Cancer risk among Swedish female alcoholics by age, birth cohort and severity of alcoholism.

We have previously reported increased risk for cancer in 15508 alcoholic women registered in the Swedish Temperance Boards compared with individually matched controls. Age at first registration was found for 14818 of these women. The women were divided into early and late alcoholic onset groups. Age 45 was used as an approximation for reproductive senescence. For subjects < 45 years at first registration with the Temperance Board we found an increased relative risk (RR) of 1.8 (95% CI 1.5-2.0), whereas for the older age at onset group we found an RR of 1.5 (95% CI 1.3-1.7). Early onset was associated with higher risk of cancer at all sites studied and in all age cohorts. We used the number of Temperance Board registrations as an index of severity of alcoholism; this measure was not associated with risk for cancer.

Swedish normative data on personality using the Temperament and Character Inventory.

The Temperament and Character Inventory (TCI) is a self-report personality questionnaire based on Cloninger's psychobiological model of personality, which accounts for both normal and abnormal variation in the two major components of personality, temperament and character. Normative data for the Swedish TCI based on a representative Swedish sample of 1,300 adults are presented, and the psychometric properties of the questionnaire are discussed. The structure of the Swedish version replicates the American version well for the means, distribution of scores, and relationships within the between scales and subscales. Further, the Swedish inventory had a reliable factor structure and test-retest performance. The results of this study confirm the theory of temperament and character as a seven-factor model of personality.

Replication of the Stockholm Adoption Study of alcoholism. Confirmatory cross-fostering analysis.

BACKGROUND: Two forms of alcoholism with distinct clinical features and mode of inheritance were first distinguished in the Stockholm Adoption Study. This involved a large sample of children born in Stockholm, Sweden, who were adopted at an early age and reared by nonrelatives. Type 1 alcoholism had adult onset and rapid progression of dependence without criminality, whereas type 2 had teenage onset of recurrent social and legal problems from alcohol abuse. METHODS: A replication study was carried out with 577 men and 660 women born in Gothenburg, Sweden, and adopted at an early age/by nonrelatives. The genetic and environmental backgrounds of the adoptees were classified by the exact procedures calibrated by discriminant analysis in the original study. RESULTS: Both type 2 and severe type 1 alcoholism were confirmed as independently heritable forms of alcoholism in male adoptees. The lifetime risk of severe alcoholism was increased 4-fold in adopted men with both genetic and environmental risk factors characteristic of type 1 alcoholism compared with the others (11.4% vs 3.0%). Neither genetic nor environmental risk factors for type 1 alcoholism by themselves were sufficient to cause alcoholism. In contrast, the risk of type 2 alcoholism was increased 6-fold in adopted sons with a type 2 genetic background compared with others; regardless of their postnatal environment (10.7% vs 2.0%). The sons with a type 2 genetic background in the replication sample had no excess of type 1 alcoholism, and vice versa. There was no increased risk of mild abuse in adopted men regardless of their genetic or environmental background. CONCLUSION: Type 1 and type 2 alcoholism are clinically distinct forms of alcoholism with causes that are independent but not mutually exclusive.

Increased cancer risk among Swedish female alcoholics.

We evaluated site-specific cancer risks in alcoholic women. We identified 15,508 alcoholic women from the records of the Temperance Boards in Sweden and obtained a comparison group by selecting for each alcoholic woman one female individual matched for region and day of birth. We obtained incidence data from the Swedish Cancer Registry. We found an increased relative risk (RR) for any cancer [RR = 1.6; 95% confidence interval (CI) = 1.5-1.8]; site-specific risks were increased for tongue (RR = 8.5; 95% CI = 2.0-37), mouth (RR = 12; 95% CI = 1.6-92), tonsil (RR = 11; 95% CI = 1.4-85), hypopharynx (RR = 9.0; 95% CI = 1.1-71), larynx (RR = 7.0; 95% CI = 0.9-57), liver (RR = 4.6; 95% CI = 1.8-12), pancreas (RR = 2.7; 95% CI = 1.6-4.6), lung (RR = 5.0; 95% CI = 3.3-7.5), breast (RR = 1.4; 95% CI = 1.2-1.7), cervix uteri (RR = 3.9; 95% CI = 2.8-5.4), and vulva, vagina, and unspecified female genital organs (RR = 4.0; 95% CI = 1.3-12). We found a decreased risk for malignant melanoma of the skin (RR = 0.5; 95% CI = 0.3-1.0). Since this was a register study, the results may be confounded by differences in smoking, dietary habits, and/or other factors in the cohort of alcoholic women and the comparison group.

Personality antecedents of alcoholism in a national area probability sample.

