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. Author manuscript; available in PMC: 2022 Jan 1.
Published in final edited form as: Addict Behav. 2020 Aug 31;112:106633. doi: 10.1016/j.addbeh.2020.106633

Characterizing the role of impaired control over alcohol in associations of impulsive personality traits with alcohol use as a function of depressive disorder

Michelle J Zaso a,b,1, Christian S Hendershot a,c,d,e, Jeffrey D Wardell a,c,e,f, R Michael Bagby c,d, Bruce G Pollock a,c, Lena C Quilty a,c
PMCID: PMC8034598  NIHMSID: NIHMS1686135  PMID: 32949836

Abstract

Impulsive personality traits have well-documented associations with at-risk drinking, although the role of impaired control over alcohol in these associations requires further study. Additionally, it remains unknown whether such relationships differ in the context of concurrent depressive disorder, which is a priority due to the high rates of mood dysregulation particularly in clinical samples. This project examined associations of impulsivity, impaired control over alcohol, and alcohol use within 201 adult general outpatients recruited from specialty mental health and addictions clinics at a psychiatric hospital. Outpatients completed the Structured Clinical Interview for DSM-IV Patient version (SCID) and assessments of impulsivity, impaired control over alcohol, and alcohol use. Over 35% of outpatients met criteria for a current depressive disorder. Path models supported associations of impulsivity with impaired control over alcohol and, in turn, at-risk drinking that differed significantly as a function of current depression. Among individuals with current depression, greater tendency to act rashly when experiencing negative affect (negative urgency) was associated with more frequent failures to control drinking (failed control) and, in turn, more at-risk drinking. In contrast, among individuals without current depression, greater positive urgency and lower sensation seeking were associated with greater failed control and, in turn, more at-risk drinking. Findings represent an important step toward clarifying the role of impaired control over alcohol in impulsivity and alcohol use associations and suggest divergent associations of negative urgency, positive urgency, and sensation seeking with at-risk drinking across clinical presentations.

Keywords: alcohol consumption, impaired control, impulsivity, depression, urgency

1. Introduction

Impulsivity has robust links with at-risk drinking (Coskunpinar, Dir, & Cyders, 2013; Stautz & Cooper, 2013). Impulsivity is a multidimensional construct encompassing predisposition to act rashly, with limited reflection on potential negative consequences (Moeller, Barratt, Dougherty, Schmitz, & Swann, 2001). The UPPS-P model outlines five domains of impulsive behavior: (i) negative urgency, tendency to act rashly when experiencing negative affect; (ii) lack of premeditation, tendency toward limited planning and preparation; (iii) lack of perseverance, tendency toward low persistence on tasks; (iv) sensation seeking, tendency to seek out novel, stimulating experiences; and (v) positive urgency, tendency to act rashly when experiencing positive affect (Cyders et al., 2007; Lynam, Smith, Whiteside, & Cyders, 2006; Whiteside & Lynam, 2001). These domains have been associated with alcohol outcomes across a wealth of investigations within meta-analyses, with sensation seeking and positive urgency demonstrating relatively stronger associations with alcohol use (Stautz & Cooper, 2013) and negative and positive urgency with alcohol problems (Coskunpinar et al., 2013).

Relatively less explored are the more proximal antecedents key to our understanding of impulsivity’s links with drinking. Impaired control over alcohol may be an important intermediary with clear phenomenological links to impulsivity, defined as “breakdown of an intention to limit consumption” (Heather, Tebbutt, Mattick, & Zamir, 1993, p. 701). Impulsivity and impaired control over alcohol both encompass behavioral under-regulation, yet may represent distinct constructs (Leeman, Patock-Peckham, & Potenza, 2012). While impulsive traits reflect general tendencies toward a multifaceted array of under-regulated behavior, impaired control over alcohol reflects failures in behavior regulation specific to alcohol. Impaired control over alcohol also implies alcohol limit setting, or at least motivation to abstain/limit drinking, unique from trait impulsivity (Leeman et al., 2012). Impaired control has long been recognized as central to addiction (see Kahler, Epstein, & McCrady, 1995), reflecting unsuccessful efforts to limit or control drinking represented in alcohol use disorder conceptualizations (American Psychiatric Association, 2013). Impaired control has clinical utility characterizing at-risk drinking, as impaired control deficits emerge early in alcohol use disorder progression (Nelson, Heath, & Kessler, 1998) and are linked to escalations in problem drinking over time (Leeman, Toll, Taylor, & Volpicelli, 2009).

