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Personality disorders in opiate addicts show prognostic specificity
Journal of Substance Abuse Treatment, Vol. 6, pp. 163-168, Printed in the USA. All rights reserved.
ORIGINAL
1989 Copyright 0
0740-5472/89 $3.00 + .OO 1989 Pergamon Press plc
CONTRIBUTION
Personality Disorders in Opiate Addicts Show Prognostic Specificity BERESE
A. KOSTEN, PhD, COMAS R. KOSTEN, MD, AND BRUCE J. ROUNSAVILLE, MD SubstanceAbuse Treatment Unit, Department of Psychiatry, Yale University School of Medicine
Abstract-Early studies examining the relationship of personality disorders to opiate addiction attempted to define an “addictive personality. “Later research found that personality d&orders in opiate addicts were common but heterogeneous. We examined whether different comorbid personality disorders have prognostic specificity. Rates of depression and alcoholism as well as assessments of specific problems were measured in a 25year follow-up of 150 treated opioid addicts. Using DSM-III criteria, we found that borderline personality disorder predicted more depressive disorders and alcoholism at follow-up; yet greater recovery from these disorders was seen. Borderline patients had more severe psychiatric problems as measured by the Addiction Severity Index. Other AH outcomes differed by personality disorder; antisocial addicts had more legal problems, and narcissistic addicts had more medical problems. These results suggest that treatment for opiate addicts be tailored to the specific needs of the patient, which can be predicted, in part, by their comorbid personality disorder diagnosis.
Keywords-Substance abuse, personality disorders, opiates, follow-up, treatment match&g. &Tori, 1973; Overall, 1973; Penk, Fudge, Robinowitz, & Neman, 1979; Zuckerman, Sola, Masterman, & Angelone, 1975). The results of later studies suggested that personality disorders were common but heterogeneous among substance abusers (Alkane, Lieberman, & Brill, 1967; Hawks, 1970; Rounsaville, Weissman, Kleber, & Wilber, 1982; Salmon & Salmon, 1977). The rates and types of comorbid personality disorders among opiate addicts revealed in previous studies are relatively consistent, despite the different methodologies used. Using DSM-III criteria to establish personality disorder diagnoses, we found that the rate of any personality disorder is 68% (Kosten, Rounsaville, & Kleber, 1982). This rate is consistent with other studies where the overall rate of personality disorders ranged from 73% to 90% (Khantzian & Treece, 1980). In our study, the most common personality disorder diagnosis is antisocial personality (Kosten et al., 1982), consistent with the early classification of drug addiction as a type of sociopathic disturbance. Our past work has described antisocial traits as common among opiate addicts although the use of different operational criteria (RDC vs. DSM-III) leads to different diagnostic rates (Rounsaville, Eyre, Weissman, & Kleber, 1983). The second most common personality
INTRODUCTION X-IERELATIONSHIP BETWEEN personality disorders and opiate addiction has been of interest over the years. Early diagnostic manuals classified drug addiction as a personality disorder. Drug addiction, which was not differentiated from alcoholism, was classified as one of the “Sociopathic Personality Disturbances” in the APA’s first manual, DSM (1952). When the APA developed DSM-II (1968), drug diagnoses were given a separate category, yet they remained among the Personality Disorders class. Drug diagnoses were removed from this class in the DSM-III (1980), reflecting a dramatic change of view. The implication from the previous diagnostic manuals was that drug addiction was a trait, relatively permanent and deviant in nature. Moreover, several studies conducted prior to 1980 attempted to define an “addictive personality” in opiate addicts (Dahlstrom, Welsh, & Dahlstrom, 1975; English
Acknowledgments: Support was provided by the National Institute on Drug Abuse Center Grant P50-04050 and Research Career Awards to TRK #K02-DA00112 and BJR #K05-DAOOG89. Requests for reprints should be sent to Therese A. Kosten, Ph.D., 27 Sylvan Avenue, New Haven, CT 06519
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disorder in our previous study is borderline personality (Kosten et al., 1982). The rates of other personality disorders are small and include narcissistic disorders, histrionic and dependent disorders, passive aggressive and avoidant personality disorders. In addition, many patients meet criteria for more than one personality disorder. Given the prevalence and heterogeneity of comorbid personality disorders in opiate addicts, we used outcome measures from a 2.5year follow-up study to examine whether there was prognostic specificity among the different personality disorders. If a specific type of comorbid personality disorder predicted specific problems in outcome, then treatment strategies would be enhanced by this knowledge. First, we evaluated psychiatric status by comparing the rates of two Axis I disorders, depression and alcoholism, at both the intake and follow-up periods, and by examining psychiatric status with the psychological symptom scale of the Addiction Severity Index (ASI) at follow-up (McLellan, Luborsky, Woody, & O’Brien, 1980). Second, to evaluate prognostic significance of personality disorders in drug-related problems, we used the AS1 to measure the degree of problems in five other areas: employment, social, legal, medical, and substance abuse. METHOD Setting and Sample
The subjects for this study were 150 treated opiate addicts located 2.5 years after the start of treatment from a target sample of 204. The original 204 opiate addicts were consecutively drawn from applicants to the Substance Abuse Treatment Unit (SATU) of Yale University in New Haven, Connecticut. Subjects were treated in one of the following four modalities: inpatient detoxification, methadone maintenance, naltrexone outpatient treatment, or a residential therapeutic community. These 150 subjects agreed to participate in a follow-up evaluation. Among the 54 subjects who were not followed, six had died, yielding a follow-up rate for survivors of 76%. There were no differences in demographic characteristics between those who agreed to participate and those who were lost to follow-up. However, there were differences in several indicators of antisocial behavior. Fewer of those lost to follow-up had school behavior problems as children (38% vs. 55%) or met DSM-III criteria for antisocial personality disorder as adults (37% vs. 63%). Those lost also had fewer arrests (7.5 vs. 11.5) and fewer previous drug abuse treatments (1.5 vs. 2.4). Those subjects evaluated for the follow-up were predominantly male (76Vo), white (41 Vo), not currently married (73Vo), and employed (51%). The mean age was 28.5 k 5 years. They had used opiates for 9.8 f 4.3 years.
