- Email: [email protected]
Psychiatric distress in antisocial drug abusers: relation to other personality disorders
Dlwtaw-. @
ALCOHOL
DEPEMEIKE Drug and Alcohol
Psychiatric
Edward Th
Job
distress in antisocial personality
Rousar,
Hopktm
Dependence 34 (1994) 149-154
l’nrwr.rtt~~
K. Brooner *, Michael W. Regier, George
Robert Sdrool
drug abusers: relation disorders
of Medicine.
Depurtn~cwt
to other
E. Bigelow
01 P.s,vdriutn~ wtd Uclt~r~t~~rrrl S~~icwc~. Bttltirmwc,
.MUI,I /ml
1 .SI
(Accepted Y July 1993)
Abstract Antisocial
drug abusers with other personality
on a measure of normal
personality
dimensions,
diagnoses the former
have been found to differ from those with the antisocial group
reporting
greater
pronenw
to emotional
distrw
tlqnosls
oral!
and instabl1il.y.
The present study examined the relationship between personality comorbidity among antisocial
drug abusers and ;I standardixd measure of current psychiatric distress level. Patients included I67 opioid drug abusers admitted to a community outpatient drug abuse treatment program. The results indicated that the presence of additional personality diagnoses among antisocial drug abusers was associated with high levels of distress compared with those with the antisocial diagnosis only and with those uith no personallt> diagnosis. Kq -
~ovrl.s: Antisocial;
Personality
disorder;
Psychiatric
distress;
1. Introduction Antisocial personality disorder (APD) is a common condition among opioid drug abusers (Rounsaville et al., 1982; Gerstley et al., 1989; Alterman and Cacciola, 1991; Brooner et al., 1992). The co-occurrence of antisocial disorder and opioid abuse has been associated with a poor treatment prognosis compared with nonantisocial opioid abusers (Woody et al., 1985), with higher rates of drug injection and needle sharing (Brooner et al.. 1990; Gill et al.. 1994) and with a higher rate of HIV-l infection (Brooner et al., 1993a). Despite the generally poor prognosis of antisocial opioid ahusers, it is important to remember that this population is clinically heterogeneous. For example, in the Woody et al. (1985) study, APD opioid abusers with a lifetime diagnosis of major depression had a remarkably better treatment outcome compared with those without the depression diagnosis. This study underscores the importance of identifying clinical heterogeneity among APD opioid abusers. * Corrcspondlng ,luthor. The Behavioral Biology Research Unit and The Francis Scott lie) MedIcal Center. Suite 1500. 5510 Nathan Shock Dri\e. Hall~morc. MD 21224. 1‘SA.
0 376-X7I6.‘04 $07
I)O
Drug abuse
Recently, Alterman and Cacciola ( 199I ) suggested another approach to characterizing clinical heterogcnrity among APD opioid abusers. Based on a review of the literature, they reported that APD opioid abusers with another personality diagnosis (particularly borderline disorder) might report higher levels of emotional distress compared with opioid abusers with only the APD diagnosis. This idea was partially confirmed in a report by Brooner et al. (1993b). who found that opioid abusers with APD plus another personality diagnosis obtained significantly higher scores on a personalit) trait measure of Neuroticism (NEO-Personality Invcntory --- NEO-PI; Costa and McCrae, 1989) compared with opioid abusers with the APD diagnosis only: in addition to higher scores on the overall Neuroticism domain, these multiply-personality-disordered i\PD patients had significantly higher scores on the depression, anxiety, self-consciousness and vulnerability facets of the Neuroticism domain. High scores on the NEO-PI Neuroticism domain. and its facets are associated with vulnerability to pervasive emotional distress and cmotional instability. Previous studies have also detected personalit\ diagnoses other than APD in treatment-seeking npioid
IW4 Elrcvw ScienceIreland Ltd. All right\ resetked
150
abusers. Khantizan and Treece (1985) reported that 3 1% of their patients were diagnosed with a personality disorder other than APD. More importantly, the presence of any personality disorder in drug abusers appears associated with greater distress, more life problems and poorer interpersonal skills compared with drug abusers without a coexisting personality diagnosis. For example, Nate et al. (1991) reported that substance abusers with any personality disorder (including APD) had more severe substance abuse, had higher scores on a global index of depression, had more negative life changes and lower problem solving skills compared with substance abusers without a personality disorder. These data suggest the potential importance of assessing drug abusers for both APD and other personality diagnoses. The present study examines the relationship of psychiatric distress to APD and other personality diagnoses in outpatient opioid abusers. Specifically. scores on the SCL-90-R (Derogatis, 1983) were compared for the following four diagnostic groups: (1) APD only - Pure APD; (2) APD plus another personality diagnosis diagnosis ~ Mixed APD; (3) personality other than APD - Other Axis II; (4) no personality diagnosis Non-Axis II. The following study hypotheses were examined: (1) the Pure APD group would have significantly lower SCL-90-R scores (i.e. less distress) than both the Mixed APD and the Other Axis II groups; (2) the Mixed APD would not have significantly different distress scores compared with the Other Axis II group; (3) the Mixed APD and the Other Axis II groups would both have significantly higher distress scores compared with the Non-Axis II group. 2. Methods 2.1. Subjects The patients were 167 opioid abusers consecutively admitted between April 1989 and December 1990 to an outpatient treatment program providing methadone, counseling and primary health care. All patients met DSM-III-R criteria for opioid dependence and all satisfied the Food and Drug Administration (FDA) guidelines for methadone substitution therapy. The patients were enrolled in a longitudinal investigation of the relationship of psychiatric comorbidity and distress to drug abuse treatment outcome. The present data are from the intake phase of that study. Informed consent was obtained after study procedures were fully described and participants were paid $30.00 for completing the intake assessment instruments (approx. 3 h total). The population had a mean age of 33.9 years (SD. = 6.8) and 53.3% were female. Most were white (70.1%). 28.7% were black, 1.2% were either Hispanic or Native American. The mean education level was 11.01 years (S.D. = 2.1) and 67.1% were unemployed. Many reported having never married (46.7%) 17.4% were cur-