Recent work models distinct components of impaired control as proximal contributors to alcohol use relative to trait impulsivity. Specifically, impaired control over alcohol can encompass attempts to control drinking (“attempted control”), failures to control drinking (“failed control”), and perceived inability to control drinking (“perceived impaired control”; Heather et al., 1993). Among heavy-drinking young adults, negative and positive urgency were associated with perceived impaired control and, in turn, greater alcohol consumption and/or problems (Wardell, Quilty, & Hendershot, 2015, 2016). Among college students, negative urgency and lack of perseverance were associated with lower perceived control and, in turn, greater alcohol consumption and problems (Patock-Peckham, Canning, & Leeman, 2018). Finally, prospective work among young adults demonstrated that perceived impaired control mediated associations of negative urgency with at-risk drinking six months later (Martínez-Loredo, Hendershot, O’Connor, & Wardell, 2020). Additional research into attempted and failed control is needed to differentiate impulsivity’s role in attempts to control drinking compared to actual failures in drinking control. Further, the extant work among young adults, coupled with the diagnostic and general clinical relevance of impaired control, highlights the need for complementary investigations within clinical samples.

Exploring impulsivity, impaired control over alcohol, and at-risk drinking within clinical samples may advance the significance of such research. It remains underexplored, for example, whether impaired control’s role as a proximal antecedent to drinking varies across co-occurring psychiatric diagnoses. Depression co-occurs frequently with at-risk drinking, reflecting shared reciprocal risks and/or causal linkages (see Boden & Fergusson, 2011). Both are also highly prevalent; 264 million adults met diagnostic criteria for a depressive disorder in 2017 (James et al., 2018), and over 20% of adults with major depressive disorder also met criteria for alcohol use disorder (Hasin et al., 2018). Depression and persistent negative affect may interfere with drinking control. Strong negative affect has a theorized role in addiction pathology through negative reinforcement (Baker, Piper, McCarthy, Majeskie, & Fiore, 2004; Koob & Volkow, 2010), and depressive symptoms have been linked to greater failures in drinking control (Leeman et al., 2009). Depression may be particularly detrimental for drinking control when coupled with high tendency to respond impulsively to negative affect. Specifically, among individuals with depression, those higher in negative urgency may report more failures and lower perceived ability to control drinking. In contrast, drinking among those without depression may be less coping-focused and instead driven by alternative motivations. Among individuals without depression, those higher in positive urgency may report more failures and lower perceived ability to control drinking. Finally, although sensation seeking has not been as strongly related to impaired control across prior investigations among young adults, it is important to characterize its role within clinical samples.

The current study examined associations of negative urgency, positive urgency, and sensation seeking, over and above other impulsivity domains, with impaired control over alcohol and at-risk drinking by depression. We hypothesized that negative urgency would relate more strongly to impaired control among individuals with depression compared to those without depression. Conversely, we hypothesized that positive urgency would relate more strongly to impaired control among individuals without depression compared to those with depression. Given limited prior research, we did not hypothesize differential relationships across the impaired control domains.

2. Materials and Methods

2.1. Participants and Procedures

Participants were recruited through the hospital research registry of a university affiliated tertiary psychiatric hospital for a larger, cross-sectional investigation from March 2014 to April 2015. Inclusion criteria included presence of current clinically significant psychiatric symptoms, attendance at an appointment with the hospital within the past 12 months, and consent to join the research registry. Exclusion criteria included severe homicidal or suicidal ideation, current psychotic disorder, and current intoxication or withdrawal. Potential participants (n=871) received a study overview, and those interested (n=354) completed a telephone screen. Of those eligible (n=279), 201 participants attended the research clinic, providing oral and written consent following an explanation of study procedures and completing two sessions of interviewing and psychometric testing. Participants received monetary compensation for participation. An institutional review board approved all procedures.