Instruments
Psychiatric diagnoses were made using the Research Diagnostic Criteria (RDC) based on information collected in the Schedule for Affective Disorders and Schizophrenia (SADS) (Endicott & Spitzer, 1978; Spitzer, Endicott, & Robins, 1978). An interview section was added to the SADS covering all items in the DSMIII criteria for personality disorders (DSM-III, American Psychiatric Association, 1980). This addendum enabled us to evaluate a wider range of personality disorders than is possible with the SADS, which is primarily limited to antisocial personality disorder. The Addiction Severity Index (McLellan et al., 1980), a structured interview yielding IO-point (O-9) clinical ratings of problem severity in six areas, was also used. The six target areas included employment, social, legal, medical, psychiatric, and substance abuse problems. The higher the scores on these scales, the more severe the problem. Previous studies demonstrated the reliability and concurrent validity of this instrument for substance abusing populations (Kosten, Rounsaville, & Kleber, 1983).
Data Analysis
Eleven types of DSM-III personality disorders were diagnosed in our sample, but the rates of many types were relatively low (less than 3%). Moreover, 24% of the patients met criteria for more than one type of personality disorder (Kosten et al., 1982). To facilitate data analyses, we collapsed several types of disorders into fewer categories and developed a hierarchical categorization of the disorders. The four categories that were presented in our previous study and will be used again in the present study include the following: 1) antisocial personality, with no other personality disorder diagnoses; 2) borderline personality, including borderline (12Vo), schizotypal (2.4Vo), schizoid (2Vo), and paranoid (1070);3) self, including histrionic (5%), dependent (3.7Vo), and narcissistic (2.4%); and 4) other, including mixed (6Vo), avoidant (1 olo), and passive aggressive (0.5%). When a patient met criteria for more than one personality disorder, the typical second disorder was antisocial personality. Thus, the hierarchical aspect of our categorization process was to assign patients that had both antisocial and another personality disorder to the appropriate first personality disorder group, not to the antisocial personality group. Using this technique, the antisocial group consisted of only “pure” antisocials. The specific rates for the four personality categories were: antisocial (44Vo), borderline (17%), self (lo%), and other (8%). In the follow-up sample of 150 addicts, no personality disorder was found in 21%, in contrast to the rate of 32% of the 204 subjects assessed at intake. To compare outcome measures across the
165
Addicts’ Personality Disorders
four personality disorder groups and the no-personality-disorder group, we used multivariate analysis of variance (MANOVA) and t tests for the AS1 scales and chi square for the rates of Axis I diagnoses. In addition to comparing the four personality groups to the no-disorder group, we collapsed the four personality groups into an any-disorder group to compare to the no-disorder group. RESULTS The demographic characteristics of the addicts in the four personality disorder groups are presented in Table 1. These assessments were made at intake. None of these characteristics were statistically significant; therefore, the comparisons of Axis I diagnoses and outcomes were not adjusted. Psychiatric Outcome The first purpose of this study was to examine the relationship of personality disorders to psychiatric status including rates of Axis I diagnoses of depressive disorder (combined major and minor) and alcoholism. By examining the rates of disorders at both intake and at follow-up, four outcomes for each disorder were possible based on the presence or absence of the disorder at one or both time periods. The first outcome, diagnosis absent, was used when the disorder was absent at both intake and follow-up. The second outcome, recovered, was defined by the presence of the Axis I at intake and the absence at follow-up. The third outcome, new diagnosis, was made when the disorder was absent at intake but present at follow-up. Finally, the fourth outcome for Axis I disorders, both times, reflected the presence of the disorder at both time periods. In addition, we assessed severity of psychiatric problems at follow-up with the ASI. The relationship of personality disorder to current depression and alcoholism is shown in Table 2. Diag-
noses of antisocial personality, self, or other personality disorders were not associated with differences in depression or alcoholism rates when compared to the no-disorder group. We collapsed the rates of diagnoses at these outcome periods across the four personality groups in order to compare the presence of any personality disorder to the no-disorder group. As shown in Table 2, the any-disorder group was not different from the no-disorder group in rates of depression or alcoholism at any outcome period. The borderline personality group was significantly different from the no-personality disorder category for alcoholism (x2 (3,N=150)=13.1 p < .05) and for depression (x2 (3,N=150)=11.5 p < .Ol). The data show that there were substantially higher rates of depressive disorders and alcoholism at intake in this group. This was reflected in the higher proportion of the recovery outcome and the both-times outcome for depression and in the recovery outcome for alcoholism. In addition, a higher proportion of borderline patients tended to be in the newly diagnosed category. Moreover, the borderline group had more severe psychiatric problems at follow-up as assessed by the AS1 (t( 147) = 2.0 p < .05) and shown in Table 3. Other Outcome Measures The second purpose of this study is to examine whether other long-term outcome measures can be predicted differentially in the four personality disorder groups. The outcomes in five areas assessed by the Addiction Severity Index (ASI) for the four personality groups and the no-personality-disorder group are presented in Table 3. In general, personality disorders are not strong predictors of these long-term outcome measures. The results of MANOVA on the AS1 outcome measures were not statistically significant when we used the separate personality groups or when we compared any disorder to the no disorder (ps > .2). However, there were trends for differences in the psychiatric and sub-
TABLE 1 Among Personality Disorder Groups
Demographic Characteristics
(N=150)
Characteristic Age/years
(SD)
Male (%) White (%) Education
(%)
Antisocial
Borderline
Self
Other
No Disorder
(n = 67)
(n = 26)
(n = 14)
(n = 10)
(n = 33)
27 (4)
27 (4)
26 (5)
31 (5)
28 (6)
85
65
57
60
72
36
50
50
40
45
22
12
7
30
30
22
15
36
10
42
42
50
59
62
53
> High School Married
(%)
Employed
(%)
