Psychological Reporb, 1991, 6 8 , 1344-1346. O Psychological Reports 1991
ASSESSMENT O F AXIS I1 PERSONALITY DISORDERS AMONG FEMALE SUBSTANCE ABUSERS ' STEPHEN F. BUTLER Northeast Psychiatric Associates Brookside Hospital, Nashua, New Hampshire BERNARD GAULIER
DEBORAH HALLER
Metro Medical Group, Detroit, Michigan
Medical Co[lege of Virginia
Summary.-16 female substance abusers were assessed for the presence of personality disorders using two structured interviews and two self-report questionnaires. Although high prevalence of personality disorders was detected by each instrument, there was little agreement among the four methods for assessing these disorders.
The effectiveness of substance abuse treatments appears to be mediated by patients' Axis I and Axis I1 psychopathology (e.g., McLellan, Luborsky, Woody, O'Brien, & Druley, 1983; Woody, McLellan, Luborsky, & O'Brien, 1985). The investigation of persondty disorders in this population presupposes reliable and valid methods for diagnosis. Unfortunately, there is little consensus in the literature regrading Axis I1 assessment methodology (Reich, 1987). The present study compared the results of alternative assessment methods for the Axis I1 personality disorders in a sample of substanceabusing women. Sixteen women (M age = 31.4 yr., SD = 9.5) were recruited from an inpatient substance-abuse ward and from an outpatient perinatal addiction program. Subjects were indigent women, 56% white, 44% black, with primary addictions of alcohol, cocaine, and opiates. As a group, they were moderately depressed (Beck Depression Inventory M = 16.7, SD = 10.8) and of low average intelligence (Shipley IQ M = 90.9, SD = 11.5). Personality disorder was assessed using two structured interviews, the Structured Clinical Interview for DSM-I11 (SCID 11) and the Structured Interview for the DSM-I11 Personality Disorders-Revised (SIDP-R; Pfohl, Blum, Zimmerman, & Stangl, 1989), and the personality disorder scales of the MMPI (Morey, Blashfield, Webb, & Jewell, 1988, adjusted for the MMPI-2) and the Millon Clinical Multiaxial Inventory-I1 (Millon-11). Two subjects did not complete the structured interviews, one did not take the Mdlon-11. As Table 1 shows, a l l instruments ~ieldeda large number of diagnoses. The majority of subjects (79% to 88%) received an Axis I1 diagnosis, 'Address correspondence to S. F. Butler, Ph.D., Department of Psychology, 11 Northwest Blvd., Nashua, NH 03063. This work was sup orted in part by NIDA Grant No. DA06094, Sidney SchnoU, P.I., and Virginia ~ o m m o n w e a l t Center l on Drug Abuse.
AXIS I1 PERSONALITY DISORDERS I N DRUG USE
1345
depending on the instrument used. The most frequently diagnosed personality disorders were antisocial, borderline, histrionic, passive-aggressive, self-defeating, and dependent. Kappa values2 between pairs of instruments yielded a range of .28 to .76 (M Kappa = 36) on presence versus absence of personality disorder. Comparisons for individual diagnoses ranged from -. 12 to 1.00 for Cluster A (paranoid, schizoid, schizotypal, M = .15), -.22 to .84 for Cluster B (antisocial, borderline, histrionic, narcissistic, M = .30), and - . I 3 to .76 for Cluster C (avoidant, dependent, obsessive-compulsive, passive-aggressive, M = .18). No pair of instruments agreed consistently better than any other pair. TABLE 1 PERSONALITY DISORDERS DIAGNOSED BY EACHINSTRUMEAT SCID-I1 (n = 14)
SIDP-R (n = 14)
MMPI-2 (n = 16)
Millon-I1 (n = 15)
Cluster A Paranoid Schizoid Schizotypal Cluster B Antisocial Borderline Histrionic Narcissistic Cluster C Avoidant Dependent Obsessive Compulsive Passive Aggressive Not Otherwise Specified Sadistic Self-defeating Total D~agnosisof Personality Disorder Number Ranee
These data suggest high prevalence of personality disorder in an indigent population of chemically dependent women. Such "dual diagnosisu deserves attention because the potential impact of personality disorder on treatment outcome is negative. However, different disorders were diagnosed for the same subjects, depending on the instrument used. While the small sample tends to over- or under-estimate "true" Kappa, the consistently poor 'Guidelines for interpreting levels of clinical or ractical significance of Kappa are: .40-.59 =Fair, .60-.74 = Good, > .75 = ~ x c e i n (Cicchetti t & Sparrow, 1981).