Kraepelin viewed alcoholism as a symptom complex caused by heritable individual differences in emotional predisposition and volitional control. Recent clinical and genetic research has distinguished subtypes of alcoholics with different personality traits, symptoms, course, mode of inheritance, and response to treatment. The heritable personality traits that influence the initiation, continuation, and severity of alcoholism were examined by interview of a national area probability sample of 1019 non-institutionalized adults across the continental United States of America. We found that harm avoidance inhibits the initiation and frequency of drinking, but increases the risk of developing problems once frequent drinking has begun. Novelty seeking increases the initiation of drinking and the probabilities of frequent and problem drinking. This supports Kraepelin's description of the etiology and course of alcoholism as a symptom complex related to individual differences in emotional predisposition.

Childhood personality predicts alcohol abuse in young adults.

431 children (233 boys, 198 girls) born in Stockholm, Sweden, had a detailed behavioral assessment at 11 years of age, including a detailed interview with their school teachers, and at age 27 years were reevaluated to identify alcoholism or alcohol abuse. Specific predictions from a neurobiological learning theory about the role of heritable personality traits in susceptibility to alcohol abuse were tested in this prospective longitudinal study. Three dimensions of childhood personality variation were identified and rated without knowledge of adult outcome. These three dimensions (novelty-seeking, harm avoidance, and reward dependence) were largely uncorrelated with one another, and each was predictive of later alcohol abuse. Absolute deviations from the mean of each of the three personality dimensions were associated with an exponential increase in the risk of later alcohol abuse. High novelty-seeking and low harm avoidance were most strongly predictive of early-onset alcohol abuse. These two childhood variables alone distinguished boys who had nearly 20-fold differences in their risk of alcohol abuse: the risk of alcohol abuse varied from 4 to 75% depending on childhood personality.

Genetic heterogeneity and the classification of alcoholism.

Recent progress toward a systematic pathophysiological model of alcoholism has led to identification of two distinct subtypes of alcoholism. These subtypes may be distinguished in terms of distinct alcohol-related symptoms, personality traits, ages of onset, and patterns of inheritance. Type 1 alcoholism is characterized by anxious (passive-dependent) personality traits and rapid development of tolerance and dependence on the anti-anxiety effects of alcohol. This leads to loss of control, difficulty terminating binges once they start, guilt feelings, and liver complications following socially encouraged exposure to alcohol intake. In contrast, type 2 alcoholism is characterized by antisocial personality traits and persistent seeking of alcohol for its euphoriant effects. This leads to early onset of inability to abstain entirely, as well as fighting and arrests when drinking. Empirical findings about sex differences, ages of onset, associated personality traits, and longitudinal course are described in a series of adoption and family studies in Sweden and the United States. Implications for future research and clinical practice are discussed.

Structure and stability of childhood personality: prediction of later social adjustment.

Four hundred and thirty-one children (233 boys, 198 girls) born in Stockholm, Sweden had detailed behavioral assessments at 11 and 15 yrs of age, including a detailed interview with their school teachers and at age 27 yrs were re-evaluated to identify convictions for violent or property crimes. Three dimensions of childhood personality variation were identified and rated without knowledge of later outcome. These three dimensions (novelty-seeking, harm-avoidance and reward-dependence) were largely uncorrelated with one another and each was moderately predictive of later personal and social adjustment, including type of adult criminality. Factor and correlational analyses confirmed predictions that the number and structure of personality dimensions based on teacher ratings throughout childhood is similar to that observed in self-reports by adults.

Alcoholism: lessons from population, family and adoption studies.

Recent population, family and adoption studies suggest that the susceptibility to alcoholism is a heterogenous phenomenon. Specific combinations of predisposing genetic factors and environmental stressors appear to interact before alcoholism develops. These studies indicate that the increasing use of alcohol markedly influence the observed inheritance of alcohol abuse. It is concluded that the problems of alcoholism is less a medical than a political problem.

The genetics of alcoholisms and related disorders.

The inheritance of alcohol abuse and other psychopathology in 862 men and 913 women adopted by non-relatives, was studied. Both male and female adoptees were at greater risk to develop alcohol abuse if their biological, but not their adoptive, parents were alcoholic. Three types of families with alcoholism were distinguished that differed in frequency of alcohol abuse, somatoform disorders in women and in relation to antisocial behaviour in male adoptees. The combination of both genetic and environmental risk factors was necessary for the development of alcoholism in the most common, milieu-limited type of alcoholism. In families with a less common, male-limited, type of vulnerability, alcohol abuse was highly heritable in men, but women had multiple somatic complaints and seldom abuse. In a third type of family the common vulnerability was expressed as antisocial behavior with violent criminality and recurrent alcohol abuse in males, but as high frequency somatization in female relatives.

Symptom patterns and causes of somatization in men: I. Differentiation of two discrete disorders.

