Abstract

Introduction

In the planning phase of the treatment of a patient with substance use disorders (SUDs), it is of fundamental importance to make an appropriate diagnosis of personality disorders (PDs).^1–3 Failure to diagnose such disorders can result in the exclusion of psychotherapeutic,^4–6 pharmacological, and social interventions, which could otherwise be essential for the recovery of the patient.^7–13

There have been many international studies in the quest to understand the relationship between personality and substance addiction, but if we eliminate those studies that did not investigate the full range of PDs, that did not use structured interviews for diagnosis, or that had limited study samples, the amount of data available is considerably reduced. Furthermore, addiction treatment programs are now organized in outpatient settings in an attempt to reduce hospital/therapeutic community residency. For this reason, it is essential to obtain credible data regarding outpatient services.

In 1995, a systematic review of literature made by Verheul et al.¹⁴ estimated a prevalence of PDs ranging from 44 to 79%. However, only 10 studies^15–24 investigated the full range of PDs using structured or semi-structured interviews and only 2 of those were carried out on outpatients. Kleinman et al.¹⁹ evaluated a sample of 76 cocaine addiction patients revealing a PD prevalence of 58%, and Brooner et al.¹⁶ examined 203 outpatients in treatment for opiate abuse, 37% of whom were diagnosed with an Axis II disorder. In the following years, important epidemiological studies were carried out with more adequate samples and standardized diagnostic methods. In a study of a sample of 366 alcoholics (in- and outpatients) by Morgenstern et al.²⁵ the prevalence of PDs was 57.9%. APD was the most frequent: 22.7% with gender differences (25.7% male, 9.1% female). Women had the highest rate of prevalence for borderline PD (BPD) (36 vs. 19%) and self-defeating disorders (22 vs. 11%). There were high rates of comorbidity among PDs not confined within a single cluster. Brooner et al.²⁶ examined 716 outpatients undergoing methadone substitution treatment. The prevalence of PDs was 35%. In Rounsaville et al.’s study,²⁷ PDs were diagnosed in a mixed (clinic and hospital) sample of 370 patients. In all, 57% of the patients had at least one PD, with particular prevalence in cluster B. It was observed that the inclusion of substance abuse symptoms produced a significant increase in the number of cases diagnosed, especially APD and BPD. Kokkevi et al.²⁸ found a prevalence of PDs in 173 addicts (in- and outpatients) at 59.5%. Driessen et al.²⁹ examined a sample of 250 alcoholics in hospital treatment revealing a 16% PD prevalence (another 17% had a PD not otherwise specified (NOS) diagnosis for a total prevalence of 33.6%). Verheul et al.³⁰ established a PD prevalence of 57% in a sample of 370 patients (in- and outpatients), with a high prevalence of APD, BPD, and avoidant personality. It was also shown that symptom profiles of PDs were not associated with anxiety/mood disorders.

Following the studies by Kleinman et al.¹⁹ and Brooner et al.^16,26, two studies were conducted on addiction outpatients. Bowden-Jones et al.³¹ worked on a multi-centric study carried out in four centers for addicts and three for alcoholics. Out of a sample of 280 patients, 37% of the addicts and 53% of the alcoholics had a PD (assessed by PAS-Q,³² a screening test for PDs). Zikos et al.³³ conducted a study on 138 alcoholics seeking outpatient treatment. The prevalence of PDs was 59% (assessed by SCID-II (Structured Clinical Interview for DSM-IV Axis II PDs)), of which 32% showed more severe psychological/social problems and a greater likelihood of treatment dropout and relapse.

Overall, because the prevalence of PDs in addicts is about four times higher than in the general population,^34–36 a more accurate consideration of the complex relationships between PDs and SUD is needed. The data suggest that personality pathology is involved in the etiology and course of SUD.³⁴

Materials and Methods

Results

Substance dependence characteristics

In 61% of cases, the primary addiction was heroin, with cocaine 4%, alcohol 28%, and PG 7% (Fig. 1). Among the opiate addicts, 30% (N = 59) had a second pathological addiction: 66% cocaine, 29% alcohol, and 5% gambling. Regarding PG, SOGS revealed that although only 22 patients had a primary diagnosis of PG, 32 patients (10%) displayed current gambling behavior and almost the same number had done so during their lifetime.

