Prevalence of personality disorder in alcohol and drug services and associated comorbidity

Inpatient staff experiences of providing treatment for males with a diagnosis of borderline personality disorder: A thematic analysis

WHAT IS KNOWN ON THE SUBJECT?: We know that there are similar rates of borderline personality disorder (BPD) diagnosed in both men and women; however, some research suggests that BPD is diagnosed later and less frequently in men. Some research suggests that males diagnosed with BPD present differently to women, but not much is known about how this influences the care men receive in inpatient mental health hospitals. WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE?: This paper is the first to specifically ask inpatient staff about men diagnosed with BPD, and to hear about their perceptions and experiences. It identified that some staff do not feel as knowledgeable in identifying and treating BPD in men compared to women. Some staff talked about how emotional difficulties like BPD are often not the first thought when men present with distress compared to women. Staff also talked about needing a safe, open and transparent working culture to be able to ask questions and to be questioned on their own assumptions, biases or lack of training. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: This paper suggests that inpatient staff may hold some assumptions about men and their emotions, such as assuming that they are less likely to struggle with emotional difficulties like BPD. Staff anxieties about risk management may influence how they perceive and care for men in inpatient wards. The findings suggest that male-specific training in identifying and treating BPD should be provided for staff on inpatient wards, to improve knowledge and confidence.

ABSTRACT

INTRODUCTION: Research highlights discrepancies in recognition of borderline personality disorder (BPD) in men, despite similar rates of prevalence across genders.

AIM

To investigate inpatient mental health professionals' experiences of delivering treatment for males with a diagnosis of BPD.

METHOD

Six mental health professionals working within adult acute inpatient wards completed a semi-structured interview. All participants were members of the nursing team. Thematic analysis was used to analyse the data.

RESULTS

Five themes were identified: Gender Differences, Stereotyping, Facilitators to Care Delivery, Barriers to Care Delivery and Ways to Improve Care. Participants talked of a lack of awareness and understanding of BPD in males impacting both diagnosis and treatment in an acute inpatient setting.

DISCUSSION

There may be factors ranging from gender stereotypes, limited knowledge and understanding of gender differences in presentations, and personal/organisational cultures influencing the formulation and treatment of males with a diagnosis of BPD in inpatient settings.

IMPLICATIONS FOR PRACTICE

The findings suggest that gender stereotypes such as masculine norms may influence how male patients' emotional difficulties are understood and managed, and that additional training in male-specific issues to improve knowledge and care provision. This research will support inpatient staff, service leads and clinical educators to identify ways to adapt care provision for men.

Perspectives of service users and carers with lived experience of a diagnosis of personality disorder: A qualitative study

WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE?: Personality disorder is a serious mental health condition affecting up to 52% of psychiatric outpatients and 70% of inpatients and forensic patients. People with a diagnosis of personality disorder have higher morbidity and mortality than those without. Service users and carers reported a lack of training for staff in the management of individuals with a diagnosis of personality disorder, particularly with regard to self-harm and suicidal behaviours. Staff burnout creates barriers to compassionate person-centred care for individuals with a diagnosis of personality disorder as staff struggled to accommodate the nature of the presentation when under significant emotional, psychological and professional strain caused by understaffing and lack of support. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: This paper adds new knowledge by informing services of ways to improve care provision from the perspectives of both carers and service users. A more holistic and less medicalised approach to the treatment of problems associated with a diagnosis of a personality disorder should be adopted, and personality disorder training introduced for all healthcare practitioners, to improve patient outcomes.

ABSTRACT

INTRODUCTION: There is limited understanding of the experience of people with complex mental health (CMH) needs, including those with a diagnosis of personality disorder (PD) and carers of those individuals. Little is known about carers of those in inpatient forensic settings, yet it has been identified that they may have additional needs when compared to general carers. Research highlights that community carer support services were perceived as inadequate and out-of-area placements were described as putting an added strain on ability to support loved ones. Understanding PD within a population of people with CMH needs and how a diagnosis described as PD impacts on care and treatment experience is vital to providing high-quality care.

AIM

To evaluate the care experience of service users and carers with lived experience of a diagnosis of PD and out-of-area placements.

METHOD

Semi-structured interviews were conducted with six service users and four carers to explore the experiences and perspectives of people with a diagnosis of PD. Interviews were audio recorded and thematically analysed.

RESULTS

Four interrelated themes were developed; Influence of a diagnosis of PD on Staff, Early and Appropriate Intervention, Recognition of the Individual and Training and Knowledge of people with a diagnosis of PD.

DISCUSSION

Anti-stigma interventions for staff, research on care provision and structural changes to services including more evidence-based therapy for individuals with a diagnosis of PD may help reduce disparate treatment and improve prognosis for recovery.

IMPLICATIONS FOR PRACTICE

This paper informs services of ways to improve care provision from the perspective of carers and service users. A more holistic and less medicalised approach to the treatment of problems associated with diagnoses of PD should be adopted, and PD training for all healthcare practitioners to improve patient outcomes.

Attachment and Therapeutic Alliance in Substance Use Disorders: Initial Findings for Treatment in the Therapeutic Community

Background: There is convincing evidence that individuals suffering from Substance Use Disorder (SUD) often present insecure attachment patterns. In contrast, a strong therapeutic alliance in treatment of SUD has been found to lead to a more positive treatment outcome. However, insecure attachment has been observed to be linked with weaker therapeutic alliance strength. The primary aim of this explorative study was to gain initial insights regarding the influence of attachment and personality characteristics on therapeutic alliance and therapy motivation in SUD patients undergoing treatment at a therapeutic community. Furthermore, SUD patients were compared to healthy controls regarding attachment, personality and mood pathology. Methods: A total sample of 68 participants, 34 inpatients in SUD treatment and 34 age-gender and education adjusted controls, were investigated. Both groups filled in the Adult Attachment Scale (AAS), the Inventory of Personality Organization (IPO-16), and the Brief Symptom Inventory (BSI-18) questionnaires. Additionally, SUD patients filled in the Working Alliance Inventory (WAI-SR) and the adapted German version of the University of Rhode Island Change Assessment scale (FEVER). Results: In line with our assumptions, SUD patients exhibited a decreased amount of attachment security (AAS) which was related to higher personality (IPO-16) and mood pathology (BSI-18). Furthermore, correlational analysis revealed the WAI-SR dimension Bond being positively associated with more secure attachment. A strong task alliance was linked to the Action stage of change (FEVER) and decreased mood but not personality pathology. Conclusion: Our findings confirm the putative negative effect of attachment and personality pathology on therapy motivation and therapeutic alliance in addiction therapy as well as more specifically in therapeutic community treatment. Future research in enhanced samples might focus more on the long-term effects of the interaction of attachment, personality and therapeutic alliance variables.

