Personality Traits Related to Binge Drinking: A Systematic Review

The pattern of alcohol consumption in the form of binge drinking (BD) or heavy episodic drinking has increased notably worldwide in recent years, especially among adolescent and young people, being currently recognized as a global health problem. Although only a minority of binge drinkers will develop a substance use disorder, BD may have negative personal and social consequences in the short and medium term. The objective of this article is to review the findings on personality traits related to binge drinkers and to emphasize the aspects that should be examined in order to make progress in this area. The main characteristics of personality related to the practice of BD, regardless of the theoretical model used, are high Impulsivity and high Sensation seeking, as well as Anxiety sensitivity, Neuroticism (Hopelessness), Extraversion and low Conscientiousness. The data obtained may have theoretical implications to elucidate the endophenotype of BD, but they are especially useful for their preventive applications. Integration into prevention programs of emotional self-control skills, decision-making, social skills, and strategies to manage negative emotions will minimize the risk factors or consequences of BD associated with personality and will improve their effectiveness. In the future, it is necessary to harmonize a common measurement instrument for the assessment of personality, develop longitudinal studies with large samples that also integrate biological and neurocognitive measurements, and determine the reciprocal relationship between personality and BD together with its modulating variables, as well as the possible cultural differences.


inTRODUCTiOn
The pattern of binge drinking (BD) or heavy episodic drinking is increasing and expanding worldwide (1). Although it is recommended to define the BD as the consumption of high quantities of alcohol (≥4/5 drinks for women/men) within a time period of 2 h (2), there is no consensus and it is frequent to consider the consumption in one occasion/sitting. BD supposes an important public health problem of which it is still necessary to know better the vulnerability factors responsible for its initiation, maintenance, or increase in frequency and intensity.
Individuals who practice BD are exposed to numerous adverse psychological and health-related outcomes (3). Acute alcohol intoxication includes accidents caused by driving while intoxicated, unwanted sexual behavior, and fights or other disruptive behaviors with possible legal implications. The repeated pattern of alcohol intoxication is related to cognitive impairments (4,5), worse health-related quality of life (6), and an increased risk of suffering psychiatric symptomatology/disorders (7,8).
The study of the characteristics or personality traits associated with the engagement of BD patterns, such as possible factors of risk or vulnerability, as well as the influence that consumption has on them, is of great theoretical and applied relevance. In this sense, it is now being suggested that personality is an endophenotype that is sensitive for identifying different subtypes of alcohol use disorders (9), also considering that the modification of behaviors linked to extreme personality traits may be beneficial for prevention and treatment of BD. Focusing on studies in adolescents and young people is not only motivated by the time of appearance and boom of the practice of BD but also because in this period of development and maturation of the organism the biological and behavioral impact of alcohol intoxications is more serious (4,5).
This article reviews existing data on personality characteristics associated with the practice of BD (considering the several definitions) and its evolution, as well as the possible relationships with other variables that increase the risk or are protective for the maintenance and problematic evolution of the consumption. We also mention limitations and future directions that may allow for progress in this area of research.

MeTHOD
The search, selection, and critical assessment of relevant studies were performed according to the PRISMA guidelines (10). The data search was conducted through the computerized databases PubMed and Scopus with "Binge drinking" (or "Heavy drinking" or "Heavy episodic drinking") and "Personality" as keywords, from January 2006 to February 2017 (Figure 1). The search and selection were performed independently and blindly by two authors, and discrepancies resolved by consensus. Table 1 presents the studies included in the present review, considering the sample characteristics, BD criteria, assessment of personality, and main results.

