Personality`s strong influence on addiction

Key personality traits are not immutable, and that’s exciting news for people dependent on substances and for the experts who treat them. Research has demonstrated that people with certain personality traits, in domains such as low levels of conscientiousness and high levels of neuroticism, are more likely to become addicted. These problematic traits can be identified with personality assessments, and traits that increase the risk for addiction can be modified, with hard work.

We believe that personality variables can influence the severity of addiction and the risk for relapse as well. At the Positive Sobriety Institute (PSI) in Chicago, we analyze an individual's personality traits upon admission, and the information we discover helps us provide an individualized treatment approach.

Many addiction professionals agree that the personality traits of addicted individuals matter. But the discussion usually ends there, largely because of the assumption that there is no malleability with personality, and the belief that it just happens, whether from nature, nurture or the interaction of the two. But based on my professional experience and research, I have seen personality traits change significantly, with the psychological buy-in of the patient, active help from therapists, and participation in 12-Step programs.

At PSI, we use the NEO-Personality Inventory-Revised (NEO-PI-R) instrument. This test reveals areas of personality that research has shown are common problematic traits among addicts. For example, if we note that the patient has high levels of neuroticism, we discuss particular areas of personal functioning that he needs to modify.

There are five major factors in the NEO that can be remembered with the acronym “OCEAN.” These are openness, conscientiousness, extroversion, agreeableness and neuroticism. Each factor has six sub-factors. For example, neuroticism is made up of anxiety, angry hostility, depression, self-consciousness, impulsiveness and vulnerability. Based on self-test responses, patients are rated as low, average or high in each sub-factor. Armed with this information, we help patients create a plan to improve problematic personality traits.

Research findings

Abundant research has shown that certain personality traits increase susceptibility to addiction, while others are protective against its development. Traits such as high levels of novelty-seeking, impulsivity, neuroticism and harm avoidance (the need to escape from distressing stimuli) often constitute risk factors for addiction. In addition, addicts frequently have lower levels than non-addicts of positive traits such as conscientiousness and persistence. (Note that the names of traits vary with the assessment instrument used.)

Since the mid-1970s, C. Robert Cloninger has researched the impact of personality on individuals, and also developed the Temperament and Character Inventory (TCI). He has analyzed personality traits in many populations, including addicts, prisoners and adoptees, finding significant differences in the studied populations compared to controls. Clearly, personality traits affect behavior.

In 1988, Kenneth J. Sher and colleagues studied 489 subjects prospectively and followed up with 457 of them six years later. These researchers found that impulsive sensation-seeking or behavioral disinhibition was predictive for later substance use disorders .

In 2014, Belcher, Volkow and colleagues noted likely genetic links to personality traits causing individuals to be susceptible to or resilient from substance use disorders. For example, positive emotionality/extroversion (PEM/E) is a condition of high motivation, positive affect, and feelings of excitement and optimism. PEM/E differences may be found in the central dopaminergic system. The researchers said high levels of PEM/E are protective against addiction.

Another personality trait identified by the researchers was negative emotionality/neuroticism (NEM/N). Such individuals are angry, anxious and depressed, and have poor responses to stress. People with substance abuse problems often have high levels of NEM/N. These responses may stem from connections within the prefrontal cortex and amygdala. Another factor increasing risk for substance abuse is constraint-disinhibition, which emanates from the right lateral inferior frontal gyrus. People who are highly disinhibited and unconstrained are more likely to have substance abuse problems.

These findings might cause some to wonder if connections linked to personality could be hard-wired and resistant to change. But research has demonstrated that up to 50% of personality traits can be changed.

Addiction's own impact

Addiction causes brain changes comparable to those seen in a traumatic brain injury. Addiction also has a toxic effect on personality that exaggerates negative aspects of personality that are already present, and even creates new problem traits.