Alcohol use patterns and disorders among individuals with personality disorders in the Sao Paulo Metropolitan Area

Introduction

Alcohol Use Disorders are frequently comorbid with personality disorders. However, the heterogeneity of the prevalence estimates is high, and most data come from high income countries. Our aim is to estimate the prevalence and association between alcohol use outcomes and the three DSM-5 clusters of personality disorders in a representative sample of the São Paulo Metropolitan Area.

Materials and methods

A representative household sample of 2,942 adults was interviewed using the WHO Composite International Diagnostic Interview and the International Personality Disorder Examination Screening Questionnaire. Lifetime PD diagnoses were multiply imputed, and AUD diagnoses were obtained using DSM-5 criteria. We conducted cross-tabulations and logistic regression to estimate the associations between AUDs and PDs.

Results and discussion

Our study did not find significant associations of PDs with heavy drinking patterns or mild AUD. Cluster B PD respondents tended to show the highest conditional prevalence estimates of most alcohol use patterns and AUD, including its severity subtypes. When alcohol outcomes were regressed on all PD Clusters simultaneously, with adjustment for sex and age, only cluster B was significantly associated with past-year alcohol use (OR 3.0), regular drinking (OR 3.2), and AUDs (OR 8.5), especially moderate and severe cases of alcohol use disorders (OR 9.7 and 16.6, respectively). These associations between Cluster B PDs and these alcohol outcomes were shown to be independent of other PD Clusters and individuals´ sex and age.

Conclusion

The main finding of our study is that AUDs are highly comorbid with PDs. The presence of Cluster B PDs significantly increases the odds of alcohol consumption and disorders and of more severe forms of AUDs. Considering the local context of poor treatment provision, more specific prevention and intervention strategies should be directed to this population.

Effects of substance use disorder on treatment process and outcome in a ten-session psychiatric treatment for borderline personality disorder

BACKGROUND

Dual diagnosis is common in Borderline Personality Disorder (BPD), one of the most common being Substance Use Disorder (SUD). Previous studies have shown that general psychiatric management (GPM) was effective in reducing borderline symptoms. In the present study, we tested whether the short GPM was as effective in the BPD + SUD as in the BPD group.

METHODS

We analysed a group of 99 patients presenting a BPD. 51 of these patients presented a SUD. The BPD group and the BPD + SUD group received a manual-based short variant of the GPM treatment. Previous studies have shown that a 10-session version of GPM was effective in reducing borderline symptoms at the end of the treatment (Psychother Psychosom 83:176-86, 2014).

RESULTS

We found no significant difference in the reduction of general symptoms, which diminished in both groups. The specific borderline symptoms were also reduced in both groups, but there was a slightly higher reduction of the borderline symptoms in the SUD group. The therapeutic alliance progressed positively in all groups. Moreover, the alliance increased more over time in the SUD group.

CONCLUSION

The short variant of GPM seems to be effective in BPD treatment independently from the presence of SUD. Therefore, this treatment could be an effective entry-level treatment for patients with dual diagnosis as well as patients with BPD only. Further studies are needed to confirm efficacy and long-term outcome.

TRIAL REGISTRATION

The trial was registered at ClinicalTrial.gov (identifier NCT01896024 ).

Drug treatment for personality disorders

There is some evidence that antidepressants, particularly the selective serotonin reuptake inhibitors and the monoamine oxidase inhibitors, have some benefits in the management of borderline personality disorder, and lesser evidence (partly because of limited trial data) for the benefits of antipsychotic drugs and mood stabilisers. There is not sufficient distinction between the different personality disorders to recommend that any one disorder should be treated by any one drug, and successful treatment is dependent on careful management, sensitive to the patient's expectations.

Stimulant use still going strong

Amphetamines, cocaine and methylenedioxymethamphetamine (MDMA, ‘ecstasy’) have been prominent on the UK drugs scene over the past decade. Much cocaine is now in the form of ‘crack’, which produces particularly acute versions of well-known complications including paranoid psychosis, mood disorders and cardiovascular problems. Ecstasy has additional hallucinogenic properties, and the slightly different range of psychiatric effects can be long-lasting. Assessment for stimulant misuse should include drug screening more than is currently common in general settings. Management comprises psychosocial (particularly behavioural counselling) and pharmacological approaches. A wide range of dopaminergic and other medications have been studied in cocaine misuse, and specialised substitute prescribing may be appropriate for heavy amphetamine injecting. There has been recent focus on problems of dual diagnosis, with particular strategies required to address stimulant misuse by people with severe mental illnesses.

Decision-making, somatic markers and emotion processing in opiate users

RATIONALE

Opiate use is associated with deficits in decision-making. A possible explanation for these deficits is provided by the somatic marker hypothesis, which suggests that substance users may experience abnormal emotional responses during decision-making involving reward and punishment. This in turn may interfere with the brief physiological arousal, i.e. somatic markers that normally occur in anticipation of risky decisions. To date, the applicability of the somatic marker hypothesis to explain decision-making deficits has not been investigated in opiate users.

OBJECTIVES

This study assessed whether decision-making deficits in opiate users were related to abnormal emotional responses and reduced somatic markers.

METHODS

Opiate users enrolled in an opiate substitute treatment program (n = 28) and healthy controls (n = 32) completed the Iowa Gambling Task (IGT) while their skin conductance responses (SCRs) were recorded. Participants' emotional responses to emotion-eliciting videos were also recorded using SCRs and subjective ratings.

RESULTS

Opiate users displayed poorer decision-making on the IGT than did controls. However, there were no differences between the groups in SCRs; both groups displayed stronger SCRs following punishment than following reward, and both groups displayed stronger anticipatory SCRs prior to disadvantageous decisions than advantageous decisions. There were no group differences in objective or subjective measures of emotional responses to the videos.

CONCLUSIONS

The results suggest that deficits in emotional responsiveness are not apparent in opiate users who are receiving pharmacological treatment. Thus, the somatic marker hypothesis does not provide a good explanation for the decision-making deficits in this group.

Manifestations of personality impairment severity: comorbidity, course/prognosis, psychosocial dysfunction, and 'borderline' personality features

Impairment in personality functioning (briefly, personality impairment) is the core pathology in personality disorder (PD) and an essential indicator of PD-severity. It also is a difficult construct to define and assess. We argue that personality-impairment severity is a latent construct that can be modeled with four indicators: within-PD comorbidity, problematic course/prognosis of both PD and comorbid clinical syndromes, PD-associated psychosocial dysfunction, and features of DSM-5-II borderline PD (BPD). Our literature review documents interrelations among the first three indicators, and studies of PD structure reveal a higher order factor of general PD severity marked most strongly by BPD features. Together, these findings indicate that BPD features may be helpful in the important tasks of defining and assessing personality-impairment severity.

