sensation reward sensitivity and the positive reinforcing effects
seeking and substance use could be partly explained of certain substances. On the other hand, impulsivity
by the association between sensation seeking and this seems to be associated with a large number of addictive
heightened response to the reinforcing properties of behaviors and processes through a general inability to
substances. Another possible explanation of the inhibit responses or behavior, while findings seem to

I. THE NATURE OF ADDICTION

 SUMMARY AND IMPLICATIONS 279
suggest that hopelessness is associated with substance and specific substances or addictive behaviors – most
misuse through a motivation to cope with high levels commonly associated with each of the four pathways.
of negative affect. The figure shows how individuals high in hopelessness
Displayed graphically in Fig. 28.1 are the four hypoth- are likely to engage in addictive behaviors through their
esized causal pathways to addiction reviewed in this need to manage or reduce their negative affect, while
chapter. Described in this figure are the distinct person- individuals high in anxiety sensitivity engage in addic-
ality traits associated with each pathway, as well as the tive behaviors, primarily substance use, because of their
underlying mechanisms that help explain the way in sensitivity to the arousal dampening effects that are very
which these personality traits are related to addictive negatively reinforcing to those who fear them. Both
behaviors. Included in Fig. 28.1 are also what one could these pathways to addiction are associated with later
refer to as addiction profiles – e.g. early or late onset, onset, are more likely to lead to gambling or using

Addictive processes
Personality
traits Causal pathway Substance/behavior
Onset of choice

Alcohol
Analgesics
Hopelessness Negative affect regulation Late onset
Gambling
(solitary setting)

Alcohol
Stress-dampening / increased
Anxiety sensitivity Late onset Sedatives
withdrawal symptoms

Most substances
Impulsivity Poor behavioral inhibition and Early onset / and addictive
general deviance proneness continued use behaviors

Alcohol
Sensitivity to reward and the Early onset / stimulants and
Sensation seeking incentive/reinforcing properties experimental some evidence
of substances use for gambling
(social setting)

Note: This figure shows that individuals high in hopelessness engage in addictive behaviors that usually have a late
onset through their need to regulate their negative affect. Their drugs of choice are usually alcohol or any other with
analgesic properties. Individuals high in anxiety sensitivity also engage in late onset addictive behaviors, such as
misuse of alcohol or substances with sedating properties, because of their sensitivity to their arousal dampening effects.
Those high on the trait of impulsivity tend to engage in a range of addictive behaviors and have a more severe
addiction profile, through deficits in response inhibition. Individuals high in sensation seeking, due to their specific
sensitivity to reward, including alcohol- or drug-induced reward, are likely to engage in early onset or experimental
substance use, especially with those with psycho-stimulant properties, or gambling in social settings.
FIGURE 28.1 Personality-related causal pathways to addiction.

