Substance-use situations and abstinence predictions in substance abusers with and without personality disorders
Deborah H.A. Van Horn
Numerous studies of substance-abuse patients have found that their rates of Axis II personality disorders (PDs) are consistently higher than in the general population (1). Comorbid PDs are believed to complicate the treatment of addicted patients. Patients with Axis II diagnoses are described as more resistant to entering treatment, less compliant with treatment, more prone to behavior that disrupts the course of treatment, and less responsive to traditional treatment for substance abuse (1-3). Psychopathology may be a risk factor for addiction, a modifier of the course of addiction, or a result of addictive behavior, and it may not always be possible to determine whether the addiction or the PD is “primary” (1, 2, 4). Regardless of the etiology of the two disorders, substance-abuse patients with PDs present “sicker” and more complex clinical pictures. In comparisons of substance-abuse patients with and without PDs, those with PDs consistently have an earlier onset of their substance-abuse problems, higher rates of polysubstance dependence, and more psychiatric symptoms (1). In addition, studies have found substance-abuse patients with PDs to be less educated, less likely to be married, and to have more legal problems, more accidents, more medical problems, and less life satisfaction than patients without Axis II diagnoses (1, 5-7). Substance abusers with Antisocial PD also engage in more risk behaviors for acquiring human immunodeficiency virus (HIV) and are more likely to be infected with HIV than those without this disorder (8, 9). Therefore, despite the well-documented difficulty in obtaining reliable diagnoses of PDs in individuals in treatment for substance abuse (10-12), the presence of a such a diagnosis upon entry into treatment is likely to have clinical significance. The heterogeneity of the dually diagnosed population makes it difficult to find global differences in course of treatment or outcome between patients with and without PDs. The presence of certain PDs may predict poorer response to treatment (6, 13, 14); however, others have found no differences in treatment retention and outcome between personality-disordered and other substance-abuse patients (15, 16).
In addition to having more severe substance-use disorders and life problems, personality-disordered patients may use substances differently than their peers without Axis II diagnoses, and differ in their confidence in their ability to remain abstinent–or “self-efficacy” for abstinence–in future common substance-use situations. Perceived self-efficacy, or judgment of one’s ability to organize and execute a particular behavioral response in a given situation, has been posited by social-learning theorists to play a central role in self-regulation, determining in large part the behavioral responses individuals are willing to attempt (17). Self-efficacy for abstinence is central to a social-learning model of relapse in the addictions: substance abusers’ confidence in their ability to cope with “high-risk” situations without turning to substance use determines in part the likelihood of their remaining abstinent when such situations arise (18).
Different patterns of substance use and self-efficacy for future abstinence would therefore imply differences in risk for relapse under different circumstances, and necessitate tailoring treatments to the unique needs of subgroups of patients. Some authors have suggested that addicts with PDs are more likely to resort to addictive behavior to cope with stress and the overwhelming dysphoria they feel in stressful circumstances (19, 20). The little research that has been done supports the notion that substance abusers with PDs drink or use drugs to manage moods–both good and bad–and to “enhance functioning,” but that they are less likely to report cravings when under situational stress than substance abusers without PDs (7, 21). The existing literature is limited, in that comparisons are made only between patients with and without any Axis II diagnosis or patients with and without Borderline PD, ignoring the heterogeneity of the dually diagnosed population. Moreover, drinking and drug-use situations are delineated very broadly, making these studies difficult to interpret. Furthermore, although cognitive factors such as self-efficacy have been implicated in the relapse process (18), there have been no studies of self-efficacy for abstinence in substance abusers with PDs. In this report, data from diagnostic evaluations, and measures of drinking and drug-use situations and self-efficacy for abstinence, obtained from 339 consecutive patients admitted to a substance-abuse unit of a private psychiatric hospital, are used to examine clinical correlates of PDs in substance abusers. Particular attention is given to patterns of alcohol and drug use and self-efficacy in personality-disordered patients.
Subjects were 339 consecutive patients admitted to the inpatient adult chemical-dependency unit of a private psychiatric hospital from June 1990 to April 1993. The subjects ranged in age from 17-71 years, with a mean of 35.0 years (SD = 11.1). Thirty percent were female. All met criteria for at least one psychoactive substance-use disorder.
Demographic data. Demographic data (age, marital status, work status, and education) were obtained in the course of the diagnostic interview.
