A DEPRESSION-AGGRESSION SYNDROME RELATED TO ACCIDENTS CAUSED BY ALCOHOLIC DRIVERS

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1 A DEPRESSION-AGGRESSION SYNDROME RELATED TO ACCIDENTS CAUSED BY ALCOHOLIC DRIVERS M e l v in L. S e l z e r, M.D.,* C h a r l e s E. P a y n e, M.D.,* J a m e s Q u i n n, M.D.,* and F r a n k l i n H. W e s t e r v e l t, P h.d.f p r e v i o u s i n v e s t i g a t i o n s have revealed both the excessive automobile accident involvement of groups of alcoholic drivers (1,2) and the over-representation of alcoholics in accident-involved driver populations (3-5). Although the greater frequency and depth of intoxication found in alcoholics probably accounts for much of their overrepresentation in traffic accidents, there remains a significant variation in accident in volvement within the alcoholic population itself. This variation may be related to u n derlying personality factors which are more likely to find expression when the alcoholic is intoxicated (6). Indeed, personality ap pears to exert considerable influence upon accident susceptibility. Conger, et al (7) studied ten young airmen responsible for two or more motor vehicle accidents over a fouryear period and compared them with ten young airmen who had no accidents during a like period. The accident group was characterized by poor control of hostility, low tolerance for tension, dependency, egocentricity, and unreflectiveness. Tillm an and Hobbs (8) studied both low and high accident taxicab drivers and found that the latter could not tolerate, and were chronically in revolt against, authority. This group, in addition to their antisocial attitudes, was characterized by impulsivity, distractibility, and m arital and fiscal irresponsibility. Since alcoholic populations constitute a significantly greater traffic risk than nonalcoholic populations (1) this study was u n dertaken to determine the relevance of both alcoholism and personality in the etiology of traffic accidents caused by a group of male chronic alcoholics. The study group consisted of 50 male chronic alcoholics serially adm itted to the V eterans R eadjustm ent C enter of the U n i versity of M ichigan M edical Center for treatm ent of serious and chronic drinking problems. T h e control group consisted of *D epartm ent of Psychiatry, T he University of M ichigan M edical School, Ann Arbor, M ichigan. fd epartm ent of M echanical Engineering, T he U niversity of M ichigan emotionally ill, nonalcoholic men serially adm itted to the same facility. The alcoholic and control groups were of similar socioeconomic backgrounds with comparable driving (mileage) exposure. The mean ages were 36 years (range 24-58) and 34 years (range 26-63) for the alcoholic and control groups respectively. In the alcoholic group, 25 patients were diagnosed as passive-aggressive personality, 10 as other character disorders, 11 were schizophrenic, and 4 were psychoneurotic. In the nonalcoholic group, 14 patients were passive-aggressive personalities, 11 had other character disorders, 17 were schizophrenic, and 8 were psychoneurotic. Method Since many alcoholics are described as hostile, depressed, and egocentric (9), all traits th at could relate to automobile accident causation, a questionnaire which included these areas of psychopathology was formulated (Table 1). In the questionnaire, depression appears as items 2, 16, 19, 26, 28, and 31; hostility as items 3, 15, 23, 24, and 25, and egocentricity as items 1 and 3. Each subject was scored by his psychotherapist for the items in Table 1 on a two-point rating scale: (1) within normal limits; (2) definitely abnormal. Item 31 ratings were obtained directly from the subjects by the authors. Each subject in the alcoholic and control groups was interviewed some weeks after admission by one of us to obtain a history of all moving traffic violation convictions and of traffic accidents caused by the subject which resulted in an injury or at least $100 damage. We also sought to determine if the subject had been drinking prior to any of these events. D rinking was defined as the consumption of beverage alcohol equivalent to four ounces or more of pure alcohol within six hours of the time of the accident or violation. To derive those areas of psychopathology w hich exerted the greatest influence on life

