Eur Child Adolesc Psychiatry (2008) 17:274–282 DOI 10.1007/s00787-007-0663-7
Ge´raldine Dorard Sylvie Berthoz Olivier Phan Maurice Corcos Catherine Bungener
Accepted: 16 October 2007 Published online: 26 February 2008
G. Dorard (&) Æ C. Bungener Laboratory of Clinical Psychopathology and Neuropsychology Paris Descartes University Institut Henri Pie´ron 71 Av Edouard Vaillant 92100 Boulogne Billancourt, France Tel.: +33-1-5520-5403 Fax: +33-1-5520-5956 E-Mail:
[email protected] S. Berthoz Æ O. Phan Æ M. Corcos Department of Psychiatry for Adolescents and Young Adults Institut Mutualiste Montsouris Univ. Paris-Sud and Paris Descartes Universities, Inserm U669 42 Bud Jourdan 75674 Paris Cdx 14, France
ORIGINAL CONTRIBUTION
Affect dysregulation in cannabis abusers A study in adolescents and young adults
j Abstract Psychiatric comorbid-
ity and impaired emotional functioning have been previously reported in adult substance abusers but have been less well documented in adolescents. Thus, we investigated mental health problems and emotion regulation abilities in adolescents and young adults with cannabis dependence. Moreover, we explored the relationships between consumption modalities and affective style. Therefore, 32 cannabis abusers (CA) and 30 healthy controls completed a battery of self-reports measuring depression (BDI-13), anxiety (STAI-Y), alexithymia (TAS20; BVAQ-B), anhedonia (PAS; SAS), and sensation seeking (SSS). The MINI was administered to evaluate cannabis dependence and axis I DSM-IV comorbid diagnoses. A semistructured clinical interview was given to determine psychoactive substance use. Statistical analyses revealed that more than half of the CA reported at least one other nondrug or alcohol comorbid diagnosis. The most common were mood and anxiety disorders. CA subjects scored significantly higher on all
ECAP 663
Introduction Adolescence is regarded as a critical developmental stage during which drug-using patterns may emerge
affective dimensions except alexithymia total scores; however, they had greater scores for the two subscales measuring the difficulties in identifying feelings. Logistic regressions demonstrated that CA subjects were more likely to experience high levels of trait anxiety, physical anhedonia and sensation seeking than the controls. Various correlations were observed between the affective scores and the substance considered. The amount of substance use and, particularly, the prevalence of polydrug use we observed are alarming. This study demonstrates that cannabis dependence in adolescents and young adults is related to a great psychological distress and specific emotional dimensions and puts emphasis on the importance of substance use prevention as early as middle school.
j Key words adolescence – substance use disorders – cannabis – emotion – comorbidity
[17, 38]. Nowadays, the use of illicit substances among adolescents and young adults has become an important public health concern. In particular, cannabis is the most commonly abused illegal substance by French young people [7, 17]. In a recent study of a
G. Dorard et al. Affect dysregulation in adolescents and young adults cannabis abusers
cohort of 16000 students, with an age ranging from 12 to 18 years [7], the observed prevalence of cannabis regular users (more than 10 uses during the previous month) was 3 times higher than that observed 10 years ago. These alarming data are very similar to that of other international epidemiological studies [1, 15, 19, 36]. In addition, various studies have demonstrated that daily or even regular cannabis use can massively affect cognitive abilities and motivation, and in turn ultimately impede educational achievement, social adjustment, and emotional reactivity (e.g. [35]). This stresses the need for better understanding the mechanisms involved in cannabis use in adolescents. Some models have been proposed to explain the relationships between substance use and mental health problems (see [32]). In adults, cannabis use is associated with high rates of comorbid psychiatric disorders, notably mood and anxiety disorders (see [18, 20]). According to some authors, these disorders occur secondary to intoxication: substance use would increase psychological symptoms by physiological mechanisms or related effects on interpersonal functioning [12]. For others, in favour of a common factor model’, the observed high comorbidity rates are the result of shared vulnerability risk factors (e.g. genetics and personality). For instance, Zuckerman suggested that the sensation seeking trait, in particular, would influence substance use: subjects elevated on the trait of sensation seeking would experience low basal level of arousal and high anhedonia, and therefore may be motivated to consume to achieve an optimal level of stimulation [44]. Conversely, the secondary substance use disorder model’ posits that mental health problems increase the risk for developing a substance use disorder (see [32]). For instance, Khantzian [21] formulated the self-medication hypothesis’ to describe his theory that drug abuse is motivated by a wish to relieve a psychological distress. In any case, the evaluation of affective style and emotional functioning has become an important topic in the process of understanding the underlying mechanisms of self-destructive behaviours, including substance use disorders. Indeed, impaired affect regulation abilities (e.g. alexithymia) have been implicated in addictive symptomatology (e.g. [9, 40]); individuals with poor emotion regulation abilities may be prone to develop addictive disorders. However, although comorbid psychiatric disorders have been extensively studied in adult substance abusers (see [18, 20]), such studies, as well as the investigation of emotion regulation dimensions among adolescents cannabis abusers are scarce. Thus, our primary purpose was to investigate mental health problems and emotion regulation abilities in adoles-
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cents and young adults consulting for a cannabis dependence disorder. The secondary purpose was to examine the relationships between substance consumption modalities and emotion regulation dimensions. Our two purposes were exploratory. Nevertheless, in line with the literature on adult substance abusers, we hypothesized that alexithymia, anhedonia and sensation seeking would represent core dimensions of the affective style of adolescents and young adults with cannabis dependence. We expected cannabis abusers to present high rates of comorbid mood and anxiety disorders. In addition, cannabis abusers were hypothesized to show greater depression, state and trait anxiety, alexithymia, physical and social anhedonia, and sensation seeking scores than a group of age- and level of education-matched healthy subjects. As regards our secondary purpose, we had no a priori hypotheses concerning the relationships between substance use consumption modalities and emotion regulation abilities.