rently married and 35.9.X were either separated or divorced. The mean age of first opioid use was 25.43 years (S.D. 6.4) and they had a mean of 45.67 (S.D. 61.8) cumulative (lifetime) months of outpatient methadone maintenance. 2.2. Procedure Psychiatric diagnoses were made using the Structured Clinical Interview for DSM-III-R (SCID-1 and SCID-2; Spitzer et al., 1992). The SCID takes approx. 2 h to administer and provides information for detecting the presence of a large number of the Axis I conditions (e.g. mood disorders, anxiety disorders. schizophrenia) and each of the personality diagnosis. The SCID was administered by three trained interviewers with masters degrees in psychology. Interviewer training consisted a minimum of 8 h of didactic review of the instrument, followed by co-rating a minimum of five interviews given by an expert interviewer and then conducting live interviews that agreed perfectly with diagnoses obtained by an expert co-rater. Interrater reliability was assessed throughout the study via expert co-ratings of a rolling subsample of patients (N = 34). Personality diagnoses were relatively infrequent in these 34 cases. with only two conditions prevalent in 5% or more of the interviews (APD, 15.4’%, kappa = 1.00; Borderline, 5.6% kappa = 1.OO). Psychiatric distress was assessed by the Symptom Checklist 90-R (SCL-90-R; Derogatis, 1983), a forcedchoice 90-item self-administered standardized questionnaire covering a wide variety of psychiatric symptoms. The SCL-90-R provides scores on nine clinical subscales (somatization, obsessive-compulsive. interpersonal sensitivity, depression, anxiety, hostility, phobic anxiety, paranoid ideation and psychoticism) and on three global indices of distress (Global Severity Index, Positive Symptom Distress Index and Positive Symptom Total). The SCL-90-R was computer administered and scored; non-patient norms were used. All data were collected between weeks 3 and 4 of treatment to reduce the influence of acute situational stress and intoxication or withdrawal on symptom reporting (Strain et al.. 1991). Study assessments were rescheduled for another day if the patient appeared intoxicated or obtained a score less than 27 on the MiniMental Status Examination (MMSE; Folstein et al.. 1975). Despite these efforts. symptom overlap between chronic drug abuse and specific criteria for various personality diagnoses probably remained. To reduce this overlap further, specific personality criteria were coded as positive only when characteristic of behavior during episodes of abstinence. 2.3. Datu unal~sis Group differences on demographic ment history variables were assessed
and drug treatusing Chi-square
with continuity correction or one-way analysis of variance (ANOVA) followed by Tukey’s Post-hoc test (as appropriate). Mean group differences (in T-scores; nonpatient norms) on the SCL-90-K subscales and global indices were assessed using a four-group ANOVA with Tukey’s post-hoc comparisons. The fbur groups consisted of patients categorized into the Pure APD group, the Mixed API) group. the Other Axis II group and the hon-Axis I I group. 3. Results
A large number of patients (101~160: 61%) failed to satisfy criteria for any personality disorder (Non Axis II). The 66 (39” (I) patients who mer the criteria for a personality disorder were categorized into one of the following mutually exclusive groups: 95 (38’Xl) APD only (Pure APD); I6 (74%) APD plus another diagnosis (Mixed APD); 15 (3X”,(,) with a diagnosis other than antisocial (Other Axis II). Although not a focus of the study. the prevalence of lifetime mood disorders (i.e. major depression and dysthymia) and specific anxiety disorders (i.e. generalized anxiety, panic disorder. agoraphobia) was calculated for each of the above
Non-Asis II (JJ = 101; 60%)
Any APD
Pure APD (IJ = 25)
Any Axis II Personality Disorder (n = 66; 40 5%)
(IJ = 4 1; 25 5%)
Other Axis II (IJ = 25; 15 5%~)
Mixed APD (lJ= l(1)
13ordcrlinc: Pass/Agcrcssive A\‘oid;lnt ScllI‘-Defeating IHistrionic IIkpd~Ilt
Paranoid Narcissistic ( )hsess/Comp
groups. Although major depression was the most common diagnosis detected in the population. there were no significant group differences in the rates of major depression or the other non-substance use Axis I conditions examined. Figure I provides descriptive information on the specific comorbid personality diagnoses detected in the Mixed APD group and tl1osc detected in the Other Axis II group. Significant differences were found bet\\ecn the I’<>LI~ groups on gender and years of education. A higher per-cent of the Pure APL) patients were maie compared with each of the remaining groups (80”~~ Pure API). 41 .6’% Non-Axls Ii. 3 I .3”i, Mixed API). 43” Other Axis II: x’ = 13.YI. df = i. P = 0.003; all pair\+ IX comparisons with Pure APD. P < 0.05). The Other Avis I I group had fewer years of education compared wilh the rernainlng groups (9.69 Other Axis II. Il.27 Non-‘4x1s II. I I.20 Pure APD and 10.60 Mixed API): F = 3.08. dt‘ = ! 16.1. P = 0.0?9: all pairwise comparisons with Other :\\I\ II. P < 0.05). There \vere no significant group dIIt&_ance~ for age. race, current employment. 01. rnarltal \l;\tus. Similarly, no signiticant group dltf’erence\ \vcr-e t’~~und for age onset of opioid use or cumulali\~ (IifclimeI months of methadone maintenance.