T. A. Kosten et al.
166 TABLE 2 Relationship of Personality Disorder Groups to Current Depression and Alcoholism Over 2.5Year Follow-up (N = 150) Diagnosis Absent (n = 89)
Recovered (n = 42)
New Diagnosis (n = 7)
Both Times (n = 12)
Depression Antisocial (87) Borderline (26) Self (14) Other (10) Any Disorder (117) No Disorder (33)
66% 31% 50% 50% 55% 76%
24% 46% 43% 30% 32% 15%
3% 12% 7% 0% 5% 3%
8% 12% 0% 20% 9% 6%
Alcoholism Antisocial (67) Borderline (26) Self (14) Other (10) Any Disorder (117) No Disorder (33)
79% 73% 79% 90% 79% 91%
5% 23% 7% 0% 9% 3%
6% 4% 0% 10% 5% 3%
11% 0% 14% 0% 8% 3%
Personality Group
TABLE 3 Relationship of Personality Disorder Groups to Clinician-Rated Outcomes on Addiction Severity index at 2.5 Years (Iv = 150) Outcome Mean (SEM)
Employment Family/Social Legal Medical Psychiatric Substance Abuse
Antisocial (n = 67)
Borderline (n = 26)
Self (n = 14)
Other (n = 10)
2.8 2.1 2.6 1.1 1.9 2.8
2.6 2.3 2.7 1.4 2.5 2.9
2.7 1.8 1.4 1.8 1.7 2.8
2.1 1.8 1.7 0.7 2.1 2.4
(0.2) (0.2) (0.2)* (0.1) (0.2) (0.2)
(0.3) (0.3) (0.3) (0.3) (0.3)* (0.2)
(0.3) (0.2) (0.3) (0.2)’ (0.2) (0.3)
No Disorder (n = 33)
(0.3) (0.2) (0.3) (0.2) (0.2) (0.2)
2.1 1.8 1.8 0.8
(0.3) (0.3) (0.3) (0.2) 1.5 (0.3) 2.2 (0.2)
Note: Symptomratingis based on a O-9 point scale where 0 represents no problem and 9 represents a severe problem. *indicates
that this personality group is significantly
different from the no disorder group (p < .05).
stance abuse outcome measures (F( 1, 146) = 3.26 and 3.27; ps c .lO, respectively) when the any-disorder
group was compared to the no-disorder group. The mean psychiatric severity rating was 2.0 + .02 for the any-disorder group compared with 1.5 f 0.3 for the no-disorder group. The mean substance abuse rating for the any-disorder group was 2.8 + 0.2 compared with 2.2 -e 0.2 for the no-disorder group. Because the number of subjects in most groups is small, further analyses were done using t tests comparing each personality disorder group to the other personality disorder groups. (We reported the psychiatric outcome measure for the borderline group above). The following findings may suggest future work when larger populations are available for study. First, the antisocial group had more legal problems (t( 147) = 2.0 p < .05), while the self group had fewer legal problems (t (147) = 2.2 p < .05). Second, the self group ex-
hibited greater medical problems (t (146) = 2.1 p < .05). Finally, there were no differences for any of the personality disorder groups in the employment, social, or substance abuse areas. DISCUSSION Our findings suggest some differential risk for increased psychiatric and other problems among opioid addict patients with personality disorders. While almost 80% of these patients have a personality disorder by DSM-III criteria, the 17% of patients in the borderline group appear to present the most serious psychiatric risk. The greater severity of psychiatric problems assessed by the Addiction Severity Index (ASI) support this notion. They also had significantly more depression than the no-personality-disorder group, and had significantly more alcoholism than the no-personality-
Addicts’ Personality Disorders
disorder group. Those with borderline diagnosis also show fluctuating diagnostic rates from intake to followup. This is consistent with the lability of this personality disorder which leads to the difficulty of determining its diagnosis. Two of the other personality disorder groups showed differential outcomes on AS1 measures. As expected, those with antisocial personality had more legal problems at the follow-up. In addition, patients in the self disorder group had more medical problems. Although these findings were not statistically strong, they may be worth future examination, since statistical power was limited by the small number of subjects within each diagnostic group. The diagnostic criteria used for substance abuse in this study include impairment in social or occupational functioning. Some of the possible manifestations of these impairments overlap with diagnostic criteria for antisocial personality and for borderline personality. The antisocial personality diagnostic criteria can include inability to sustain work behavior, lack of ability to be a responsible parent, or no respect for the law. One diagnostic criterion for borderline personality is impulsivity, which can be expressed in substanceabusing behavior. Another possible overlapping criterion in borderlines is self-damaging acts, which can be exhibited by drug abuse or overdose. The overlap of diagnostic criteria between substance abuse and personality disorders occurs in the two most commonly diagnosed comorbid disorders, antisocial and borderline personality. This may reflect a failure in the diagnostic system or a true propensity for certain personality types to be substance abusers. At present, we cannot separate the alternatives, but future studies using DSMIII-R criteria for substance abuse should help clarify this point. The general issue of heterogeneity among substance abusers has been addressed in our previous work and is an important limiting factor in follow-up studies of this population (Rounsaville, Weissman, & Wilber, 1982). In DSM-III as well as in the new DSM-III-R the number of separate personality disorders can present difficult problems for designing long-term studies. Substance abusers do not have a single “addictive personality,” and the most common personality disorder, antisocial personality, does not differentiate from the other personality disorder groups in long-term outcome, except for future illegal activities. Moreover, the presence of any personality disorder is not associated with greater risk of problem severity. This further supports the need to address differentially the specific problems of substance abusers with different personality disorder diagnoses. The more important issue to our field is mental health services utilization, and this service need is better predicted by the less common personality disorders such as borderline disorder or narcissistic disorder.