I. THE NATURE OF ADDICTION

280 28. PERSONALITY AND ADDICTION PROCESSES

substances in solitary contexts, and opting for (i.e. drug use) but also in other addictive behaviors or
substances with analgesic effects, in the case of hopeless- maladaptive behaviors related to the personality profiles
ness, or anxiolytic effects, in the case of anxiety (i.e. such as gambling or antisocial behaviors in the case
sensitivity. of impulsivity). Indeed a personality-targeted approach,
With regard to the more disinhibited pathways to targeting specific pathways to addiction, has already
addiction, Fig. 28.1 shows a third pathway indicating been shown to be effective in the prevention/early inter-
that those high on the trait of impulsivity are likely to vention of substance misuse, as well as other behavioral
engage in a range of addictive behaviors, as well as to problems, in adolescence and adulthood. Although the
engage in continued or severe addiction, through defi- effectiveness of this approach in the prevention or treat-
cits in response inhibition. The fourth pathway illus- ment of nonsubstance-related addictions has yet to be
trates how individuals high in sensation seeking assessed, the consistent results obtained in the preven-
through their specific sensitivity to reward, including tion of alcohol and drug misuse so far identifies this
alcohol- or drug-induced reward, are likely to engage approach as promising and cost-effective, which can
in early onset or experimental substance use, develop only improve current efforts in tackling substance use
drug-taking patterns to enhance psychostimulation problems and other addictions so prevalent in society.
(e.g. binge drinking), and/or engage in gambling,
particularly in casinos or race-tracks or other social
contexts, where emotions related to gains and losses SEE ALSO
are heightened. Although these two pathways are
similar in that they are both related to early onset of Behavioral Economic Factors in Addictive Processes,
addictive behaviors, they differ in a number of ways, The Biopsychosocial Model of Addiction, Cognitive
one of the most important being that individuals high Factors in Addictive Processes, Emotions and Addictive
in impulsivity, as opposed to high sensation-seekers, in Processes, Impulsivity, Disinhibition, and Risk Taking in
the context of substances that produce potent psychosti- Addiction, Interpersonal Factors and Addictive Disor-
mulant reward, are not protected by an intact response ders, Self-Medication, Adolescent Substance Use: Symp-
inhibition system and more easily develop compulsive toms and Course, Symptoms and Course: Alcohol Use
(or uncontrolled) self-administration. Disorder in Adulthood, Models of Relationships
It is important to highlight that these pathways to between Substance Use and Mental Disorders,
addiction, like personality dimensions, which should Substance Use and Mood Disorders, Substance Use in
not be considered as discrete but continuous measures, Response to Anxiety Disorders
are not mutually exclusive and can overlap in some indi-
viduals. Thus, for example, individuals might experi-
ment with alcohol or other substances in adolescence List of Abbreviations
to satisfy their need for rewarding, novel or intense
5-HTT serotonin transporter
experiences, but might then be unable to control their 5-HTTLPR serotonin transporter gene-linked polymorphic
substance use due to their impulsivity, and thus, their region
inability to self-regulated behavior. AS anxiety sensitivity
Although addiction is a complex phenomenon, DRD2 and DRD4 dopamine receptors
H hopelessness
involving a range of biological, environmental, and
IMP impulsivity
psychological factors, the evidence reviewed identifies MAOA monoamine oxidase A
personality traits as important etiologic and moderating PET positron emission tomography
factors. This evidence makes it clear that addiction is not SS sensation seeking
homogeneous and thus highlights the need to either
tailor intervention approaches to specific profiles of Glossary
addictions or to target personality profiles directly along Affect Emotion or subjectively experienced feeling and its influence
with treatment as usual. The evidence also identifies on behavior.
personality traits or the different pathways to addiction Anxiety sensitivity a personality trait characterized by fear of anxiety-
related physical sensations due to an unrealistic expectation that
as key targets for prevention efforts. Although most they could lead to “catastrophic” consequences such as loss of
current prevention approaches target behaviors, such physical or mental control.
as substance use or gambling, directly, it seems more Arousal a state of alertness and of high responsiveness to stimuli.
logical that interventions would want to target liability Comorbidity the simultaneous presence of two conditions or disor-
factors rather than behavior. Prevention models that ders in a patient or participant, e.g. substance use dependence and
depression.
target liability, like the ones described in this chapter, Cross-sectional a study design which provides information on the
rather than specific behaviors are relevant to those characteristics of, and statistical relationships between, variables at
engaging not only in the specific behavior targeted a specified moment in time.

