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Personality structure predicts early dropout in patients with substancerelated disorders and comorbid personality disorders

Emanuele Preti1, Chiara Rottoli1, Serena Dainese1, Rossella Di Pierro1, Fabio Rancati1,
Fabio Madeddu1

1. Department of Psychology, University of Milano-Bicocca, Piazza dellAteneo Nuovo 1,


20126, Milano, Italy;
2. Casa di Cura CREST, Piazzale Baracca 1, 20123, Milano, Italy.

Riassunto

Questo studio si propone di indagare i fattori predittivi di un precoce dropout in pazienti con doppia
diagnosi, prendendo in esame variabili socio-demografiche, diagnostiche e di struttura della
personalit.

Abbiamo ipotizzato che la struttura di personalit del paziente dimostrasse capacit predittive
migliori rispetto alle variabili descrittive per ci che concerne l'abbandono precoce del trattamento.
A quarantasette pazienti ricoverati consecutivamente in una comunit residenziale per doppia
diagnosi sono stati somministrati la Structured Interview of Personality Organization (STIPO), la
Structured Clinical Interview for Axis II Disorders (SCID II), la Response Evaluation Measure 71
(REM71), la Symptom Check List 90R (SCL90-R) e infine la Borderline Personality Disorder
Check List (BPDCL).

Differenze significative sono emerse tra il gruppo dropout (coloro che hanno abbandonato la
comunit) e il non-dropout: problemi negli investimenti e nella corenza del s (STIPO) erano pi
elevati nel gruppo dropout; nello stesso gruppo un numero significativamente alto di pazienti
mostra un'organizzazione di personalit borderline (88.9%). I risultati sostengono l'uso di interviste
che indagano la struttura della personalit nella valutazione di pazienti con doppia diagnosi.

Parole chiave :

disturbi di personalit ; disturbi correlati alle sostanze ; doppia diagnosi ; assessment; struttura di
personalit

Abstract

This study aims at investigating the predictive factors of early dropout in dual diagnosis patients,
considering socio-demographic, diagnostic and personality structure variables.

We hypothesized that the personality structure of the patient will show better predictive properties
on dropout compared with descriptive variables. Forty-seven patients consecutively admitted in a
dual diagnosis residential treatment unit were administered the Structured Interview of Personality
Organization (STIPO), the Structured Clinical Interview for Axis II Disorders (SCID II), the
Response Evaluation Measure 71 (REM71), the Symptom Check List 90R (SCL90-R) and the
Borderline Personality Disorder Check List (BPDCL).

Significant differences emerged between the dropout and no-dropout group: investments and selfcoherence problems (STIPO) were higher among dropouts; moreover, in the dropout group a
significantly higher number of patients showed a borderline personality organization (88.9%).
Results support the use of structural interviews in the assessment of dual diagnosis patients;
implications regarding research and clinical practice are discussed.

Key words:

personality disorders; substance-related disorders; dual diagnosis; assessment; personality


structure

1. Introduction

The term dual diagnosis has been introduced to describe the phenomenon in which substance
abuse or dependence co-occurs with other psychiatric disorders. Two of the most commonly cooccurring diagnoses are personality disorders (PD) and substance use disorders (SUD). Verheul,
Van den Brink and Hartgers (1995) found that 44% of people with alcohol use disorders and 77%
of people who abuse opiates would meet the criteria for a PD, identifying cluster B disorders as
those most commonly associated with SUD. Moreover, studies about patients with PDs confirm the
relationship with substance use: Trull, Sher, Minks-Brown, Durbin and Burr (2000) and Skodol,
Oldham and Gallaher (1999) reported a high prevalence of substance use in more than half of
subjects with borderline personality disorder (BPD). A recent review of a large epidemiological
study (over 40,000 individuals) found a comorbidity rate of 30% between PDs and alcohol
dependence and of 40% between PDs and substances dependence (Trull, Jahng, Tomko, Wood
and Sher, 2010).
The Diagnostic and Statistical Manual of Mental Disorders, 4th edition revised (DSM-IV-TR;
American Psychiatric Association, 2000) categorical definition of personality disorder consists of an
enduring pattern of inner experience and behavior that deviates markedly from the expectations of
an individuals culture, is pervasive and inflexible, leads to clinically significant distress and is
manifested in at least two of the following areas: cognition, affectivity, interpersonal functioning and
impulse control. An alternative way of considering PDs is the dimensional method; among the
dimensional models, Otto Kernbergs object relations model (1984) can be particularly useful
regarding the clinical assessment and treatment planning of dual diagnosis patients. Kernberg
proposes a severity continuum, from the lower psychotic level, through the borderline level, to the
higher neurotic level, based on the assessment of three major dimensions. Identity integration
corresponds to a stable inner experience of self and others, which brings the sense of a cohesive
self. Identity diffusion corresponds to an inner world in which experiences of self and others are
superficial and polarized. Defense mechanisms help people to manage internal conflicts between
competing impulses and feelings; these mechanisms vary in terms of their maturity levels. A
mature defense is flexible, optimizes ones ability to deal with everyday life, and usually belongs to

