Dimensions of Personality Structure among patients with Substance Use Disorders and co-occurring Personality Disorders: A comparison with psychiatric outpatients and healthy controls Rossella Di Pierro, Emanuele Preti, Nicoletta Vurro, Fabio Madeddu PII: DOI: Reference:
S0010-440X(14)00092-3 doi: 10.1016/j.comppsych.2014.04.005 YCOMP 51285
To appear in:
Comprehensive Psychiatry
Received date: Revised date: Accepted date:
10 February 2014 4 April 2014 4 April 2014
Please cite this article as: Di Pierro Rossella, Preti Emanuele, Vurro Nicoletta, Madeddu Fabio, Dimensions of Personality Structure among patients with Substance Use Disorders and co-occurring Personality Disorders: A comparison with psychiatric outpatients and healthy controls, Comprehensive Psychiatry (2014), doi: 10.1016/j.comppsych.2014.04.005
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ACCEPTED MANUSCRIPT Dimensions of Personality Structure among patients with Substance Use Disorders and co-occurring Personality Disorders: a comparison with
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psychiatric outpatients and healthy controls
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Rossella Di Pierro, Emanuele Preti, Nicoletta Vurro, Fabio Madeddu Department of psychology, University of Milano-Bicocca
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Corresponding author: Rossella Di Pierro
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[email protected]
Department of psychology, University of Milano-Bicocca
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Piazza dell’Ateneo Nuovo, 1 – 20126 Milano
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Abstract Background
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Although dual diagnosis has been a topic of great scientific interest for a long time, few studies
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have investigated the personality traits that characterise patients suffering from Substance Use Disorders and co-occurring Personality Disorders through a dimensional approach. The present
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study aimed to evaluate structural personality profiles among dual diagnosis inpatients to identify
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specific personality impairments associated with dual diagnosis. Methods
The present study involved 97 participants divided into three groups: 37 dual diagnosis inpatients, 30 psychiatric outpatients and 30 nonclinical controls. Dimensions of personality functioning were
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assessed and differences between groups were tested using Kernberg’s dimensional model of personality.
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Results
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Results showed that dual diagnosis was associated with the presence of difficulties in three main dimensions of personality functioning. Dual diagnosis inpatients reported a poorly integrated
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identity with difficulties in the capacity to invest, poorly integrated moral values, and high levels of self-direct and other-direct aggression. Conclusions
The present study highlighted that a dimensional approach to the study of dual diagnosis may clarify the personality functioning of patients suffering from this pathological condition. The use of the dimensional approach could help to advance research on dual diagnosis, and it could have important implications on clinical treatment programs for dual diagnosis inpatients.
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1. Introduction
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Dual diagnosis (DD) is defined as the “co-occurrence in the same individual of a psychoactive
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substance use disorder and another psychiatric disorder” by the World Health Organization [1]. More specifically, the most frequent DD in clinical contexts involves the co-occurrence between
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Substance Use Disorders (SUDs) and Personality Disorders (PDs). Empirical studies have showed
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high rates of co-occurrence between SUDs (both alcoholism and drug abuse) and PDs, with reported rates typically ranging from 30% to 75% [2, 3]. In particular, many investigators have documented the high frequency with which Cluster B PDs co-occur with SUDs, especially Antisocial Personality Disorder (ASPD) and Borderline Personality Disorder (BPD) [4, 5, 6, 7, 8, 9,
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10, 11, 12]. In Rounsaville et al. [13], at least one personality disorder was present in the majority of SUDs patients, with cluster B being particularly prominent (45.7%), and especially prominent
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were antisocial personality disorder (ASPD) (27.0%) and borderline personality disorder (BPD)
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(18.4%).
The epidemiological and clinical attention to DD is supported by the finding that patients with co-
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occurring PDs are more likely to relapse [14], to be polyabusers [15], to have poorer treatment response and outcome [16], to show more severe psychopathology, to isolate themselves and to be dissatisfied [17]. Finally, recent studies have shown that patients with SUDs and co-occurring PDs are more inclined to act impulsively, to express aggressiveness and anger [17, 18], to have more difficulties in respecting social rules, and to be prone to antisocial behaviours [19, 20, 21, 22, 23, 24, 25]. Despite the frequent comorbidity between SUDs and PDs, few studies have investigated the personality profiles of these patients. Indeed, the study of personality among DD patients (SUDs and co-occurring PDs) has been conducted mainly from a descriptive-categorical standpoint [26], whereas no studies have investigated dimensional aspects of personality in DD patients.
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Otto Kernberg’s personality theory [27] describes personality pathology from a dimensional point of view [28]. Kernberg conceptualises personality pathology along a severity continuum where
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there are three levels of personality organisation: the psychotic level, the borderline level, and the
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neurotic level. In particular, the level of personality organisation might be described by three main
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dimensions: Identity, Defense mechanisms, and Reality testing. The Identity dimension refers to the presence of flexible, realistic and integrated representations of self and others that results in the
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ability to tolerate both the positively and negatively imbued qualities of the self and others [29]. In contrast, identity diffusion - the marker of borderline organisation - is characterised by inflexible, unstable and poorly integrated experiences of self and others that often result in instable and conflicting interpersonal relationships [30]. The Defense mechanisms dimension refers to the
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capability to manage internal conflicts between feelings or impulses. Pathological personalities at the borderline or psychotic level generally use immature defenses, which maintain a distorted,
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fragmentary and caricatured sense of self and others, as in the case of splitting. The Reality testing
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dimension is the ability to distinguish aspects of experience from the inner world and the external world. Generally, the psychotic level is characterised by distortions of this capability. Indeed,
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reality testing is mostly maintained at the neurotic level; whereas this capability might be temporarily distorted at the borderline level. In addition to these three personality dimensions, Kernberg indicates that personality structure might be described also through other dimensions, such as the quality of the individual’s object relations, aggression both as internal and behavioural attitude, the use of adaptive coping strategies, and the presence of moral values. Whereas no studies have analysed personality characteristics of DD patients through a dimensional approach, the aim of the present study was to investigate the personality structure among DD patients (SUDs and co-occurring PDs). In particular, we investigated whether DD was associated with specific dimensions of Kernberg’s personality model, comparing DD patients with psychiatric patients without SUDs and nonclinical controls. We hypothesized that the personality profile of
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patients with SUDs and co-occurring PDs would result in a more severe personality organization
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than psychiatric patients and nonclinical controls.