Personality disorder services in England: findings from a national survey

Aims and method We aimed to evaluate the availability and nature of services for people affected by personality disorder in England by conducting a survey of English National Health Service (NHS) mental health trusts and independent organisations. Results In England, 84% of organisations reported having at least one dedicated personality disorder service. This represents a fivefold increase compared with a 2002 survey. However, only 55% of organisations reported that patients had equal access across localities to these dedicated services. Dedicated services commonly had good levels of service use and carer involvement, and engagement in education, research and training. However, a wider multidisciplinary team and a greater number of biopsychosocial interventions were available through generic services. Clinical implications There has been a substantial increase in service provision for people affected by personality disorder, but continued variability in the availability of services is apparent and it remains unclear whether quality of care has improved.

Personality disorder and alcohol treatment outcome: systematic review and meta-analysis

BackgroundPersonality disorders commonly coexist with alcohol use disorders (AUDs), but there is conflicting evidence on their association with treatment outcomes.AimsTo determine the size and direction of the association between personality disorder and the outcome of treatment for AUD.MethodWe conducted a systematic review and meta-analysis of randomised trials and longitudinal studies.ResultsPersonality disorders were associated with more alcohol-related impairment at baseline and less retention in treatment. However, during follow-up people with a personality disorder showed a similar amount of improvement in alcohol outcomes to that of people without such disorder. Synthesis of evidence was hampered by variable outcome reporting and a low quality of evidence overall.ConclusionsCurrent evidence suggests the pessimism about treatment outcomes for this group of patients may be unfounded. However, there is an urgent need for more consistent and better quality reporting of outcomes in future studies in this area.

Severe war-related trauma and personality pathology: a case-control study

BACKGROUND

Exposure to war-related trauma has long been recognised to have an adverse effect on mental health. We attempted to investigate whether people who have clinically significant personality-related problems 15 years after a war are more likely to have been exposed to severe war-related trauma than those who do not have significant personality difficulties.

METHODS

A case -control study was conducted in southern Croatia, fifteen years after the 1991-1995 war. We recruited 268 participants: 182 cases who scored positively on the International Personality Disorder Examination scale (IPDE), and 86 controls who were IPDE negative. Severity of war-related trauma was assessed according to the 17 items on the Harvard Trauma Questionnaire (HTQ) trauma event scale, which were considered to be of severe (catastrophic) nature based on the ICD-10 description of catastrophic trauma and the opinion of trauma experts. All participants also completed measures of mental health (depression, anxiety and PTSD), social functioning and current substance misuse.

RESULTS

Cases (IPDE positive) were eight times more likely to report exposure to severe war-related trauma than controls. This association increased after adjustments for demographic factors (OR = 10.1, 95% CI 5.0 to 20.4). The types of severe trauma most frequently reported were either the participants'own life being in direct danger or witnessing extreme violence inflicted on others or the result of violence towards others (murder, torture, seeing burned or disfigured bodies). Prevalences of depression, anxiety and PTSD were high among IPDE positive participants 15 years after exposure to war trauma. Their level of interpersonal dysfunction was considerably higher than that in controls (OR = 10.39, 95% CI 3.51 to 30.75). Alcohol consumption in cases was significantly higher with a mean of 14.24 units per week (sd = 11.03) when compared to controls whose mean number of alcohol units was 9.24 (sd = 7.25), t (73) = 2.16, p < 0.05, mean difference 4.99 (95% CI = 0.39 to 9.60). Similarly, a significantly higher number of cases reported current substance misuse (8.2% vs. 0.0%) X2 (1, n = 268) = 7.51, p < 0.05).

CONCLUSION

Exposure to severe war-related trauma is a risk factor for interpersonal dysfunction15 years after people were exposed to an armed conflict. These findings have implications for assessing and meeting the long-term mental health needs of people in war-affected regions. Further research needs to be done to increase our understanding about the relationship between severe war trauma and personality related problems.

Associations between personality disorder characteristics and treatment outcomes in people with co-occurring alcohol misuse and depression

BACKGROUND

Personality disorders are highly comorbid with alcohol misuse and depressive symptomatology; however, few studies have investigated treatment outcomes in this population. The aim of this study was to examine relationships between baseline personality disorder cluster profiles and overall and treatment-related changes for those with co-occurring alcohol misuse and depression.

METHODS

Secondary analysis was conducted using a subset of data (N = 290) from two randomised controlled trials of psychological interventions for co-occurring alcohol misuse and depression, which did not specifically target personality disorders. Baseline dimensional personality disorder cluster scores were derived from the International Personality Disorder Examination Questionnaire (IPDEQ). Four treatment conditions were compared: a brief integrated intervention, followed by no further treatment, or nine further sessions of integrated-, alcohol-, or depression-focused treatment. Associations between IPDEQ scores and changes in alcohol use, depressive symptoms and functioning from baseline to the 6- and the 12-month follow-ups were of primary interest.

RESULTS

Personality disorder cluster scores moderately negatively impacted on overall change (primarily Cluster C), as well as treatment-related outcomes (primarily Cluster A), particularly changes in depressive symptoms and psychosocial functioning. Longer interventions appeared to be more effective in the longer-term (e.g., at 12-month follow-up), with integrated interventions relatively more effective than single-focused ones for individuals with higher personality disorder cluster scores.

CONCLUSIONS

Greater attention needs to be paid to particular personality disorder clusters during the assessment and treatment of individuals with co-occurring alcohol misuse and depression. Integrated interventions, incorporating motivational interviewing and cognitive behaviour therapy, may provide a useful therapeutic framework. Integrated interventions also provide opportunities for adjunctive components focussing on other issues and coping strategies (e.g., to offset negative affective states), potentially tailored to the characteristics and needs of individual participants.

The two-faceted nature of impulsivity in patients with borderline personality disorder and substance use disorder

BACKGROUND

Impulsivity, which has been the subject of extensive debate in psychiatric research, is a clinically important concept, especially with respect to Borderline Personality Disorder (BPD) and Substance Use Disorders (SUD). The current study aims to examine the presence of two aspects of impulsivity (self-reported impulsivity and delay discounting) in patients with BPD, SUD (alcohol use=AUD or drug use=DUD) and the combination of both disorders (BPD+SUD).

METHODS

Patients were recruited from eight different mental health treatment service facilities. A total of 345 participants were assessed and divided into six groups: (1) healthy controls (non-BPD, non-SUD), (2) patients with BPD (non-SUD), (3) DUD (non-BPD), (4) AUD (non-BPD), (5) BPD+AUD and (6) BPD+DUD.

RESULTS

The behavioural measure of impulsivity is more conservative than the results of self-reported impulsivity. Furthermore, ANOVA indicated that BPD and SUD have significant effects on self-reported impulsivity, even when demographic variables, income, other psychiatric symptoms or depression are considered as covariates. On the other hand, the main effects of BPD and SUD are mediated by psychiatric symptoms and depression when delay discounting is considered as a dependent variable.