2 298 L A W A N D L A W E N F O R C E M E N T time accident totals, the psychopathology ratings were correlated with the num ber of accidents for which each patient adm itted responsibility. The 32 items in Table 1 were the predictor variables while the num ber of autom obile accidents was the dependent variable (Y ). In addition to determ ining w hether any individual predictor variables were significantly correlated with automobile accidents, we were also interested in determ ining w hether any combinations of personality factors could forecast high accident potential. The latter was obtained by the Stepwise Regression program from the U niversity of M ichigan Executive System L ibrary and run on an IBM 709/7090 computer. T a b l e 1 Psychopathology Predictor Variables 1. Sense of estrangem ent or isolation from others 2. T houghts of self-destruction (occasional) 3. Low frustration tolerance 4. Im m ature thinking processes 5. Excessive preoccupation w ith fantasy 6. Passive attitude tow ard the world as determ ining his fate w ithout reference to his behavior 7. Lack of assertiveness 8. Faulty reality testing. 9. Obsessional rum ination 10. Relationships w ith others largely of a taking nature 11. H eterosexual adjustm ent 12. Compulsive, repetitive patterns of behavior 13. Egocentricity 14. M arked affective lability (sharp mood swings) 15. Chronic or frequently recurrent rage or resentm ent tow ard others 16. Feelings of sadness and despondency 17. Patient dom inated by males 18. Impulsiveness 19. Sense of boredom and loneliness 20. Paranoid ideation 21. Infantile orientation to others as providers of insatiable dem ands for food, love and com fort 22. Patient dom inated by females 23. D estructive or aggressive behavior when drunk 24. D estructive or aggressive behavior when sober 25. Aggressive behavior tow ard others manifested in a concealed or passive fashion 26. Sense of hopelessness and futility 27. Feeling of om nipotence and invulnerability 28. Self-loathing, self-deprecation 29. Ch ronic anxiety 30. Ability to establish meaningful relationships 31. H istory of serious suicidal preoccupation or a t tem pts 32. Alcoholism Results Accidents and Moving Violations: As shown in Table 2, when the accidents and moving violations of the alcoholic and nonalcoholic groups are compared, two striking facts emerge. T he 50 alcoholics were responsible for approxim ately twice the num ber of traffic accidents and twice the num ber of violations as their nonalcoholic counterparts ( P < ). Secondly, the significant differences between the alcoholic and nonalcoholic groups were due to traffic events occurring when the alcoholics had been drinking; total accidents and violations incurred when sober were virtually identical for the two groups. Psychopathology and Automobile Accidents: To determine if psychopathology is significantly related to the incidence of traffic accidents, the ratings for the variables shown in Table 1 were correlated with the number of accidents for which each driver adm itted responsibility. Alcoholic Drivers: T he d ata obtained for the 50 alcoholic drivers was used to determ ine the degree of correlation between traffic accidents and each of the first 31 psychopathology variables in Table 1. These were obtained in the form of simple product m om ent correlation coefficients with the 11 psychopathology variables significantly related to automobile accidents shown in Table 3. The highest degree of relationship was found between paranoid ideation (variable 20) and accidents, with a correlation coefficient of 0.50 (Table 3). The other significantly correlated predictor variables were as follows: Four variables indicating depression: thoughts of self-destruction, serious suicidal preoccupation or attem pts, feelings of sadness and despondency, and self-loathing, self-deprecation (variables 2, 31, 16, 28). Three variables associated with aggressive thought or behavior: low frustration tolerance, chronic or recurrent rage or resentm ent tow ard others, and aggressive behavior when drunk (variables 3, 15,23). T a b le 2 Lifetime Traffic Accidents and Moving Violations, Drinking and Sober, Incurred by 50 Alcoholic and. 50 Nonalcoholic Men Drinking 50 Alcoholics N onalcoholics 6 Acciden ts Sober Total D rinking Violations Sober Total