167
The borderline patients had the greatest need for psychiatric services. An example of a patient with this diagnosis was D.K. who was quite ill when originally interviewed. At intake this 30-year-old female met criteria for both major depressive disorder and alcoholism, as well as opioid dependence and borderline personality disorder. During the 2.5 years, she continued to have substantial psychological problems and had taken a deliberate drug overdose in a suicide attempt when her baby died at age 7 months. The cause of the infant’s death was never fully determined, but the infant’s father, D.K.‘s common-law husband, was arrested initially for murder. While these charges were eventually dropped, the quality of the relationship between D.K. and her husband was mirrored in these charges and proceedings. When the infant was found dead by D.K., a violent argument broke out between D.K. and her husband, and this argument led to the police coming to the house. The husband was then arrested, and charged with murder based on the report of D.K. Both of them had been drinking heavily on the previous night, and D.K. said that she could remember nothing from that afternoon until the police arrived the next morning. The case was finally dropped for lack of evidence, and the couple had gotten back together several months before the follow-up interview. At that interview, D.K. no longer met criteria for current major depressive disorder or current alcoholism. She was a member of a methadone maintenance program and described her life as empty and boring. She seemed to be in a lull between the major disruptions that characterized her relationships. The methadone program had stabilized her chaotic lifestyle by providing twice to three times weekly counseling, as well as the daily contact in order to get methadone for her opioid dependence and disulfiram for her alcoholism. This intensive treatment program had clearly transformed D.K. from an impulsive and affectively unstable street hustler to a somewhat docile and bored program member, but her borderline personality disorder still came across through her self-described feelings of emptiness. It seemed only a matter of time before her current equilibrium and concomitant boredom would be disrupted. Patients with self or narcissistic disorders appeared to have an interesting distinction of reporting more medical problems at follow-up. J.F. was a typical patient in this group. He was a 36-year-old homosexual whose older lover had died of AIDS during the 2.5 years after his initial interview. This death had led to intense and probably well-founded anxiety in J.F., since he not only felt terribly abandoned by the death, but also felt that he would also soon die of AIDS. At the initial evaluation he was very active and was considered hypomanic in addition to having a histrionic personality disorder with strong dependent features. At the follow-up it appeared that the loss of his lover
T, A. Kosten
168
had intensified these dependent features, and J.F. had turned to the medical establishment to fill his dependency needs. He was a regular patient of the emergency room and had had HIV testing for the AIDS virus confirmed six times. While he did not have AIDS or AIDS related complex (ARC), he had multiple fluctuating medical complaints that he considered early signs of AIDS and was attributing many symptoms of opioid withdrawal to AIDS. Opioid withdrawal symptoms resemble a severe case of influenza, so that his attribution of many of these symptoms to pneumocystis pneumonia, an early complication of AIDS, would sometimes generate a substantive work-up by a medical resident in the emergency room. Thus, the more severe medical problems reported by this diagnostic group may be related to anxiety and hypochondriasis within the context of a potentially fatal illness, AIDS. Opioid addicts with personality disorder have dual liabilities from the effects of their substance abuse, as well as from the difficulties with interpersonal relationships associated with their personality disorder. As illustrated by the two cases described, the substance abuse may lead to dramatic parental irresponsibilities and to fatal illness, such as AIDS, while the personality disorder may interfere with the patient’s obtaining appropriate interpersonal support to cope with these massive complications of drug abuse. Maladaptive styles of enlisting help from others lead either to alienation of others (e.g., the dead infant’s father who might have been supportive) or to inappropriately targeted help (e.g., the multiple medical work-ups for pneumocystis pneumonia instead of addressing the anxiety about AIDS and its self-medication through drug use). The challenge for clinical research and practice in this area is to develop comprehensive treatment programs that provide the structure and limit setting needed to control the substance abuse as well as properly arranged support to modify interpersonal limitations in patients with comorbid personality disorders.
REFERENCES Alkane, H., Lieberman, L., & Brill, L.A. (1967). A conceptual model of the life cycle of addiction. Infernational Journal of the Addictions, 2, 221-240.
et al.