impulsivity and Sensation Seeking
The two most studied personality traits for BD are Impulsivity and Sensation seeking. Impulsivity is a multidimensional construct associated with poor planning skills, difficulty maintaining attention, and risk-taking behavior. Sensation seeking is defined as the general need for adventure and excitement, the preference for unforeseeable situations and friends, and the willingness to take risks simply for the experience of living them. Many studies have observed higher scores in binge drinkers in both Impulsivity (11,12,26,27,29) and Sensation seeking (12,16,22,25,26,30,31,34), when compared with non-binge drinkers. Both traits are considered risk factors for lifetime, whose joint presence has been labeled as "disinhibited personality" (18), although they are especially present in adolescence, characterized by increased impulsive decision making and behavior (40). Similarly, the scores of Impulsivity and Sensation seeking are related to the number of drinks consumed per episode (14,20,23) and the frequency of BD (17,18,23).
The existing data have been obtained independently of the personality model or the measurement instrument used, either by conceptualizing Impulsivity and Sensation seeking as independent but related features or considering Sensation seeking as a facet of impulsivity. In this second case, the meta-analysis of Stautz and Cooper (40) about the Impulsivity facets as risk factors for problematic alcohol use in adolescence, including BD, were in this order: Sensation seeking, Lack of premeditation, Negative urgency, and Lack of perseverance. These are the dimensions evaluated by the UPPS Impulsive Behavior Scale, frequently used in this field of study. The Negative urgency or tendency to act rashly when experiencing negative emotions is related to BD (34,35) and is also the only facet related to its severity (16) and to alcohol use disorders as well (34). According to this, BD has been conceptualized as a maladaptive short-term coping strategy devoted to relieving negative affective states (16), which is congruent with the expectations of tension reduction with alcohol that present the binge drinkers, especially in men (14). In the same way, the consideration of facets from Sensation seeking (Thrill and adventure, Experience seeking, Disinhibition, and Boredom susceptibility) indicates that Thrill and adventure and Boredom susceptibility are associated with BD (3). Both facets are externalizing and have psychopathological connections, according to the model of Krueger et al. (41).
A very relevant aspect is that the relationship between BD and Impulsivity and/or Sensation seeking can be modulated by several factors. It should be noted that personality profile of BD could be modulated by sex since the highest levels of Impulsivity and/ or Sensation-Seeking come from the men's scores (11,12,29). Moreover, Sensation seeking is the strongest predictor of personality for discriminating binge drinkers from non-drinkers and moderate drinkers in men (22). The expectancies of consumption are mediating in the relationships between the personality traits and BD. Thus, binge drinkers with high Impulsivity show positive expectancies (17), whereas in subjects with high Sensation seeking the greater frequency of episodes of BD is modulated by the positive consequences from drinking (23). Recent work by Lannoy et al. (24) points to the existence of three types of binge drinkers according to their facets of Impulsivity and drinking motives: Emotional (higher Sensation seeking and Urgency), Recreational (higher Lack of Premeditation and Perseverance), and Hazardous (moderate to high drinking motives). This proposal represents an advance with possible practical implications in the future.

The Big Five Personality Model
This personality model considers five dimensions: Extraversion, Neuroticism/Emotional stability, Conscientiousness, Openness (to new experiences)/Intellect, and Agreeableness. Personality data using the Big Five model are inconclusive in cross-sectional studies of BD. High Extraversion is the feature most consistently associated with BD (22,29,31), also being related to a higher frequency of BD and more negative consequences (37). In relation to Conscientiousness, which negatively correlated with impulsivity (42), although binge drinkers exhibit usually low scores (5,19,32,37), high values (especially in men) have been also described (29). In this sense, a lower level of self-oriented Perfectionism, which could be considered as a form of hyper Conscientiousness, has also been observed in BD (21). Low Conscientiousness is considered as associated with less prosocial and more health-promoting behaviors (dietary and lifestyles) in general (43). Finally, high Openness has been related to BD in women (28). Some studies have not found relationships between these personality characteristics and BD (32,33), although they are characterized for including small samples of BD, basically of social drinkers.
The Neuroticism/Emotional stability is the strongest predictor of personality trait that discriminates between binge drinkers and non-drinkers and moderate drinkers in women (22), with low scores in binge drinkers. This could suggest that a higher emotional instability avoids heavy alcohol intake. However, with the Zuckerman personality model (ZKPQ), a higher Neuroticismanxiety has been observed in binge drinkers, although this is a consequence of the results from women (12). High levels of Neuroticism also explain the negative consequences of alcohol consumption in both sexes (29). The review by De Wever and Quaglino (44) suggests the need to study further the involvement of affective factors (anxiety and depression), which may be premorbid and appear or are aggravated by the consumption. Neuroticism is precisely the most important personality dimension related to many forms of psychopathology, including anxiety, depression, and substance use disorders (12).
Other traits of interest studied are the type-D personality and the Boredom proneness. The first is characterized by a high tendency toward experiencing negative emotions and inhibiting the expression of emotions and behaviors in social situations. Boredom proneness is associated with undesirable emotional states such as depression, hopelessness, loneliness, amotivational orientation and is negatively related to life satisfaction and autonomy orientation. Both are considered risk variables for The scores in Dysfunctional Impulsivity were higher in the BD group compared to the nonbinge group, while no differences were found in Functional Impulsivity. Men showed a higher degree of Functional and Dysfunctional Impulsivity, although in Dysfunctional Impulsivity significant differences were observed only in the BD group. Students with high Sensation seeking reported drinking more and had a higher frequency of BD than students with low levels. They also experienced more positive consequences as a result of their drinking.
Positive consequences mediated the relation between Sensation seeking and both drinking and BD frequency.  Extraversion was positively associated with more frequency of BD and more negative consequences, whereas Conscientiousness was associated with less BD and fewer consequences (sober and drunk). Under intoxication, drinkers reported lower levels of Agreeableness (impaired control of aggressiveness and low empathy), Conscientiousness (lower self-control) and Openness/Intellect, and higher Extraversion (more sociability) and Emotional Stability (more stress-dampening and anxiolytic effects).  mental health, since type-D personality predicts the amount of alcohol consumed (8) and Boredom proneness influences the social expectancies (15) of BD.