3 M. L. S E L Z E R, C. E. P A Y N E, J. Q U IN N, AND F. H. W E S T E R V E L T 299 Excessive preoccupation with fantasy, obsessional rum ination, and marked affective lability (variables 5, 9, 14) completed the list of significantly correlated variables. T a b le 3 Significant Correlations between Psychopathology Variables and Automobile Accidents of 50 Alcoholic Drivers Item Variables Significant Correlations (p = 0.0 5, r= ) 20. Paranoid Sadness and despondency Suicidal preoccupation or attem pts Occasional self-destructive thoughts.28 28! Self-loathing Chronic rage and resentm ent Aggressive-destructive when drunk Low frustration tolerance Preoccupation with fantasy Obsessional rum ination Affective lability.28 All correlation d ata for the alcoholic group was subm itted to a stepwise regression program to find the most predictive combination (equation) of psychopathology variables from which high accident responsibility could be determined. The first procedure in generating a predicting equation was to find the best single predictor of accidents among the psychopathology variables in Table 3. Hence, variable 20 ( paranoid ideation ), the variable showing the greatest correlation w ith automobile accidents, was the first variable entering the predicting equation with a resultant coefficient of determination of 0.25 (Table 4). The coefficient of determination is the square of the coefficient of correlation and signifies that at this stage one might theoretically explain 25% of the variation in the dependent variable Y (automobile accidents).* The second variable entering the predicting equation was variable 16 ( feelings of sadness and despondency ), raising the explainable variance in Y from 25% to 35%. T he ^'Subsequent steps in form ing the predicting equations are of a different form. Additional variables are incorporated into the equation only if they can further reduce the variation remaining in Y. A variable can enter the equation only if its relative contribution exceeds a specific threshold. This threshold is taken to be a reduction in remaining variation of at least four times the variation of the predictor itself (F = 4.00) and corresponds to a significance level of at least 5%. The com putation is term inated when the potential contribution of each rem aining variable no longer exceeds this threshold. entry of variable 24 ( destructive or aggressive behavior when sober ) raised the v ariance to 44%. (Variable 24, when taken by itself, did not previously show a significant correlation with Y and is inversely related to Y in the regression analysis (Table 4 ).) (The negative relationship here indicates that the alcoholics in this study w'ho manifested a high level of aggressive behavior when sober tended to have a lower automobile accident rate.) T he final variable to enter the predicting equation was 15 ( chronic or frequently recurrent rage or resentm ent toward others ), increasing the coefficient of determination to 0.50, accounting for 50% of the variation in the num ber of accidents. Since this com bination of four v ariables can only explain 50% of the total variation in the dependent variable (au to mobile accidents), factors other than those in the equation obviously also exerted considerable influence on the occurrence of accidents. Utilizing the regression coefficients shown in Table 4, the following theoretical predicting equation could be formulated for com parable alcoholic individuals: N A = X PARA X SAD 0.42 X DSOB X RAGE W here: N A = N um ber of accidents PARA= Paranoid ideation rating of 1 or 2* SAD = Sadness and despondency rating of 1 or 2* DSOB = Destructive behavior when sober rating of 1 or 2* RAGE = Chronic rage or resentment rating of 1 or 2* (*Ratings are as follows: W ithin normal limits = 1; Abnormal = 2.) T a b l e 4 Regression Coefficients for Prediction of Automobile Accidents of 50 Alcoholic Drivers Variable Regressive Coefficients Constant Term Paranoid ideation Feelings of sadness and despondency D estructive or aggressive behavior when sober Chronic or frequently recurrent rage or resentm ent tow ard others.19 M ultiple Correlation Coefficient.71 Coefficient of D eterm ination.50