(IJ = 8) (IJ = 6) (Q = 4) (IJ = 4) (II= 3) (fJ=2) (17 = 2) (IJ = 0) (IJ = 0)
Avoidant Borderline Paranoid Histrionic Dependent Ohsess/Comp &II‘-Dcfcating Narcissistic Pass/Aggressive
(lJ=‘-)) (n=7) Q_l=.!i) (n=3) (n = 3) (IJ = 3) @=2) (rJ= I) (IJ = 0)
IS’
Table
E
K,lll\i,V
(‘I if/
/)rri,q ./l/U/l/lI/
lk/“‘“‘i
.;-1 I IWJ 1 i-lo-
15-l
I
SCL-90-R
T-scores (non-patient
norms)
for Non-AXIS (1) Non-Axis
II
(II = 101) Mean SCL-90-R
S.D.
If. Pure APD.
Mlxcd
API)
and Other
(2) Pure API)
(3)
(II = 25)
0, = 16)
Axis
If drug abuher\ Tuhcy‘\
(4)
Mixed
Mean
S.I>.
Mean
IO.
I
Af’D
Other
AXIS If”
po\t-hoc
compiirIwn\
01 = 15) SD.
Mean
S.D.
scores
Somatization
53.0
9.7
53.6
hl Y
0.X
597
IO.1
4.3 >
I. 3 > 7
Obsessive/compulsive
51.4
8.8
50.6
7.‘)
62.4
6.7
5X.X
0.5
43
I.2
Interpersonal
51.3
X.6
51.1
x.2
hi.0
Y0
61.2
Yl
3.3 >
I.2
Depression
53.4
10.0
53.5
x.4
63.2
70
61.X
IO.0
4.3 >
I.2
Anxiet) Hostiht)
49.9 47.x
10.3 x.5
49.‘)
IO.4 X.X
60.2
IO.4
57.4
11.x
4.3 >
I.1
4Y.3
h-3 I
Y. I
54.5
IO.5
4.3 >
I:.1 > ‘;‘I
49.0
6.5
50.4
7.9
57 3
IO. I
55.5
Il.3
4.3 > I: 3 > 2
Phobic
sensitivity
anxiety
Paranoid
ideation
Psychoticism Global
severity
scores
Global
Severity
Index
Positive
Symptom
Distress
Positive
Symptom
Total
“Personality
diagnoses
Index
within
the Other
>
50.7
X.9
50.7
Y.2
61.3
0. I
60.3
X.6
4.3 >
I.2
51.0
X.6
57.3
X.Y
hl 3
H.7
61.4
0.X
3.3 >
I.2
51.x
IO.5
52.0
Y.9
64.3
x.5
61.X
Y.X
4.3 >
I.2
50.2
X.5
46.6
5.6
57.4
7.3
56.~
7.2
4.3 >
I.2
52.4
I I.0
53.X
Y.8
64.4
7.3
60.X
IO.2
4.3 >
I. 3 > 2
Axis
II group
were not mutually
As shown in Table 1, univariate ANOVAs revealed significant differences among the four diagnostic groups on all clinical subscales and all global distress indices of the SCL-90-R. ‘Post-hoc comparisons among the four groups also revealed significant differences. The NonAxis II group had significantly lower scores on each of the SCL-90-R subscales compared with both the Mixed APD and the Other Axis II groups (P < 0.001). No significant differences were found between the Non-Axis II and the Pure APD groups, and both of these groups obtained lower distress scores on many of the subscales compared with the Mixed APD and the Other Axis II groups. In general, these data indicate low levels of psychiatric distress among patients in either the NonAxis II and the Pure APD groups. As expected, the Pure APD group had significantly lower distress scores on each of the subscales compared with the Mixed APD group. In contrast, comparisons between the Mixed APD and the Other Axis II groups reveal many more similarities than differences. In fact, these two groups differed significantly on the hostility subscale only; the Mixed APD group reported more hostility (63.1 vs. 54.5, respectively; Tukey’s = 4.29, P < 0.01). Thus, high levels of psychiatric distress characterize both the Mixed APD and the Other Axis II groups. It might be argued that the above findings are more related to gender differences since significantly more of the Pure APD group were male compared with the three remaining groups. This interpretation, however, does not appear valid. First, SCL-90-R sexadjusted norms (T-scores) were used for analyses. Second, examination of the means showed the same group relations and the same magnitude of differences for both
cxcIuGvc
50 multiple
diagnoses
> 3
were possible.