CONCLUSIONS

When self-reported, impulsivity is over-estimated as compared to reports based on behavioural measures. These results provide support for the notion that impulsivity is not a unitary construct, and that it instead has different manifestations in BPD and SUD patients.

A systematic review of interventions for co-occurring substance use and borderline personality disorders

ISSUES

The aim of this study was to undertake a systematic review on effective treatment options for co-occurring substance use and borderline personality disorders to examine effective treatments for this group.

APPROACH

A systematic review using a narrative analysis approach was undertaken as there were too few studies within each intervention type to undertake a meta-analysis. The inclusion criteria comprised of English language studies (between 1999 and 2014) and a sample of >70% borderline personality disorder, with measurable outcomes for substance use and borderline personality disorder. All abstracts were screened (n = 376) resulting in 49 studies assessed for eligibility, with 10 studies, examining three different treatment types, included in the final review.

KEY FINDINGS

There were four studies that examined dialectical behaviour therapy (DBT), three studies that examined dynamic deconstructive psychotherapy (DDP) and three studies that examined dual-focused schema therapy (DFST). Both DBT and DDP demonstrated reductions in substance use, suicidal/self-harm behaviours and improved treatment retention. DBT also improved global and social functioning. DFST reduced substance use and both DFST and DPP improved treatment utilisation, but no other significant positive changes were noted.

IMPLICATIONS

Overall, there were a small number of studies with small sample sizes, so further research is required. However, in the absence of a strong evidence base, there is a critical need to respond to this group with co-occurring borderline personality disorder and substance use.

CONCLUSION

Both DBT and DPP showed some benefit in reducing symptoms, with DBT the preferred option given its superior evidence base with women in particular.

Comorbid bipolar disorder and borderline personality disorder and substance use disorder

Bipolar disorder (BD) and borderline personality disorder (BPD) are disabling and life-threatening conditions. Both disorders share relevant comorbidities, particularly the risk of having a lifetime substance use disorder (SUD). We tested the hypothesis that patients with both BD type I (BDI) or II (BDII) and BPD would have a higher rate of SUD than would patients with either disorder alone. A total of 3651 psychiatric patients were evaluated with semistructured diagnostic interviews for Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, axis I and II disorders. A total of 63 patients were diagnosed with both BD and BPD, and these patients were significantly more likely to have a SUD compared with BDII patients without BPD (76% vs. 50%, χ = 9.69, p < 0.01). There were no differences when comparing the comorbid group with BPD patients without BD (76% vs. 71%, χ = 0.519, p = 0.4). The present study shows the importance of taking both BPD and BD into consideration insofar as the co-occurrence of the disorders increased the risk of having a SUD especially when compared with BDII alone.

The impact of personality disorders on legally supervised community treatment: a systematic literature review

Mental health needs are common among community corrections offenders and many are enrolled in some form of supervised or mandated treatment. One category of mental health problem which may be germane to both treatment completion and recidivism among those in legally supervised treatment is the diagnosis of Personality Disorder (PD). This systematic review reports on sixteen studies comprised of full or mixed legally-supervised samples of offender in community-based treatment and examines the impact of PDs on treatment completion. These studies were difficult to compare because of the differences in program setting, definition of treatment completion, definition of PD, method of PD assessment and type of treatment, among other variables. The impact of antisocial personality disorder in treatment was a common focus, and other PDs were rarely assessed. The relevance of DSM PD categories to offender management in community corrections as well as the limitations of the current PD diagnostic categories is discussed.

Screening for personality disorder in drug and alcohol dependence

Comorbidity of personality disorders in addiction is common, and there is a need for efficient detection methods. This study describes the use of two quick screening instruments: the self-reported versions of the Iowa Personality Disorder Screen (IPDS-SR) and the Standardised Assessment of Personality Abbreviated Scale (SAPAS-SR). The sample included 53 inpatients dependent on alcohol and/or drugs, with a 42% prevalence of any DSM-IV personality disorder. The Personality Assessment Schedule (PAS) was used as gold standard. Receiver-Operant-Characteristic (ROC) was used for analysis. The Area Under the Curve for the IPDS-SR was 0.84 (95% CI 0.72-0.93) and for the SAPAS-SR was 0.82 (95% CI 0.70-0.93). An IPDS-SR score of 5 or more correctly classified 77.4% of patients, with a sensitivity of 86.4% and a specificity of 71%. A SAPAS-SR score of 4 or more correctly classified 73.6% of patients, with a sensitivity of 81.8% and a specificity of 67.7%. Both instruments were quick, easy to administer, and acceptable to use by this population. They can be implemented in routine clinical practice in busy substance misuse departments. However further research into the implications of positive screenings is required.

Personality disorders in addiction outpatients: prevalence and effects on psychosocial functioning

AIM

To evaluate the prevalence of personality disorders (PDs) in the outpatients attending an addiction service, with particular attention to the effects of PDs on social and occupational functioning and on the intensity of treatment required.

DESIGN

A cross-sectional epidemiological study with the assessment of 320 outpatients, through SCID-II (Structured Clinical Interview for DSM-IV Axis II PDs), SOGS (South Oaks Gambling Screen), and questionnaire extracted from EuropASI.

RESULTS

The percentage prevalence of PDs was 62.2% (confidence interval at 95% (95% CI): 57–68). PDs were positively associated with placement in an addiction treatment community (odds ratio (OR) = 2.98, CI = 1.77–5.03), having received lifetime treatment at the mental health center (MHC) (OR = 3.67, CI = 1.67–8.07) or having attempted suicide (OR = 2.30, CI = 1.05–5.02). Furthermore, PDs were related to a reduced probability of keeping a job (OR = 0.54, CI = 0.31–0.95) or starting a family (OR = 0.51, CI = 0.30–0.87).

CONCLUSION

Axis II comorbidity occurs in 62% of addiction outpatients and has substantial effects on social and occupational functioning as well as on treatment programs.

Differences between axes depend on where you set the bar: associations among symptoms, interpersonal relationship and alexithymia with number of personality disorder criteria

Personality disorders are better understood as entities that vary according to severity along specific domains rather than a phenomenon separate from and unrelated to Axis I disorders. This study explores whether patients who were rated as having greater numbers of personality disorder traits reported greater levels of interpersonal problems, psychiatric symptoms, and alexithymia. The sample was composed of 506 consecutive patients assessed in a private outpatient center who were administered the SCID-II Symptom-Checklist (SCL-90-R), Inventory of Interpersonal Problems (IIP-47), and Toronto Alexithymia-Scale (TAS-.20). Based upon the number of personality disorder traits identified in the SCID, participants were classified into five groups: 0-4, 5-9, 10-14, 15-19, and 20 or more personality disorder traits met. Comparisons between groups revealed that symptom severity and levels of interpersonal problems increased between groups as the number of personality disorder traits increased. After covarying for symptom severity, there were no significant between-groups differences for levels of alexithymia. Findings are consistent with the claims that the simple Axis I-Axis II distinction is not an optimal strategy to understand personality pathology. It instead may be more fruitful to consider group differences in terms of numbers of personality disorder traits met.