Methods j Participants Thirty-two adolescents and young adults, with a mean age of 17.2 years (SD = 1.7, [14–20]; 27 males, 5 females), all being evaluated for cannabis dependence, were included in the group of cannabis abusers (CA). They were recruited in the Centre Emergence—Espace Tolbiac addiction unit of the Institut Mutualiste Montsouris, Paris. This medical and psychological consultation location aimed at helping freely subjects searching treatment for cannabis withdrawal. The patients’ treatment started on request of the patients’ parents (56%), the patient him/herself (28%), the justice (12%) or a physician (4%). Exclusion criteria were mental retardation, organic brain disease, chronic or severe somatic disorder with possible effect on psychological state, psychotic disorder, inability to read or fill out the questionnaires or refusal to participate. Among the CA group, 5 (15.6%) were in middle school (14–15 years old), 18 (56.3%) were in high school (15–18 years old), 6 (18.8%) were in vocational school (14–18 years old) and 3 (9.4%) were in university (18 years old and more). Thirty age- and level of education-matched adolescents and young adults, with a mean age of 16.7 years (SD=1.1, [14–20]; 19 males, 11 females) were included in the control group. They were recruited among students attending a scholar drug use prevention program. The control participants ensured verbally that they were not regular cannabis users,
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and that they had never experienced illicit drugs; we used the MINI (see Methods) to assess they were free of past or current psychiatric and drug use disorders. The protocol was approved by the Pitie´-Salpeˆtrie`re Hospital Ethical Committee, and all subjects (and at least one of their parents for those under 18 years of age) gave their written informed consent.
j Materials The French version of the Mini International Neuropsychiatric Interview (MINI 5.0.0) [24] was used to assess cannabis dependence as well as other DSM-IV Axis I psychiatric disorders. In addition to the MINI, a semi-structured clinical interview developed for this study evaluated the use of cannabis, alcohol, and tobacco in great detail. Questions included age of first use, past and current frequency and quantity, as well as use patterns (e.g. alone or socially, time of first and last use, variation of use during week or week-end, motivation for drug use). In addition, the consumption of other stimulants (amphetamines and ecstasy), cocaine and derivatives, LSD, mushrooms hallucinogens, heroin, or other opiate derivatives was investigated (e.g. age of first use, age of last use, lifetime number of units). All the study participants were asked to complete several self-reports including: The 13-item Beck Depression Inventory (BDI-13) [8]: individuals are asked to respond to statements on the basis of how they have felt over the past week. BDI-13 scores were considered as a continuous variable, as well as a categorical variable using the validated cutoff scores [8]. The State and Trait Anxiety Inventory-Form Y (STAI-Y) [5]: the state portion of the scale (STAI-S) (item 1–20) asks subjects to report the extent of their anxiety at present; in the trait scale (STAI-T) (item 21–40) respondents report the intensity of their anxiety in general. The 20-item Toronto Alexithymia Scale (TAS-20) [28] captures three interrelated and core alexithymic features: Difficulty identifying feelings (F1), Difficulty describing feelings (F2), and Concrete thinking (F3). We used the cutoff scores established for French samples [29]. The Bermond-Vorst Alexithymia QuestionnaireForm B (BVAQ-B) [42] is a 20-item scale that includes five factors: Verbalizing (B1: difficulty verbalizing emotional experiences); Fantasizing (B2: poor daydreaming and fantasies); Identifying (B3: poor insight into ones emotional experiences); Emotionalizing (B4: low emotional excitability to emotion-inducing events); and Analyzing (B5: difficulty analyzing one’s own emotional states and reactions). Three BVAQ-B
factors are assumed to correspond to the three TAS20 factors: B1 and F2, B3 and F1, B5 and F3. The Physical Anhedonia Scale (PAS) [25–27] is a 61-item true or false questionnaire assessing the degree to which individuals have a deficit in the ability to feel rewarded by physical sensations such as touch, movement, eating, smell and sound. The revised Social Anhedonia Scale (SAS) [22] is a 40-item true or false questionnaire measuring social withdrawal, a lack of interest in social relationships, and the inability to experience pleasure derived from interpersonal relationships. The Sensation Seeking Scale-form V (SSS) [6] is a 40-item true or false questionnaire measuring interindividual proneness to have comportments, and/or look for situations that are supposed to induce intense stimulations and give powerful sensations to the subject. It captures four interrelated and core sensation seeking features: Disinhibition (DIS), Thrilladventure seeking (TA), Experience seeking (ES), and Boredom susceptibility (BS).