< .40 = Poor,
1346
S. F. BUTLER, E T A L .
agreement observed here calls into question the interinstrument reliability and validity of these widely used instruments, as well as the construct validity of the DSM-111-R Axis I1 diagnoses. Further work should focus on developing a valid, clinical standard for personality disorders against which to measure reliabihty and validity of interviews and tests. REFERENCES C I C C ~ ~D.EV., ~ ~&, SPARROW, S. W. (1981) Developing criteria for establishing interrater reliability of specific items: applications to assessment of adapuve behavior. American Journal of Mentul Deficiency, 86, 127-137. MCLELLAN, A. T., LLJBORSKY, L., WOODY,G. E., O'BRIEN, C. P., & DRULEY,K. A. (1983) Predicting response to alcohol and drug abuse treatments: role of psychiatric severity. Archives of General Psychiatry, 40, 620-625. MOREY,L. C., BLASHFIELD, R. K., WEBB, W. W., & JEWELL,J. (1988) MMPI scales for DSM-I11 personality disorders: a preliminary validation study. Journal of Clinical Psychology, 44, 47-50. PFOHL, B., BLUM, N., ZLMMERMAN, M., & STANGL,D. (1989) Structured Interview for DSM-111-R personality. Univer. of Iowa CoUege of Medicine, Iowa City, IA. REICH,J. H. (1987) Instruments measuring DSM-I11 and DSM-111-R personality disorders. Journal of Personality Disorders, 1, 220-240. WOODY,G. E., MCLELLAN,A. T., LUBORSKY, L., & O'BRIEN, C. I! (1985) Sociopathy and psychotherapy outcome. Archives of General Psychiatry, 42, 1081-1086.
Accepted July 10, 1991.
ASSESSMENT O F AXIS I1 PERSONALITY DISORDERS AMONG FEMALE SUBSTANCE ABUSERS ' STEPHEN F. BUTLER Northeast Psychiatric Associates Brookside Hospital, Nashua, New Hampshire BERNARD GAULIER
DEBORAH HALLER
Metro Medical Group, Detroit, Michigan
Medical Co[lege of Virginia
Summary.-16 female substance abusers were assessed for the presence of personality disorders using two structured interviews and two self-report questionnaires. Although high prevalence of personality disorders was detected by each instrument, there was little agreement among the four methods for assessing these disorders.
The effectiveness of substance abuse treatments appears to be mediated by patients' Axis I and Axis I1 psychopathology (e.g., McLellan, Luborsky, Woody, O'Brien, & Druley, 1983; Woody, McLellan, Luborsky, & O'Brien, 1985). The investigation of persondty disorders in this population presupposes reliable and valid methods for diagnosis. Unfortunately, there is little consensus in the literature regrading Axis I1 assessment methodology (Reich, 1987). The present study compared the results of alternative assessment methods for the Axis I1 personality disorders in a sample of substanceabusing women. Sixteen women (M age = 31.4 yr., SD = 9.5) were recruited from an inpatient substance-abuse ward and from an outpatient perinatal addiction program. Subjects were indigent women, 56% white, 44% black, with primary addictions of alcohol, cocaine, and opiates. As a group, they were moderately depressed (Beck Depression Inventory M = 16.7, SD = 10.8) and of low average intelligence (Shipley IQ M = 90.9, SD = 11.5). Personality disorder was assessed using two structured interviews, the Structured Clinical Interview for DSM-I11 (SCID 11) and the Structured Interview for the DSM-I11 Personality Disorders-Revised (SIDP-R; Pfohl, Blum, Zimmerman, & Stangl, 1989), and the personality disorder scales of the MMPI (Morey, Blashfield, Webb, & Jewell, 1988, adjusted for the MMPI-2) and the Millon Clinical Multiaxial Inventory-I1 (Millon-11). Two subjects did not complete the structured interviews, one did not take the Mdlon-11. As Table 1 shows, a l l instruments ~ieldeda large number of diagnoses. The majority of subjects (79% to 88%) received an Axis I1 diagnosis, 'Address correspondence to S. F. Butler, Ph.D., Department of Psychology, 11 Northwest Blvd., Nashua, NH 03063. This work was sup orted in part by NIDA Grant No. DA06094, Sidney SchnoU, P.I., and Virginia ~ o m m o n w e a l t Center l on Drug Abuse.