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2. Methods
2.1 Participants
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The present study involved three groups of participants: 37 DD inpatients (SUDs and co-occurring PDs) consecutively admitted in a residential treatment service for patients with SUD and cooccurring PDs, 30 psychiatric outpatients without SUDs consecutively admitted in a public mental health centre and 30 community individuals recruited through fliers posted in meeting places in the
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community and through word of mouth. Inclusion criteria for all participants were: 1) Be over 18 years old; 2) Exhibit no significant cognitive impairment; 3) Not meet the criteria for a current
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manic episode or psychotic disorder.
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The DD group included 26 males (70.3%) and 11 females (29.7%), with an overall mean age of 35.41 years (SD ± 9.16 years; range 18-53). The majority of participants were single (75.7%; N =
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28), 13.5% (N = 5) of participants were separated or divorced, and 10.8% (N=4) were married. The majority of DD inpatients were unemployed (56.8%; N = 21), although 70.3% (N = 26) of them reported a high education level (high school or above). The psychiatric group (P) included 23 females (76.7%) and 7 males (23.3%) with an overall mean age of 42.97 years (SD ± 14.15 years; range 19-69). The majority of participants were single (N = 12; 40%), 30% (N=9) were separated or divorced, and 30% (N=9) were married. Fifty percent of psychiatric outpatients were employed (N = 15), and only 26.7% of participants were unemployed. A majority, 58.6% (N=17), of psychiatric outpatients reported a high level of education and 41.4% (N=12) of participants reported a low level of education. No data were available on the level of education for one participant.
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The control group (C) included 23 females (76.7%) and 7 males (23.3%) with an overall mean age of 40.97 years (SD ± 14.35 years; range 22-63). Among the control group, 51.7% (N = 15) of
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participants were married, 34.5% (N=10) were single and 13.7% (N=4) were separated or divorced.
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Finally, the majority of nonclinical participants were employed (83.3%; N = 25) and they reported a
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high level of education (90%; N=27).
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2.2 Measures
The Structured Clinical Interview for DSM-IV Axis II Personality Disorders [SCID-II; 31] is a 140item semi-structured interview designed to provide categorical assessment of DSM-IV Axis-II disorders. The SCID-II interview was preceded by the administration of its self-report screening
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questionnaire. Given the diagnostic purposes of the SCID, it was not administered to the nonclinical participants.
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The Structured Interview for Personality Organization [STIPO; 32] is a 100-item structured
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interview for the assessment of personality structure based on Kernberg’s theory of personality organization. Personality domains and subdomains measured by the STIPO are presented in Table 1
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[33]. Items are rated on a three point scale (0 = no pathology; 1 = some pathology, sub-threshold; 2 = significant to severe pathology). The Italian version of the interview [34] has demonstrated good psychometric proprieties: Crohnbach’s α was between .78 and .92 and inter-rater reliability was between .82 and .97. The interview takes an average of 90 to 180 minutes to administer.
2.3 Procedure The present study was approved by the Research Ethics Board of the University of Milano-Bicocca. Assessment procedures were performed after participants provided written informed consent. The SCID II and the STIPO were administered by a clinical psychologist.
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2.4 Statistical analyses All analyses were performed using SPSS 18.0 (SPSS, Chicago, IL). Descriptive statistics were used
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to describe the sociodemographic and psychopathologic characteristics among the three groups.
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Analysis of Variance (ANOVA) was used to test differences in personality domains and
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subdomains of the STIPO between the three groups of participants, controlling for the effect of
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gender.
3. Results
3.1 Descriptive Characteristics
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Among the DD group, the majority of participants (64.8%; N= 24) had a dependence diagnosis and 13 participants (35.2%) had an abuse diagnosis. Data on Axis I disorders were gathered from
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clinical records; participants of the DD group had no other Axis I diagnoses different than SUDs.
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Moreover, the majority of participants were polysubstance users (72.9; N= 27), and the most common combination of substances was cocaine and alcohol (32.4%; N=12).
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Among the psychiatric group, the majority of participants (50%; N=13) had a mood disorder diagnosis, followed by anxiety disorders (26.9%; N= 7), adjustment disorder (16.7%; N= 5) and eating disorders (3.8%; N= 1). Data on Axis I disorders were gathered from clinical records; data were unavailable for 4 psychiatric outpatients.
3.2 PDs diagnoses among the two clinical groups Among the DD group, 36 out of the 37 participants (97.3%) had at least one PD; whereas PDs were present to a lesser extent among the psychiatric group (40%; N=12). Personality disorders among the two clinical groups are presented in Table 2.
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With regard to the prevalence of PDs, statistically significant differences between the two groups were found only for the Antisocial Personality Disorder (χ2 (1) = 15.67; p < .001) and the Not
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Otherwise Specified Personality Disorder (χ2 (1) = 10.04; p = .002). Indeed, Antisocial Personality
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Disorder showed higher prevalence among the DD group (40.5%; N = 15) than the psychiatric
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group (none of the participants of this group was diagnosed as ASPD). Similarly, the prevalence of the Not Otherwise Specified Personality Disorder was higher among the DD group (24.3%; N = 9)
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compared to the psychiatric group (10%; N=3).
The other PDs showed similar frequencies among the two groups, with no statistically significant differences between them.
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3.3 Differences in personality characteristics: the STIPO domains and subdomains. Structural personality aspects among the three groups of participants, and differences between
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groups, are presented in Table 3. Moreover, Figure 1 illustrates personality profiles for each group
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of participants.
Differences between groups were tested controlling for the effect of gender. Nevertheless, statistical
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analyses did not show significant gender effects on differences in personality dimensions between the three groups.
As regards the Identity domain, significant group differences were found. Post-hoc comparisons indicated that the DD group reported higher identity diffusion than the psychiatric group (p< .01) and the control group (p< .001). Specifically, the DD group showed a significantly higher impairment of the Capacity to Invest than the psychiatric group (p< .05) and the control group (p< .001). On the contrary, the other identity subdomains did not discriminate between the DD group and the psychiatric group (Table 3). Significant group differences were found in the Object Relations domain. Both the DD (p< .001) and the psychiatric group (p< .001) had higher impairments in this domain compared to control
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group. Significant group differences were also found in the Primitive Defenses domain. The two clinical groups showed higher impairment (DD: p< .001; Psychiatric: p< .001) compared to control
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group. Again, significant group differences were found in the Coping and Rigidity domain. The two
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clinical groups showed higher impairment (DD: p< .001; Psychiatric: p< .001) than the control
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group.
