Identification of borderline personality disorders among substance abuse inpatients

0740-5472185 53.00 + .OO

Journal of Subsronce Abuse Treatmenr, Vol. 2, pp. 229-232,1985

Copyright o 1986 Pergamon Press Ltd

Printed in the USA. All rights reserved.

TECHNICAL

REPORT

Identification of Borderline Personality Disorders among Substance Abuse Inpatients DAVID J. INMAN, POD VA Medical Center, Coatesville, Pa.

LOY 0. BASCUE, POD Independent

Practice, Devon, Pa.

VA Medical Center, Coatesville, Pa.

Ab&act - By means of a structured interview procedure, individuals with borderline personality disorders were identified among a sample of 50 patients admitted to an inpatient substance abuse treatment program. When given a series of psychological tests, borderline patients were shown to be more pathological than a nonborderline group of substance abusers in a number of areas including depression, impulse control, antisocial tendencies and reality testing. Time spent in treatment was also shorter for the borderline group. Implications for substance abuse treatment programs and the potential impact of these patients on such programs is discussed. Keywords-Borderline stance abuse.

personality,

MMPI,

psychometrics,

INTRODUCTION

personality

disorders,

diagnosis,

sub-

as borderline personality disorders (Harticollis & Harticollis, 1980; Perry & Klerman, 1980; Johnson & Connelly, 1981). Moreover, the literature which describes the treatment of individuals diagnosed as experiencing a borderline personality disorder suggests that such individuals might periodically need hospitalization (Adler, 1973). Specifically, the literature suggests (Gunderson & Singer, 1975) that because of the maladaptive traits of such individuals, they can be risks for transient psychotic episodes, self destructive behavior including suicide, and impulsive violence. In turn, as a treatment modality hospitalization can provide the structure and support needed to promote emotional stability and behavioral predictability. Of course, since people with borderhne personality disorders are prone to drug and alcohol abuse, it is not uncommon for them to be treated in hospital substance abuse programs. For example, Nate, Saxon, and Shore (1983) found that between 12.8% and 39.9% of patients admitted to a private inpatient alcohol program were described as having a borderline

WHILE THECONCEPTof borderline personality disorder has been employed in ambiguous and even contradictory ways in the psychiatric literature (Gunderson & Singer, 1975; Spitzer, Endicott & Gibbon, 1979; Perry & Klerman, 1980), there is growing agreement that the disorder is characterized by enduring maladaptive personality traits which typically include low anxiety tolerance, poor impulse control, displays of intense affect such as anger and depression, poor self image, and interpersonal behavior which can be characterized as aggressive, manipulative, and demanding (American Psychiatric Association, 1980). In addition, there is agreement among researchers and clinicians that drug and alcohol abuse are also common features of individuals ultimately diagnosed The authors wish to express their appreciation to Maria Showalter, MS for her valuable assistance in the analysis of the data in this study. Reprints can be requested from David J. Inman, PhD, Psychology Service (116B), V.A. Medical Center, Coatesville, PA 19320.

229

D. J. Inman, L. 0. Bascue and T. Skoloda

230

personality disorder and Johnson and Connelly (1981) found that among physicians hospitalized for alcoholism treatment, 28% were described as being in this diagnostic category. Thus, whether formally diagnosed or not, there is potential for admission of individuals with borderline personality organization into substance abuse programs. Moreover, as Adler (1977) and Cunderson and Singer (1975) have pointed out, because of their impulsivity, emotional turmoil, and manipulative style, these individuals can sometimes subject hospital staff to considerable stress. Perhaps especially for substance abuse treatment staffs, work with borderline disordered individuals requires a special awareness of patient needs and behaviors as well as special preparation to cope with the stress involved in the treatment process itself. Given the potential for borderline disordered patients being admitted to substance abuse treatment programs and the difficulty such individuals might potentially cause in treatment, this study has three purposes. The first purpose is to document the extent borderline personality disordered individuals are found in an inpatient hospital detoxification unit. The second purpose is to identify psychological test indices which might help to identify individuals with borderline personality disorders and the third purpose is to compare the length of substance abuse treatment of patients with borderline personality to those without this specific disorder as an initial attempt at determining if there is a differential treatment response between these two groups.