AXIS I1 PERSONALITY DISORDERS I N DRUG USE
1345
depending on the instrument used. The most frequently diagnosed personality disorders were antisocial, borderline, histrionic, passive-aggressive, self-defeating, and dependent. Kappa values2 between pairs of instruments yielded a range of .28 to .76 (M Kappa = 36) on presence versus absence of personality disorder. Comparisons for individual diagnoses ranged from -. 12 to 1.00 for Cluster A (paranoid, schizoid, schizotypal, M = .15), -.22 to .84 for Cluster B (antisocial, borderline, histrionic, narcissistic, M = .30), and - . I 3 to .76 for Cluster C (avoidant, dependent, obsessive-compulsive, passive-aggressive, M = .18). No pair of instruments agreed consistently better than any other pair. TABLE 1 PERSONALITY DISORDERS DIAGNOSED BY EACHINSTRUMEAT SCID-I1 (n = 14)
SIDP-R (n = 14)
MMPI-2 (n = 16)
Millon-I1 (n = 15)
Cluster A Paranoid Schizoid Schizotypal Cluster B Antisocial Borderline Histrionic Narcissistic Cluster C Avoidant Dependent Obsessive Compulsive Passive Aggressive Not Otherwise Specified Sadistic Self-defeating Total D~agnosisof Personality Disorder Number Ranee
These data suggest high prevalence of personality disorder in an indigent population of chemically dependent women. Such "dual diagnosisu deserves attention because the potential impact of personality disorder on treatment outcome is negative. However, different disorders were diagnosed for the same subjects, depending on the instrument used. While the small sample tends to over- or under-estimate "true" Kappa, the consistently poor 'Guidelines for interpreting levels of clinical or ractical significance of Kappa are: .40-.59 =Fair, .60-.74 = Good, > .75 = ~ x c e i n (Cicchetti t & Sparrow, 1981).
< .40 = Poor,
1346
S. F. BUTLER, E T A L .
agreement observed here calls into question the interinstrument reliability and validity of these widely used instruments, as well as the construct validity of the DSM-111-R Axis I1 diagnoses. Further work should focus on developing a valid, clinical standard for personality disorders against which to measure reliabihty and validity of interviews and tests. REFERENCES C I C C ~ ~D.EV., ~ ~&, SPARROW, S. W. (1981) Developing criteria for establishing interrater reliability of specific items: applications to assessment of adapuve behavior. American Journal of Mentul Deficiency, 86, 127-137. MCLELLAN, A. T., LLJBORSKY, L., WOODY,G. E., O'BRIEN, C. P., & DRULEY,K. A. (1983) Predicting response to alcohol and drug abuse treatments: role of psychiatric severity. Archives of General Psychiatry, 40, 620-625. MOREY,L. C., BLASHFIELD, R. K., WEBB, W. W., & JEWELL,J. (1988) MMPI scales for DSM-I11 personality disorders: a preliminary validation study. Journal of Clinical Psychology, 44, 47-50. PFOHL, B., BLUM, N., ZLMMERMAN, M., & STANGL,D. (1989) Structured Interview for DSM-111-R personality. Univer. of Iowa CoUege of Medicine, Iowa City, IA. REICH,J. H. (1987) Instruments measuring DSM-I11 and DSM-111-R personality disorders. Journal of Personality Disorders, 1, 220-240. WOODY,G. E., MCLELLAN,A. T., LUBORSKY, L., & O'BRIEN, C. I! (1985) Sociopathy and psychotherapy outcome. Archives of General Psychiatry, 42, 1081-1086.
Accepted July 10, 1991.