Cocaine abuse or dependency and other pyschiatric disorders. Madrid study on dual pathology

OBJECTIVES

The main objective of this study was to analyse the cocaine addict subgroup from the Madrid study of prevalence of dual disorders in community mental health and substance misuse services.

MATERIAL AND METHODS

The sample consisted of 837 outpatients from Madrid, Spain. We compared 488 subjects who had a lifetime diagnosis of cocaine abuse or dependence, and 222 subjects who did not have a cocaine substance use disorder. We used the Mini International Neuropsychiatric Interview to evaluate axis I mental disorders, and the Personality Disorder Questionnaire to evaluate personality disorders.

RESULTS

Almost three-quarters (73.4%) of cocaine addicts had a current dual disorder. Most prevalent were mood and anxiety disorders. Almost half (49.6%) had a personality disorder. Most of them (94.9%) had other substance use disorders. Cocaine addicts did not have higher prevalence rates of dual pathology than addicts with no cocaine abuse or dependence. Cocaine addicts were associated to a diagnosis of antisocial personality disorder, agoraphobia, and post-traumatic stress disorder, and they had an early age of onset of alcohol and cannabis use.

CONCLUSIONS

Dual pathology is no higher in cocaine addicts in treatment than in addicts who do not use cocaine, however cocaine addicts started other drugs earlier, and were associated with specific mental disorders.

A voxel-based morphometry study comparing problem gamblers, alcohol abusers, and healthy controls

BACKGROUND

Alcohol use disorders (AUDs) are associated with smaller grey matter volumes in cortical and subcortical brain regions which are related to cognitive impairments often found in these disorders. Similar cognitive impairments have been found in patients suffering from problem gambling behaviour. However, in contrast to AUDs, gambling behaviour does not entail brain exposure to toxic agents. Although there are many clinical, neuropsychological, and neurobiological similarities between PG and substance use disorders it has not yet been established whether pathological gambling, similar to alcohol use disorders, is associated with abnormal regional grey matter volumes.

METHODS

With whole-brain voxel-based morphometry we compared a group of 40 treatment seeking problem gamblers, 36 subjects with an alcohol use disorder, and 54 healthy controls to evaluate potential group differences in regional grey matter volumes, corrected for age, IQ, smoking status, and total intracranial volume (TIV).

RESULTS

Significantly smaller grey matter volumes in left superior frontal cortex, left precentral cortex, right insula, right putamen, left thalamus, bilateral superior parietal cortex and right supramarginal cortex were present in subjects with an alcohol use disorder compared to healthy controls and problem gamblers. No significant grey matter volume differences were present between problem gamblers and healthy controls.

CONCLUSION

In conclusion, we replicated previous findings of smaller grey matter volumes in subjects with an alcohol use disorder and found no significant morphological brain abnormalities in problem gamblers.

BAP updated guidelines: evidence-based guidelines for the pharmacological management of substance abuse, harmful use, addiction and comorbidity: recommendations from BAP

The British Association for Psychopharmacology guidelines for the treatment of substance abuse, harmful use, addiction and comorbidity with psychiatric disorders primarily focus on their pharmacological management. They are based explicitly on the available evidence and presented as recommendations to aid clinical decision making for practitioners alongside a detailed review of the evidence. A consensus meeting, involving experts in the treatment of these disorders, reviewed key areas and considered the strength of the evidence and clinical implications. The guidelines were drawn up after feedback from participants. The guidelines primarily cover the pharmacological management of withdrawal, short- and long-term substitution, maintenance of abstinence and prevention of complications, where appropriate, for substance abuse or harmful use or addiction as well management in pregnancy, comorbidity with psychiatric disorders and in younger and older people.

Personality differences between drug injectors and non-injectors among substance-dependent patients in substitution treatment

BACKGROUND

Understanding personality differences between injectors and non-injectors in substitution treatment may provide new insights to help improve treatment programs.

OBJECTIVE

The aim of this study was to compare drug injectors and non-injectors in terms of personality disorders and dimensions.

METHODS

Forty participants recruited from substance abuse treatment centers (23 injectors and 17 non-injectors) completed the self-report Personality Diagnostic Questionnaire 4th version and Temperament and Character Inventory. Mann-Whitney U tests were used to compare means of personality disorder traits, temperament, and character differences between injectors and non-injectors.

RESULTS

The mean (SD) age of the sample (72.5% male) was 36.5 (8.7) years. Injectors reported more borderline personality disorders and increased global personality disturbance (p < .05). Similarly, Anticipatory worry, Shyness, and Fatigability facet scores were higher among injectors (p < .01). Attachment, Purposeful, and Congruent second nature facet scores were higher among non-injectors (p < .01).

CONCLUSION

According to the route of drug administration, drug dependents differed in terms of personality disorders and dimensions.

SCIENTIFIC SIGNIFICANCE

These results may have implications for the implementation of treatment programs. New research in this area may contribute to the understanding and prevention of intravenous drug use.

Pathological personality traits among patients with absent, current, and remitted substance use disorders

Personality traits may provide underlying risk factors for and/or sequelae to substance use disorders (SUDs). In this study Schedule for Nonadaptive and Adaptive Personality (SNAP) traits were compared in a clinical sample (N=704, age 18-45) with current, past, or no historical alcohol or non-alcohol substance use disorders (AUD and NASUD) as assessed by DSM-IV semi-structured interview. Results corroborated previous research in showing associations of negative temperament and disinhibition to SUD, highlighting the importance of these traits for indicating substance use proclivity or the chronic effects of substance use. Certain traits (manipulativeness, self-harm, disinhibition, and impulsivity for AUD, and disinhibition and exhibitionism for NASUD) were higher among individuals with current relative to past diagnoses, perhaps indicating concurrent effects of substance abuse on personality. The positive temperament characteristics detachment and entitlement distinguished AUDs and NASUDs, respectively, perhaps clarifying why this higher order trait tends to show limited relations to SUD generally. These findings suggest the importance of systematically integrating pathological and normative traits in reference to substance-related diagnosis.

Problem drug use, drug misuse and deliberate self-harm: trends and patient characteristics, with a focus on young people, Oxford, 1993-2006

BACKGROUND

Drug misuse is related to self-harm and suicide. However, relatively little is known about deliberate self-harm (DSH) in patients with drug problems and whether drug misuse by DSH patients is increasing.

METHODS

We used data collected by the Oxford Monitoring System for Attempted Suicide to study the characteristics of DSH patients with drug problems who presented to the general hospital in Oxford between 1993 and 2006, and who underwent psychosocial assessment at their first presentation in the study period. We also studied trends in problem drug use and drugs misused over this period.