Substance Use Risk Profile Scale (SURP)
In the area of risk for substance consumption, including alcohol, the SURP scale has been developed, which evaluates four dimensions: Anxiety sensitivity, Sensation seeking, Impulsivity, and Hopelessness (a lower order factor of Neuroticism). To a lesser or greater extent, all of these dimensions appear to be implicated as risk factors in BD. In several studies using the SURP, binge drinkers scored higher in Sensation seeking, Impulsivity and Hopelessness than non-bingers (5,27,30), and all the personality traits were related to alcohol problems (30). This scale, with very adequate psychometric properties, is the one selected to assess personality in the "Preventure" prevention program, which will be discussed later.

Changes and evolution of the Personality Traits Related to BD
In longitudinal studies, Impulsivity and Sensation seeking are prognostic factors for the maintenance and intensification of the BD pattern (5,13) and alcohol/drug-related problems and other disorders (18,27). This is observed independently of the personality instrument of measurement. Ashenhurst et al. (13) proposed a deviant pattern of personality maturation without a reduction in both Impulsivity and Sensation seeking as age increases in young adults who developed an increasing trajectory of BD. Anxiety sensitivity also predicts future BD (5). Faster rates of increase in alcohol use have been related to high Anxiety sensitivity and coexisting anxiety symptoms (27). Zhang et al. (39) have proposed several alcohol consumption trajectories, based on a cohort followed for 15 years, which can give meaning to the heterogeneity of existing results with the Big Five model. These authors suggest two risk profiles, the "Resilient" one, more vulnerable to social pressure for drinking, and the "Reserved" one, with higher risk for alcoholism. The first is characterized by high Agreeableness, Extroversion, and Openness, whereas the second is defined by high Conscientiousness and low Extraversion, Openness, and Agreeableness. High Extraversion also appeared related to BD in other longitudinal study (5).
In connection with the consumption expectations, it is interesting to examine the effects on the perceived personality related to intoxication as compared with the sober state. Using the Big Five personality model, it has been observed that binge drinkers report increases in Extraversion, and greater decreases in Neuroticism (anxiolytic effects) and Agreeableness (more aggressive) than non-binge drinkers, a pattern modulated by sex (36,37). Four different drunk types have been noted (38), whose consideration in the future may complement the explanatory model of BD (Table 1).