males and females. Third, subsequent analyses using gender as a grouping variable failed to reveal any significant gender by group interactions. 4. Discussion This study provides further confirmation of the clinical heterogeneity of APD opioid abusers. Specifically. each of the study hypotheses were confirmed. Antisocial drug abusers with another personality diagnosis had higher levels of psychiatric distress compared with those with APD only. This finding adds empirical support to Alterman and Cacciola’s ( 199 1) hypothesis regarding the possible impact of personality disorder comorbidity in APD drug abusers on psychiatric distress levels. Although Brooner et al. (1993b) had shown previously that APD drug abusers with other personality diagnoses had higher scores on Neuroticism than drug abusers with the APD diagnosis only, that study assessed personality traits rather than levels of current psychiatric distress. The Pure APD group (i.e. APD only) also reported less symptom distress than drug abusers with a personality diagnosis other than APD (i.e. Other Axis II group). In general, the low level of psychiatric distress reported by Pure APD patients in this study is more consistent with Cleckley’s (1941) clinical description of the nondistressed psychopath. This issue warrants further research attention. A rational starting point for future study might include determining scores on the Psychopathy Checklist-Revised (PCL-R; Hare, 198s) between non-distressed (i.e. Pure APD) versus distressed (i.e. Mixed APD) drug abusers; the PCL-R has recently
been shown to be a reliable measure of psychopathy among outpatient opioid abusers (Alterman et al., 1993). Based on the present study, one might expect that ‘Mixed APD’ patients would score lower on psychopathy compared with ‘Pure APD’ patients. Further, the interactions between level of psychiatric distress and level of psychopathy could be investigated in relation to treatment outcome; one might expect that the combination of high distress and low psychopathy in APD patients may be related to an improved treatment prognosis (Woody et al.. 1985; Alterman and Cacciola, 1991). The fact that Mixed APD patients were remarkably similar to those in the Other Axis II group deserves further comment. First, this finding is not particularly surprising. By definition, the Mixed APD also met criteria for many of the personality diagnoses represented in the Other Axis II group, particularly borderline personality which is usually associated with high levels of distress and emotional instability. Second, the reliability and stability of the personality diagnoses (including APD to a lesser extent) remain uncertain (Perry, 1992); this issue may be even more problematic among chronic drug abusers (Alterman and Cacciola, 1991). Despite efforts in the present study to address this issue, some overlap almost certainly remained between the symptoms associated with drug abuse and those associated with many personality diagnoses. Furthermore, while interrater reliability for both APD and borderline disorder was excellent in the present study, only a small number of positive cases were included in the analyses. Interrater agreement for other personality diagnoses could not be determined given the very small number of cases detected in the rolling subsample of 34 patients for whom joint interviews were completed. Despite these important study limitations, the presence of most any personality diagnosis may represent a stable marker of emotional distress and chronically poor interpersonal functioning. Other studies appear to support this view. Nate et al. ( I99 11, for example, found that the presence of any personality diagnosis in drug abusers was related to high distress. low life satisfaction and poor problem solving skills. Similarly, Shea et al. (1990) reported that the presence of personality disorder was associated with a worst outcome in social functioning among patients participating in an NIMH multicenter study on treatment of depression. In summary, the results from the present study converge with those obtained in the Brooner et al. (1993b) study of personality trait dimensions of drug abusers. Taken together. these studies reveal the presence of a subgroup of antisocial drug abusers that can be characterized by high symptom distress and personality traits resulting in marked vulnerability to chronic and pervasive emotional instability. neuroticism and Although the relationship between these clinical features
and treatment prognosis in APD drug abusers is unknown, it is relatively clear that treatment entry and retention are motivated behaviors. For many patients, the motivation includes the desire for reduced levels of distress. Chronic dysphoria might serve a similar role in APD patients, possibly contributing to improved treatment retention even in response to standard care interventions. 5. Acknowledgements This work was supported by USPHS research grants DA05569 and DA05273 from the National Institute on Drug Abuse. 6. References Alterman. New Alterman
(1991)The
A.1. and Cacciola. J.S.
sorder diagnosis Ment.
antIsocial perwnality
in substance abuser\:
problems
dl-
and ~wles.
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M. (lYY.1) Reliability
01
Dis. 179. 401-409.
A.I.. Cacciola. J.S. and Rutherford,
the Revised Psychopathy
Checklist
in wb\tance
abuae patient\.
Psychol. Assessment. 5. 44-44X. Brooner. R.K..
Bigelow. G.E.. Stram. E. and Schmidt. c‘.W/. (IYYO) In-
travenous drug abuse with antisoclal personality disorder. mcrcased HIV
risk behavior.
Brooner. R.K., Antisocial
Drug Alcohol
Schmidt, C.W..
behavior of intravenous
of antisocialpersonality
diagnosis
Depend.
26. 3Y-44
( IYY2)
Felch. L.J. and Bigelow. G.1:.
drug abusers: lmplicatlons
for
disorder. Am. J. Psychiatry 149.