American Psychiatric Association. (1952). Diagnostic and Statistical Manual of Mental Diseases. Washington: Author. American Psychiatric Association. (1968). Diagnostic and StatisticalManual of Mental Diseases (2nd ed.). Washington: Author. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Diseases (3rd ed.). Washington: Author. Dahlstrom, W.G., Welsh, G.S., & Dahlstrom, L. (1975). An MMPI handbook; Research applications (Vol. 2, rev. ed). Minneapolis: University of Minnesota Press. Endicott, J., & Spitzer, R.L. (1978). A diagnostic interview-The schedule for affective disorders and schizophrenia. Archives of General Psychiatry, 31, 837-844. English, G.E., & Tori, C.A. (1973). Psychological characteristics of drug abuse clients seen in a community mental health center. Journal of Community Psychology, 1, 403-407. Hawks, D.V. (1970). The epidemiology of drug dependence in the United Kingdom. Bulletin of Narcotics, 2, 21-22. Khantzian, E.J., & Treece, C.J. (1980). Heroin addiction-The diagnostic dilemma for psychiatry. In R.W. Pickens & L.L. Heston (Eds.), Psychiatricfactors in drug abuse (pp. 21-45). New York: Grune & Stratton. Kosten, T.R., Rounsaville, B.J., & Kleber, H.D. (1982). DSM-III personality disorders in opiate addicts. Comprehensive Psychiatry, 23, 572-581. Kosten, T.R., Rounsaville, B.J., & Kleber, H.D. (1983). Concurrent validity of the addiction severity index. Journal of Nervous and Mental Diseases, 171, 606-610. McLellan, A.T., Luborsky, L., Woody, G.E.,&O’Brien, C.P. (1980). An improved diagnostic evaluation instrument for substance abuse patients: the addiction severity index. Journal of Nervous and Mental Diseases, 168, 26-33. Overall, J.E. (1973). MMPI personality patterns of alcoholics and narcotic addicts. Quarterly Journal of the Study of Alcohol, 34, 104-111. Penk, W.E., Fudge, J.W., Robinowitz, R., & Neman, R.S. (1979). Personality characteristics of compulsive heroin, amphetamine, and barbituate users. Journal of Consulting & Clinical Psychology,47, 583-585. Rounsaville, B.J., Eyre, S.L., Weissman, M.M., & Kleber, H.D. (1983). The antisocial opiate addict. Advances in Alcohol& Substance Abuse, 2, 29-42. Rounsaville, B. J., Weissman, M.M., Kleber, H.D., & Wilber, C.H. (1982). The heterogeneity of psychiatric diagnosis in treated opiate addicts. Archives of General Psychiatry, 39, 161-166. Salmon, R., & Salmon, S. (1977). The causes of heroin addictionA review of the literature. Part I. International Journal of the Addictions, 12, 679-696. Spitzer, R.L., Endicott, J., & Robins, E. (1978). Research diagnostic criteria: Rationale and reliability. Archives of General Psychiatry, 35, 773-789. Zuckerman, M., Sola, S., Masterman, J., & Angelone, J.V. (1975). MMPI patterns in drug abusers before and after treatment in therapeutic communities. Journal of Consulting & Clinical Psychology, 43, 286-296.
ORIGINAL
1989 Copyright 0
0740-5472/89 $3.00 + .OO 1989 Pergamon Press plc
CONTRIBUTION
Personality Disorders in Opiate Addicts Show Prognostic Specificity BERESE
A. KOSTEN, PhD, COMAS R. KOSTEN, MD, AND BRUCE J. ROUNSAVILLE, MD SubstanceAbuse Treatment Unit, Department of Psychiatry, Yale University School of Medicine
Abstract-Early studies examining the relationship of personality disorders to opiate addiction attempted to define an “addictive personality. “Later research found that personality d&orders in opiate addicts were common but heterogeneous. We examined whether different comorbid personality disorders have prognostic specificity. Rates of depression and alcoholism as well as assessments of specific problems were measured in a 25year follow-up of 150 treated opioid addicts. Using DSM-III criteria, we found that borderline personality disorder predicted more depressive disorders and alcoholism at follow-up; yet greater recovery from these disorders was seen. Borderline patients had more severe psychiatric problems as measured by the Addiction Severity Index. Other AH outcomes differed by personality disorder; antisocial addicts had more legal problems, and narcissistic addicts had more medical problems. These results suggest that treatment for opiate addicts be tailored to the specific needs of the patient, which can be predicted, in part, by their comorbid personality disorder diagnosis.
Keywords-Substance abuse, personality disorders, opiates, follow-up, treatment match&g. &Tori, 1973; Overall, 1973; Penk, Fudge, Robinowitz, & Neman, 1979; Zuckerman, Sola, Masterman, & Angelone, 1975). The results of later studies suggested that personality disorders were common but heterogeneous among substance abusers (Alkane, Lieberman, & Brill, 1967; Hawks, 1970; Rounsaville, Weissman, Kleber, & Wilber, 1982; Salmon & Salmon, 1977). The rates and types of comorbid personality disorders among opiate addicts revealed in previous studies are relatively consistent, despite the different methodologies used. Using DSM-III criteria to establish personality disorder diagnoses, we found that the rate of any personality disorder is 68% (Kosten, Rounsaville, & Kleber, 1982). This rate is consistent with other studies where the overall rate of personality disorders ranged from 73% to 90% (Khantzian & Treece, 1980). In our study, the most common personality disorder diagnosis is antisocial personality (Kosten et al., 1982), consistent with the early classification of drug addiction as a type of sociopathic disturbance. Our past work has described antisocial traits as common among opiate addicts although the use of different operational criteria (RDC vs. DSM-III) leads to different diagnostic rates (Rounsaville, Eyre, Weissman, & Kleber, 1983). The second most common personality
INTRODUCTION X-IERELATIONSHIP BETWEEN personality disorders and opiate addiction has been of interest over the years. Early diagnostic manuals classified drug addiction as a personality disorder. Drug addiction, which was not differentiated from alcoholism, was classified as one of the “Sociopathic Personality Disturbances” in the APA’s first manual, DSM (1952). When the APA developed DSM-II (1968), drug diagnoses were given a separate category, yet they remained among the Personality Disorders class. Drug diagnoses were removed from this class in the DSM-III (1980), reflecting a dramatic change of view. The implication from the previous diagnostic manuals was that drug addiction was a trait, relatively permanent and deviant in nature. Moreover, several studies conducted prior to 1980 attempted to define an “addictive personality” in opiate addicts (Dahlstrom, Welsh, & Dahlstrom, 1975; English
Acknowledgments: Support was provided by the National Institute on Drug Abuse Center Grant P50-04050 and Research Career Awards to TRK #K02-DA00112 and BJR #K05-DAOOG89. Requests for reprints should be sent to Therese A. Kosten, Ph.D., 27 Sylvan Avenue, New Haven, CT 06519