Two distinct patterns of somatization were identified in 807 Swedish adopted men, using comprehensive lifetime psychiatric and sick-leave records. "Diversiform" somatizers had a high frequency of brief sickness occasions for a wide diversity of complaints, particularly pain in the head, joints, and abdomen. "Asthenic" somatizers had a lower frequency and diversity of complaints. They recuperate more slowly, however, and were more often disabled by fatigue, weakness, and minor illnesses such as upper respiratory infections. Both types of somatizers had associated psychosocial maladjustment, but they had discrete clinical patterns, with infrequent overlap. Diversiform somatizers had a higher risk of alcohol abuse, psychiatric hospitalization, and substandard income than either asthenic somatizers or non-somatizers. Asthenic somatizers had a higher risk of divorce than either diversiform somatizers or non-somatizers. Men with prominent somatization had an excess of psychiatric treatment for alcoholism or anxiety disorders, but, unlike female somatizers, no excess of criminality. These clinical differences suggest that the psychiatric processes associated with somatization may be qualitatively different in men and women. The method used here is generally applicable in genetic epidemiology to identify natural clinical subtypes within a heterogeneous phenotype.

Symptom patterns and causes of somatization in men: II. Genetic and environmental independence from somatization in women.

The genetic and environmental antecedents of clinically distinct disorders leading to somatization were compared in 807 Swedish men and 859 Swedish women adopted at an early age by non-relatives. Asthenic somatization, the predominant form in men, was a neurotic disorder associated with a lower incidence of criminality in the somatizers' biological parents than in the biological parents of non-somatizers of either sex. In contrast, most female somatizers and a minority of men with diversiform somatization had disorders that were associated with a higher incidence of criminality in their biological parents than in other biological parents. Likewise, female somatizers, but not male somatizers, had an excess of alcoholic biological fathers when compared to other adoptees. In addition, different postnatal environmental background factors contributed to the risk for somatization in each sex. These findings support the distinctions among the different types of somatizers and show that the usual causes of somatization are fundamentally different in men and women. This illustrates the utility of the adoption paradigm in resolving genetic and environmental contributions to the familial aggregation of developmentally complex phenotypes.

Psychopathology in adopted-out children of alcoholics. The Stockholm Adoption Study.

The inheritance of alcohol abuse and other psychopathology was studied in 862 men and 913 women adopted by nonrelatives at an early age in Sweden. Both male and female adoptees had a greater risk of alcohol abuse if their biologic, but not adoptive, parents were alcoholic. We distinguished two types of alcoholism that have distinct genetic and environmental causes and that differ in frequency of alcohol abuse and somatoform disorders in women. The combination of both genetic and environmental risk factors is required for development of alcoholism in the most common type. In contrast, in families with the less common type of susceptibility, alcohol abuse is highly heritable in the men, but the women have multiple somatic complaints without alcohol abuse. The implications of these findings of genetic heterogeneity and gene-environment interaction are discussed in relation to research, prevention, and treatment.

An adoption study of somatoform disorders. I. The relationship of somatization to psychiatric disability.

The relationship between psychiatric impairment and disability due to somatic complaints was studied in 859 women adopted at an early age by nonrelatives in Sweden. The clinical data were derived from the comprehensive registrations for all medical treatment and sick-leave compensation that are kept about Swedish residents by the National Health Insurance Board. The adoptees were compared with nonadopted controls who were individually matched for social and demographic variables. We identified a somatization syndrome that is consistently associated with psychiatric impairment and repeated brief periods of disability with chief complaints of headache, backache, and abdominal distress on different occasions. A method for clinically distinguishing "somatizers" from other women was derived in one sample and was shown to have a classification accuracy of 97% in a replication sample. Somatizers accounted for 36% of all cases of psychiatric disability and 48% of all sick-leave occasions in adopted women. Compared with nonadoptees, there was an excess of somatizers in adoptees, a population known to have an excess of biological parents who are criminal and/or alcoholic.

An adoption study of somatoform disorders. II. Identification of two discrete somatoform disorders.

linical heterogeneity among women with prominent somatization was studied in a population of 859 adopted women in Sweden. We distinguished two groups of "somatizers" who differ in both the diversity of their somatic complaints and the frequency of their periods of disability. Type 1 or high-frequency somatizers have a high frequency of psychiatric, abdominal, and back complaints. Type 2 or diversiform somatizers have less frequent disability, but a greater diversity of complaints per occasion than do other somatizers. Diversiform somatizers have psychiatric chief complaints or backache in a lower proportion of their sick periods than either high-frequency somatizers or nonsomatizers. Quantitative measures of frequency and diversity were derived in a series of discriminant analyses. The distribution of scores on these measures indicated that high-frequency somatization and diversiform somatization were discrete disorders with little clinical overlap and rare intermediate cases. This demonstration of two discrete types of somatizers was confirmed in a replication sample.