Significant group differences were found in the Aggression domain. The DD group reported higher
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aggression compared to both the control group (p< .001) and the psychiatric group (p< .001). Specifically, the two clinical groups differed in both the Aggression’s subdomains. As regards SelfDirected Aggression, the DD group reported greater difficulties compared to both the psychiatric group (p< .001) and the control group (p< .001). The difference between the psychiatric group and
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the control group was marginal (p= .06). Again, significant group differences were found in the Other-Directed Aggression subdomain: the DD group reported grater difficulties compared to both
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the psychiatric group (p< .01) and the control group (p< .001). The psychiatric group and the
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control group showed no significant differences (p= .24). Significant group differences were also found in the Moral Values domain. The DD group reported
(p< .001).
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significant higher scores compared to both the psychiatric group (p< .001) and the control group
Finally, significant group differences were found in the Reality Testing domain. The psychiatric group showed greater difficulties in reality testing than the DD group (p< .05) and the control group (p< .01).
4. Discussion
According to Kernberg’s personality model, the present study investigated personality structure profiles in DD inpatients (SUDs and co-occurring PDs) and in psychiatric outpatients. Although
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DD has been an important research topic for many years, the majority of studies have been based on the categorical approach to personality. In this sense, the use of a dimensional approach to the study
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of personality among DD inpatients may lead to a deeper knowledge of this psychopathological
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condition.
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Findings from this study showed that DD (co-occurrence of SUDs and PDs) was associated with specific impairments in three personality dimensions: Identity, Aggression, and Moral Values.
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Indeed, DD inpatients reported greater difficulties in these personality dimensions than both psychiatric outpatients and nonclinical controls.
In the present study, DD inpatients reported severe difficulties in undertaking work and study commitments or free time activities, and in keeping them with continuity and responsibility.
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Although empirical studies have not yet directly investigated capabilities to invest in social activities among DD inpatients, our results are in line with findings from previous studies. Indeed,
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many studies have demonstrated that DD, both in case of co-occurring PDs or psychotic disorders,
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has been associated with psychosocial problems and social isolation [35, 36, 37, 38, 39]. Additionally, the main treatment models for DD inpatients generally include psychosocial programs
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[37, 40, 41]. In particular, the majority of residential treatment settings for DD aim to “develop responsible drug-free lifestyles through a program of group living with firm behavioural norms and a hierarchical system of responsibilities and privileges” [42]. Previous studies have demonstrated that patients with SUDs and co-occurring PDs were more inclined to engage in aggressive behaviours and to express anger [17, 18]. Differently from previous studies, our results highlighted that the greater aggression of DD inpatients involves also selfdirected behaviours. Indeed, the majority of studies on the association between aggression and DD have been focused on the other-directed manifestations of aggression [43], and few studies have investigated self-directed aggressive behaviours among DD patients [44]. Despite the association between self-directed aggression and DD has not yet received sufficient attention, literature on
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SUDs has showed a strong association with self-directed aggression [45]. In this sense, an indirect evidence of this association is the prevalence rates of suicide and non-suicidal self-injury (NSSI)
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behaviours among SUDs patients. The lifetime prevalence of suicide among SUDs patients ranges
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between 15% and 45% [46, 47, 48] and NNSI ranges between 29% to 52% [49, 50, 51, 52].
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Another personality dimension that characterised DD inpatients in our sample was the lack of an integrated and mature system of moral values. The moral values dimension measured by the STIPO
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reflects the Super-Ego functioning and the degree to which the individual has internalised stable moral values that guide his behaviour [32]. Our results suggested that DD inpatients have an internalised values system that is unstable and poorly integrated, resulting in antisocial behaviours, difficulties in taking responsibility for their behaviours, and difficulties in respecting social rules.
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These findings are not surprising given that most studies showed that individuals with SUDs and co-occurring PDs are more likely to engage in antisocial behaviours [19, 20, 21, 22, 23, 24, 25].
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Again, as shown in the present study, literature on DD have demonstrated that antisocial personality
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disorder often co-occur with SUDs [19, 21, 53, 54, 55]. Finally, in line with theoretical expectations, the reality testing dimension was more impaired in the
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psychiatric group. Indeed, the reality testing dimension measured by the STIPO refers to difficulties in discriminating between inner experiences and outer reality: impairments that are often associated with psychotic symptoms. This last result confirms the utility of considering the specific aspects of the personality profile. Whereas identity pathology is connected with the severity of personality pathology, damaged reality testing indicates the possible presence of a psychotic disorder and thus the need for different management and therapeutic strategies. Taken together, our results support the hypothesis that patients with SUDs and co-occurring PDs present a more severe profile of personality compared to psychiatric patients. Particularly, the higher severity in the Identity, Aggression, and Moral values dimensions of DD patients suggest the need of specific therapeutic and clinical management instruments.
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The results of the current study can be better understood in the context of the study’s limitations. The main limitation concerns differences on socio-demographic and psychopathological
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characteristics between the groups we considered. First of all, the three groups differed on the level
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of education. Psychiatric participants reported a lower level of education than DD participants and
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nonclinical controls. Additionally, the distribution of PDs within the DD group and the psychiatric group was not homogeneous. The psychiatric group showed a lower prevalence of any PD (40%)
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compared to the DD group (97.3%). In particular, the high prevalence of ASPD among the DD group, and the total absence of it among the psychiatric group, did not allow us to control its effect on the personality dimensions we studied. Therefore, it is possible that some of the results we found might be partly explained by the presence of antisocial personality disorder among DD inpatients.
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In this sense, future research on structural characteristics of personality should consider clinical groups with more homogeneous distribution of PDs. This would help researchers to understand
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whether personality traits are linked to the presence of DD or to the presence of specific PDs.
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Despite this, it is important to note that the heterogeneity of the psychiatric sample reflects the ecological reality of public mental health services in Italy. In this sense, the adoption of a
practice.