Participants in this convenience sample were 18 to 87 years old (M=39.66, SD=13.76) and 50% female. Participants were 76% White, 9% Asian, 5% Latin American, 4% Aboriginal, 3% Black, 3% indicated “other,” and 2% multiracial based on consolidated Statistics Canada groupings. Participants were receiving a range of outpatient services (e.g., psychiatric consultation, group psychotherapy), and 63% reported current unemployment due to psychological (n=58) or medical (n=21) disability, underemployment (n=21), role as a student (n=13), retirement (n=10), or role as caregiver/homemaker (n=2). All participants exhibited current psychiatric symptomatology based on the Structured Clinical Interview for DSM-IV Patient version (SCID-I/P; First, Spitzer, Gibbon, & Williams, 1995), including current depressive or bipolar disorders (n=89; 45%), anxiety disorders (n=99; 50%), substance use disorders (n=38; 19%), and eating disorders (n=6; 3%); most participants (n=158; 79%) met criteria for multiple current psychiatric diagnoses. Twelve percent met criteria for current and 42% for lifetime DSM-IV alcohol abuse or dependence.

2.2. Measures

2.2.1. Impulsivity.

Participants completed the 59-item UPPS-P Impulsive Behavior Scale (Cyders et al., 2007; Lynam et al., 2006) assessing negative urgency (Cronbach’s α=.87), positive urgency (α=.95), sensation seeking (α=.87), premeditation (α=.84), and perseverance (α=.79) using a 1 (strongly agree) to 4 (strongly disagree) scale.

2.2.2. Impaired control.

Participants responded to five items assessing attempted control (α=.95; Part 1; e.g., “I tried to limit the amount I drank”) and ten items assessing failed control (α=.74; Part 2; e.g., “I started drinking even after deciding not to”) over the past six months on the Impaired Control Scale (Heather et al., 1993) using a 0 (never) to 4 (always) scale; participants’ N/A (does not apply) responses were recoded to 0 (Heather et al., 1993). Participants also completed ten items assessing perceived impaired control (α=.93; Part 3; e.g, “I would find it difficult to limit the amount I drink”) using a 0 (strongly agree) to 4 (strongly disagree) scale. Relevant items were reverse scored, with subscale sum scores calculated (≥80% of items required to compute a composite score; Heather, Booth, & Luce, 1998).

2.2.3. Alcohol Use Disorders Identification Test (AUDIT).

Participants completed the Alcohol Use Disorders Identification Test (AUDIT) capturing alcohol use frequency/quantity, dependence symptoms, and alcohol problems (Babor, Higgins-Biddle, Saunders, & Monteiro, 2001). Participants were given the definition of a standard drink as a 12-oz can or glass of beer or cooler, a 5-oz glass of wine, or a drink containing one shot of liquor. A sum score was computed (α=.90).

2.2.4. Depressive disorder.

The Structured Clinical Interview for DSM-IV Patient version (SCID-I/P; First et al., 1995) was administered by licensed psychologists with over ten years’ experience as a semi-structured interview for psychiatric diagnoses. Thirty-five percent of participants met criteria for current depressive disorder, including major depressive disorder (n=66) and depressive disorder not otherwise specified (n=5).

2.3. Data Analytic Approach

Descriptive statistics and independent samples t tests comparing study variables by depression were conducted in SPSS, Version 24. Path analyses using maximum likelihood (ML) estimation were conducted in Mplus, Version 7.4 (Muthén & Muthén, 1998–2017). Path analysis estimates complex relationships among multiple constructs in a single model. Fully saturated path models were estimated, and no model fit statistics are reported. Models examined negative urgency, positive urgency, and sensation seeking as simultaneous predictors (while controlling for premeditation and perseverance) to examine unique associations of impulsivity domains with impaired control and AUDIT score. Participant sex, race, and education did not have significant bivariate associations with AUDIT score and were not included as covariates. The first path model tested the total effect of negative urgency, positive urgency, and sensation seeking on AUDIT score (X→Y), controlling for other impulsivity domains. The second path model tested the indirect effect of negative urgency, positive urgency, and sensation seeking on AUDIT score through the three impaired control subscales (X→M→Y; Figure 1), controlling for other impulsivity domains. Paths from impulsivity to each impaired control domain (a paths) and from each impaired control domain to AUDIT score (b paths) represent the indirect effects. Consistent with the cross-sectional data, path models examined atemporal associations (Winer et al., 2016), and results are referenced as indirect effects. Significance testing for indirect effects was estimated using the MODEL INDIRECT command (Muthén & Muthén, 1998–2017) with 1,000 bias-corrected bootstrapped samples. Indirect effects were tested regardless of total effects, because mediation can occur without a significant total effect if inclusion of a mediator strengthens associations between the predictor and outcome (i.e., suppression; MacKinnon, Krull, & Lockwood, 2000). There were missing data from one participant on depressive diagnoses, one on impulsivity, and two on all model variables except AUDIT score that were dropped from path analysis.