RESULTS

During the 14-year study period, 11,426 patients presented of whom 9,248 underwent psychosocial assessment and it was known whether or not they had a drug problem. Problem drug use was present in 805/9,248 (8.7%) patients. Problem drug use was more common in males (13.6%) than in females (5.3%). Problem drug users were younger, more likely to be socially disadvantaged, to have a personality disorder and comorbid alcohol problems and to have a further episode of DSH within a year. Problem drug use in young females was associated with higher suicidal intent scale (SIS) scores. During the study period, problem drug use and drug misuse increased in females, but not in males. Cannabis and cocaine misuse increased with time.

CONCLUSIONS

Provision of help for DSH patients with problem drug use is particularly challenging due to their complex social and clinical characteristics and increased risk of further self-harm, suicide and accidental death. It may require extensive liaison between different services. The increasing misuse of drugs by female DSH patients and the higher SIS scores of young females are of concern.

Association between peptic ulcer and personality disorders in a nationally representative US sample

OBJECTIVE

To assess the association between peptic ulcer and a wide range of personality disorders in a large sample representative of the general population in the United States.

METHODS

Data were drawn from the National Epidemiologic Survey on Alcohol and Related Conditions, on the basis of a face-to-face interview of more than 43,000 adults. Univariate and multivariate logistic regression were used to examine the relationship between self-reported "stomach ulcer" and personality disorders.

RESULTS

All seven personality disorders assessed in the National Epidemiologic Survey on Alcohol and Related Conditions (i.e., avoidant, dependent, obsessive-compulsive, paranoid, schizoid, histrionic, and antisocial personality disorders) were associated with stomach ulcer, with odds ratio ranging from 2.26 (obsessive compulsive personality disorder) to 5.54 (dependent personality disorder). Participants with ulcer were five times more likely to have more than three personality disorders than participants without ulcer. The relationship between ulcer and personality disorders was only slightly attenuated after adjusting for sociodemographic conditions, physical and psychiatric disorders, and addictions.

CONCLUSIONS

Self-reported peptic ulcer is associated with increased rates of personality disorders, beyond the influence of psychiatric disorders or addictions.

The effect of referral for brief intervention for alcohol misuse on repetition of deliberate self-harm: an exploratory randomized controlled trial

BACKGROUND

Referral for brief intervention among people who misuse alcohol is reported to be effective but its impact among those who present to services following deliberate self-harm (DSH) has not been examined.

METHOD

Consecutive patients who presented to an Emergency Department (ED) following an episode of DSH were screened for alcohol misuse. Those found to be misusing alcohol were randomly assigned to brief intervention plus a health information leaflet or to a health information leaflet alone. The primary outcome was whether the patient reattended an ED following a further episode of DSH during the subsequent 6 months. Secondary outcomes were alcohol consumption, mental health and satisfaction with care measured 3 and 6 months after randomization.

RESULTS

One hundred and three people took part in the study. Follow-up data on our primary outcome were obtained for all subjects and on 63% for secondary outcomes. Half those referred for brief intervention received it. Repetition of DSH was strongly associated with baseline alcohol consumption, but not influenced by treatment allocation. There was a non-significant trend towards the number of units of alcohol consumed per drinking day being lower among those randomized to brief intervention.

CONCLUSIONS

Referral for brief intervention for alcohol misuse following an episode of DSH may not influence the likelihood of repetition of self-harm. Longer-term interventions may be needed to help people who deliberately harm themselves and have evidence of concurrent alcohol misuse.

Personality disorder: a new global perspective

Personality disorder is now being accepted as an important condition in mainstream psychiatry across the world. Although it often remains unrecognized in ordinary practice, research studies have shown it is common, creates considerable morbidity, is associated with high costs to services and to society, and interferes, usually negatively, with progress in the treatment of other mental disorders. We now have evidence that personality disorder, as currently classified, affects around 6% of the world population, and the differences between countries show no consistent variation. We are also getting increasing evidence that some treatments, mainly psychological, are of value in this group of disorders. What is now needed is a new classification that is of greater value to clinicians, and the WPA Section on Personality Disorders is currently undertaking this task.

Comorbid psychiatric disorders in substance dependence patients: A control study

BACKGROUND

The purpose of this study was to investigate the comorbidity of mental disorders among a random sample of substance dependence patients from a psychiatric inpatients department and the general population.

MATERIALS AND METHODS

Comprehensive data was collected from inpatients with substance abuse/dependence and comorbidity of mental disorders at the Ranchi Institute of Neuropsychiatry and Allied Sciences (RINPAS) and from normal controls from the general population during the period January 2007 to May 2007.

RESULTS

The results show that the most prevalent comorbid disorders in substance dependence patients and substance abusers were depressive disorders.

CONCLUSIONS

The majority of substance dependence patients suffered from comorbid mental disorders. Comorbidity needs to be taken into account when analyzing the relationship between substance dependence and depression and in planning treatment strategies for comorbid conditions.

The Alcohol Use Disorders Identification Test (AUDIT): reliability and validity of the Greek version

BACKGROUND

Problems associated with alcohol abuse are recognised by the World Health Organization as a major health issue, which according to most recent estimations is responsible for 1.4% of the total world burden of morbidity and has been proven to increase mortality risk by 50%. Because of the size and severity of the problem, early detection is very important. This requires easy to use and specific tools. One of these is the Alcohol Use Disorders Identification Test (AUDIT).

AIM

This study aims to standardise the questionnaire in a Greek population.

METHODS

AUDIT was translated and back-translated from its original language by two English-speaking psychiatrists. The tool contains 10 questions. A score >or= 11 is an indication of serious abuse/dependence. In the study, 218 subjects took part: 128 were males and 90 females. The average age was 40.71 years (+/- 11.34). From the 218 individuals, 109 (75 male, 34 female) fulfilled the criteria for alcohol dependence according to the Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV), and presented requesting admission; 109 subjects (53 male, 56 female) were healthy controls.

RESULTS

Internal reliability (Cronbach alpha) was 0.80 for the controls and 0.80 for the alcohol-dependent individuals. Controls had significantly lower average scores (t test P < 0.001) when compared to the alcoholics. The questionnaire's sensitivity for scores >8 was 0.98 and its specificity was 0.94 for the same score. For the alcohol-dependent sample 3% scored as false negatives and from the control group 1.8% scored false positives. In the alcohol-dependent sample there was no difference between males and females in their average scores (t test P > 0.05).

CONCLUSION

The Greek version of AUDIT has increased internal reliability and validity. It detects 97% of the alcohol-dependent individuals and has a high sensitivity and specificity. AUDIT is easy to use, quick and reliable and can be very useful in detection alcohol problems in sensitive populations.