482-487. Brooner.
R.K..
Greenfield.
(1993a) Antisocial intravenous Brooner.
C.N.
and Bigelo\+.
drug abusers. Am. J. Psychlatr!
R.K..
Costa,
L.. Schmidt.
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Herbst,
( 1903b)
P.T.
J.H..
Schmidt.
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G.1:.
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C.W..
Higeloa,
pcrsonahty
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and
disorder among drug
abusers: relations to other personality diagnoses and the fi\e-factor model of personality. Cleckley.
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H. (1941) The Mask of Sanity.
Costa, Jr.. P-f.
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NtO-PI!NEO-PI-1
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()dessa
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( 19X3)
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Manual
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Psychomrtrlc
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Baltimore. Folstein. M.F.,
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State’: a practtcal method for grading the cognltlvc \latc 01 patlent\ for the clinician. J. Psychiatr. Gerstley. L.. McLellan.
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for lhc a\re\\mcnt
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ALCOHOL
DEPEMEIKE Drug and Alcohol
Psychiatric
Edward Th
Job
distress in antisocial personality
Rousar,
Hopktm
Dependence 34 (1994) 149-154
l’nrwr.rtt~~
K. Brooner *, Michael W. Regier, George
Robert Sdrool
drug abusers: relation disorders
of Medicine.
Depurtn~cwt
to other
E. Bigelow
01 P.s,vdriutn~ wtd Uclt~r~t~~rrrl S~~icwc~. Bttltirmwc,
.MUI,I /ml
1 .SI
(Accepted Y July 1993)
Abstract Antisocial
drug abusers with other personality
on a measure of normal
personality
dimensions,
diagnoses the former
have been found to differ from those with the antisocial group
reporting
greater
pronenw
to emotional
distrw
tlqnosls
oral!
and instabl1il.y.
The present study examined the relationship between personality comorbidity among antisocial
drug abusers and ;I standardixd measure of current psychiatric distress level. Patients included I67 opioid drug abusers admitted to a community outpatient drug abuse treatment program. The results indicated that the presence of additional personality diagnoses among antisocial drug abusers was associated with high levels of distress compared with those with the antisocial diagnosis only and with those uith no personallt> diagnosis. Kq -
~ovrl.s: Antisocial;
Personality
disorder;
Psychiatric
distress;
1. Introduction Antisocial personality disorder (APD) is a common condition among opioid drug abusers (Rounsaville et al., 1982; Gerstley et al., 1989; Alterman and Cacciola, 1991; Brooner et al., 1992). The co-occurrence of antisocial disorder and opioid abuse has been associated with a poor treatment prognosis compared with nonantisocial opioid abusers (Woody et al., 1985), with higher rates of drug injection and needle sharing (Brooner et al.. 1990; Gill et al.. 1994) and with a higher rate of HIV-l infection (Brooner et al., 1993a). Despite the generally poor prognosis of antisocial opioid ahusers, it is important to remember that this population is clinically heterogeneous. For example, in the Woody et al. (1985) study, APD opioid abusers with a lifetime diagnosis of major depression had a remarkably better treatment outcome compared with those without the depression diagnosis. This study underscores the importance of identifying clinical heterogeneity among APD opioid abusers. * Corrcspondlng ,luthor. The Behavioral Biology Research Unit and The Francis Scott lie) MedIcal Center. Suite 1500. 5510 Nathan Shock Dri\e. Hall~morc. MD 21224. 1‘SA.
0 376-X7I6.‘04 $07
I)O
Drug abuse
Recently, Alterman and Cacciola ( 199I ) suggested another approach to characterizing clinical heterogcnrity among APD opioid abusers. Based on a review of the literature, they reported that APD opioid abusers with another personality diagnosis (particularly borderline disorder) might report higher levels of emotional distress compared with opioid abusers with only the APD diagnosis. This idea was partially confirmed in a report by Brooner et al. (1993b). who found that opioid abusers with APD plus another personality diagnosis obtained significantly higher scores on a personalit) trait measure of Neuroticism (NEO-Personality Invcntory --- NEO-PI; Costa and McCrae, 1989) compared with opioid abusers with the APD diagnosis only: in addition to higher scores on the overall Neuroticism domain, these multiply-personality-disordered i\PD patients had significantly higher scores on the depression, anxiety, self-consciousness and vulnerability facets of the Neuroticism domain. High scores on the NEO-PI Neuroticism domain. and its facets are associated with vulnerability to pervasive emotional distress and cmotional instability. Previous studies have also detected personalit\ diagnoses other than APD in treatment-seeking npioid
IW4 Elrcvw ScienceIreland Ltd. All right\ resetked
150