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dimensional approach leads to psychopathological profiles that can be more useful for clinical
5. Conclusion
In conclusion, the present study showed that individuals with SUDs and co-occurring PDs are characterised by a specific personality profile. Again, the study provided indirect evidence of the utility of a dimensional approach to the study of the pathological manifestations of personality. Particularly, the STIPO domains allow the assessment of the areas that are indicated in the DSM 5 Alternative Model for Personality Disorders [56], in line with the Levels of Personality Functioning
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Scale [57, 58]. In this sense, our results underline the importance of identity assessment in determining the severity of personality pathology. Indeed, the STIPO is currently one of the few
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validated interviews allowing a dimensional assessment of personality structure, and our results
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suggest that this instrument is particularly suited to assess level of personality functioning and
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impairment in line with the DSM 5 indications.
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[42] Bornovalova MA, Daughters SB. How does dialectical behavioral therapy facilitate treatment retention among individuals with comorbid borderline personality disorder and substance use
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[43] Alcorn JL, Gowin JL, Green CE, Swann AC, Moeller FG, Lane SD. Aggression, impulsivity
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and psychopathic traits in combined antisocial personality disorder and substance use disorder. J
[44] Links PS, Heslegrave RJ, Mitton JE, van Reekum R, Patrick J. et al. Borderline personality disorder and substance abuse: consequences of comorbidity. Can J Psychiatry 1995; 40(1):9-14. [45] Mino A, Bousquet A, Broers B. Substance abuse and drug related death, suicidal ideation, and
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[46] Evren C, Sar V, Dalbudak E, Cetin R. Lifetime PTSD and quality of life among alcohol-
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[47] Rossow I, Lauritzen G. Shattered childhood: A key issue in suicidal behavior among drug addicts?. Addict 2001;96(2):227-240. [48] Driessen G, Gunther N, Van Os J. Shared social environment and psychiatric disorder. A multilevel analysis of individual and ecological effects. Soc Psychiatry Psychiatr Epidemiol 1998;33:606-612. [49] Evren C, Evren B. Self-mutilation in substance-dependent patients and relationship with childhood abuse and neglect, alexithymia and temperament and character dimensions of personality. Drug Alcohol Depend 2005;80(1):15-22.
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[50] Evren C, Evren B. The relationship of suicide attempt history with childhood abuse and neglect, alexithymia and temperament and character dimensions of personality in substance
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dependents. Nordic J Psychiatry 2006;60(4):263-269.
[51] Evren C, Sar V, Evren B, Semiz U. Dissociation and alexithymia among men with alcoholism.
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Psychiatry Clin Neurosci 2008;62(1):40-47.
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[52] Zlotnick C, Mattia JI, Zimmerman M. Clinical correlates of self-mutilation in a sample of general psychiatric patients. J Nerv Mental Disease 1999;187:296-301. [53] Skodol AE, Stout RL, McGlashan TH, Grilo CM, Gunderson JG, Shea MT et al. Cooccurrence of mood and personality disorders: A report from the Collaborative Longitudinal
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Personality Disorders Study (CLPS). Depress Anxiety 1999;10:175-182.
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[54] Goldstein RB, Compton WM, Pulay AJ, Ruan WJ, Pickering RP, Stinson FS, Grant BF. Antisocial behavioral syndromes and DSM-IV drug use disorders in the United States: Results from
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2007;90(2):145-158.
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the National Epidemiologic Survey on Alcohol and Related Conditions. Drug Alcohol Depend
[55] Goldstein RB, Dawson DA, Sasha TD, Ruan WJ, Compton WM, Grant BF. Antisocial behavioral syndromes and DSM-IV alcohol use disorders: Results from the National Epidemiologic Survey on Alcohol and Related Conditions. Alcoholism Clin Exp Research 2007;31(5):814-828. [56] American Psychiatric Association (APA). Diagnostic and Statistical Manual of Mental Disorders (5th ed.).Washington, DC: Author; 2013. [57] Bender DS, Morey LC, Skodol AE. Toward a model for assessing level of personality functioning in DSM-5, part I: A review of theory and methods. J Pers Assess 2011;93(4):332-346.
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[58] Morey LC, Berghuis H, Bender DS, Verheul R, Krueger RF, Skodol AE. Toward a model for assessing level of personality functioning in DSM-5, part II: Empirical articulation of a core
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dimension of personality pathology. J Pers Assess 2011;93(4):347-353.
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Figure 1. STIPO Profile for the dual diagnosis group (DD), the psychiatric group (P), and the nonclinical group (NC) 4 3.5
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2 1.5 1
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0.5
P
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DD
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0
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Mean
3 2.5
NC
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Table 1. The domains and subdomains of the STIPO [33]. DOMAIN
SUBDOMAIN A. Capacity to invest B. Sense of self Coherence and continuity Self valutation C. Sense of others
OBJECT RELATIONS
A. Interpersonal relationships B. Intimate relationships and sexuality C. Internal working model of relationships
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IDENTITY
PRIMITIVE DEFENSES
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COPING/RIGIDITY AGGRESSION
A. Self-directed aggression B. Other-directed aggression
MORAL VALUES
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PT
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REALITY TESTING
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Table 2. DSM-IV-TR Personality Disorders among Dual Diagnosis inpatients (DD) and Psychiatric outpatients (P).