Figure 1.

Figure 1.

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Standardized parameter estimates of the indirect effects of impulsivity domains on AUDIT score through impaired control as a function of current depressive disorder. For paths significant in either group, parameter estimates for participants with depression (n = 69) are shown to the left of the dash, and estimates for participants without depression (n = 128) are shown to the right of the dash. Bolded coefficients and lines indicate significant paths at p < .05 in either group. AUDIT = Alcohol Use Disorders Identification Test.

* p < .05. ** p < .01. *** p < .001.

Multigroup analyses tested differences among impulsivity, impaired control, and AUDIT score associations by depression. Multigroup analyses allow equality tests of model parameters across groups of a categorical moderator (Muthén & Muthén, 1998–2017). To examine differences in path coefficients and endogenous covariances by depression, separate χ2 difference tests were conducted to compare a least restrictive model (with the specific parameter allowed to vary across groups) to a nested, more restrictive model (with the specific parameter constrained to be equal across groups). Significant χ2 difference tests suggested invariance of the path coefficient or endogenous covariance across groups.

3. Results

3.1. Descriptive Statistics

There was considerable variability in AUDIT scores across the sample (range=0–37), with 33% of participants meeting criteria for hazardous drinking (i.e., 8+; Babor et al., 2001) and 22% reporting current abstinence from alcohol. Higher negative and/or positive urgency was associated with greater attempts to control drinking, more failures to control drinking, and greater perceived impaired control (Table 1). Bivariate analyses demonstrated low to moderate correlations among the impaired control subscales (rs=.17–.57, p<.05; Table 1). Higher negative and positive urgency, lack of premeditation, and lack of perseverance were associated with higher AUDIT score (Table 1). Participants with depression (M=2.02, SD=0.77) reported lower positive urgency than those without depression (M=2.30, SD=0.80), t(197)=2.40, p=.02. There were no significant differences in any additional impulsivity domains, impaired control subscales, or AUDIT score by depression, ts=−0.31–1.54, ps>.05.

Table 1.

Descriptive Statistics and Bivariate Correlation Coefficients of Study Variables

Variable M(SD) 1. 2. 3. 4. 5. 6. 7. 8.
1. AUDIT 7.65 (8.33) –
2. Negative urgency 2.71 (0.64) .25*** –
3. Positive urgency 2.21 (0.80) .27*** .63*** –
4. Sensation seeking 2.48 (0.71) .13 .30*** .34*** –
5. Lack of premeditation 2.07 (0.54) .19** .41*** .34*** .40*** –
6. Lack of perseverance 2.44 (0.54) .17* .30*** .28*** .10 .29*** –
7. Attempted control 9.07 (7.53) .29*** .15* .12 .03 .02 .02 –
8. Failed control 12.23 (7.68) .60*** .32*** .25*** −.01 .14 .14 .17* –
9. Perceived impaired control 11.82 (11.22) .60*** .22** .27*** .07 .06 .05 .21** .57***
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N = 191 – 201 due to missing data. AUDIT = Alcohol Use Disorders Identification Test.

*

p < .05.

**

p < .01.

***

p < .001.

3.2. Total Effects of Impulsivity Domains on AUDIT

Multigroup analyses suggested invariance of each path coefficient from impulsivity to AUDIT score by depression, χ2(1)=0.10–1.39, ps>.05. Although the set of predictors was associated with AUDIT score among the full sample, R2=.09, p=.02, none of the impulsivity domains demonstrated a significant, unique association while controlling for the shared variance with the other domains, βs=0.01–0.16, ps>.05.