interventions Considering Personality Traits
There is no doubt that investing time and resources in promoting health at an early age, prior to the onset of consumption, has positive repercussions, including minimizing the pattern of BD. The alcohol selective prevention program "Preventure, " a brief A Systematic Review of Personality and BD Frontiers in Psychiatry | www.frontiersin.org July 2017 | Volume 8 | Article 134 personality-targeted intervention for youth, is an outstanding example of this strategy (45). This program covers three main components: psychoeducational, motivational interviewing, and cognitive behavioral. The intervention has been particularly effective in preventing the growth of BD in early adolescents of both sexes with high Sensation Seeking and Impulsivity and in girls with higher Anxiety sensitivity. This has been evidenced over 36-month follow-up in Australia (46), at a 24-month postintervention in England (47), and at a 12-month follow-up in the Netherlands (45) to mention only studies with longer follow-up periods.
Although our review is focused on personality, an overall explanatory model of BD must also incorporate attitudes, motives, expectancies, or metacognitions referring to consumption, since these are mediating variables in the relationships between personality and BD (17,44), in addition to participating in the prediction of alcohol-related problems (23,30). Binge drinkers, regardless of their personality characteristics, exhibit higher alcohol expectancies for social facilitation (31) and positive metacognitions (19) than regular moderate drinkers and abstainers. This is especially important in selective prevention, in which the restructuring of dysfunctional metacognitions (e.g., drinking alcohol to avoid negative judgments from others) may help in the control of drinking, while the establishment of adaptive emotional regulation strategies (16,24) may increase the success of the interventions. As a harm reduction strategy, moreover, educating in protective patterns of drinking is effective in reducing the BD frequency in individuals with high Impulsivity and Sensation seeking (20).
Prevention should be initiated at an early school age and not limited to specific actions, since the general objective should be to promote the empowerment and integral health of young people. The inclusion of multiple elements to promote protective factors seems to be the best strategy to revert to healthier habits and a better quality of life in the short and long term. From this perspective, and for a greater success of these approaches, it is necessary to consider the personality characteristics that represent a vulnerability factor for the initiation and maintenance of BD.

LiMiTATiOnS AnD FUTURe DiReCTiOnS
There is great heterogeneity in the scales used for personality assessment, based on various theoretical models, which makes it difficult to compare the results of different studies. An effort is required to agree on a measurement instrument that integrates those dimensions or facets that represent the main risk factors in BD. We consider that the use of the SURP is very appropriate. Moreover, when it is complemented with the Big Five dimensions of Conscientiousness (for its relevance in health habits) and Extraversion, it could improve the information collected on personality. Furthermore, only a minority of articles has compared the scores obtained with normative data from their corresponding countries, or in the cases where these do not exist, making some sort of conversion to normative scores (z, T,…). That is, finding higher or lower scores of a certain dimension in BD with respect to another group does not always imply that these are values outside the normal population range.
The epidemiological characteristics of the samples, especially sex, age, and race, are rarely analyzed as factors of interaction with the personality traits associated with BD. Most studies collect this information merely as descriptive of the sample, analyze it independently, or only consider it as a control. It is essential to develop future works that explore the modulating effect of epidemiological variables on representative samples, since the studies that have done so have pointed out that the data are not generalizable to the entire population.
It is also required to consider and control for other variables that are known to influence the appearance and maintenance of BD when they are not the objective of the study, highlighting the presence of psychiatric symptomatology or mental disorders, stressful life events, and circadian rhythmicity. In relation to the latter, an adequate sleep (48) and a morning typology (49) are protective factors for heavy drinking and for extreme personality traits.
The development of longitudinal studies, a minority to date, is the only way to elucidate the specific weight of the personality traits in the initiation and maintenance of BD and/or relate problems, as well as the impact of BD practice in personality. At the same time, this would allow us to define the age with the greatest vulnerability and the best time for the implementation of prevention programs.
For an integral and explanatory perspective of BD, studies should integrate also biological and neurocognitive evaluations. BD is not a unitary phenomenon but consists of a combination of history, personality, and brain domains (5), and this is how it should be examined. Only this approach will help to delineate subgroups of risk for BD and to interpret different trajectories and consequences of its practice in the short, medium, and long term.
Finally, multicenter and multicountry studies will allow us to explore whether there are sociocultural differences in BD, and whether these require specific adaptations in both preventive and treatment approaches. The "Preventure" program, for example, has only been carried out in Anglo-Saxon countries and its development in a Mediterranean or Latin American country may lead to different effectiveness and may require some methodological adjustment.

AUTHOR COnTRiBUTiOnS
AA and JFN collected the materials and resources needed for this review and wrote this article. DAF provided suggestions and revised each draft of the manuscript.

FUnDinG
This work was supported by a grant from the Spanish Ministry of Economy, Industry and Competitiveness PSI2015-65026 (MINECO/FEDER/UE). The funding sources have no involvement in the planning, conduction or evaluation of this study.