Paranoid
2
Schizothypic
-
Schizoid
%
N
df
p-value
.17
1
0.68
1.25
1
0.26
1.25
1
0.26
10.0
2.31
1
0.13
-
3.45
1
0.06
-
15.67
1
< 0.001
-
1
3.3
-
-
1
3.3
Borderline
9
24.3
3
Narcisistic
4
10.8
-
Antisocial
15
40.5
-
Histrionic
-
-
1
3.3
1.25
1
0.26
Avoidant
4
10.8
1
3.3
1.34
1
0.25
Dependent
1
2.7
1
3.3
.02
1
0.88
Ossessive-Compulsive
2
5.4
1
3.3
.17
1
0.68
Passive-Aggressive
4
10.8
3
10.0
.01
1
0.91
4
10.8
5
16.7
.49
1
0.48
15
40.5
2
6.7
10.04
1
0.002
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Not Otherwise Specified
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3.3
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1
Depressive
5.4
Χ2
%
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N
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Axis I Disorder
P
T
DD
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Table 3. STIPO’s domains and subdomains: Means, Standard Deviations and differences between the dual diagnosis group (DD), the psychiatric group (P) and the nonclinical group (NC). P
NC
M
SD
M
SD
Identity
3.35a
0.98
2.73b
0.78
Capacity to Invest
3.05a
1.20
2.47b
Coherence and Continuity
2.73a
0.96
2.60a
Self-valuation
2.86a
1.21
2.40a
Self of Others
3.27a
0.90
2.87a
Object Relations
3.05a 2.89a
Intimate relationships and sexuality
2.65a
Internal working model of relationships
2.76a 3.30a
Coping/Rigidity
Self-directed aggression
Reality Testing abc
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Moral Values
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Other-directed aggression
1.43c
0.50
41.11
< .001
0.86
1.27c
0.45
27.14
< .001
0.77
1.17b
0.46
28.65
< .001
0.77
1.27b
0.58
20.52
< .001
0.94
1.50b
0.63
35.99
< .001
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F (2;91)
p
2.80a
0.85
1.27b
0.45
30.51
< .01
1.54
2.60a
1.22
1.23b
0.63
10.78
< .001
1.09
2.90a
1.09
1.50b
0.94
11.37
< .001
1.18
2.33a
0.80
1.23b
0.43
24.52
< .001
0.94
2.93a
0.74
1.43b
0.57
46.19
< .001
3.31a
1.14
2.93a
0.91
1.37b
0.56
27.56
< .001
3.43a
1.01
2.00b
0.74
1.07c
0.25
64.03
< .001
3.46a
0.99
1.73b
0.83
1.23b
0.57
54.56
< .001
2.78a
1.57
1.73b
0.74
1.23b
0.43
12.38
< .001
2.14a
0.95
2.10b
0.71
1.13c
0.35
45.96
< .001
1.68a
0.78
2.10b
0.66
1.13c
0.43
9.77
< .001
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Aggression
SD
1.18
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Primitive Defenses
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Interpersonal relationships
M
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STIPO’s domains and subdomains
T
DD
Means followed by the same letter in a line are not significantly different at the 5% probability level
S0010-440X(14)00092-3 doi: 10.1016/j.comppsych.2014.04.005 YCOMP 51285
To appear in:
Comprehensive Psychiatry
Received date: Revised date: Accepted date:
10 February 2014 4 April 2014 4 April 2014
Please cite this article as: Di Pierro Rossella, Preti Emanuele, Vurro Nicoletta, Madeddu Fabio, Dimensions of Personality Structure among patients with Substance Use Disorders and co-occurring Personality Disorders: A comparison with psychiatric outpatients and healthy controls, Comprehensive Psychiatry (2014), doi: 10.1016/j.comppsych.2014.04.005
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ACCEPTED MANUSCRIPT Dimensions of Personality Structure among patients with Substance Use Disorders and co-occurring Personality Disorders: a comparison with
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psychiatric outpatients and healthy controls
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Rossella Di Pierro, Emanuele Preti, Nicoletta Vurro, Fabio Madeddu Department of psychology, University of Milano-Bicocca
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Corresponding author: Rossella Di Pierro
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[email protected]
Department of psychology, University of Milano-Bicocca
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Piazza dell’Ateneo Nuovo, 1 – 20126 Milano
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Abstract Background
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Although dual diagnosis has been a topic of great scientific interest for a long time, few studies
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have investigated the personality traits that characterise patients suffering from Substance Use Disorders and co-occurring Personality Disorders through a dimensional approach. The present
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study aimed to evaluate structural personality profiles among dual diagnosis inpatients to identify
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specific personality impairments associated with dual diagnosis. Methods
The present study involved 97 participants divided into three groups: 37 dual diagnosis inpatients, 30 psychiatric outpatients and 30 nonclinical controls. Dimensions of personality functioning were
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assessed and differences between groups were tested using Kernberg’s dimensional model of personality.
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Results
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Results showed that dual diagnosis was associated with the presence of difficulties in three main dimensions of personality functioning. Dual diagnosis inpatients reported a poorly integrated
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identity with difficulties in the capacity to invest, poorly integrated moral values, and high levels of self-direct and other-direct aggression. Conclusions
The present study highlighted that a dimensional approach to the study of dual diagnosis may clarify the personality functioning of patients suffering from this pathological condition. The use of the dimensional approach could help to advance research on dual diagnosis, and it could have important implications on clinical treatment programs for dual diagnosis inpatients.
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1. Introduction
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Dual diagnosis (DD) is defined as the “co-occurrence in the same individual of a psychoactive
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substance use disorder and another psychiatric disorder” by the World Health Organization [1]. More specifically, the most frequent DD in clinical contexts involves the co-occurrence between
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Substance Use Disorders (SUDs) and Personality Disorders (PDs). Empirical studies have showed
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high rates of co-occurrence between SUDs (both alcoholism and drug abuse) and PDs, with reported rates typically ranging from 30% to 75% [2, 3]. In particular, many investigators have documented the high frequency with which Cluster B PDs co-occur with SUDs, especially Antisocial Personality Disorder (ASPD) and Borderline Personality Disorder (BPD) [4, 5, 6, 7, 8, 9,
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10, 11, 12]. In Rounsaville et al. [13], at least one personality disorder was present in the majority of SUDs patients, with cluster B being particularly prominent (45.7%), and especially prominent
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were antisocial personality disorder (ASPD) (27.0%) and borderline personality disorder (BPD)
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(18.4%).
The epidemiological and clinical attention to DD is supported by the finding that patients with co-
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occurring PDs are more likely to relapse [14], to be polyabusers [15], to have poorer treatment response and outcome [16], to show more severe psychopathology, to isolate themselves and to be dissatisfied [17]. Finally, recent studies have shown that patients with SUDs and co-occurring PDs are more inclined to act impulsively, to express aggressiveness and anger [17, 18], to have more difficulties in respecting social rules, and to be prone to antisocial behaviours [19, 20, 21, 22, 23, 24, 25]. Despite the frequent comorbidity between SUDs and PDs, few studies have investigated the personality profiles of these patients. Indeed, the study of personality among DD patients (SUDs and co-occurring PDs) has been conducted mainly from a descriptive-categorical standpoint [26], whereas no studies have investigated dimensional aspects of personality in DD patients.
