Alcohol use disorders constitute a major global health challenge, representing widespread psychiatric conditions characterized by substantial neurobiological disruption [1]. Recent decades have witnessed mounting alcohol consumption worldwide, especially within developing nations, creating extensive health burdens through acute intoxication effects, chronic dependency patterns, and complex biochemical alterations [2]. These disorders frequently present with concurrent psychological manifestations encompassing depressive states, anxiety disorders, and psychotic symptoms, contributing to significant disability and early mortality. The connection between alcohol misuse and self-destructive behaviors has historical recognition dating to early psychiatric observations by Kraepelin [4]. Global suicide mortality has risen approximately 60% during recent decades, with estimates projecting 1.5 million annual deaths by 2020[3]. Alcohol-related disorders show strong prevalence among populations demonstrating suicidal tendencies, with alcohol potentially facilitating disinhibition, compromised judgment, and impulsive actions leading to self-harm [5].

Research into alcohol-violence relationships has extensively explored psychopharmacological mechanisms affecting cognitive functioning, particularly attention regulation and decision-making processes [6]. Evidence indicates that excessive alcohol consumption impairs judgment in potentially aggressive circumstances, increasing propensity toward violent behaviors. The World Health Organization characterizes violence as "intentional application of physical force or power, whether threatened or actual, directed against oneself, others, or communities"[7].

Examining the intricate relationships among alcohol dependence, hostile attitudes, violent behaviors, and suicidal tendencies remains essential for creating effective treatment strategies. This investigation seeks to provide detailed understanding of these behavioral patterns within alcohol-dependent populations.

This cross-sectional investigation took place within the Psychiatry Department inpatient unit at Sree Balaji Medical College, Chennai, spanning August 2016 through August 2017. Sample size determination followed Driessen and colleagues' research documenting 40% suicidal behavior prevalence among alcohol-dependent treatment seekers[9], utilizing 95% confidence intervals and 80% statistical power, establishing minimum requirements of 46 participants. Fifty male patients meeting ICD-10 alcohol dependence criteria were enrolled through consecutive recruitment. Institutional Ethics Committee approval was secured, with comprehensive informed consent obtained from all subjects.

Participant inclusion required ages 18-60 years, confirmed alcohol dependence syndrome diagnosis per ICD-10 standards, and clinical stability permitting assessment. Exclusion criteria encompassed concurrent substance dependencies, mood or psychotic disorders, cognitive impairments or organic brain conditions, and active delirium tremens during hospitalization.

Data collection employed structured demographic and clinical questionnaires. Mini Mental State Examination screening excluded cognitive dysfunction. Assessment batteries included CAGE alcohol screening instrument, Michigan Alcohol Screening Test for dependency severity evaluation, Beck's Suicidal Intent Scale for self-harm assessment, Extrapunitive-Intropunitive Scale for hostility measurement, and Historical Clinical Risk Management Scale-20 for violence risk evaluation[8].

Statistical procedures utilized SPSS version 29.02 software. Categorical variables appeared as frequencies and percentages, continuous variables as means with standard deviations. Chi-square analysis examined variable associations, while receiver operating characteristic curves determined HCR-20 predictive capacity for violence risk. Statistical significance threshold was p<0.05.

The study cohort consisted of 50 male subjects aged 38.78±8.39 years (range 25-58). Educational backgrounds included 40% primary schooling, 40% secondary education, 18% college graduates, and 2% without formal education. Employment categories comprised 66% semi-skilled laborers, 16% skilled workers, 12% unemployed individuals, and 6% professionals. Marital circumstances showed 84% married, 10% single, and 6% separated status.(Table 1)

Table 1: Demographic and Clinical Characteristics (n=50)

Clinical evaluation demonstrated that 52% of subjects began alcohol use during ages 15-20, while 72% maintained consumption exceeding 10 years. Familial alcohol abuse history appeared in 78% of cases, predominantly affecting immediate relatives.