Diagnosis. Diagnoses were determined with the Structured Clinical Interview for DSM-III-R, Patient Version (SCID-P, 22), and the Structured Clinical Interview for DSM-III-R Personality Disorders (SCID-II; 23). These well-validated, widely used, semistructured interviews rely on both subjects’ self-reported information and interviewer judgment to arrive at DSM-III-R (24) diagnoses. They were administered by experienced master’s-level clinicians trained by one of us (A.F.F.). In the SCID-II interview, the interviewers attempted to evaluate long-term patterns of clinically relevant behavior that existed even during periods of abstinence from alcohol and drugs; however, in cases of near-continuous substance use, the interviewers relied on clinical judgment to determine whether the behavior patterns reported in response to interview prompts were clinically significant and unlikely to be a direct result of intoxication or withdrawal. As part of their administration of the SCID-P, the clinical evaluators completed the Global Assessment Scale (GAS; 25), indicating subjects’ overall level of psychosocial functioning.
Substance-use situations. Antecedents of subjects’ addictive behavior were assessed with the Inventory of Drinking Situations (IDS; 26), a self-report measure assessing the frequency of heavy drinking or drug use in various situations in the preceding year. Subjects indicated how much of the time they drank or used drugs in 100 situations classified as unpleasant emotions, physical discomfort, pleasant emotions, testing personal control, urges and temptations, conflict with others, social pressures to drink/use, and pleasant times with others. Scores on these scales were classified as “low risk” (33% or less), “moderate risk” (34-66%), or “high risk” (67% or greater). For the present analysis, response categories of “moderate” and “high” risk were grouped together.
Self-efficacy. Self-efficacy for abstaining from addictive behavior was assessed with the Situational Confidence Questionnaire (SCQ; 27), a self-report measure asking subjects to rate, on a scale of 0-100%, their confidence that they would be able to resist the urge to drink or use drugs heavily in 39 situations classified as negative emotions/frustrations, physical discomfort, social tensions, pleasant emotions, positive social situations, urges and temptations, testing personal control, and social problems at work. The first seven scales correspond to similarly named scales on the IDS. Scale scores were classified as “low risk” (67% or greater), “moderate risk” (34-66%), or “high risk” (33% or less). For the present analysis, response categories of “moderate” and “high” risk were grouped together.
Subjects completed the diagnostic interviews and other measures as part of their evaluation following the initial detoxification period (approximately 1 week) in the hospital. Diagnostic interviews were typically completed in two sessions on the same day or consecutive days; the other measures were administered in a separate session. Of 339 subjects who completed diagnostic interviews, 242 completed substance-use and self-efficacy measures. There were no demographic or diagnostic differences between subjects with and without complete data; however, those who completed all measures had a mean GAS score of 49.7 (SD = 11.0), and those who did not had a mean GAS score of 45.3 (SD – 7.9). This difference, although small, was significant (t = -3.55, df = 134.8, p = .001). Prevalence and clinical correlates of Axis II disorders were computed for the entire sample; substance-use situations and self-efficacy data are presented for those subjects with complete data. For the purpose of evaluating results, one-way analysis of variance (ANOVA) was used to test group differences in continuous variables; [chi square] analysis was used to test association between categorical variables.
Prevalence and Clinical Correlates of Axis II Disorders
According to the SCID-II interviews, 71.7% of the sample were diagnosed with DSM-III-R Axis II PDs. The most prevalent such disorder was Borderline PD, diagnosed in 18.6% of the sample. In decreasing order of prevalence, the remaining PDs were present as follows: Antisocial PD in 14.5% of the sample, Obsessive-Compulsive PD in 13.9%, Avoidant PD in 13.0%, Passive-Aggressive PD in 12.4%, Dependent PD in 11.5%, Narcissistic PD in 10.0%, Paranoid PD in 8.6%, Histrionic PD in 5.9%, Schizotypal PD in 1.8%, and Schizoid PD in 0.3%.
To obtain adequately large subgroups for further analyses, PD diagnoses were grouped into three clusters as specified in DSM-III-R. Cluster A PDs, comprising Paranoid, Schizoid, and Schizotypal PDs, were diagnosed in too few patients (9% of the sample) for meaningful comparisons to be made, and this group was not included in further analyses. Cluster B PDs, comprising Antisocial, Borderline, Histrionic, and Narcissistic PDs, are, in the literature, those most commonly associated with addiction, and were present in 35% of the sample. Overall, Cluster C PD diagnoses, including Avoidant, Dependent, Obsessive-Compulsive, and Passive-Aggressive PDs, were most prevalent, having been diagnosed in 49% of the sample.