MATERIALS

AND METHOD

Subjects

This study was conducted in accordance with the guidelines established by the Human Subjects Committee at Coatesville V.A. Medical Center. Fifty adult male veterans seeking substance abuse treatment at the Veterans Administration Medical Center in Coatesville, Pennsylvania were randomly selected throughout 1982 from among the total patients admitted to the detoxification unit that year. Twenty-five of those selected were alcoholics and 25 were poly-drug abusers; most of the latter group also reported alcohol as being among the substances they used or abused. The mean age of the subjects was 37 (SD = 9.98) with the age range between 22 and 60 years old. The mean level of education in the sample was 12.18 years (SD = 1.82) with 70% having a high school education or less and only 6% having completed college. A small minority of the subjects (80/o) were married at the time of the interview but most of the subjects were either single (40070). separated (25%) or divorced (27%).

Procedure

& Instruments

Following medical examination and detoxification which occurred during the initial 5 day period of hospitalization, the men were interviewed to request their anonymous participation in the study. Those who agreed to participate were then interviewed by three doctoral level clinically experienced psychologists who met as a group with each subject. After each interview, the psychologists independently rated each subject on the Borderline Personality Scale (BPS-II) developed by Perry and Klerman (1980). Within a week thereafter, each subject completed the Minnesota Multiphasic Personality Inventory (Hathaway & McKinley, 1967) a 566-item true/false questionnaire which was designed to delineate traits that are characteristic of various psychological abnormalities; the Beck Depression Inventory (Beck & Beamsderfer, 1974), a 32-item multiple choice questionnaire which provides an assessment of the degree of depression experienced by the individual; and the Shipley Institute of Living Scale (Boyle, 1967), a 60-item inventory assessing verbal and mathematical abilities. Scores on the Shipley were converted to WAIS IQ equivalents (Paulson & Tien-Teh Lin, 1970) to provide a measure of the general intellectual ability of the subject. The subjects were then followed throughout their inpatient stay at the medical center to determine the number of inpatient days in substance abuse treatment and the type of discharge they ultimately obtained. Final data on all participants was obtained by March of 1983. The BPS II, used to assess borderline personality organization, is a personality scale composed of 52 items which were found to be significantly associated with characteristics of borderline personality disorders (Perry, 1980). The BPS II was found to be moderately correlated (r = .42) with a scale based on the DSM III criteria for borderline personality disorder. The scale is divided into four subscales: Mental Status, Personal History, Interpersonal Relations, and Defense Mechanisms. Correlations of BPS II subscales with overall BPS II score are as follows: Mental Status (.86), Personal History (.81), Interpersonal Relations (.85), and Defense Mechanisms (.87). Thus, no single subscale of the BPS II appeared to be more sensitive than the other subscales in selecting borderline personalities, and it would appear that the BPS II has relatively high internal consistancy. The borderline group was identified by averaging the scores on the BPS II for the three raters and determining whether this score exceeded 145, the cutoff recommended by Perry (198 1). Subjects who obtained an average score of less than 145 on the BPS II were assigned to the nonborderline group. When the group assignment based on the average BPS II score was compared to assignment that would