Figure 1

Primary substance dependence diagnosis. In 61% of cases, the primary addiction was heroin, with cocaine 4%, alcohol 28%, and PG 7%.

The average age for starting opiate use was 19 ± 4, for cocaine 22 ± 7, and for alcohol 28 ± 11 (Table 2). Considering the substance of primary use, 63% were in complete remission (greater than six months), 12% in partial remission (less than six months), and 25% continued use. These clinical assessments were confirmed by urine tests for opiates/cocaine and blood tests for alcohol.

Table 2

Age at the first substance use and years of treatment.

	M	MIN	MAX	DS
Average age at first opiate use	19	12	39	±4.3
Average age at first alcohol use	28	12	61	±11.1
Average age at first cocaine use	22	12	53	±7.2
Number of years in treatment	5.6	1	24	±5.0

The specific medicines used for the treatment of the primary addiction were methadone 32%, buprenorphine 13%, and gamma-hydroxybutyrate with or without disulfiram 14%. A total of 39% of patients were not being treated with specific medicines, particularly when the diagnosed primary addiction was cocaine or PG.

In all, 48% had been placed at least once in a therapeutic community. A total of 39% had been hospitalized for detoxification, 61% had been arrested, and 32% had been to prison. The presence of infective and liver diseases is an important clinical factor. Overall, 46% of the service patients had a family history of substance abuse or addiction (Table 3).

Table 3

Number (n) and proportion (%) of subjects according to clinical-substance dependence characteristics.

CLINICAL-SUBSTANCE DEPENDENCE VARIABLES	N	%
Primary substance
opiate	196	61.0
cocaine	13	4.0
alcohol	89	28.0
gambling	22	7.0
Comorbidity	84	26.2
wIth opiate addiction	59
alcohol	17	5.3
cocaine	39	12.2
gambling	3	0.9
with alcohol addiction	8
opiate	0	0.0
cocaine	6	1.9
gambling	2	0.6
with gambling addiction	17
opiates	6	1.9
alcohol	6	1.9
cocaine	5	1.6
Gambling
non-gambler	210	65.6
ex-gambler	28	8.8
pathological gambler	32	10.0
occasional gambler	50	15.6
Intravenous substance use	174	54.4
Smokers	218	68.1
Addiction status (primary substance)
remission	202	63.0
partial remission	38	12.0
continued use	80	25.0
Pharmacological treatment (primary substance)
methadone	102	32.0
buprenorphine	42	13.0
gamma-hydroxybutyrate	15	5.0
disulfiram	19	6.0
gamma-hydroxybutyrate and disulfiram	9	3.0
other	7	2.0
none	126	39.0
Psychotherapeutic treatment	61	19.0
Therapeutic community treatment history	154	48.0
Hospitalised for detoxification	125	39.0
Illnesses
cardiac disease	24	7.5
hepatic disease	108	33.8
respiratory disease	22	6.9
infectious disease	91	28.4
neural disease	26	8.1
osteoarticular disease	41	12.8
other pathologies	33	10.3
Family addiction history	146	45.6
Arrest history	195	61.0
Prison	103	32.0

Discussion

The primary aim of this study is to determine the prevalence of PDs among SUD patients assisted by an outpatient service. Almost two out of three patients fulfill the criteria for at least one PD (62%) and 27% present comorbidity in several PDs. The most common Axis II disorders found were borderline personality (15%), antisocial personality (13.8%), avoidant personality (7.8%), passive-aggressive personality (4.7%), obsessive-compulsive personality (4.7%), and paranoid personality (4.4%).