Among subjects diagnosed as having an Axis II disorder, 39% had more than one such diagnosis. Men and women were equally likely to be diagnosed as having a PD. As compared to subjects without PDs, subjects with Axis II diagnoses were younger (mean [no Axis III = 39.2 years, SD = 11.5, vs. mean [Axis II] = 33.4 years, SD = 10.6; F[1,334] = 18.9, p [is less than] .0001), and their overall level of functioning as rated with the GAS was slightly but significantly lower (mean [no Axis II] = 50.2, SD = 10.2, vs. mean [Axis II] = 47.8, SD = 8.5; F[1,330] = 5.07, p [is less than].05). Subjects with Axis II diagnoses were less likely to have more than a secondary education (39% vs. 54%) and were less likely to be married (36% vs. 50%) than were subjects without PDs. Subjects with Axis II diagnoses were also more likely to be diagnosed with concurrent mood (49% vs. 32%) and anxiety disorders (28% vs. 15%), and were more likely to have an illicit drug as their primary drug of choice (42% vs. 24%).
Axis II Diagnoses, Substance-Use Situations, and Self-Efficacy for Abstinence
Drinking and drug-use situations and self-efficacy for abstinence were compared for subjects with and without PDs. In addition, subjects with B-cluster and C-cluster diagnoses were compared to each other and to subjects without PDs.
As compared to subjects without Axis II disorders, subjects with Axis II disorders reported having drunk or used drugs more frequently in response to pleasant emotions, urges and temptations, social pressures to drink or use drugs, and pleasant times with others. There were no differences between groups in self-reported use of alcohol or drugs in response to unpleasant emotions, physical discomfort, testing personal control, or conflict with others. When self-reported substance-use situations of subgroups of subjects with PDs were compared to those of subjects without Axis II diagnoses, results were essentially the same as those found for the Axis II group as a whole, and there were no differences in substance-use situations between subjects with B-cluster and those with C-cluster diagnoses.
Subjects with Axis II diagnoses reported lower self-efficacy than those without Axis II disorders for remaining abstinent in the presence of social problems at work and of urges and temptations. There were no differences between the Axis II group as a whole and the non-Axis II group in self-efficacy for abstinence on any of the other scales. There were some notable differences in self-efficacy for abstinence for subgroups of the Axis II patients: B-cluster patients reported lower self-efficacy for abstinence in response to negative emotions and testing personal control than did non-Axis II patients; and C-cluster patients reported lower self-efficacy for abstinence in response to social tensions. Although the B-cluster and C-cluster groups each differed from the non-Axis II group on these scales, they did not differ from each other. These results are summarized in Table 1.
Table 1. Substance-Use Situations and Self-Efficacy for Abstinence
as moderate to high risk
Non-Axis II Any Axis II
(N = 60) (N = 182)
Unpleasant emotions 80 85
Physical discomfort 52 59
Pleasant emotions 65 81(*)
Testing control 65 73
Urges/temptations 53 75([double dagger])
Conflict with others 60 70
Positive social 58 78([double dagger])
Social pressures to drink/use 60 79([dagger])
Self-efficacy for abstinence
Negative emotions 33 46
Negative physical 16 24
Pleasant emotions 25 21
Testing control 38 51
Urges/temptations 21 41([dagger])
Social tensions 25 37
Positive social 39 47
Work problems 20 34(*)
(N = 85) (N = 128)
Unpleasant emotions 87 89
Physical discomfort 58 61
Pleasant emotions 79 81(*)
Testing control 77 73
Urges/temptations 795 73([dagger])
Conflict with others 73 71
Positive social 82([double dagger]) 76(*)
Social pressures to
drink/use 84([double dagger]) 78([dagger])
Negative emotions 51(*) 43
Negative physical 25 24
Pleasant emotions 25 20
Testing control 55([dagger]) 50
Urges/temptations 42([dagger]) 42([dagger])
Social tensions 35 40(*)
Positive social 52 46
Work problems 39(*) 33
(*) p [is less than or equal to] .05.
([dagger]) p [is less than or equal to] .01.
([double dagger]) p [is less than or equal to] .005.
All comparisons are between Axis II groups and the non-Axis II group.
In our assessment of 339 consecutive patients admitted to the adult-chemical-dependency unit of a private psychiatric hospital, we found that 71.7% of the sample were given diagnoses of an Axis II PD. This finding is consistent with the existing literature on dual diagnoses, and suggests that such comorbidity be considered the norm rather than the exception. Also consistent with the existing literature was our finding that the full range of PDs was present in our sample, and that dually diagnosed patients presented a more severe clinical picture.