Table 2: Behavioral Pattern Prevalence (n=50)

Beck's Suicidal Intent Scale evaluation revealed 36% of participants displayed positive suicidal ideation scores: 18% mild, 14% moderate, and 4% severe intensity. Hostility assessment identified 66% with outward-directed tendencies (harm toward others) and 34% with inward-directed patterns (self-harm tendencies).(Table 2)

Table 3: Hostility-Suicidal Behavior Association

A highly significant association was observed between hostility direction and suicidal behavior (p<0.001). Participants with intropunitive hostility demonstrated markedly higher suicidal intent compared to those with extrapunitive hostility. (Table 3)

Violence evaluation documented intimate partner physical aggression in 48%, emotional abuse in 38%, sexual violence in 28%, and general violence in 10%. Earlier initiation ages (15-20 years) correlated with increased violence rates across categories, achieving statistical significance specifically for sexual violence and age relationships (p=0.015).(Table 2)

Table 4: Suicidal Intent and Hostility Direction Correlation

The association between hostility direction and suicidal intent was statistically significant (χ²=28.47, p<0.001), with intropunitive individuals demonstrating markedly higher suicidal intent across all severity levels.(Table 4)

Table 5: Age Group and Sexual Violence Correlation

Younger participants (25-35 years) demonstrated significantly higher sexual violence prevalence versus older age groups.(Table 5)

Table 6: HCR-20 Component Analysis

Risk stratification using HCR-20 total scores showed that approximately half the participants (24 individuals, 48%) qualified as low-risk (scores 10-14), while 16 participants (32%) fell within minimal risk range (scores <10). Seven participants (14%) received medium-risk classification (scores 15-18), and only 3 participants (6%) were designated high-risk (scores >18) for future violent conduct.(Table 6)

Receiver operating characteristic analysis for HCR-20 total scores demonstrated moderate discriminative capacity for violence risk prediction (Area Under Curve = 0.783, 95% CI: 0.651-0.915). The optimal threshold score of 9.50 produced 82% sensitivity and 59% specificity for identifying individuals at future violent behavior risk. Participants exceeding this threshold showed significantly increased probability of violent acts during subsequent evaluation periods.

This investigation demonstrates substantial suicidal behavior prevalence among alcohol-dependent individuals, with findings consistent with prior research documenting similar rates in treatment-seeking populations[9,10]. Our observed prevalence corresponds with Centers for Disease Control reports indicating comparable rates among substance abuse treatment recipients[11]. Compared to general population statistics, alcohol use disorder patients exhibit approximately 10-fold elevated suicide risk, reinforcing established connections between alcohol dependence and self-destructive behaviors[12].

Higher suicidal intent prevalence within the 46-58 age group mirrors Indian research findings showing increased suicide completion ratios among elderly populations compared to younger demographics[13]. The dose-response relationship between alcohol consumption quantity and suicidal intent supports previous findings of dramatically increased suicide risk during alcohol intoxication periods[14]. Early-onset alcohol use among participants with suicidal behaviors aligns with research establishing connections between younger substance abuse initiation and subsequent suicide risk[15].

The strong association between inward-directed hostility and suicidal behavior represents a significant finding, with participants demonstrating self-directed hostile characteristics exhibiting elevated suicidal intent across severity levels. This supports research identifying hostility as a suicide predictor[16]. The predominance of outward-directed hostility suggests increased propensity for external aggression among alcohol-dependent individuals, consistent with research on hostile attitudes and relationship aggression[17].

Intimate violence prevalence in our study exceeds general population rates while corresponding to National Family Health Survey data regarding lifetime violence exposure among Indian women [18]. International epidemiological research has documented similar domestic violence patterns among married women experiencing physical abuse[19]. Although alcohol contributes to substantial proportions of violent incidents and elevates domestic violence risk[20], our findings showed no significant correlation between consumption duration/quantity and intimate violence, supporting research characterizing alcohol as a correlate rather than direct causal factor[21].

The relationship between early alcohol initiation and violence corresponds with research documenting reciprocal associations between adolescent substance use and violent behaviors[22]. HCR-20's moderate predictive capacity provides clinically valuable screening utility, with majority of participants classified as low-risk and smaller proportions in medium-to-high risk categories for future violence.

Study limitations encompass hospital-based sampling potentially restricting generalizability, limited sample size, brief observation duration, and absence of control group comparisons. Future investigations should incorporate community-based samples, longitudinal monitoring, and control groups to enhance findings validity.

The neurobiological foundation underlying alcohol's effects on aggression and suicidality involves complex neurotransmitter system interactions, including glutamatergic and GABAergic pathways, dopaminergic circuits, and executive cognitive processes [23, 24]. Understanding these mechanisms remains vital for developing targeted interventions addressing alcohol dependence syndrome's multifaceted presentations.

Alcohol dependence syndrome exhibits elevated prevalence of suicidal ideation, violent behaviors, and hostile attitudes with important clinical significance. Inward-directed hostility demonstrates strong correlation with increased suicidal intent, while early alcohol initiation predisposes toward violent conduct. Thorough assessment utilizing risk evaluation instruments and focused interventions targeting hostile thought patterns are fundamental for managing these complex behavioral presentations in alcohol-dependent populations.

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