Table 6 compares the results of this study with those present in literature published between 1992 and 2012 in samples greater than 100 and using standardized diagnostic instruments. Among studies conducted solely in outpatient settings, our prevalence data are higher than those of Brooner et al.^16,26 and Bowden-Jones et al.,³¹ but in line with Zikos’ research.³³ Our data are within the average if we consider the overall results of studies in both outpatient and hospital settings.

The rates of prevalence in the diverse studies vary from 33 to 91%. According to Verheul et al.,⁴³ sampling factors (setting, gender, age group), diagnostic criteria (time-frame, exclusion of substance-related pathology), and assessment procedures (method, time of measurement) are the variables most responsible for the huge varieties in prevalence rates. These factors partly explain the ample range of variability in the prevalence of PDs in addicts, but they testify to the need for further studies to achieve reliable and comparable prevalence data, which could explain the relationship between these two pathological dimensions more clearly.

Such a high rate of PD prevalence raises the question of the consequences in clinical-therapeutic and social terms.

From the clinical-therapeutic point of view, it has emerged that having a PD increases threefold the probability of needing treatment in a therapeutic community and almost four times the probability of requiring access to MHC. This not only underscores the greater need for resources on behalf of these patients but also brings into discussion the motivations behind the treatment of patients in therapeutic communities. It must be pointed out that even though all the patients have a SUD, it is the ones with an Axis II psychic disorder, for whom simple outpatient treatment would not be sufficient, who mostly require treatment in a therapeutic community. Finally, it has been demonstrated how much a PD increases the risk of suicide (OR = 2.3). A total of 22% of patients have attempted to end their lives, and of these, 84% had a PD.

The social functioning of these people is greatly compromised. Among the service users without a job, 74% have a PD, and even considering all the confounding variables, employment remains an associated factor (OR = 0.5). A total of 27% of the patients receive disability benefits, and among these, 72% have a PD (P = 0.03, chi-square test). Among those who live alone, with their original family or in assisted accommodation, 69% have a PD (P < 0.001, chi-square test). We can conclude that the ability to work and start a family is influenced by having a PD.

Among the variables not influenced by the presence of PDs are the types of substances used in prevalence, as well as treatment with specific medicines, which remain directly linked to the addiction and are not affected by character. Significant differences were not observed with regard to having legal proceedings or having been to prison among the populations with and without PD. This signifies that the incarceration of addicts is a consequence of the addiction itself (possession of illegal substances, deviant behavior such as theft and drug-pushing driven by craving). Among those who had been to prison, 65% did not have an antisocial personality. Access to services helps in the containment of the illness, stems the need to resort to illegal behavior, and reduces the risk of going to prison. The patients currently in treatment with alternative measures to detention are in the majority of cases people unknown to the service before incarceration (including a considerable number of foreigners).

The treatment of addiction has been greatly influenced by the push to control the social phenomenon of addiction and by the fear of emergent pathologies such as HIV. Substance addiction has long been interpreted as a moral failing, and as such alternately ignored or repressed. Since the 1980s however, there have been articles available in literature that inquire into the significance of addiction and that define it as a disease. Addiction has been alternately proposed as a PD⁴⁴ or as an independent pathology classified among the 15 possible mental disorders.^45,46 In the last decade, there has been increased interest in the reasons for these clinical symptoms and the psychopathological implications. Attention is slowly moving from the substance and the dysfunctional behavior to the person and his need for care. In this article, it has been shown that 62% of the patients of a public service for pathological addiction are affected by a PD. This Italian datum integrates the data present in international literature and queries the adequacy of our services in facing a clinical situation of this type. It is important that services be prepared to make timely and accurate diagnoses of PDs and are able to implement the treatment procedures that are deemed in international literature to be most effective. Treatment also directed toward the dimension of character could help improve the quality of patients’ lives and their psychosocial functioning, as well as prevent the chronic nature of the disease.

Acknowledgments

Footnotes

REFERENCES