4 300 L A W A N D L A W E N F O R C E M E N T Nonalcoholic Drivers: T he d ata p ertaining to the nonalcoholic control group was submitted to the same statistical procedures used for the alcoholic group in order to determ ine whether the results obtained above were specific for the alcoholic drivers. (Since our list of personality variables was designed with an alcoholic population in mind, the findings for the control group do not accurately reflect the role of personality in the etiology of accidents incurred by nonalcoholic persons. T he control group d ata is for comparison only.) Only three of the predictor variables were significantly related to the incidence of automobile accidents in the nonalcoholic group and these are shown in T able 5. V ariable 9 ( obsessional rum ination ) had the highest correlation with Y. V ariable 31 ( serious suicidal preoccupation or attem p ts ) was also significantly correlated as was variable 11 ( heterosexual a d justm ent ). In the control group, the predictor variables comprising the final predicting equation were the same three variables which showed significant individual correlation with automobile accidents (Table 6 ). T a b l e 5 Significant Correlations between Psychopathology Variables and Automobile A ccidents of 50 Nonalcoholic Drivers Significant Correlations Item Variables (p 0.05, r 0.27) 9. Obsessional rum ination Suicidal preoccupation or attem pts Heterosexual adjustm ent.29 T a b l e 6 Regression Coefficients for Prediction of Automobile Accidents of 50 Nonalcoholic Drivers V ariable Regression Coefficients C onstant T erm Obsessional rum ination Serious suicidal preoccupation or attem pts H eterosexual adjustm ent.67 M ultiple Correlation Coefficient.55 Coefficient of D eterm ination.31 Variable 9 ( obsessional rum ination ), by virtue of having the highest significant correlation w ith Y, was autom atically in corporated into the predicting equation. T h e resultant coefficient of determ ination was The coefficient of determination increased to 0.24 and 0.31 following the entry of variables 31 and 11 respectively into the predicting equation. The final coefficient of determ ination for the nonalcoholic group, 0.31, was relatively low compared to the final coefficient of 0.50 derived for the 50 alcoholic drivers. Thus, a greater am ount of variation in automobile accidents remains unexplained for the nonalcoholic group than for the alcoholic group. This contrast may indicate that certain types of psychopathology play a more significant role in the accidents incurred by alcoholic populations. The ability to sublimate, to find socially acceptable channels for underlying psychopathological urges, or to restrain unwelcome impulses is often seriously undermined by alcohol (6). Hence, the alcoholic, when intoxicated, is more likely to express underlying illness (as when driving a car) than his nonalcoholic counterpart. Total Driver Group: Eleven predictor variables were significantly related to automobile accidents in the combined 100-man driver group (50 alcoholics and 50 nonalcoholics) as shown in Table 7. W ith the exception of variable 32 ( alcoholism ), all of the significantiy correlated variables were significantly correlated with automobile accidents in the previous statistical treatm ent of the alcoholic group or the nonalcoholic group alone, predom inantly the former. T a b le 7 Significant Correlations between Psychopathology Variables and Automobile Accidents of 100 Drivers Significant Correlations Item Variables (p = 0.05, r= ) 20. Paranoid Alcoholism Suicidal preoccupation or attem pts O ccasional self-destructive thoughts Sadness and despondency Self-loathing Aggressive-destructive when drunk Chronic rage and resentment Low frustration tolerance Obsessional rum ination Preoccupation with fantasy.29 Although alcoholism itself is a significant factor in the combined group with a correlation coefficient of 0.35 (Table 7), the final predicting equation (elements of which are shown in Table 8) derived from all the variables in a stepwise regression analysis did not include alcoholism. As before, the first variable to enter the predicting equa

5 M. L. S E L Z E R, C. E. P A Y N E, J. Q U IN N, AND F. H. W E S T E R V E L T 301 tion was the individual variable having the greatest correlation with Y : variable 20 ( paranoid ideation ) (Table 7.). The resultant coefficient of determ ination was The second entering variable was variable 31 ( suicidal ) increasing the coefficient of determination from 0.13 to In step 3, variable 32 ( alcoholism ) entered, raising the coefficient to In steps 4 and 5, variables 24 ( aggressive when sober ; negatively expressed) and 23 ( aggressive when drunk ) entered and raised the coefficient to In step 6, variable 32 ( alcoholism ) was removed from the equation, lowering the explainable variance to Hence, for the 100-driver group, the combination of variables 20, 23, 24, and 31 provided virtually all of the information contributed by the variable of alcoholism, causing alcoholism to fall