163
T. A. Kosten et al.
164
disorder in our previous study is borderline personality (Kosten et al., 1982). The rates of other personality disorders are small and include narcissistic disorders, histrionic and dependent disorders, passive aggressive and avoidant personality disorders. In addition, many patients meet criteria for more than one personality disorder. Given the prevalence and heterogeneity of comorbid personality disorders in opiate addicts, we used outcome measures from a 2.5year follow-up study to examine whether there was prognostic specificity among the different personality disorders. If a specific type of comorbid personality disorder predicted specific problems in outcome, then treatment strategies would be enhanced by this knowledge. First, we evaluated psychiatric status by comparing the rates of two Axis I disorders, depression and alcoholism, at both the intake and follow-up periods, and by examining psychiatric status with the psychological symptom scale of the Addiction Severity Index (ASI) at follow-up (McLellan, Luborsky, Woody, & O’Brien, 1980). Second, to evaluate prognostic significance of personality disorders in drug-related problems, we used the AS1 to measure the degree of problems in five other areas: employment, social, legal, medical, and substance abuse. METHOD Setting and Sample
The subjects for this study were 150 treated opiate addicts located 2.5 years after the start of treatment from a target sample of 204. The original 204 opiate addicts were consecutively drawn from applicants to the Substance Abuse Treatment Unit (SATU) of Yale University in New Haven, Connecticut. Subjects were treated in one of the following four modalities: inpatient detoxification, methadone maintenance, naltrexone outpatient treatment, or a residential therapeutic community. These 150 subjects agreed to participate in a follow-up evaluation. Among the 54 subjects who were not followed, six had died, yielding a follow-up rate for survivors of 76%. There were no differences in demographic characteristics between those who agreed to participate and those who were lost to follow-up. However, there were differences in several indicators of antisocial behavior. Fewer of those lost to follow-up had school behavior problems as children (38% vs. 55%) or met DSM-III criteria for antisocial personality disorder as adults (37% vs. 63%). Those lost also had fewer arrests (7.5 vs. 11.5) and fewer previous drug abuse treatments (1.5 vs. 2.4). Those subjects evaluated for the follow-up were predominantly male (76Vo), white (41 Vo), not currently married (73Vo), and employed (51%). The mean age was 28.5 k 5 years. They had used opiates for 9.8 f 4.3 years.
Instruments
Psychiatric diagnoses were made using the Research Diagnostic Criteria (RDC) based on information collected in the Schedule for Affective Disorders and Schizophrenia (SADS) (Endicott & Spitzer, 1978; Spitzer, Endicott, & Robins, 1978). An interview section was added to the SADS covering all items in the DSMIII criteria for personality disorders (DSM-III, American Psychiatric Association, 1980). This addendum enabled us to evaluate a wider range of personality disorders than is possible with the SADS, which is primarily limited to antisocial personality disorder. The Addiction Severity Index (McLellan et al., 1980), a structured interview yielding IO-point (O-9) clinical ratings of problem severity in six areas, was also used. The six target areas included employment, social, legal, medical, psychiatric, and substance abuse problems. The higher the scores on these scales, the more severe the problem. Previous studies demonstrated the reliability and concurrent validity of this instrument for substance abusing populations (Kosten, Rounsaville, & Kleber, 1983).
Data Analysis
Eleven types of DSM-III personality disorders were diagnosed in our sample, but the rates of many types were relatively low (less than 3%). Moreover, 24% of the patients met criteria for more than one type of personality disorder (Kosten et al., 1982). To facilitate data analyses, we collapsed several types of disorders into fewer categories and developed a hierarchical categorization of the disorders. The four categories that were presented in our previous study and will be used again in the present study include the following: 1) antisocial personality, with no other personality disorder diagnoses; 2) borderline personality, including borderline (12Vo), schizotypal (2.4Vo), schizoid (2Vo), and paranoid (1070);3) self, including histrionic (5%), dependent (3.7Vo), and narcissistic (2.4%); and 4) other, including mixed (6Vo), avoidant (1 olo), and passive aggressive (0.5%). When a patient met criteria for more than one personality disorder, the typical second disorder was antisocial personality. Thus, the hierarchical aspect of our categorization process was to assign patients that had both antisocial and another personality disorder to the appropriate first personality disorder group, not to the antisocial personality group. Using this technique, the antisocial group consisted of only “pure” antisocials. The specific rates for the four personality categories were: antisocial (44Vo), borderline (17%), self (lo%), and other (8%). In the follow-up sample of 150 addicts, no personality disorder was found in 21%, in contrast to the rate of 32% of the 204 subjects assessed at intake. To compare outcome measures across the
165
Addicts’ Personality Disorders