3.3. Indirect Effects of Impulsivity Domains on AUDIT through Impaired Control

Multigroup analyses suggested significant differences in several paths from impulsivity to failed control by depression in the indirect effects model. Specifically, paths from sensation seeking to failed control, χ2(1)=4.12, p=.04, and from negative urgency to failed control, χ2(1)=4.88, p=.03, differed significantly by depression. Greater negative urgency was associated with failed control among individuals with (ß=.56, p<.001) but not without (ß=.15, p=.17) depression (Figure 1). In contrast, greater sensation seeking was negatively associated with failed control among individuals without (ß=−.28, p=.004) but not with (ß=−.00, p=.97) depression. Subsequent indirect effects analyses were conducted separately by depression status. Among individuals with depression, there was a significant indirect effect of negative urgency on AUDIT score through failed control (point estimate = 0.18, 95% confidence interval [CI] = 0.05,0.40). Greater negative urgency was associated with more failed control and, in turn, greater AUDIT score. In contrast, among individuals without depression, there were significant indirect effects of sensation seeking on AUDIT score through failed control (−0.12[−0.25,−0.04]) and of positive urgency on AUDIT score through failed control (0.10[0.02,0.24]). Greater positive urgency and lower sensation seeking were associated with more failed control and, in turn, greater AUDIT score. Finally, despite associations of attempted and perceived impaired control with AUDIT score, no impulsivity domains were uniquely associated with attempted or perceived impaired control, and there were no significant indirect effects through these impaired control domains.

4. Discussion

The current study tested differential relations of impulsivity and impaired control with at-risk drinking as a function of depression in a diagnostically diverse outpatient sample. Among individuals with depression, greater negative urgency was associated with more frequent failures to control drinking and greater at-risk drinking. Among individuals without depression, greater positive urgency and lower sensation seeking were associated with more failures to control drinking and greater at-risk drinking. Findings represent an initial step characterizing impulsivity, impaired control, and drinking relations across diagnostic groups within a general psychiatric sample. Findings complement evidence for the intermediary role of impaired control in impulsivity and drinking relations from cross-sectional samples of heavy-drinking young adults (Wardell, Quilty, et al., 2015; Wardell et al., 2016) and college students (Patock-Peckham et al., 2018) as well as a prospective study of young adults (Martínez-Loredo et al., 2020). The current study replicates and extends these investigations by identifying, for the first time, a role of depression in moderating such associations.

Among individuals with depression, those reporting greater tendency to act rashly when experiencing negative affect reported more failures to control drinking. Findings support the role of negative affect in addiction (Baker et al., 2004; Koob & Volkow, 2010) and align with tension reduction theories, whereby drinking may serve to regulate negative emotion (Greeley & Oei, 1999). Depression and persistent negative affect may increase vulnerability to maladaptive coping-motivated drinking, especially among individuals high in negative urgency. Such individuals may expect drinking to relieve tension, acting rashly on these expectations and experiencing failures in drinking control. Depression may compound such processes with persistent negative affect increasing opportunities for coping-motivated drinking and/or decreasing regulatory abilities necessary for adaptive coping. Any perceived or limited, temporary reduction in negative affect may reinforce this maladaptive cycle over time. Thus, future work should characterize the prospective relationships among negative urgency, impaired control, and drinking as well as the mechanisms underlying negative urgency’s link to failed control among individuals with depression.

Among individuals without depression, those endorsing stronger tendency to act rashly when experiencing positive affect reported more failures to control drinking and more at-risk drinking. Findings are consistent with a recent demonstration linking positive urgency to greater failed control and intravenous alcohol self-administration among non-treatment-seeking adults (Vaughan et al., 2019). Within this prior investigation, however, both attempted and failed control were intermediaries in positive urgency and alcohol relationships, as compared to only failed control in the present study. Failed control may capture impulsivity’s links to at-risk drinking more saliently among heavier-drinking and/or more complex clinical samples. Interestingly, another investigation found positive urgency also associated with greater intention to drink among binge drinkers (Stevens, Littlefield, Talley, & Brown, 2017), suggesting positive urgency could precipitate both greater planned drinking events and more failures in drinking control despite drinking plans. Given that relatively few studies examining impulsivity and impaired control have modeled both attempted and failed control, more research is needed to resolve such nuances.