below the threshold of potential contribution. Variable 32 ( alcoholism ) was found to be very nearly represented by a linear combination of the four variables which entered prior to step 6 (T able 8). Since alcoholism alone was significantly related to automobile accidents and the relationship between alcoholism and automobile accidents can be replaced by a similar relationship between accidents and the four variable shown in Table 8, it ap pears that these personality variables, when present in concert, may play a role in the high incidence of autom obile accidents in curred by certain alcoholic drivers. T a b l e 8 Regression Coefficients for Prediction of A utom obile Accidents of 100 Drivers Variable Regression Coefficients Constant T erm Paranoid ideation Serious suicidal preoccupation o r attem pts Destructive or aggressive behavior when sober Destructive or aggressive behavior when drunk.18 M ultiple Correlation Coefficient.59 Coefficient of D eterm ination.35 Conclusions T he differences in accident involvement and moving violations between the alcoholics and nonalcoholics in this study were significantly related to driving behavior which occurred after alcohol had been consumed. Alcohol cannot drive a car, however, and we questioned whether intoxication alone could explain the alcoholic group s significantly higher incidence of accident involvement. As seen in this study, a num ber of p ersonality variables appear to be significantly related to accidents caused by alcoholics. Paranoid thinking trends showed the highest correlation with accidents, a finding that surprised us at the time, but probably should not have since paranoid thoughts are often the precursor of angry and impulsive actions which, even if transient, may result in highway disaster. N ot infrequently, these alcoholic men would entertain paranoid thoughts only when drinking. The appearance of four depressive variables significantly related to automobile accidents was not unexpected, particularly those variables denoting prior suicidal p reoccupation or attempts. The automobile is an almost ideal instrum ent of self-destruction because of its availability, the frequency of its use, the generally inherent hazards of driving, and the fact th a t it offers the in dividual an opportunity to imperil or end his life without conscious awareness of his suicidal intent. Since we live in a culture where speed and daring are admired, the automobile may offer the depressed and frustrated alcoholic an opportunity to end his life in what he may perceive as a burst of glory (10). The appearance of three variables which could result in, or are expressions of anger (variables 3, 15, 23), is hardly surprising in view of the vast literature indicating that many alcoholics are chronically hostile. However, the alcoholic is often a very dependent individual, fearful of giving offense. T he automobile accident may have great appeal as a means of almost socially acceptable violence for an individual unable to display his anger in a less devious m anner. T he significant correlation between v ariable 23 ( destructive or aggressive behavior when drunk ) and automobile accidents raises the question as to whether the driver who is a chronic alcoholic incurs accidents because he is intoxicated or becomes intoxicated in order to cause an accident. The appearance of variable 23 as significantly correlated with accidents may indicate that automobile accidents caused by certain alcoholics may be but one of several ways in which these alcoholics express underlying anger, anger which can only be expressed when they are intoxicated. The association between alcoholism and crimes of violence is well documented (11,12). In one typical study, 33% of 143 felons convicted of m urder, m anslaughter, or felonious assault acknowledged a chronic drinking problem and for the most part had been drinking at the time the crime was com m itted(1 2). Yet