abusers. Khantizan and Treece (1985) reported that 3 1% of their patients were diagnosed with a personality disorder other than APD. More importantly, the presence of any personality disorder in drug abusers appears associated with greater distress, more life problems and poorer interpersonal skills compared with drug abusers without a coexisting personality diagnosis. For example, Nate et al. (1991) reported that substance abusers with any personality disorder (including APD) had more severe substance abuse, had higher scores on a global index of depression, had more negative life changes and lower problem solving skills compared with substance abusers without a personality disorder. These data suggest the potential importance of assessing drug abusers for both APD and other personality diagnoses. The present study examines the relationship of psychiatric distress to APD and other personality diagnoses in outpatient opioid abusers. Specifically. scores on the SCL-90-R (Derogatis, 1983) were compared for the following four diagnostic groups: (1) APD only - Pure APD; (2) APD plus another personality diagnosis diagnosis ~ Mixed APD; (3) personality other than APD - Other Axis II; (4) no personality diagnosis Non-Axis II. The following study hypotheses were examined: (1) the Pure APD group would have significantly lower SCL-90-R scores (i.e. less distress) than both the Mixed APD and the Other Axis II groups; (2) the Mixed APD would not have significantly different distress scores compared with the Other Axis II group; (3) the Mixed APD and the Other Axis II groups would both have significantly higher distress scores compared with the Non-Axis II group. 2. Methods 2.1. Subjects The patients were 167 opioid abusers consecutively admitted between April 1989 and December 1990 to an outpatient treatment program providing methadone, counseling and primary health care. All patients met DSM-III-R criteria for opioid dependence and all satisfied the Food and Drug Administration (FDA) guidelines for methadone substitution therapy. The patients were enrolled in a longitudinal investigation of the relationship of psychiatric comorbidity and distress to drug abuse treatment outcome. The present data are from the intake phase of that study. Informed consent was obtained after study procedures were fully described and participants were paid $30.00 for completing the intake assessment instruments (approx. 3 h total). The population had a mean age of 33.9 years (SD. = 6.8) and 53.3% were female. Most were white (70.1%). 28.7% were black, 1.2% were either Hispanic or Native American. The mean education level was 11.01 years (S.D. = 2.1) and 67.1% were unemployed. Many reported having never married (46.7%) 17.4% were cur-
rently married and 35.9.X were either separated or divorced. The mean age of first opioid use was 25.43 years (S.D. 6.4) and they had a mean of 45.67 (S.D. 61.8) cumulative (lifetime) months of outpatient methadone maintenance. 2.2. Procedure Psychiatric diagnoses were made using the Structured Clinical Interview for DSM-III-R (SCID-1 and SCID-2; Spitzer et al., 1992). The SCID takes approx. 2 h to administer and provides information for detecting the presence of a large number of the Axis I conditions (e.g. mood disorders, anxiety disorders. schizophrenia) and each of the personality diagnosis. The SCID was administered by three trained interviewers with masters degrees in psychology. Interviewer training consisted a minimum of 8 h of didactic review of the instrument, followed by co-rating a minimum of five interviews given by an expert interviewer and then conducting live interviews that agreed perfectly with diagnoses obtained by an expert co-rater. Interrater reliability was assessed throughout the study via expert co-ratings of a rolling subsample of patients (N = 34). Personality diagnoses were relatively infrequent in these 34 cases. with only two conditions prevalent in 5% or more of the interviews (APD, 15.4’%, kappa = 1.00; Borderline, 5.6% kappa = 1.OO). Psychiatric distress was assessed by the Symptom Checklist 90-R (SCL-90-R; Derogatis, 1983), a forcedchoice 90-item self-administered standardized questionnaire covering a wide variety of psychiatric symptoms. The SCL-90-R provides scores on nine clinical subscales (somatization, obsessive-compulsive. interpersonal sensitivity, depression, anxiety, hostility, phobic anxiety, paranoid ideation and psychoticism) and on three global indices of distress (Global Severity Index, Positive Symptom Distress Index and Positive Symptom Total). The SCL-90-R was computer administered and scored; non-patient norms were used. All data were collected between weeks 3 and 4 of treatment to reduce the influence of acute situational stress and intoxication or withdrawal on symptom reporting (Strain et al.. 1991). Study assessments were rescheduled for another day if the patient appeared intoxicated or obtained a score less than 27 on the MiniMental Status Examination (MMSE; Folstein et al.. 1975). Despite these efforts. symptom overlap between chronic drug abuse and specific criteria for various personality diagnoses probably remained. To reduce this overlap further, specific personality criteria were coded as positive only when characteristic of behavior during episodes of abstinence. 2.3. Datu unal~sis Group differences on demographic ment history variables were assessed
and drug treatusing Chi-square
with continuity correction or one-way analysis of variance (ANOVA) followed by Tukey’s Post-hoc test (as appropriate). Mean group differences (in T-scores; nonpatient norms) on the SCL-90-K subscales and global indices were assessed using a four-group ANOVA with Tukey’s post-hoc comparisons. The fbur groups consisted of patients categorized into the Pure APD group, the Mixed API) group. the Other Axis II group and the hon-Axis I I group. 3. Results