In contrast to descriptive statements in the theoretical and clinical literature, our dually diagnosed subjects did not report greater use of alcohol and drugs to manage stressors and negative emotions than did subjects without Axis II diagnoses. Rather, they reported more use of alcohol and drugs in response to good moods, pleasant social situations, and urges and temptations both in and out of a social context–use that is perhaps best characterized as “impulsive.” Furthermore, they did not report less substance use than subjects without PDs in any type of situation assessed.
Dually-diagnosed patients’ greater self-reported use of substances in positive or impulsive settings was not entirely matched by lower self-efficacy estimates for abstinence in those situations. Rather, subjects with Axis II diagnoses, relative to those without such diagnoses, reported lower self-efficacy for abstinence in response to urges and temptations and social problems at work. B-cluster patients, who may be described as “dramatic,” “emotional,” or “erratic” (28), reported lower self-efficacy for abstinence in response to negative emotions and testing personal control, and “anxious” (28) C-cluster patients reported lower self-efficacy for abstinence in response to difficult social situations. These patients’ perceptions of their ability to remain abstinent in future hypothetical situations appeared consistent with the clinical features of their assigned diagnoses. To the extent that estimating the relative likelihood of various responses to hypothetical future situations is a more “projective” task than reporting on the frequency of past behavior, it stands to reason that a measure of perceived self-efficacy would yield results concordant with an interview assessment of how subjects believe they generally think and behave across situations.
An important limitation of the present study is the use of a single SCID-II administration to arrive at diagnoses of PD without having formally assessed the reliability of this instrument in our setting. Although the SCID-II appears to be as reliable as other similar diagnostic interviews for Axis II disorders (10), investigators have reported test-retest reliabilities of SCID-II diagnoses in substance abusers ranging from poor to excellent (10-12, 29). The frequent changes in personality diagnoses over time may in part be due to how treatment for substance abuse encourages patients to change their attitudes toward the relationship between substance use and behavior patterns (12). However, the well-documented tendency for dually-diagnosed substance abusers to have more complex clinical presentations suggests that Axis II diagnosis early in treatment is likely to have clinical significance.
The lack of agreement between self-reported past substance use and efficacy estimates for future abstinence probably represents some degree of self-misappraisal on the part of at least one of our subject groups. An additional limitation of the present study is the lack of external validation of subjects’ self-reported past substance-use behavior, which might help untangle the contradictions in our findings. Future research including collateral reports of subject substance-use situations may determine whether certain subject groups are prone to misrepresenting past substance use or to making unrealistic judgments of their ability to remain abstinent in formerly high-risk situations.
Our results partly confirm and partly contradict statements in the theoretical and clinical literature about substance use and risk for relapse in personality-disordered patients. The findings in the study point to the need for careful individual assessment rather than reliance on assumptions about the population, and to the need for validation of patients’ self-reports of past substance use. Further research may show whether self-reports of past behavior or self-efficacy for future behavior is a better predictor of posttreatment success in abstinence from substance use.
Preparation of this article was supported in part by National Institute of Drug Abuse grant U01 DA-07663 to A.F.F. Portions of this research were presented in May 1994 at the American Psychiatric Association annual meeting in Philadelphia, Pennsylvania.
(1.) O’Malley, S. S., Kosten, T. R., and Renner, J. A., Dual diagnosis: Substance abuse and personality disorders, New Dir. Ment. Health Serv. 115-137 (1990).
(2.) Nace, E. P., Personality disorder in the alcoholic patient, Psychiatr. Ann. 19:256-260 (1989).
(3.) Walker, R., Substance abuse and B-cluster disorders II: Treatment recommendations, J. Psychoactive Drugs 24:233-241 (1992).
(4.) Gerstley, L. J., Alterman, A. I., McLellan, A. T., et al., Antisocial personality disorder in patients with substance abuse disorders: A problematic diagnosis? Am. J. Psychiatry 147:173-178 (1990).
(5.) Carroll, K. M., Ball, S. L., and Rounsaville, B. J., A comparison of alternate systems for diagnosing antisocial personality disorder in cocaine abusers, J. Nerv. Ment. Dis. 181:436-443 (1993).
(6.) Kosten, T. A., Kosten, T. R., and Rounsaville, B. J., Personality disorders in opiate addicts show prognostic specificity, J. Subst. Abuse Treat. 6:163-168 (1989).
(7.) Nace, E. P., Davis, C. W., and Gaspari, J. P., Axis II comorbidity in substance abusers, Am. J. Psychiatry 148:118-120 (1991).
(8.) Brooner, R. K., Greenfield, L., Schmidt, C. W., et al., Antisocial personality disorder and HIV infection among intravenous drug users, Am. J. Psychiatry 150:53-58 (1993).