6 302 L A W A N D L A W E N F O R C E M E N T no one to our knowledge has suggested that a m an murders merely because he was intoxicated at the time. Similarly, we should be cautious about accepting intoxication as a total explanation of traffic accidents caused by an intoxicated alcoholic. Intoxication alone cannot explain all autom obile accidents, particularly serious accidents, anymore th an it does m urder or felonious assault when committeed by an alcoholic who is intoxicated at the time the event occurs. The personality variables preoccupation with fantasy and obsessional rum ination, both significantly correlated with automobile accidents caused by drivers in the alcoholic group, suggest a reduction in the driver s awareness of external events, thus making him more vulnerable to involvement in automobile accidents. M arked affective lability, another significantly correlated variable, can lead to behavior resulting in automobile accidents when the individual s mood is a t either end of the affective spectrum. O n the one hand, a driver abruptly plunged into a gloomy state may suffer sufficient mental pain to care little about his im m ediate fate. Conversely, a driver suddenly euphoric or exhilarated (with his judgm ent and accuracy already compromised by alcohol) may attem pt maneuvers which increase the likelihood of an accident. T he data derived from the regression analyses indicate that certain combinations of personality difficulty are highly predictive of accident potential. W hether this in form ation will have any practical significance is questionable considering how little progress has been made thus far toward removing the alcoholic, accident-inclined driver from the traffic scene. Although we have derived an d presented d a ta to indicate th a t the alcoholic s personality may play a significant role in his excessive accident involvement, this should not be construed as minimizing intoxication as a causative agent. Rather, the high incidence of traffic accidents caused by alcoholic drivers should be regarded as the outcome of the interplay between certain deleterious personality traits which may be liberated when the individual becomes intoxicated and the im pairm ent caused by alcohol intoxication. Given these prior circumstances the resultant traffic events can be regarded as inevitabilities rath e r th an accidents. Summary An attem pt has been made to determine w hether or not: (a) alcoholic drivers are responsible for significantly more traffic accidents and moving violations than nonalcoholics, (b) accidents and violations incurred by alcoholic drivers are significantly related to drinking, (c) the alcoholic s psychopathology is significantly related to traffic accidents. Traffic violation and accident histories were obtained by interview from 50 alcoholic and 50 nonalcoholic male patients admitted to an open psychiatric ward. Each patient was evaluated by his psychotherapist to determ ine the presence of certain types of psychopathology and these psychopathology variables were correlated with the number of traffic accidents reported by each patient. A stepwise regression analysis was then used to determine if any combination of personality variables was significantly related to high accident potential. T he 50 alcoholic drivers were responsible for approximately twice as many traffic violations and accidents as the 50 nonalcoholic drivers. The significant excess of both violations and accidents caused by the alcoholic drivers occurred after they had been drinking. In the alcoholic group, paranoid ideation was the psychopathology variable most highly correlated with traffic accidents. O ther highly correlated psychopathology variables were those related to despondency, suicidal preoccupation or attempts, and chronic anger. A regression analysis based on the d ata obtained from the alcoholic group indicated th a t a com bination of four psychopathology variables was predictive of a high accident rate in the alcoholic group. These variables were paranoid ideation, chronic rage, feelings of despondency, and aggressive behavior when sober, with the latter variable having no inverse relationship to traffic accidents. Although the above data indicates that personality problems play a significant role in the high accident involvement of many alcoholics, this should not be construed as minimizing intoxication as a causative agent. Rather, the high incidence of traffic accidents found in groups of alcoholic drivers is probably the end result of the interplay between certain deleterious personality traits liberated when the individual becomes intoxicated and the impairment caused by alcohol intoxication. R e f e r e n c e s 1 S c h m id t, W. S. a n d S m a rt, R. G.: A lcoholics, D rin k in g a n d T ra ffic A c cid e n ts. Quart. J. Stud. Ale. 20: , W ilb a r, C.: C rash A ssignm ent. T ra ffic A ccid e n ts S c ru tin iz ed by th e P ennsy lv ania D e p a rtm e n t of H e a lth. Amer. J. Public Health. 50: , 1960.