I. THE NATURE OF ADDICTION

 FURTHER READING 281
Disinhibition the inability to restrain or prevent a behavior or Cloninger, C.R., Sigvardsson, S., Bohman, M., 1988. Childhood
impulse (opposed to inhibition). personality predicts alcohol abuse in young adults. Alcoholism:
Extraversion a personality factor characterized by interest in the Clinical and Experimental Research 12, 494–505.
outside world rather than the self, associated with traits such as Conrod, P.J., Pihl, R.O., Stewart, S.H., Dongier, M., 2000. Validation of
sociability and assertiveness. a system of classifying female substance abusers on the basis of
Factor analysis a statistical technique which examines the internal personality and motivational risk factors for substance abuse.
structure of a set of variables by analyzing the correlations between Psychology of Addictive Behaviors 14, 243–256.
them, to identify underlying dimensions or factors. Cooper, M.L., Agocha, V.B., Sheldon, M.S., 2000. A motivational
Go/No-go task a task in which stimuli are presented in a continuous perspective on risky behaviours: the role of personality and affect
stream and participants are asked to either perform a motor regulatory processes. Journal of Personality 68, 1059–1088.
response (go) or withhold a response (no-go) to specific stimuli. Iacono, W.G., Malone, S.M., McGue, M., 2008. Behavioral disinhibition
Hopelessness a personality trait characterized by a tendency to have and the development of early-onset addiction: common and
negative expectations concerning self and future life. specific influences. Annual Review of Clinical Psychology 4,
Impulsivity a personality trait often characterized by a deficit in 325–348.
reflectiveness and planning, rapid decision-making and action, and Leyton, M., Boileau, I., Benkelfat, C., et al., 2002. Amphetamine-
a failure to inhibit a behavior that is likely to result in negative induced increases in extracellular dopamine, drug wanting, and
consequences. novelty seeking. Neuropsychopharmacology 27, 1027–1035.
Inhibition the act or process of restraining or preventing a behavior or O’Connor, R.M., Farrow, S., Colder, C.R., 2008. Clarifying the anxiety
impulse, or the state of being “restrained.” sensitivity and alcohol use relation: considering alcohol expec-
Longitudinal a study design in which the same sample of research tancies as moderators. Journal of Studies on Alcohol and Drugs 69,
participants is examined repeatedly over time (over several time 765–772.
points). Pihl, R.O., Peterson, J.B., 1995. Alcoholism: the role of different moti-
Positron emission tomography medical imaging technique that vational systems. Journal of Psychiatry and Neuroscience 20,
produces three-dimensional images of the brain. This technique 372–396.
monitors regional cerebral blood flow in the brain by recording the Sher, K.J., Grekin, E.R., Williams, N.A., 2005. The development of
emission of gamma rays when radioactively labeled glucose or alcohol use disorders. Annual Review of Clinical Psychology 1,
some other substance introduced into the bloodstream is metabo- 493–523.
lized by neurons as they are activated. Stewart, S.H., Devine, H., 2000. Relations between personality and
Sensation seeking a personality trait characterized by a strong need drinking motives in young adults. Personality and Individual
for stimulation, a low tolerance to boredom, and a willingness to Differences 29, 495–511.
take risks for the sake of having novel and varied experiences. Tarter, R.E., Kirisci, L., Mezzich, A., et al., 2003. Neurobehavioral
Stop task similar to a go/no-go task, but one in which most stimuli disinhibition in childhood predicts early age at onset of
require a motor response (“go” response), and a less frequent substance use disorder. American Journal of Psychiatry 160,
“stop” or “no-go” stimuli is presented immediately after the “go” 1078–1085.
signal, to which participants are asked to interrupt or inhibit the Verdejo-Garcia, A., Lawrence, A.J., Clark, L., 2008. Impulsivity as
already-initiated motor response. a vulnerability marker for substance use disorders: review of
findings from high-risk research, problem gamblers and genetic
Further Reading association studies. Neuroscience and Biobehavioral Reviews 32,
777–810.
Blaszczynski, A., Nower, L., 2002. A pathway model of problem and Verheul, R., van den Brink, W., 2000. The role of personality pathology
pathological gambling. Addiction 97, 487–499. in the aetiology and treatment of substance use disorders. Current
Clark, D.B., Cornelius, J.R., Kirisci, L., Tarter, R.E., 2005. Childhood Opinion in Psychiatry 13, 163–169.
risk categories for adolescent substance involvement: a general Zuckerman, M., 1999. Vulnerability to Psychopathology: A Biosocial
liability typology. Drug of Alcohol and Dependence 77, 13–21. Model. American Psychological Association, Washington, DC.

I. THE NATURE OF ADDICTION