(9.) Compton, W. M., Cottler, L. B., Shillington, A. M., et al., Is antisocial personality disorder associated with increased HIV risk behaviors in cocaine users? Drug Alcohol Depend. 37:37-43 (1995).
(10.) First, M. B., Spitzer, R. L., Gibbon, M., et al., Structured Clinical Interview for DSM-III-R Personality Disorders (SCID-II) II: Multisite test-retest reliability study, J. Pers. Disord. 9:92-104 (1995).
(11.) Ross, H. E., Swinson, R., Doumani, S., et al., Diagnosing comorbidity in substance abusers: A comparison of the test-retest reliability of two interviews, Am. J. Drug and Alcohol Abuse 21:167-185 (1995).
(12.) Weiss, R. D., Najavits, L. M., Muenz, L. R., et al., Twelve-month test-retest reliability of the Structured Clinical Interview for DSM-III-R personality disorders in cocaine-dependent patients, Compr. Psychiatry 36:384-389 (1995).
(13.) Nurnberg, H. G., Rifkin, A., and Doddi, S., A systematic assessment of the comorbidity of DSMIII–R personality disorders in alcoholic outpatients, Compr. Psychiatry 34:447-454 (1993).
(14.) Poldrugo, F., and Forti, B., Personality disorders and alcoholism treatment outcome, Drug Alcohol Depend. 21:171-176 (1988).
(15.) Cacciola, J. S., Alterman, A. I., Rutherford, M. J., et al., Treatment response of antisocial substance abusers, d. Nerv. Merit. Dis. 183:166-171 (1995).
(16.) Clopton, J. R., Weddige, R. L., Contreras, S., et al., Treatment outcome for substance misuse patients with personality disorder, Int. J. Addict. 28:1147-1153 (1993).
(17.) Bandura, A., Social Foundations of Thought and Action: A Social Cognitive Theory, Prentice-Hall, Englewood Cliffs, NJ, 1986.
(18.) Marlatt, G. A., Relapse prevention: Theoretical rationale and overview of the model, in Relapse Prevention.’ Maintenance Strategies in the Treatment of Addictive Behaviors (G. A. Marlatt and J. R. Gordon, Eds.), Guilford Press, New York, 1985, pp. 3-70.
(19.) DeJong, C. A., Van den Brink, W., Harteveld, F. M., et al., Personality disorders in alcoholics and drug addicts, Compr. Psychiatry 34:87-94 (1993).
(20.) Walker, R., Substance abuse and B-cluster disorders I: Understanding the dual diagnosis patient, J. Psychoact. Drugs 24:223-232 (1992).
(21.) Nace, E. P., Saxon, J. J., and Shore, N., A comparison of borderline and nonborderline alcoholic patients, Arch. Gen. Psychiatry 40:54-56 (1983).
(22.) Spitzer, R. L., Williams, J. B. W., Gibbon, M., et al., Structured Clinical Interview/hr DSMIII-R, Patient Edition (SCID-P), American Psychiatric Press, Washington, D.C., 1990.
(23.) Spitzer, R. L., Williams, J. B. W., Gibbon, M., et al., Structured Clinical Interview./or DSMIII-R Axis H Disorders (SCID-H), American Psychiatric Press, Washington, D.C., 1990.
(24.) American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 3rd Ed., American Psychiatric Association, Washington, D.C., 1987.
(25.) Endicott, J., Spitzer, R. L., Fliess, J. L., et al., The Global Assessment Scale: A procedure for measuring overall severity of psychiatric disturbance, Arch. Gen. Psychiatry 33:766-771 (1976).
(26.) Annis, H. M., Inventory of Drinking Situations, Addiction Research Foundation, Toronto, 1982.
(27.) Annis, H. M., Situational Confidence Questionnaire, Addiction Research Foundation, Toronto, 1982.
(28.) American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 4th Ed., American Psychiatric Association, Washington, D.C., 1994.
(29.) Malow, R. M., West, J. A., Williams, J. L., et al., Personality disorders classification and symptoms in cocaine and opioid addicts, J. Consult. Clin. Psychol. 57:765-767 (1989).
Deborah H. A. Van Horn, Ph.D.(*) Department of Psychiatry Allegheny University of the Health Sciences Philadelphia, Pennyslvania
Arlene F. Frank, Ph.D. Charter Brookside Hospital Nashua, New Hampshire
(*) To whom correspondence should be addressed at Treatment Research Institute, 2005 Market Street, Suite 1120, Philadelphia, PA 19103. E-mail: DVANHORN@TREATSEARCH.com
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