Identification

231

of Borderline

have resulted from the scores of individual raters, all three raters agreed on group assignment in the majority of cases (31 out of 50). In 18 cases, two out of three raters agreed on the assignment, and in only one case was group assignment due to the influence of a single rater’s score. The reliability of the mean scores of the three raters was estimated using a single factor, repeated measures model of analysis of variance as described by Winer (1962). The estimated reliability of the mean of the three raters calculated by this method was .81. Using the Spear-man-Brown prophecy formula (Winer, 1962), the reliability of a single rater was estimated at .59. Thus the average of the three raters represents a more reliable measurement of a subject’s borderline score. Twenty-eight of the fifty subjects (56%) obtained an average score of greater than 145 and therefore met the criterion for inclusion in the borderline group. The remaining 44% scored below 145 and were assigned to the nonborderline group. There was a nonsignificant trend for poly-drug abusers to be more numerous (60’70) in the borderline group whereas alcoholics were more numerous (64%) in the nonborderline group (x’ = 2.922, DF = 1, p = .09). RESULTS The borderline group was compared to the nonborderline group on each of the clinical and validity scales of the MMPI and the differences between groups were determined by independent t test (see Table 1). The borderline group was found to be significantly higher than the nonborderline group on the following MMPI Scales- F (validity), D (depression), Hy (hysteria), Pd (psychopathic deviancy), Pa (paranoia), Pt (psychasthenia), SC (schizophrenia), and Ma (mania). On the Beck Depression Inventory, the bor-

derline group scored as significantly more depressed than the nonborderline group with the mean score of the borderline group almost double the score of the nonborderline group (t = 3.45, df = 40.5, p I .OOl). The Shipley Hartford yielded no significant difference.between the two groups in terms of their converted WAIS equivalent IQ scores (t = 1.05, df = 30.6, p = .30). In terms of the number of days of inpatient substance abuse treatment received by the two groups, the borderline group had significantly fewer inpatient days of treatment (x = 30) than the nonborderline group (x = 49) when analyzed by t-test (t = 3.01, p = .004). However, the borderline group was not significantly different from the nonborderline group in terms of the type of discharge received (Regular vs. Against Medical Advice) when analyzed by Chisquare (x2 = 3.29, df = 3, p = .35).

DISCUSSION The proportion of substance abusers who were rated in the borderline range of the BPS II (56%) was much higher than found either by Johnson and Connelly (1981) or Nate, Saxon, and Shore (1983). This may be due to the populations studied since Johnson and Connelly used only addicted physicians in their sample, while Nate, Saxon, and Shore studied only alcoholics. No previous study has compared the difference in incidence of borderline personality disorders in groups of both alcoholics and drug abusers and no other study has selected subjects specifically from a detoxification unit. Nevertheless, since in the present study borderline disorders were more numerous among poly-drug abusers, the results suggest that borderline disorders might be generally more frequent among poly-drug abusers than among alcoholics.

TABLE 1 Differences between borderline and nonborderline groups on MMPI scales analyzed by t-test (MMPI scores available for 3 subjects) MMPI

Scale

k K Hs D HY Pd MF Pa Pt SC Ma Si 'levelof significance

Borderline N = 25

Nonborderline N = 22

t

Prob.

3.16(*2.2) 16.4(*10.1) 12.84(~4.56) 20.08(*12.5) 29.80(*7.7) 27.36(*7.29) 32.7(*5.2) 28.04(*5.10) 16.16(*6.49) 35.52(&10.63) 40.60(~15.09) 26.04(*4.84) 30.96(*10.8)

4.50(*2.4) 7.8(*4.6) 12.59(*12.5) 14.8(*5.5) 23.3(*5.8) 23.18(*6.21) 27.6(*3.92) 27.7(*3.6) 11.81(~3.17) 30.45(*5.43) 30.80(*6.93) 22.36(*5.01) 26.22(*10.52)