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Otto Kernberg’s personality theory [27] describes personality pathology from a dimensional point of view [28]. Kernberg conceptualises personality pathology along a severity continuum where
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there are three levels of personality organisation: the psychotic level, the borderline level, and the
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neurotic level. In particular, the level of personality organisation might be described by three main
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dimensions: Identity, Defense mechanisms, and Reality testing. The Identity dimension refers to the presence of flexible, realistic and integrated representations of self and others that results in the
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ability to tolerate both the positively and negatively imbued qualities of the self and others [29]. In contrast, identity diffusion - the marker of borderline organisation - is characterised by inflexible, unstable and poorly integrated experiences of self and others that often result in instable and conflicting interpersonal relationships [30]. The Defense mechanisms dimension refers to the
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capability to manage internal conflicts between feelings or impulses. Pathological personalities at the borderline or psychotic level generally use immature defenses, which maintain a distorted,
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fragmentary and caricatured sense of self and others, as in the case of splitting. The Reality testing
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dimension is the ability to distinguish aspects of experience from the inner world and the external world. Generally, the psychotic level is characterised by distortions of this capability. Indeed,
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reality testing is mostly maintained at the neurotic level; whereas this capability might be temporarily distorted at the borderline level. In addition to these three personality dimensions, Kernberg indicates that personality structure might be described also through other dimensions, such as the quality of the individual’s object relations, aggression both as internal and behavioural attitude, the use of adaptive coping strategies, and the presence of moral values. Whereas no studies have analysed personality characteristics of DD patients through a dimensional approach, the aim of the present study was to investigate the personality structure among DD patients (SUDs and co-occurring PDs). In particular, we investigated whether DD was associated with specific dimensions of Kernberg’s personality model, comparing DD patients with psychiatric patients without SUDs and nonclinical controls. We hypothesized that the personality profile of
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patients with SUDs and co-occurring PDs would result in a more severe personality organization
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than psychiatric patients and nonclinical controls.
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2. Methods
2.1 Participants
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The present study involved three groups of participants: 37 DD inpatients (SUDs and co-occurring PDs) consecutively admitted in a residential treatment service for patients with SUD and cooccurring PDs, 30 psychiatric outpatients without SUDs consecutively admitted in a public mental health centre and 30 community individuals recruited through fliers posted in meeting places in the
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community and through word of mouth. Inclusion criteria for all participants were: 1) Be over 18 years old; 2) Exhibit no significant cognitive impairment; 3) Not meet the criteria for a current
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manic episode or psychotic disorder.
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The DD group included 26 males (70.3%) and 11 females (29.7%), with an overall mean age of 35.41 years (SD ± 9.16 years; range 18-53). The majority of participants were single (75.7%; N =
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28), 13.5% (N = 5) of participants were separated or divorced, and 10.8% (N=4) were married. The majority of DD inpatients were unemployed (56.8%; N = 21), although 70.3% (N = 26) of them reported a high education level (high school or above). The psychiatric group (P) included 23 females (76.7%) and 7 males (23.3%) with an overall mean age of 42.97 years (SD ± 14.15 years; range 19-69). The majority of participants were single (N = 12; 40%), 30% (N=9) were separated or divorced, and 30% (N=9) were married. Fifty percent of psychiatric outpatients were employed (N = 15), and only 26.7% of participants were unemployed. A majority, 58.6% (N=17), of psychiatric outpatients reported a high level of education and 41.4% (N=12) of participants reported a low level of education. No data were available on the level of education for one participant.
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The control group (C) included 23 females (76.7%) and 7 males (23.3%) with an overall mean age of 40.97 years (SD ± 14.35 years; range 22-63). Among the control group, 51.7% (N = 15) of
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participants were married, 34.5% (N=10) were single and 13.7% (N=4) were separated or divorced.
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Finally, the majority of nonclinical participants were employed (83.3%; N = 25) and they reported a
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high level of education (90%; N=27).
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2.2 Measures
The Structured Clinical Interview for DSM-IV Axis II Personality Disorders [SCID-II; 31] is a 140item semi-structured interview designed to provide categorical assessment of DSM-IV Axis-II disorders. The SCID-II interview was preceded by the administration of its self-report screening
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questionnaire. Given the diagnostic purposes of the SCID, it was not administered to the nonclinical participants.
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The Structured Interview for Personality Organization [STIPO; 32] is a 100-item structured
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interview for the assessment of personality structure based on Kernberg’s theory of personality organization. Personality domains and subdomains measured by the STIPO are presented in Table 1
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[33]. Items are rated on a three point scale (0 = no pathology; 1 = some pathology, sub-threshold; 2 = significant to severe pathology). The Italian version of the interview [34] has demonstrated good psychometric proprieties: Crohnbach’s α was between .78 and .92 and inter-rater reliability was between .82 and .97. The interview takes an average of 90 to 180 minutes to administer.
2.3 Procedure The present study was approved by the Research Ethics Board of the University of Milano-Bicocca. Assessment procedures were performed after participants provided written informed consent. The SCID II and the STIPO were administered by a clinical psychologist.
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2.4 Statistical analyses All analyses were performed using SPSS 18.0 (SPSS, Chicago, IL). Descriptive statistics were used
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to describe the sociodemographic and psychopathologic characteristics among the three groups.
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Analysis of Variance (ANOVA) was used to test differences in personality domains and
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subdomains of the STIPO between the three groups of participants, controlling for the effect of
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gender.
3. Results
3.1 Descriptive Characteristics
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Among the DD group, the majority of participants (64.8%; N= 24) had a dependence diagnosis and 13 participants (35.2%) had an abuse diagnosis. Data on Axis I disorders were gathered from
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clinical records; participants of the DD group had no other Axis I diagnoses different than SUDs.
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Moreover, the majority of participants were polysubstance users (72.9; N= 27), and the most common combination of substances was cocaine and alcohol (32.4%; N=12).
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Among the psychiatric group, the majority of participants (50%; N=13) had a mood disorder diagnosis, followed by anxiety disorders (26.9%; N= 7), adjustment disorder (16.7%; N= 5) and eating disorders (3.8%; N= 1). Data on Axis I disorders were gathered from clinical records; data were unavailable for 4 psychiatric outpatients.
3.2 PDs diagnoses among the two clinical groups Among the DD group, 36 out of the 37 participants (97.3%) had at least one PD; whereas PDs were present to a lesser extent among the psychiatric group (40%; N=12). Personality disorders among the two clinical groups are presented in Table 2.