A large number of patients (101~160: 61%) failed to satisfy criteria for any personality disorder (Non Axis II). The 66 (39” (I) patients who mer the criteria for a personality disorder were categorized into one of the following mutually exclusive groups: 95 (38’Xl) APD only (Pure APD); I6 (74%) APD plus another diagnosis (Mixed APD); 15 (3X”,(,) with a diagnosis other than antisocial (Other Axis II). Although not a focus of the study. the prevalence of lifetime mood disorders (i.e. major depression and dysthymia) and specific anxiety disorders (i.e. generalized anxiety, panic disorder. agoraphobia) was calculated for each of the above
Non-Asis II (JJ = 101; 60%)
Any APD
Pure APD (IJ = 25)
Any Axis II Personality Disorder (n = 66; 40 5%)
(IJ = 4 1; 25 5%)
Other Axis II (IJ = 25; 15 5%~)
Mixed APD (lJ= l(1)
13ordcrlinc: Pass/Agcrcssive A\‘oid;lnt ScllI‘-Defeating IHistrionic IIkpd~Ilt
Paranoid Narcissistic ( )hsess/Comp
groups. Although major depression was the most common diagnosis detected in the population. there were no significant group differences in the rates of major depression or the other non-substance use Axis I conditions examined. Figure I provides descriptive information on the specific comorbid personality diagnoses detected in the Mixed APD group and tl1osc detected in the Other Axis II group. Significant differences were found bet\\ecn the I’<>LI~ groups on gender and years of education. A higher per-cent of the Pure APL) patients were maie compared with each of the remaining groups (80”~~ Pure API). 41 .6’% Non-Axls Ii. 3 I .3”i, Mixed API). 43” Other Axis II: x’ = 13.YI. df = i. P = 0.003; all pair\+ IX comparisons with Pure APD. P < 0.05). The Other Avis I I group had fewer years of education compared wilh the rernainlng groups (9.69 Other Axis II. Il.27 Non-‘4x1s II. I I.20 Pure APD and 10.60 Mixed API): F = 3.08. dt‘ = ! 16.1. P = 0.0?9: all pairwise comparisons with Other :\\I\ II. P < 0.05). There \vere no significant group dIIt&_ance~ for age. race, current employment. 01. rnarltal \l;\tus. Similarly, no signiticant group dltf’erence\ \vcr-e t’~~und for age onset of opioid use or cumulali\~ (IifclimeI months of methadone maintenance.
(IJ = 8) (IJ = 6) (Q = 4) (IJ = 4) (II= 3) (fJ=2) (17 = 2) (IJ = 0) (IJ = 0)
Avoidant Borderline Paranoid Histrionic Dependent Ohsess/Comp &II‘-Dcfcating Narcissistic Pass/Aggressive
(lJ=‘-)) (n=7) Q_l=.!i) (n=3) (n = 3) (IJ = 3) @=2) (rJ= I) (IJ = 0)
IS’
Table
E
K,lll\i,V
(‘I if/
/)rri,q ./l/U/l/lI/
lk/“‘“‘i
.;-1 I IWJ 1 i-lo-
15-l
I
SCL-90-R
T-scores (non-patient
norms)
for Non-AXIS (1) Non-Axis
II
(II = 101) Mean SCL-90-R
S.D.
If. Pure APD.
Mlxcd
API)
and Other
(2) Pure API)
(3)
(II = 25)
0, = 16)
Axis
If drug abuher\ Tuhcy‘\
(4)
Mixed
Mean
S.I>.
Mean
IO.
I
Af’D
Other
AXIS If”
po\t-hoc
compiirIwn\
01 = 15) SD.
Mean
S.D.
scores
Somatization
53.0
9.7
53.6
hl Y
0.X
597
IO.1
4.3 >
I. 3 > 7
Obsessive/compulsive
51.4
8.8
50.6
7.‘)
62.4
6.7
5X.X
0.5
43
I.2
Interpersonal
51.3
X.6
51.1
x.2
hi.0
Y0
61.2
Yl
3.3 >
I.2
Depression
53.4
10.0
53.5
x.4
63.2
70
61.X
IO.0
4.3 >
I.2
Anxiet) Hostiht)
49.9 47.x
10.3 x.5
49.‘)
IO.4 X.X
60.2
IO.4
57.4
11.x
4.3 >
I.1
4Y.3
h-3 I
Y. I
54.5
IO.5
4.3 >
I:.1 > ‘;‘I
49.0
6.5
50.4
7.9
57 3
IO. I
55.5
Il.3
4.3 > I: 3 > 2
Phobic
sensitivity
anxiety
Paranoid
ideation
Psychoticism Global
severity
scores
Global
Severity
Index
Positive
Symptom
Distress
Positive
Symptom
Total
“Personality
diagnoses
Index
within
the Other
>
50.7
X.9
50.7
Y.2
61.3
0. I
60.3
X.6
4.3 >
I.2
51.0
X.6
57.3
X.Y
hl 3
H.7
61.4
0.X
3.3 >
I.2
51.x
IO.5
52.0
Y.9
64.3
x.5
61.X
Y.X
4.3 >
I.2
50.2
X.5
46.6
5.6
57.4
7.3
56.~
7.2
4.3 >
I.2
52.4
I I.0
53.X
Y.8
64.4
7.3
60.X
IO.2
4.3 >
I. 3 > 2
Axis
II group
were not mutually
As shown in Table 1, univariate ANOVAs revealed significant differences among the four diagnostic groups on all clinical subscales and all global distress indices of the SCL-90-R. ‘Post-hoc comparisons among the four groups also revealed significant differences. The NonAxis II group had significantly lower scores on each of the SCL-90-R subscales compared with both the Mixed APD and the Other Axis II groups (P < 0.001). No significant differences were found between the Non-Axis II and the Pure APD groups, and both of these groups obtained lower distress scores on many of the subscales compared with the Mixed APD and the Other Axis II groups. In general, these data indicate low levels of psychiatric distress among patients in either the NonAxis II and the Pure APD groups. As expected, the Pure APD group had significantly lower distress scores on each of the subscales compared with the Mixed APD group. In contrast, comparisons between the Mixed APD and the Other Axis II groups reveal many more similarities than differences. In fact, these two groups differed significantly on the hostility subscale only; the Mixed APD group reported more hostility (63.1 vs. 54.5, respectively; Tukey’s = 4.29, P < 0.01). Thus, high levels of psychiatric distress characterize both the Mixed APD and the Other Axis II groups. It might be argued that the above findings are more related to gender differences since significantly more of the Pure APD group were male compared with the three remaining groups. This interpretation, however, does not appear valid. First, SCL-90-R sexadjusted norms (T-scores) were used for analyses. Second, examination of the means showed the same group relations and the same magnitude of differences for both
cxcIuGvc
50 multiple
diagnoses
> 3
were possible.