j Statistical analyses Data were analyzed using the SPSS 11.0. Of the 32 cannabis abusers, 2 had a MINI partially uncompleted, 7 had an investigation of their substance use modalities partially uncompleted, and 5 were not given the PAS and the SAS. Consequently, statistical analyses of the MINI included 30 CA subjects; those of the substance use modalities included 25 CA subjects; and those of the self-reports included all the CA subjects, except for the PAS and the SAS, which included 27 CA subjects only. Regarding the control subjects, one participant left the TAS20 uncompleted. Descriptive statistics for quantitative measures (mean, variance, standard deviation) and for qualitative measures (percentage) were first calculated. We used the Kolmogorov–Smirnov test for goodness-of-fit to assess the normality of the distribution of the selfreport scores. We used independent-samples t-tests and Mann–Whitney U-tests to estimate the group effect for the different self-report scores that were, respectively, normally and not normally distributed. To estimate the respective power of each trait affective dimension in the difference between the two groups, we conducted logistic regressions. In the first model (Model 1), all the self-reports’ total scores were entered simultaneously (STAI-T, TAS20, BVAQ-B, SSS, PAS, SAS). In the second one (Model 2), the selfreport subscores were entered (STAI-T, F1, F2, F3, B1, B2, B3, B4, B5, DIS, TA, ES, BS, PAS, SAS). Finally, using Pearson’s correlation coefficients, we calculated the correlation matrix relating the self-report scores and the quantitative substance use measures. Since
G. Dorard et al. Affect dysregulation in adolescents and young adults cannabis abusers
our paper and study was not designed to lead to a single final conclusion and decision, comparisons were not adjusted for multiple testing (i.e. Bonferroni correction; [3]).
Results j Psychiatric comorbidities Regarding mood disorders, 8 CA subjects (26.7%) had comorbid current major depression, one had past major depressive episode, 6 had comorbid dysthymia over the previous 2 years, 3 had past hypomania, and 2 had past mania. Regarding anxiety disorders, 2 CA subjects presented lifetime panic attack, 2 had current agoraphobia, 2 had current social phobia, and 6 had a generalized anxiety disorder over the previous 6 months. Regarding substances use disorders, 18 subjects met DSM-IV criteria for comorbid alcohol abuse, and 3 had alcohol dependence. No other Axis I disorders were observed in the CA group on the basis of the MINI evaluations.