The addict who is newly admitted to treatment may be very different from the person she was before addiction took hold. Even with prior personality risk factors for addiction, the addicted woman likely was more mentally healthy prior to addiction. Once addicted, she may become fixated on the next fix, and her personality may bear little resemblance to the person she was before substances loomed large in her life. She is generally more narcissistic than before, less flexible, and significantly less altruistic. Her levels of empathy are usually lower than they were in the pre-addiction stage.

Identifying her current personality weaknesses so she is aware of them will help her learn to become mindful of how she can change, and mindful that she indeed can change. Therapists assist with these trait shifts.

Our process

When patients are admitted to treatment, we first use the Millon Clinical Multiaxial Inventory (MCMI-III). The results of this test are held in confidence, and are compared with findings from the NEO-PI-R. We look for congruence between the two measures, because sometimes patients are deeply in denial when entering treatment and perceive themselves far differently from what they are. The MCMI-III helps us explore potential discrepancies with the patient.

Staff members discuss assessment results with the patient and talk about areas of possible improvement. We seek psychological buy-in from the patient, and the process is highly collaborative. We also provide patients with Positive Sobriety, a manual I wrote that explains addiction and helps patients zero in on areas to improve. The manual offers workbook activities to assist them in self-analysis.

At the seven-week point, a stage at which we often discharge patients, we reassess with the NEO. We often find that traits previously too high or too low have improved. After discharge, patients attend weekly groups where they talk about personality issues and actions they learned to improve problem areas. They also receive individual counseling, where they work further on personality and other issues. We test again at the six-month, 12-month and two-year point. In each case, we help patients compare their results over time, and we provide information on the meaning of the test findings.

For example, at the six-month point, a person may find he is slipping into lower levels of conscientiousness, which test scores reveal. He then can remember (or be reminded of) what worked in treatment to help him become more persistent and less impulsive, and can avoid walking off the plank into the perilous seas of addiction.

Improving conscientiousness

The most important area of personality among many addicted individuals is conscientiousness. With conscientiousness, the person goes to appointments and meetings—on time—and follows through on obligations. Conversely, if conscientiousness is low, the person is unlikely to do what is needed to recover from addiction and to stave off relapse. Most addicts relapse after treatment because of the now/later issue. They want what they want now and don’t want to delay gratification because of a bigger reward out there. They’re not thinking ahead and they’re not following through on plans.

Much of what we do in addiction treatment is to increase self-awareness, so that people are not operating on automatic pilot. This is where mindfulness and understanding problem traits help. When people are not in the reactive mode only, they can check out what’s going on inside. That skill is one of our primary areas of focus.

Identifying maladaptive personality traits and helping patients modify them are major steps toward helping patients with addiction issues. The combination of traditional and positive therapy allows patients to become true partners in their healing process. These skills significantly assist patients when they leave treatment.

Daniel Angres, MD, is Chief Medical Officer for RiverMend Health Addiction Services in Chicago, Medical Director at the Positive Sobriety Institute, and Adjunct Associate Professor of Psychiatry at Northwestern Feinberg School of Medicine's Department of Psychiatry and Behavioral Sciences.

A case history

Patient X, 48, struggled with anger, which also was his main trigger for hydrocodone abuse. X was confused by his anger, since he reacted in different ways at different times. This confusion lifted when he viewed his NEO Personality Inventory results and realized he needed to make changes. In this case, the personality assessment revealed he was high in neuroticism. X’s results also showed that he was close to the timid quadrant because of mixed scores on agreeableness. Depending on circumstances, X was either aggressive or avoidant.

Recognizing that he had extreme variability in his anger styles helped X establish better ways to handle anger. Feedback from his group helped him determine which style he was triggered to use. For example, he scored high in trust, but when trust was ill-placed, he felt betrayed and subsequently behaved aggressively. In contrast, X was timid when experiencing the anger of others, probably because he scored low in straightforwardness.

For X, knowledge was power, and therapy helped him modify his troublesome traits. X reported that he became less confrontational when angry with others and more assertive when others were angry with him. He told us this new knowledge was pivotal to his ongoing recovery.