7 M. L. S E L Z E R, C. E. P A Y N E, J. Q U IN N, AND F. H. W E S T E R V E L T B je rv e r, K. B., G o ld b e rg, L., a n d L in d a, P.: B lood-a lcohol L evels in H o sp ita liz ed V ictim s of T ra ffic A c cid e n ts. I n : Proceedings of the Second International Conference on Alcohol and Road Traffic. T o ro n to ; A lcoholism R esearch F o u n d a tio n : P o p h a m, R. E.: A lcoholism a n d T ra ffic A c cid e n ts. A P re lim in a ry S tu d y. Quart. J. Stud. Ale. 17: , S m a rt, R. G., a n d S c h m id t, W. S.: P ro b lem D rin k in g as a F a c to r in D rin k in g D riv e r O f fe n s e s / Canad. J. Corrections. 3: , S elzer, M. L.: A lcoholism a n d th e L a w. Michigan Law Review. 5 6: , C o n g e r, J., G askill, H., G la d, D. H assel, L. R a in e y, R. a n d S aw yer, W.: P sychological a n d Psychophysiological F a c to rs in M o to r V ehicle A c cid e n ts. J. Am er. M ed. Assn>, 169: , T illm a n, W., a n d H o b b s, G : T h e A ccid ent- P ro n e A u to m o b ile D riv e r: a S tu d y o f Psyc h ia tric a n d Social B a c k g ro u n d. A m. J. Psychiat. 106: , Z w e rlin g, I., a n d R o se n b a u m, M. : A lcohol A d d ic tio n a n d P e rso n a lity. I n : A rie ti, S., American Handbook of Psychiatry; p p N ew Y o rk. B asic B ooks; S elzer, M. L., a n d P ayne, C. E.: A u to m o b ile A c cid ents, S u icid e a n d U n conscio u s M o tiv a tio n. A m. J. Psychiat. 119: , C rim in a l O ffe n d e rs a n d D rin k in g In v o lv e m e n t. A P re lim in a ry A nalysis. D ivision of A lcoholic R e h a b ilita tio n, D e p a rtm e n t of P u b lic H e a lth, B erkeley, C a lifo rn ia. 12 G u ze, S. B., T u aso n, V., G a tfie ld, P., S te w a rt, M., a n d P ic k en, B.: P sy ch ia tric Illness a n d C rim e w ith P a rtic u la r R e fere n ce to A lcoholism. A S tu d y o f 223 C rim in a ls. /. Nerv. M ent. Dis. 134: , M r. Lanay: Dr. Selzer, I am curious to know why you used the mentally ill in this study as a control group with the alcoholic? Dr. Selzer: Because of the method we used in the study. This method depended upon somebody who had very intimate knowledge of the person, which in this case was the psychiatrist treating him, both in the alcoholic and in the control group. M r. Lanay: Was this information from the psychotherapist the result of testing or was it the result of his impressions of the p atient? D r. Selzer: I t was strictly clinical im pressions. No testing was used in this study. There was history regarding the patients obtained from their families, friends, and so on. We had the total inform ation on each p atient, but it was the psychotherapist who made each of these ratings. Dr. Bacon: Is there any question about the sample being of a highly selective type just because they were in a psychiatric hospital, knowing what we do about the policies of hospitals and alcoholics? D r. Selzer: This was a voluntary hospital. Dr. Bacon: All of these patients came, as m uch as alcoholics come, of their own volition, so this was a volitional group that came of its own accord for treatment. They impressed me as a group who were much more passive and much more dependent than the people who are in state hospitals. I think they must have been different than the alcoholics, let us say, than those treated privately. If you are feeling that they are sicker than alcoholics who don t wind up in hospitals, I just can t say. I know that other persons have studied them in terms of long-term results and the results are very poor. D ISCUSSION Dr. Fox: You must have been exposed to some question as to the possibility that you were finding a relationship between these phenomena and reported accidents rather than actual number of accidents as may have been recorded in some official document. I w onder how you dealt w ith th at question. D r Selzer: You mean the accuracy of the reporting? D r. Fox: Yes. D r. Selzer: We did some random checks and found th at they were reasonably accurate, but there seems to be a fadeaway. There was m uch better reporting of accidents of the immediate preceding five years than before that. If I were to do the study again, I think I would simply limit the reporting span to the accidents of the previous five years. D r. Fox: Could you possibly come up with the hypothesis of what is the relationship between the measures you took and the likelihood of reporting an accident, w ithout regard to the actual number that the man may have had. Would this show similar trends in both the control and the experimental group, thereby leading you to the findings that you got? D r. Selzer: I m sorry, I can t answer that. T h at s your hypothesis. M r. Jeffery: As I understand it, your nondrinking accidents totaled 69 and your nonalcoholics totaled 73. Is that correct? Couldn t that be a question of the amount of alcohol they had rath er than their condition? Dr. Selzer: You could say that, but you would have to ignore some of the other conditions I have presented. You would have to know how much alcohol a man has had and if he is drunk when he is driving. I don t know.