Sensation seeking was associated with less failed control among individuals without depression. Interestingly, sensation seeking was not significantly associated with failed control on its own in ancillary models that did not control for other impulsivity facets, suggesting that aspects of sensation seeking unique from urgency may be driving its negative relationship with failed control. After controlling for tendency to respond impulsively to emotional extremes and general lack of planning, the remaining variance unique to sensation seeking may reflect more preference for stimulating activities, such as planned heavy drinking. Greater intention to drink may correlate with lower failed control if drinkers do not perceive limit violations during planned heavy drinking episodes. This discrepant pattern of results for negative/positive urgency compared to sensation seeking does align with recent research suggesting sensation seeking may be conceptually distinct from impulsivity (see MacKillop et al., 2016; Sharma, Markon, & Clark, 2014). However, the current findings on sensation seeking must be viewed as preliminary, because sensation seeking was not associated with failed control (Vaughan et al., 2019) or other impaired control components (Wardell, Quilty, et al., 2015; Wardell et al., 2016) in prior investigations. Given the discrepancies across this limited research, replication efforts are necessary.

Several limitations highlight promising directions for future research. Most notably, findings were based upon cross-sectional data such that the temporal ordering of these relationships remains to be established and causality remains unknown. Research highlights dynamic relations of impulsivity with alcohol use (e.g., Quinn & Harden, 2013), and future prospective work should examine such dynamism and the temporal ordering of impulsivity, impaired control, and alcohol use (e.g., Martínez-Loredo et al., 2020). Second, findings relied upon self-report. While self-report scales capture the subjective component of impaired control (Leeman et al., 2014) and have demonstrated links to prospective drinking (Leeman et al., 2009), experimental paradigms could reduce reliance on self-report by developing and validating behavioral indices of impaired control (Leeman et al., 2013; Wardell, Le Foll, & Hendershot, 2018). Experimental approaches also could facilitate examination of how self-reported impaired control relates to within-person processes influencing alcohol consumption at the event level (e.g., Wardell, Ramchandani, & Hendershot, 2015). Further, ecological momentary assessment studies could enhance ecological validity by examining drinking limit violations and impaired control in real-time (Muraven, Collins, Morsheimer, Shiffman, & Paty, 2005; Remmerswaal, Jongerling, Jansen, Eielts, & Franken, 2019). Third, findings were based on a convenience sample of primarily Caucasian general psychiatric outpatients. This general outpatient sample allowed us to examine impulsivity and impaired control relationships across a range of drinking behavior, as compared to primarily heavier drinking as in an exclusive alcohol use treatment-seeking sample. The current findings should not be applied to clinical alcohol use populations without sufficient replication among samples with sufficient variability in drinking outcomes. Finally, findings were based on a subset (23%) of prospective participants, and systematic demographic/clinical features may have impacted individuals’ interest in and/or ability to participate such that future research is needed to assess generalizability.

The current study is the first to our knowledge to identify differences in impulsivity, impaired control, and drinking as a function of depression. In a diagnostically diverse outpatient sample, negative urgency (in the presence of depression) or positive urgency/sensation seeking (in the absence of depression) were associated with failures to control drinking and, in turn, at-risk drinking. Findings represent a novel demonstration of clinical heterogeneity in impulsivity’s proximal relations with drinking through impaired control.

Acknowledgements

The authors would like to thank the participants for sharing their experiences as well as the team of research analysts and volunteers for assistance with data collection.

Role of Funding Sources

This research was supported by a grant from the CAMH Foundation to the last author. Preparation of this article was supported by the National Institute on Alcohol Abuse and Alcoholism at the National Institutes of Health grant T32 AA007583 in support of the first author. These funding sources had no role in the study design, collection, analysis or interpretation of the data, writing the manuscript, or the decision to submit the manuscript for publication.

Footnotes

Conflict of Interest The authors have no conflicts of interest to disclose.

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