four personality disorder groups and the no-personality-disorder group, we used multivariate analysis of variance (MANOVA) and t tests for the AS1 scales and chi square for the rates of Axis I diagnoses. In addition to comparing the four personality groups to the no-disorder group, we collapsed the four personality groups into an any-disorder group to compare to the no-disorder group. RESULTS The demographic characteristics of the addicts in the four personality disorder groups are presented in Table 1. These assessments were made at intake. None of these characteristics were statistically significant; therefore, the comparisons of Axis I diagnoses and outcomes were not adjusted. Psychiatric Outcome The first purpose of this study was to examine the relationship of personality disorders to psychiatric status including rates of Axis I diagnoses of depressive disorder (combined major and minor) and alcoholism. By examining the rates of disorders at both intake and at follow-up, four outcomes for each disorder were possible based on the presence or absence of the disorder at one or both time periods. The first outcome, diagnosis absent, was used when the disorder was absent at both intake and follow-up. The second outcome, recovered, was defined by the presence of the Axis I at intake and the absence at follow-up. The third outcome, new diagnosis, was made when the disorder was absent at intake but present at follow-up. Finally, the fourth outcome for Axis I disorders, both times, reflected the presence of the disorder at both time periods. In addition, we assessed severity of psychiatric problems at follow-up with the ASI. The relationship of personality disorder to current depression and alcoholism is shown in Table 2. Diag-
noses of antisocial personality, self, or other personality disorders were not associated with differences in depression or alcoholism rates when compared to the no-disorder group. We collapsed the rates of diagnoses at these outcome periods across the four personality groups in order to compare the presence of any personality disorder to the no-disorder group. As shown in Table 2, the any-disorder group was not different from the no-disorder group in rates of depression or alcoholism at any outcome period. The borderline personality group was significantly different from the no-personality disorder category for alcoholism (x2 (3,N=150)=13.1 p < .05) and for depression (x2 (3,N=150)=11.5 p < .Ol). The data show that there were substantially higher rates of depressive disorders and alcoholism at intake in this group. This was reflected in the higher proportion of the recovery outcome and the both-times outcome for depression and in the recovery outcome for alcoholism. In addition, a higher proportion of borderline patients tended to be in the newly diagnosed category. Moreover, the borderline group had more severe psychiatric problems at follow-up as assessed by the AS1 (t( 147) = 2.0 p < .05) and shown in Table 3. Other Outcome Measures The second purpose of this study is to examine whether other long-term outcome measures can be predicted differentially in the four personality disorder groups. The outcomes in five areas assessed by the Addiction Severity Index (ASI) for the four personality groups and the no-personality-disorder group are presented in Table 3. In general, personality disorders are not strong predictors of these long-term outcome measures. The results of MANOVA on the AS1 outcome measures were not statistically significant when we used the separate personality groups or when we compared any disorder to the no disorder (ps > .2). However, there were trends for differences in the psychiatric and sub-
TABLE 1 Among Personality Disorder Groups
Demographic Characteristics
(N=150)
Characteristic Age/years
(SD)
Male (%) White (%) Education
(%)
Antisocial
Borderline
Self
Other
No Disorder
(n = 67)
(n = 26)
(n = 14)
(n = 10)
(n = 33)
27 (4)
27 (4)
26 (5)
31 (5)
28 (6)
85
65
57
60
72
36
50
50
40
45
22
12
7
30
30
22
15
36
10
42
42
50
59
62
53
> High School Married
(%)
Employed
(%)
T. A. Kosten et al.
166 TABLE 2 Relationship of Personality Disorder Groups to Current Depression and Alcoholism Over 2.5Year Follow-up (N = 150) Diagnosis Absent (n = 89)
Recovered (n = 42)
New Diagnosis (n = 7)
Both Times (n = 12)
Depression Antisocial (87) Borderline (26) Self (14) Other (10) Any Disorder (117) No Disorder (33)
66% 31% 50% 50% 55% 76%
24% 46% 43% 30% 32% 15%
3% 12% 7% 0% 5% 3%
8% 12% 0% 20% 9% 6%
Alcoholism Antisocial (67) Borderline (26) Self (14) Other (10) Any Disorder (117) No Disorder (33)
79% 73% 79% 90% 79% 91%
5% 23% 7% 0% 9% 3%
6% 4% 0% 10% 5% 3%
11% 0% 14% 0% 8% 3%
Personality Group
TABLE 3 Relationship of Personality Disorder Groups to Clinician-Rated Outcomes on Addiction Severity index at 2.5 Years (Iv = 150) Outcome Mean (SEM)
Employment Family/Social Legal Medical Psychiatric Substance Abuse
Antisocial (n = 67)
Borderline (n = 26)
Self (n = 14)
Other (n = 10)
2.8 2.1 2.6 1.1 1.9 2.8
2.6 2.3 2.7 1.4 2.5 2.9
2.7 1.8 1.4 1.8 1.7 2.8
2.1 1.8 1.7 0.7 2.1 2.4
(0.2) (0.2) (0.2)* (0.1) (0.2) (0.2)
(0.3) (0.3) (0.3) (0.3) (0.3)* (0.2)
(0.3) (0.2) (0.3) (0.2)’ (0.2) (0.3)
No Disorder (n = 33)
(0.3) (0.2) (0.3) (0.2) (0.2) (0.2)
2.1 1.8 1.8 0.8
(0.3) (0.3) (0.3) (0.2) 1.5 (0.3) 2.2 (0.2)
Note: Symptomratingis based on a O-9 point scale where 0 represents no problem and 9 represents a severe problem. *indicates
that this personality group is significantly
different from the no disorder group (p < .05).