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With regard to the prevalence of PDs, statistically significant differences between the two groups were found only for the Antisocial Personality Disorder (χ2 (1) = 15.67; p < .001) and the Not
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Otherwise Specified Personality Disorder (χ2 (1) = 10.04; p = .002). Indeed, Antisocial Personality
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Disorder showed higher prevalence among the DD group (40.5%; N = 15) than the psychiatric
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group (none of the participants of this group was diagnosed as ASPD). Similarly, the prevalence of the Not Otherwise Specified Personality Disorder was higher among the DD group (24.3%; N = 9)
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compared to the psychiatric group (10%; N=3).
The other PDs showed similar frequencies among the two groups, with no statistically significant differences between them.
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3.3 Differences in personality characteristics: the STIPO domains and subdomains. Structural personality aspects among the three groups of participants, and differences between
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groups, are presented in Table 3. Moreover, Figure 1 illustrates personality profiles for each group
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of participants.
Differences between groups were tested controlling for the effect of gender. Nevertheless, statistical
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analyses did not show significant gender effects on differences in personality dimensions between the three groups.
As regards the Identity domain, significant group differences were found. Post-hoc comparisons indicated that the DD group reported higher identity diffusion than the psychiatric group (p< .01) and the control group (p< .001). Specifically, the DD group showed a significantly higher impairment of the Capacity to Invest than the psychiatric group (p< .05) and the control group (p< .001). On the contrary, the other identity subdomains did not discriminate between the DD group and the psychiatric group (Table 3). Significant group differences were found in the Object Relations domain. Both the DD (p< .001) and the psychiatric group (p< .001) had higher impairments in this domain compared to control
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group. Significant group differences were also found in the Primitive Defenses domain. The two clinical groups showed higher impairment (DD: p< .001; Psychiatric: p< .001) compared to control
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group. Again, significant group differences were found in the Coping and Rigidity domain. The two
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clinical groups showed higher impairment (DD: p< .001; Psychiatric: p< .001) than the control
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group.
Significant group differences were found in the Aggression domain. The DD group reported higher
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aggression compared to both the control group (p< .001) and the psychiatric group (p< .001). Specifically, the two clinical groups differed in both the Aggression’s subdomains. As regards SelfDirected Aggression, the DD group reported greater difficulties compared to both the psychiatric group (p< .001) and the control group (p< .001). The difference between the psychiatric group and
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the control group was marginal (p= .06). Again, significant group differences were found in the Other-Directed Aggression subdomain: the DD group reported grater difficulties compared to both
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the psychiatric group (p< .01) and the control group (p< .001). The psychiatric group and the
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control group showed no significant differences (p= .24). Significant group differences were also found in the Moral Values domain. The DD group reported
(p< .001).
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significant higher scores compared to both the psychiatric group (p< .001) and the control group
Finally, significant group differences were found in the Reality Testing domain. The psychiatric group showed greater difficulties in reality testing than the DD group (p< .05) and the control group (p< .01).
4. Discussion
According to Kernberg’s personality model, the present study investigated personality structure profiles in DD inpatients (SUDs and co-occurring PDs) and in psychiatric outpatients. Although
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DD has been an important research topic for many years, the majority of studies have been based on the categorical approach to personality. In this sense, the use of a dimensional approach to the study
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of personality among DD inpatients may lead to a deeper knowledge of this psychopathological
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condition.
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Findings from this study showed that DD (co-occurrence of SUDs and PDs) was associated with specific impairments in three personality dimensions: Identity, Aggression, and Moral Values.
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Indeed, DD inpatients reported greater difficulties in these personality dimensions than both psychiatric outpatients and nonclinical controls.
In the present study, DD inpatients reported severe difficulties in undertaking work and study commitments or free time activities, and in keeping them with continuity and responsibility.
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Although empirical studies have not yet directly investigated capabilities to invest in social activities among DD inpatients, our results are in line with findings from previous studies. Indeed,
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many studies have demonstrated that DD, both in case of co-occurring PDs or psychotic disorders,
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has been associated with psychosocial problems and social isolation [35, 36, 37, 38, 39]. Additionally, the main treatment models for DD inpatients generally include psychosocial programs
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[37, 40, 41]. In particular, the majority of residential treatment settings for DD aim to “develop responsible drug-free lifestyles through a program of group living with firm behavioural norms and a hierarchical system of responsibilities and privileges” [42]. Previous studies have demonstrated that patients with SUDs and co-occurring PDs were more inclined to engage in aggressive behaviours and to express anger [17, 18]. Differently from previous studies, our results highlighted that the greater aggression of DD inpatients involves also selfdirected behaviours. Indeed, the majority of studies on the association between aggression and DD have been focused on the other-directed manifestations of aggression [43], and few studies have investigated self-directed aggressive behaviours among DD patients [44]. Despite the association between self-directed aggression and DD has not yet received sufficient attention, literature on
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SUDs has showed a strong association with self-directed aggression [45]. In this sense, an indirect evidence of this association is the prevalence rates of suicide and non-suicidal self-injury (NSSI)
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behaviours among SUDs patients. The lifetime prevalence of suicide among SUDs patients ranges
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between 15% and 45% [46, 47, 48] and NNSI ranges between 29% to 52% [49, 50, 51, 52].
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Another personality dimension that characterised DD inpatients in our sample was the lack of an integrated and mature system of moral values. The moral values dimension measured by the STIPO
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reflects the Super-Ego functioning and the degree to which the individual has internalised stable moral values that guide his behaviour [32]. Our results suggested that DD inpatients have an internalised values system that is unstable and poorly integrated, resulting in antisocial behaviours, difficulties in taking responsibility for their behaviours, and difficulties in respecting social rules.
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These findings are not surprising given that most studies showed that individuals with SUDs and co-occurring PDs are more likely to engage in antisocial behaviours [19, 20, 21, 22, 23, 24, 25].
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Again, as shown in the present study, literature on DD have demonstrated that antisocial personality
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disorder often co-occur with SUDs [19, 21, 53, 54, 55]. Finally, in line with theoretical expectations, the reality testing dimension was more impaired in the
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psychiatric group. Indeed, the reality testing dimension measured by the STIPO refers to difficulties in discriminating between inner experiences and outer reality: impairments that are often associated with psychotic symptoms. This last result confirms the utility of considering the specific aspects of the personality profile. Whereas identity pathology is connected with the severity of personality pathology, damaged reality testing indicates the possible presence of a psychotic disorder and thus the need for different management and therapeutic strategies. Taken together, our results support the hypothesis that patients with SUDs and co-occurring PDs present a more severe profile of personality compared to psychiatric patients. Particularly, the higher severity in the Identity, Aggression, and Moral values dimensions of DD patients suggest the need of specific therapeutic and clinical management instruments.