Treatment-naive active alcoholics have greater psychiatric comorbidity than normal controls but less than treated abstinent alcoholics

BACKGROUND

Most alcoholism research in the U.S. uses convenience samples of treated alcoholics. The findings from treated samples have traditionally been applied to all alcoholics, including the 75% of alcoholics who are untreated. Improper generalization from select samples to an entire population is called 'Berkson's fallacy'. We compared untreated versus treated alcoholics, in order to ascertain whether both groups belonged to the same population with regard to psychiatric comorbidity.

METHODS

We compared psychiatric comorbidity in 1) active treatment-naive alcoholics (TNA; n=86) 2) treated long-term abstinent alcoholics (TAA; n=52) and 3) non-alcoholic controls (NAC;n=118). We examined lifetime and current diagnoses, lifetime symptom counts, and psychological measures in the anxiety, mood and externalizing disorder domains.

RESULTS

TNA did not differ from NAC in psychiatric diagnosis rates, were abnormal compared to NAC on all psychological measures, had more externalizing symptoms than NAC, and showed a strong trend for men to have more symptoms in the mood and anxiety domains. TAA compared to TNA had higher diagnosis rates (all domains), symptom counts (all domains), and psychological measures of deviance proneness, but were comparable to TNA on anxiety and mood psychological measures.

CONCLUSIONS

The abnormal thinking (psychological measures) in TNA (versus NAC) does not extend to behavior (symptoms) to the degree that it does in TAA. These results underline the importance of the use of subdiagnostic measures of psychiatric comorbidity in studies of alcoholics. The finding of lesser comorbidity in TNA versus TAA confirms the presence of Berkson's fallacy in generalizing from treated samples to all alcoholics.

The prevalence of personality disorder in schizophrenia and psychotic disorders: systematic review of rates and explanatory modelling

BACKGROUND

Personality disorder (PD) in psychosis is poorly studied. As PD can affect outcome in mental disorders, it is important to understand its prevalence in order to plan services, understand prognosis more fully and maximize management options. MethodLiterature searching revealed 3972 potential papers. Twenty papers including 6345 patients were included in the final analysis. There was great variation in prevalence and multilevel modelling was used to identify possible reasons for this heterogeneity.

RESULTS

The prevalence of PD varied from 4.5% to 100%. Multilevel analysis suggested country of study, study type, the instruments used to diagnose PD and patient care correlated with the prevalence data explaining the study level heterogeneity, with 34.2, 33.4, 17.0 and 4.5% by each variable respectively. Personality studies in Canada and Sweden reported lower PD prevalence, whereas in Spain it was higher than the multinational study. Compared with randomized controlled trials, case-control studies reported lower prevalence [odds ratio (OR)=0.35, 95% confidence interval (CI) 0.15-0.79] and observational studies higher prevalence (OR 70.5, 95% CI 8.5-583). Primary-care patients were less likely to be diagnosed (OR 0.02, 95% CI 0-0.19) than hospital patients, and out-patients had higher prevalence (OR 12.5, 95% CI 1.77-88.6).

CONCLUSIONS

The reported prevalence of PD in schizophrenia varies significantly. Statistical modelling suggests care, country, study type and diagnostic tools for PD all bias prevalence rates. The number of papers reaching the inclusion criteria, the relative paucity of information and the difficulties in developing an accurate statistical model limited interpretation from the study.

Inter-rater agreement of comorbid DSM-IV personality disorders in substance abusers

BACKGROUND

Little is known about the inter-rater agreement of personality disorders in clinical settings.

METHODS

Clinicians rated 75 patients with substance use disorders on the DSM-IV criteria of personality disorders in random order, and on rating scales representing the severity of each.

RESULTS

Convergent validity agreement was moderate (range for r = 0.55, 0.67) for cluster B disorders rated with DSM-IV criteria, and discriminant validity was moderate for eight of the ten personality disorders. Convergent validity of the rating scales was only moderate for antisocial and narcissistic personality disorder.

DISCUSSION

Dimensional ratings may be used in research studies and clinical practice with some caution, and may be collected as one of several sources of information to describe the personality of a patient.

Treating patients with two or more personality disorders: an introduction

A high percentage of patients diagnosed with one personality disorder (PD) have, at the same time, at least one other PD. However, psychotherapists lack clinical guidance and research evidence on treating such complex patients. This issue of the Journal of Clinical Psychology: In Session attempts to bridge the gap. In this Introduction, the editors outline the subsequent articles in this issue and address the terminology, prevalence, and possible causes of Axis II comorbidity. They argue that comorbidity is, in part, ascribable to problems in classification systems and can be reduced by defining PDs in a more multifaceted manner. They provide several clinical vignettes to portray frequent difficulties encountered by psychotherapists in treating these complex, co-occurrent cases.

Critical developments in the assessment of personality disorder

BACKGROUND

The assessment of personality disorder is currently inaccurate, largely unreliable, frequently wrong and in need of improvement.

AIMS

To describe the errors inherent in the current systems and to indicate recent ways of improving personality assessment.

METHOD

Historical review, description of recent developments, including temporal stability, and of studies using document-derived assessment.

RESULTS

Studies of interrater agreement and accuracy of diagnosis in complex patients with independently established personality status using document-derived assessment (PAS-DOC) with a four personality cluster classification, showed very good agreement between raters for the flamboyant cluster B group of personalities, generally good agreement for the anxious/dependent cluster C group and inhibited (obsessional) cluster D group, but only fair agreement for the withdrawn cluster A group. Overall diagnostic accuracy was 71%.

CONCLUSIONS

Personality function or diathesis, a fluctuating state, is a better description than personality disorder. The best form of assessment is one that uses longitudinal repeated measures using a four-dimensional system.

MMPI-2 clusters of alcohol-dependent patients and the relation to Cloninger's temperament-character inventory

OBJECTIVE

Psychometric research in the field of alcohol dependence has concentrated on identifying certain (personality) characteristics (i.e. typologies). This paper is aimed to identify such typologies and studies the relation of the Minnesota Multiphasic Personality Inventory-2 (MMPI-2) and Cloninger's temperament-character inventory (TCI).

METHOD

To find MMPI-2 scales associated with maximization of group differences between 222 DSM-IV alcohol dependent inpatients and a control group of 222 normal subjects, discriminant analysis was used. In addition, a cluster analysis was performed with these scales, and the MMPI-2 mean scale values of the resulting patient clusters were examined for their TCI-correlates.

RESULTS

The discriminant analyses showed several MMPI-2 scales that could clearly distinguish between alcohol-dependent patients and the normal controls. Cluster analysis resulted in semantically different MMPI-2 profiles implying qualitatively different groups of patients. When related to TCI scales, these differences revealed harm avoidance, self-directedness, and persistence, amongst others, as important elements in the description of the clusters.