males and females. Third, subsequent analyses using gender as a grouping variable failed to reveal any significant gender by group interactions. 4. Discussion This study provides further confirmation of the clinical heterogeneity of APD opioid abusers. Specifically. each of the study hypotheses were confirmed. Antisocial drug abusers with another personality diagnosis had higher levels of psychiatric distress compared with those with APD only. This finding adds empirical support to Alterman and Cacciola’s ( 199 1) hypothesis regarding the possible impact of personality disorder comorbidity in APD drug abusers on psychiatric distress levels. Although Brooner et al. (1993b) had shown previously that APD drug abusers with other personality diagnoses had higher scores on Neuroticism than drug abusers with the APD diagnosis only, that study assessed personality traits rather than levels of current psychiatric distress. The Pure APD group (i.e. APD only) also reported less symptom distress than drug abusers with a personality diagnosis other than APD (i.e. Other Axis II group). In general, the low level of psychiatric distress reported by Pure APD patients in this study is more consistent with Cleckley’s (1941) clinical description of the nondistressed psychopath. This issue warrants further research attention. A rational starting point for future study might include determining scores on the Psychopathy Checklist-Revised (PCL-R; Hare, 198s) between non-distressed (i.e. Pure APD) versus distressed (i.e. Mixed APD) drug abusers; the PCL-R has recently
been shown to be a reliable measure of psychopathy among outpatient opioid abusers (Alterman et al., 1993). Based on the present study, one might expect that ‘Mixed APD’ patients would score lower on psychopathy compared with ‘Pure APD’ patients. Further, the interactions between level of psychiatric distress and level of psychopathy could be investigated in relation to treatment outcome; one might expect that the combination of high distress and low psychopathy in APD patients may be related to an improved treatment prognosis (Woody et al.. 1985; Alterman and Cacciola, 1991). The fact that Mixed APD patients were remarkably similar to those in the Other Axis II group deserves further comment. First, this finding is not particularly surprising. By definition, the Mixed APD also met criteria for many of the personality diagnoses represented in the Other Axis II group, particularly borderline personality which is usually associated with high levels of distress and emotional instability. Second, the reliability and stability of the personality diagnoses (including APD to a lesser extent) remain uncertain (Perry, 1992); this issue may be even more problematic among chronic drug abusers (Alterman and Cacciola, 1991). Despite efforts in the present study to address this issue, some overlap almost certainly remained between the symptoms associated with drug abuse and those associated with many personality diagnoses. Furthermore, while interrater reliability for both APD and borderline disorder was excellent in the present study, only a small number of positive cases were included in the analyses. Interrater agreement for other personality diagnoses could not be determined given the very small number of cases detected in the rolling subsample of 34 patients for whom joint interviews were completed. Despite these important study limitations, the presence of most any personality diagnosis may represent a stable marker of emotional distress and chronically poor interpersonal functioning. Other studies appear to support this view. Nate et al. ( I99 11, for example, found that the presence of any personality diagnosis in drug abusers was related to high distress. low life satisfaction and poor problem solving skills. Similarly, Shea et al. (1990) reported that the presence of personality disorder was associated with a worst outcome in social functioning among patients participating in an NIMH multicenter study on treatment of depression. In summary, the results from the present study converge with those obtained in the Brooner et al. (1993b) study of personality trait dimensions of drug abusers. Taken together. these studies reveal the presence of a subgroup of antisocial drug abusers that can be characterized by high symptom distress and personality traits resulting in marked vulnerability to chronic and pervasive emotional instability. neuroticism and Although the relationship between these clinical features
and treatment prognosis in APD drug abusers is unknown, it is relatively clear that treatment entry and retention are motivated behaviors. For many patients, the motivation includes the desire for reduced levels of distress. Chronic dysphoria might serve a similar role in APD patients, possibly contributing to improved treatment retention even in response to standard care interventions. 5. Acknowledgements This work was supported by USPHS research grants DA05569 and DA05273 from the National Institute on Drug Abuse. 6. References Alterman. New Alterman
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