stance abuse outcome measures (F( 1, 146) = 3.26 and 3.27; ps c .lO, respectively) when the any-disorder
group was compared to the no-disorder group. The mean psychiatric severity rating was 2.0 + .02 for the any-disorder group compared with 1.5 f 0.3 for the no-disorder group. The mean substance abuse rating for the any-disorder group was 2.8 + 0.2 compared with 2.2 -e 0.2 for the no-disorder group. Because the number of subjects in most groups is small, further analyses were done using t tests comparing each personality disorder group to the other personality disorder groups. (We reported the psychiatric outcome measure for the borderline group above). The following findings may suggest future work when larger populations are available for study. First, the antisocial group had more legal problems (t( 147) = 2.0 p < .05), while the self group had fewer legal problems (t (147) = 2.2 p < .05). Second, the self group ex-
hibited greater medical problems (t (146) = 2.1 p < .05). Finally, there were no differences for any of the personality disorder groups in the employment, social, or substance abuse areas. DISCUSSION Our findings suggest some differential risk for increased psychiatric and other problems among opioid addict patients with personality disorders. While almost 80% of these patients have a personality disorder by DSM-III criteria, the 17% of patients in the borderline group appear to present the most serious psychiatric risk. The greater severity of psychiatric problems assessed by the Addiction Severity Index (ASI) support this notion. They also had significantly more depression than the no-personality-disorder group, and had significantly more alcoholism than the no-personality-
Addicts’ Personality Disorders
disorder group. Those with borderline diagnosis also show fluctuating diagnostic rates from intake to followup. This is consistent with the lability of this personality disorder which leads to the difficulty of determining its diagnosis. Two of the other personality disorder groups showed differential outcomes on AS1 measures. As expected, those with antisocial personality had more legal problems at the follow-up. In addition, patients in the self disorder group had more medical problems. Although these findings were not statistically strong, they may be worth future examination, since statistical power was limited by the small number of subjects within each diagnostic group. The diagnostic criteria used for substance abuse in this study include impairment in social or occupational functioning. Some of the possible manifestations of these impairments overlap with diagnostic criteria for antisocial personality and for borderline personality. The antisocial personality diagnostic criteria can include inability to sustain work behavior, lack of ability to be a responsible parent, or no respect for the law. One diagnostic criterion for borderline personality is impulsivity, which can be expressed in substanceabusing behavior. Another possible overlapping criterion in borderlines is self-damaging acts, which can be exhibited by drug abuse or overdose. The overlap of diagnostic criteria between substance abuse and personality disorders occurs in the two most commonly diagnosed comorbid disorders, antisocial and borderline personality. This may reflect a failure in the diagnostic system or a true propensity for certain personality types to be substance abusers. At present, we cannot separate the alternatives, but future studies using DSMIII-R criteria for substance abuse should help clarify this point. The general issue of heterogeneity among substance abusers has been addressed in our previous work and is an important limiting factor in follow-up studies of this population (Rounsaville, Weissman, & Wilber, 1982). In DSM-III as well as in the new DSM-III-R the number of separate personality disorders can present difficult problems for designing long-term studies. Substance abusers do not have a single “addictive personality,” and the most common personality disorder, antisocial personality, does not differentiate from the other personality disorder groups in long-term outcome, except for future illegal activities. Moreover, the presence of any personality disorder is not associated with greater risk of problem severity. This further supports the need to address differentially the specific problems of substance abusers with different personality disorder diagnoses. The more important issue to our field is mental health services utilization, and this service need is better predicted by the less common personality disorders such as borderline disorder or narcissistic disorder.
167
The borderline patients had the greatest need for psychiatric services. An example of a patient with this diagnosis was D.K. who was quite ill when originally interviewed. At intake this 30-year-old female met criteria for both major depressive disorder and alcoholism, as well as opioid dependence and borderline personality disorder. During the 2.5 years, she continued to have substantial psychological problems and had taken a deliberate drug overdose in a suicide attempt when her baby died at age 7 months. The cause of the infant’s death was never fully determined, but the infant’s father, D.K.‘s common-law husband, was arrested initially for murder. While these charges were eventually dropped, the quality of the relationship between D.K. and her husband was mirrored in these charges and proceedings. When the infant was found dead by D.K., a violent argument broke out between D.K. and her husband, and this argument led to the police coming to the house. The husband was then arrested, and charged with murder based on the report of D.K. Both of them had been drinking heavily on the previous night, and D.K. said that she could remember nothing from that afternoon until the police arrived the next morning. The case was finally dropped for lack of evidence, and the couple had gotten back together several months before the follow-up interview. At that interview, D.K. no longer met criteria for current major depressive disorder or current alcoholism. She was a member of a methadone maintenance program and described her life as empty and boring. She seemed to be in a lull between the major disruptions that characterized her relationships. The methadone program had stabilized her chaotic lifestyle by providing twice to three times weekly counseling, as well as the daily contact in order to get methadone for her opioid dependence and disulfiram for her alcoholism. This intensive treatment program had clearly transformed D.K. from an impulsive and affectively unstable street hustler to a somewhat docile and bored program member, but her borderline personality disorder still came across through her self-described feelings of emptiness. It seemed only a matter of time before her current equilibrium and concomitant boredom would be disrupted. Patients with self or narcissistic disorders appeared to have an interesting distinction of reporting more medical problems at follow-up. J.F. was a typical patient in this group. He was a 36-year-old homosexual whose older lover had died of AIDS during the 2.5 years after his initial interview. This death had led to intense and probably well-founded anxiety in J.F., since he not only felt terribly abandoned by the death, but also felt that he would also soon die of AIDS. At the initial evaluation he was very active and was considered hypomanic in addition to having a histrionic personality disorder with strong dependent features. At the follow-up it appeared that the loss of his lover
T, A. Kosten
168
had intensified these dependent features, and J.F. had turned to the medical establishment to fill his dependency needs. He was a regular patient of the emergency room and had had HIV testing for the AIDS virus confirmed six times. While he did not have AIDS or AIDS related complex (ARC), he had multiple fluctuating medical complaints that he considered early signs of AIDS and was attributing many symptoms of opioid withdrawal to AIDS. Opioid withdrawal symptoms resemble a severe case of influenza, so that his attribution of many of these symptoms to pneumocystis pneumonia, an early complication of AIDS, would sometimes generate a substantive work-up by a medical resident in the emergency room. Thus, the more severe medical problems reported by this diagnostic group may be related to anxiety and hypochondriasis within the context of a potentially fatal illness, AIDS. Opioid addicts with personality disorder have dual liabilities from the effects of their substance abuse, as well as from the difficulties with interpersonal relationships associated with their personality disorder. As illustrated by the two cases described, the substance abuse may lead to dramatic parental irresponsibilities and to fatal illness, such as AIDS, while the personality disorder may interfere with the patient’s obtaining appropriate interpersonal support to cope with these massive complications of drug abuse. Maladaptive styles of enlisting help from others lead either to alienation of others (e.g., the dead infant’s father who might have been supportive) or to inappropriately targeted help (e.g., the multiple medical work-ups for pneumocystis pneumonia instead of addressing the anxiety about AIDS and its self-medication through drug use). The challenge for clinical research and practice in this area is to develop comprehensive treatment programs that provide the structure and limit setting needed to control the substance abuse as well as properly arranged support to modify interpersonal limitations in patients with comorbid personality disorders.
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