CONCLUSION

Evidence for the validity of MMPI-2 constructs as well as those of the TCI in the assessment of alcohol-dependent patients was provided.

Psychiatric comorbidity in long-term abstinent alcoholic individuals

BACKGROUND

A high prevalence of comorbid psychiatric disorders has been demonstrated in individuals with an alcohol use disorder in both community and treatment samples, with higher comorbidity in treatment samples. In this study, we examined lifetime and current psychiatric diagnoses in long-term abstinent alcoholic individuals (LTAA; mean abstinence=6.3 years; n=52) compared with age and gender-comparable non-alcoholic controls (NC; n=48). We asked the following questions: (1) to achieve long-term abstinence, must an individual be relatively psychiatrically healthy (i.e., comparable with NC) and (2) can ongoing abstinence be maintained in the face of a current psychiatric disorder?

METHODS

Lifetime and current (prior 12 months) psychiatric diagnoses were assessed in the mood, anxiety, and externalizing disorder domains using the computerized Diagnostic Interview Schedule (c-DIS).

RESULTS

Over 85% of LTAA had a lifetime psychiatric diagnosis, compared with 50% of NC. Long-term abstinent alcoholic individuals had a higher prevalence than NC of lifetime mood, anxiety, and externalizing disorder diagnoses. Long-term abstinent alcoholic individuals also had a greater prevalence than NC of current mood and anxiety diagnoses. Although LTAA had a greater lifetime prevalence of an antisocial personality disorder (ASPD) than NC, no LTAA or NC had a current ASPD diagnosis. Finally, there was no association of duration of abstinence with lifetime or current psychiatric diagnoses, consistent with psychiatric diagnoses having little effect on relapse.

CONCLUSIONS

Our results suggest that: (1) the presence of a lifetime psychiatric diagnosis does not militate against achieving long-term abstinence, (2) abstinence can be maintained in the presence of a current mood or anxiety disorder, and (3) a current diagnosis of ASPD may not be compatible with long-term abstinence. The relatively low levels of antisocial behavior compared with preabstinence (as indicated by no LTAA meeting current criteria for ASPD) raises the question of whether the neurobiology underlying antisocial behavior is changed in abstinence, or brought under increased executive control, or both.

Personality disorders among danish alcoholics attending outpatient treatment

The aim of the present study was firstly to describe the characteristics of alcoholic outpatients (A) suffering from co-morbid personality disorder (PD) of either the cluster B (A+PDB) or cluster C (A+PDC) type. Secondly, to investigate the effect of various kinds of treatment to be able to single out the most beneficial therapy. Thirdly, to identify the most beneficial treatment. The patients were offered the following outpatient treatments: cognitive behaviour therapy, family therapy and supportive consultations. The material consisted of 363 patients who started psychosocial treatment at the outpatient alcohol clinic at Odense University Hospital, Denmark. It was possible to re-interview 276 (76%) patients 1 year after onset of treatment. Of the 363 patients, 87% were alcohol-dependent (ICD-10) and 34% fulfilled the ICD-10-R criteria for PDs. The basic interviews focused on the seven main areas of the Addiction Severity Index. A+PDC had significantly more serious medical problems than A-PD, while the A+PDB group had significantly more employment, drug use and social problems than the A-PD. As for psychiatric status, A-PD had significantly different scores compared with A+PDB and A+PDC. A+PDB were younger and had a longer history of alcohol abuse than A-PD and A+PDC. After treatment there was no significance between the patients with and without PD concerning alcohol outcome and psychosocial outcome. The significance of co-morbid PD for the prognosis of alcohol abusers may be overestimated. Our results indicate that A+PD can be treated as successfully as other patients in an outpatient alcohol clinic can.

Cluster C personality disorders in major depressive episodes: the relationship between hostility and suicidal behavior

There is some evidence for an association between Cluster C Personality Disorders (CCPD) and suicidal behavior. We compared depressed inpatients with and without CCPD in terms of suicidal behavior and associated psychopathology. Cluster A or B personality disorder co-morbidity were exclusion criteria for both groups (cases and controls). Depressed inpatients with "pure" CCPD had higher levels of suicidal ideation but not more previous suicide attempts compared with patients without CCPD. Greater suicidal ideation in depressed patients with CCPD in our study was associated with more hostility. Future studies examining the relationship between suicidal ideation and hostility in CCPD may clarify whether treatment focused on hostility might be of use for decreasing suicidal ideation in depressed patients with CCPD (Spitzer, Williams, Gibbon et al., 1990).

Decision-Making Deficits in Alcohol-Dependent Patients With and Without Comorbid Personality Disorder

BACKGROUND

Impairments in decision making are a consistent finding in substance use disorder (SUD) populations. However, decision-making deficits are not specific for SUDs and are also reported in the context of other psychiatric disorders such as antisocial and borderline personality disorders (PDs). Given the frequent comorbidity between SUD and cluster B PD, it might be questioned whether the decision-making impairments typically reported in SUD populations reflect the addictive disorder, the cluster B PD, or a combination of the 2.

METHODS

In the current study, we compare the decision-making performance of non-substance-abusing controls (n=53) on the Iowa Gambling Task (IGT) with the decision-making performance of 3 abstinent alcohol-dependent samples, i.e., alcoholic patients without any PD (n=38), alcoholic patients with a cluster A or C PD (n=19), and alcoholic patients with a cluster B PD (n=23).

RESULTS

Overall, all 3 alcohol-dependent subsamples performed inferior compared with controls. Between alcoholic subsamples, the alcoholic patients with a cluster A or C PD had the highest IGT score, followed by the alcoholic patients without a PD, while the cluster B alcoholic patients were the most impaired.

CONCLUSION

These findings suggest that impairments in decision making underlie both alcohol dependence and cluster B PD, and alcoholic patients with a comorbid cluster B PD are particularly impaired in their decision making. These deficits may underlie the severe problems that characterize cluster B alcoholic patients specifically in inappropriate behaviors (e.g., poly substance abuse, legal, and professional dysfunction).

Personality disorders in alcoholics: a comparative pilot study between the IPDE and the MCMI-II

In this paper, the most frequent personality disorders (PDs) related to alcoholism are described. 105 participants took part in the study (50 consecutively recruited treatment-seeking alcoholics and 55 subjects from the general population). All subjects were assessed with the IPDE and the MCMI-II. According to the results in the IPDE, 22% of alcoholics, versus 7.27% of the normal sample, showed at least one PD. The most prevalent PDs were the Avoidance personality disorder (10%), followed by the Non-specified (8%) and Borderline (6%). When the MCMI-II was used a significantly higher prevalence of PDs was observed (52% in alcoholics and 18.1% in the normal sample), without coincidence in the kind of PDs diagnosed. This lack of consistency is probably related to the assessment tools, mainly the IPDE, which is more accurate and conservative than self-report inventories, which present a tendency for over-diagnosis.