-1.94 3.83 -15 1.89 3.22 2.11 3.71 .24 2.96 2.09 2.89 2.55 1.51

.06 .0005* .87 .07 .002' .04* .0006' .81 .005* .04* .006* .01* .13

5 .05

D. J. Inman, L. 0. Bascue and T. Skoloda

232

Not only were a large number of borderline disorders identified in the present study, it was also found that individuals with this disorder are systematically different from nonborderline substance abusers in their psychological test scores and in their response to treatment programs. The borderline group evidenced higher elevations on many MMPI scales with scales F, D, Pd, Pa, and SC being particularly striking since these were markedly higher than the scores of nonborderline substance abusers. It is suggested from these data that individuals with borderline personality disorders display greater pathology than nonborderline substance abusers even on a structured personality inventory such as the MMPI. Although so many high elevations make it difficult to emerge with a “Borderline Profile”, it is important to note that these elevations indicate difficulties in the areas of depression, antisocial tendencies, inadequate reality . testing, and poor impulse control. These traits are consistent with theory and clinical evidence on borderline disorders. It would appear that a high score on the BPS II is indicative of difficulties in these areas, and that the BPS II demonstrates substantial construct validity in identification of borderline personality disorders. Thus, the BPS II appears to offer promise as an assessment instrument for identifying borderline pathology in substance abuse patients. The borderline group also reported more depressive symptoms than the nonborderline group on the Beck Depression Inventory; this pattern was similar to the differences between groups found on the D (depression) scale of the MMPI. A related finding was reported by Rounsaville, Weissman, Crits-Christoph, Wilber & Kelber (1982) who studied 157 opiate addicts at the entrance to a drug treatment program and found that 60% of this group evidenced elevated depressive symptomatology. The last finding is that borderlines are likely to leave treatment more rapidly than nonborderline substance abusers. The mean days of inpatient treatment was significantly different between the borderline group and the nonborderline group (p I .Ol) with the borderline group spending less time (39% fewer days) in treatment. This finding may be explained by poor impulse controls which render borderline substance abusers more likely to act out when they become anxious during treatment. Such acting out may take the form of behavior which brings them into conflict with program policies and leads them in turn to premature discharge, or it may be expressed by simply leaving the program precipitously when treatment becomes anxiety-provoking. Such a finding suggests that the treatment staff in substance abuse inpa-

In summary, the present study presents three significant findings regarding borderline personality disorders. First, individuals with borderline personality disorders are commonly admitted to inpatient substance abuse programs because of their propensity to become involved in episodic drug and alcohol abuse. Second, substance abusers with borderline personality disorders differ systematically from nonborderline substance abusers on predictable personality traits and the BPS II shows potential at identifying such traits. Finally, borderline substance abusers tend to leave treatment more rapidly than other substance abusers.

tient programs recognize the tendency for borderline patients to leave treatment earlier than other substance abusers due to their difficulty in tolerating the itresses of treatment itself.

Spitzer, R.L., Endicott. J.. & Gibbon, M. (1979). Crossing the border into borderline personality and borderline schizophrenia. Archives of General Psvchiarcv. 36. 7-24. Winer, B.J. (1962). Statistical Principles in Experimental Design. New York: McGraw Hill.

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Karger. Boyle, B.S. (1967). Shipley Institute of Living Scale. Los Angeles: Western Psychological Services. Gunderson, J.G., & Singer, M.T. (1975). Defining borderline patients: An overview. American Journal of Psychiatry, 132, l-10. Harticollis, P., & Harticollis, P.C. (1980). Alcoholism, borderline and narcissistic disorders: a psychoanalytic overview. Phenomenology and Treatment of Alcoholism. Frann, W.E., Karacan, I., & Pokorny, A.D., et al. (Eds.). New York: Spectrum Publications, 93-l 10. Hathaway, S.R., & McKinley, J.C. (1%7). Manualfor rheMnnesota Multiphasic Personality Inventory. New York: Psychological Corporation. Johnson, R.P., & Connelly, J.C. (1981). Addicted physicians: A closer look. Journal of the American Medical Association, 245, 253-257.

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Perry, J.C.. & Klerman, G.L. (1980). Clinical features of the borderline personality disorder. American Journal of Psychiafry, 137, 165-173. Rounsaville, B.J., Weissman, M.M., Crits-Christoph, K., Wilber, C., & Kelber, H. (1992). Diagnosis and symptoms of depression in opiate addicts. Archives of General fsychiafry, 39, 151-156.