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The results of the current study can be better understood in the context of the study’s limitations. The main limitation concerns differences on socio-demographic and psychopathological
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characteristics between the groups we considered. First of all, the three groups differed on the level
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of education. Psychiatric participants reported a lower level of education than DD participants and
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nonclinical controls. Additionally, the distribution of PDs within the DD group and the psychiatric group was not homogeneous. The psychiatric group showed a lower prevalence of any PD (40%)
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compared to the DD group (97.3%). In particular, the high prevalence of ASPD among the DD group, and the total absence of it among the psychiatric group, did not allow us to control its effect on the personality dimensions we studied. Therefore, it is possible that some of the results we found might be partly explained by the presence of antisocial personality disorder among DD inpatients.
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In this sense, future research on structural characteristics of personality should consider clinical groups with more homogeneous distribution of PDs. This would help researchers to understand
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whether personality traits are linked to the presence of DD or to the presence of specific PDs.
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Despite this, it is important to note that the heterogeneity of the psychiatric sample reflects the ecological reality of public mental health services in Italy. In this sense, the adoption of a
practice.
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dimensional approach leads to psychopathological profiles that can be more useful for clinical
5. Conclusion
In conclusion, the present study showed that individuals with SUDs and co-occurring PDs are characterised by a specific personality profile. Again, the study provided indirect evidence of the utility of a dimensional approach to the study of the pathological manifestations of personality. Particularly, the STIPO domains allow the assessment of the areas that are indicated in the DSM 5 Alternative Model for Personality Disorders [56], in line with the Levels of Personality Functioning
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Scale [57, 58]. In this sense, our results underline the importance of identity assessment in determining the severity of personality pathology. Indeed, the STIPO is currently one of the few
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validated interviews allowing a dimensional assessment of personality structure, and our results
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suggest that this instrument is particularly suited to assess level of personality functioning and
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impairment in line with the DSM 5 indications.
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Figure 1. STIPO Profile for the dual diagnosis group (DD), the psychiatric group (P), and the nonclinical group (NC) 4 3.5
T RI P
2 1.5 1
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0.5
P
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PT
ED
DD
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0
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Mean
3 2.5
NC
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Table 1. The domains and subdomains of the STIPO [33]. DOMAIN
SUBDOMAIN A. Capacity to invest B. Sense of self Coherence and continuity Self valutation C. Sense of others
OBJECT RELATIONS
A. Interpersonal relationships B. Intimate relationships and sexuality C. Internal working model of relationships
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RI P
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IDENTITY
PRIMITIVE DEFENSES
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COPING/RIGIDITY AGGRESSION
A. Self-directed aggression B. Other-directed aggression
MORAL VALUES
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REALITY TESTING
23
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Table 2. DSM-IV-TR Personality Disorders among Dual Diagnosis inpatients (DD) and Psychiatric outpatients (P).
Paranoid
2
Schizothypic
-
Schizoid
%
N
df
p-value
.17
1
0.68
1.25
1
0.26
1.25
1
0.26
10.0
2.31
1
0.13
-
3.45
1
0.06
-
15.67
1
< 0.001
-
1
3.3
-
-
1
3.3
Borderline
9
24.3
3
Narcisistic
4
10.8
-
Antisocial
15
40.5
-
Histrionic
-
-
1
3.3
1.25
1
0.26
Avoidant
4
10.8
1
3.3
1.34
1
0.25
Dependent
1
2.7
1
3.3
.02
1
0.88
Ossessive-Compulsive
2
5.4
1
3.3
.17
1
0.68
Passive-Aggressive
4
10.8
3
10.0
.01
1
0.91
4
10.8
5
16.7
.49
1
0.48
15
40.5
2
6.7
10.04
1
0.002
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Not Otherwise Specified
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3.3
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1
Depressive
5.4
Χ2
%
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N
PT
Axis I Disorder
P
T
DD
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Table 3. STIPO’s domains and subdomains: Means, Standard Deviations and differences between the dual diagnosis group (DD), the psychiatric group (P) and the nonclinical group (NC). P
NC
M
SD
M
SD
Identity
3.35a
0.98
2.73b
0.78
Capacity to Invest
3.05a
1.20
2.47b
Coherence and Continuity
2.73a
0.96
2.60a
Self-valuation
2.86a
1.21
2.40a
Self of Others
3.27a
0.90
2.87a
Object Relations
3.05a 2.89a
Intimate relationships and sexuality
2.65a
Internal working model of relationships
2.76a 3.30a
Coping/Rigidity
Self-directed aggression
Reality Testing abc
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Moral Values
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Other-directed aggression
1.43c
0.50
41.11
< .001
0.86
1.27c
0.45
27.14
< .001
0.77
1.17b
0.46
28.65
< .001
0.77
1.27b
0.58
20.52
< .001
0.94
1.50b
0.63
35.99
< .001
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F (2;91)
p
2.80a
0.85
1.27b
0.45
30.51
< .01
1.54
2.60a
1.22
1.23b
0.63
10.78
< .001
1.09
2.90a
1.09
1.50b
0.94
11.37
< .001
1.18
2.33a
0.80
1.23b
0.43
24.52
< .001
0.94
2.93a
0.74
1.43b
0.57
46.19
< .001
3.31a
1.14
2.93a
0.91
1.37b
0.56
27.56
< .001
3.43a
1.01
2.00b
0.74
1.07c
0.25
64.03
< .001
3.46a
0.99
1.73b
0.83
1.23b
0.57
54.56
< .001
2.78a
1.57
1.73b
0.74
1.23b
0.43
12.38
< .001
2.14a
0.95
2.10b
0.71
1.13c
0.35
45.96
< .001
1.68a
0.78
2.10b
0.66
1.13c
0.43
9.77
< .001
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Aggression
SD
1.18
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Primitive Defenses
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Interpersonal relationships
M
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STIPO’s domains and subdomains
T
DD
Means followed by the same letter in a line are not significantly different at the 5% probability level