j Cannabis, alcohol and tobacco consumption Descriptive statistics of cannabis consumption modalities are presented in Table 1. During the previous month, 19 CA (66%) reported having used cannabis daily, and only 4 (16%) reported having used cannabis less than 3 times per week. CA subjects declared that the foremost drives for cannabis consumption were to achieve: a feeling of detachment (50%), relaxation and anxiety sedation (37.5%), and euphoria (12.5%). Eighteen (72%) reported smoking their first joint in the morning. Fifteen CA (60%) reported having used cannabis essentially on their own during the past six months. Five adolescents declared smoking joints always lonesome. Table 1 Cannabis use (n = 25) Mean ± SD (range) Age of first use Age of first purchase Nb max of joints per day Age of max use Nb of month of daily use Nb of current joints per day Nb of current joints per week
13.3 ± 1.3 [11–16] 14.2 ± 1.6 [11–17] 15.3 ± 8.5 [4–40] 16.3 ± 1.4 [14–20] 31.3 ± 17.8 [12–72] 4.9 ± 3.1 [1–15] 30.5 ± 23.5 [2–105]
Nb max of joints per day: Number maximum of joints per day since the first use; Age of max use: Age at which the number of joints per day was the more elevated since the first cannabis use; Nb of month of daily use: Number of month with a daily use of cannabis since the first use; Nb of current joints per day: number of current joints per day on during the previous month; Nb of current joints per week: number of joints per week during the previous month
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Table 2 Alcohol and tobacco use
Age of first alcohol use Age of first alcohol intoxication Nb of alcohol units per day of use Fq of alcohol use per month Age of first tobacco use Age of daily tobacco use Nb of cigarettes per day
N
Mean ± SD [range]
25 24 23 23 25 23 22
13.4 ± 1.7 [11–18] 14.1 ± 1.8 [12–18] 4.1 ± 2.5 [1–10] 9.6 ± 10.1 [1–30] 12.1 ± 1.9 [9–16] 13.5 ± 1.5 [11–16] 12.3 ± 7.6 [3–25]
Age of first alcohol use: age of first alcohol consumption outside the family environment; Nb of alcohol units per day of use: number of alcohol units per day of alcohol consumption during the previous month; Fq of alcohol use per month: Number of days of alcohol use during the previous month; Nb of cigarettes per day: Number of cigarettes per day of tobacco consumption during the previous month
Descriptive statistics of the CA participants’ alcohol and tobacco consumption modalities are presented in Table 2. Among those who used alcohol during the past month (n = 23), 8 subjects reported having used alcohol generally on their own. Four subjects (17.4%) declared using alcohol exclusively lonely, whereas 15 (65.2%) said their consumption was solely social. Among the CA who reported a daily use of tobacco (n = 22), 18.2% were smoking their first cigarette less than 5 min after waking up, 22.7% less than 30 min after waking up, and 59.1% more than 30 minutes after waking up.
j Use of other drugs The other drug the CA participants’ used most often was ecstasy. Nine CA subjects (36%) had experienced ecstasy at least once, and mean age of first ecstasy use was 17.1 (1.3) years (ranging from 15 to 19). Mean lifetime ecstasy units (tablets) was 15.5 (26.7) (ranging from 1 to 80). Moreover, 8 CA (32%) had used hallucinogenic mushrooms at least once, with a mean age of first consumption of 17.2 (0.9) years (ranging from 16 to 19), and a mean lifetime units of 4.2 (6.6) (ranging from 1 to 20). In addition, 4 of the CA subjects reported having used cocaine at least once, 3 reported having used opiates at least once, 3 reported having used LSD at least once, and 3 reported having used sedatives, tranquilizers or pain relievers without medical prescription at least once.
j Affective style Descriptive statistics of both groups on the self-report questionnaires are presented in Table 3. Using the BDI-13 as a categorical variable, we found that 25% of the CA subjects and 6.7% of the controls had a severe depressive symptomatology,
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Table 3 Descriptive statistics of the CA subjects and controls on the selfreport questionnaires BDI-13 STAI-S STAI-T TAS20 F1 F2 F3 BVAQ-B B1 B2 B3 B4 B5 SSS DIS TA ES BS PAS SAS
CA (n = 32) Mean ± SD range
Controls (n = 30) Mean ± SD range
Between group differences
P
10.8 ± 5.9 [0–22] 45.6 ± 11 [22–66] 52.4 ± 11.6 [23–74] 52.6 ± 12.5 [25–76] 19.4 ± 6 [9–31] 14.6 ± 5.2 [5–25] 18.6 ± 4.4 [10–27] 50.5 ± 9.3 [35–74] 11.6 ± 3.6 [6–20] 8.3 ± 2.6 [4–14] 11.6 ± 3.1 [4–19] 10.2 ± 2.6 [6–17] 8.8 ± 3.2 [4–15] 26.2 ± 5.6 [14–36] 7 ± 2.1 [2–10] 8.2 ± 1.8 [4–10] 5.9 ± 2.1 [2–10] 5 ± 1.8 [1–7] 20 ± 7.1 [9–35] 10 ± 4.1 [4–20]
4.8 ± 4.8 [0–17] 34.1 ± 9.8 [22–66] 39.8 ± 11.5 [24–72] 48.6 ± 9.7 [26–70] 16.4 ± 5.1 [8–26] 14.2 ± 3.7 [5–20] 17.9 ± 4.8 [10–28] 46.4 ± 9.70 [25–63] 11.7 ± 3.9 [5–20] 8.2 ± 2.7 [4–15] 9.5 ± 2.6 [4–15] 9.1 ± 2.9 [4–15] 7.9 ± 2.9 [4–15] 21.3 ± 7.3 [7–34] 4.2 ± 2.4 [0–9] 7.5 ± 2.3 [1–10] 5.9 ± 2.2 [2–10] 3.7 ± 2.1 [0–9] 13.2 ± 6.5 [4–28] 7.7 ± 4.4 [0–16]
Z = 3.92