a higher personality organization (as the neurotic one). Conversely, an immature defense style is
more rigid, maladaptive and can interfere with adaptive functioning. Reality testing refers to the
process of relating ones self to the external world and distinguishing between inner and outer
reality. Three other factors are contemplated in Kernbergs model: quality of object relations,
aggression, coping strategies and moral values. The neurotic level is the healthiest level of
personality organization and is characterized by intact reality testing, an integrated identity and a
generally mature defense style. People at this level have a consistent sense of purpose and life
goals. They are also able to deeply commit to and care about other people, as well as view them
accurately. At the borderline level, reality testing is generally intact, but people have a fragmented
and inconsistent sense of self and others. This fragmented sense of self is the most significant and
defining feature of the borderline level and results in severe and repetitive problems with
interpersonal relationships. People with borderline personality organization also tend to rely on
primitive defense mechanisms, especially splitting. This defense mechanism is characterized by a
tendency to view the world and other people in a polarized manner, as "all good" or "all bad",
flipping back and forth between these two extremes based on moment-to-moment perceptions. At
the opposite end of the personality organization dimension is the psychotic level, characterized by
compromised reality testing, an inconsistent sense of self and others and an immature defense
style.
Comorbid personality pathology in patients with a SUD has been related to poor treatment
outcomes. One of the most important problems in dual diagnosis treatment is the high rate of
dropout (lack of adherence); a substantial proportion (ranging from 13 to 31%) of individuals who
seek treatment for a SUD do not complete treatment (Daughters et al., 2005). Researchers have
become increasingly interested in examining potential predictors of treatment dropout. Kokkevi,
Stefanis, Anastasopoulou and Kostogianni (1998) found that approximately 3/4 of patients with a
substance use disorder also have a PD (specifically antisocial, paranoid and avoidant personality
disorders) and that they prematurely abandon treatment more often compared to those who do not
have a PD. Comorbid patients also appear to have more psychological, social, familial and medical
problems, and worse pretreatment conditions; however, they respond to therapy as much as noncomorbid patients, even if some areas remain problematic at follow up after seven months

(Cacciola, Alterman, Rutherford, McKay & Mulvaney, 2001). Comorbidity with an Axis II disorder
appears to be the best predictor of early dropout (Pettinati, Pierce, Belden & Meyers, 1999).
Samuel, LaPaglia, Maccarelli, Moore and Ball (2011) found that antisocial and histrionic personality
disorders are predictive of an earlier dropout, whereas BPD became a significant predictor of
dropout when considering nine months of treatment.
A small number of studies have examined the effect of BPD on dropout from residential substance
abuse treatment programs, and the results are mixed. Whereas Martnez-Raga, Marshall, Keaney,
Ball and Strang (2002) found that SUD patients with BPD were more likely to have an unplanned
discharge, Dingle and King (2009) failed to find any significant association between BPD and
residential substance abuse treatment completion, most likely because of variability in the gender
distribution of these studies and the lack of attention to the influence of gender on the BPD-dropout
relationship. Dropout is more frequent among male patients, and borderline men exhibit more
severe substance abuse and difficulty in controlling anger (Tull & Gratz, 2012). Antisocial
personality disorder appears to be the most investigated and is present in high percentages among
substance abusers. This disorder includes a large group of subjects with both antisocial behavior
and psychopathic traits such as lack of empathy and remorse; the latter conditions are associated
with a higher risk of dropout (Verheul & Van den Brink, 2004).
In summary, studies show that although it is possible to treat the comorbidity between substance
abuse and personality disorder, patients cannot benefit from treatment as much as those who do
not have a co-diagnosis. The personality traits interact with each other, as well as with a possible
disorder on Axis I, towards motivation to change. It is often difficult to compare studies because of
the different methods used, in addition to the difficulties of monitoring patients during long periods
of follow-up. However, young age, male gender, an early onset in substance abuse, polysubstance
abuse and Axis II comorbidities appear to be the best dropout predictors (Madeddu, Prunas,
Mantelli & Ravera, 2005; Preti, Prunas, Ravera & Madeddu, 2011).
Finally, the categories and criteria presented by the DSM include a highly heterogeneous group of
patients; therefore, some patient profiles with little responsiveness to treatment may often be
obscured, as in the case of antisocial psychopaths (Verheul & Van den Brink, 2004).
The aim of this study is to investigate the predictive factors of early dropout (before six months) in

a residential community for dual diagnosis patients.


We compared the dropout group, which includes subjects who abandoned their treatment within
six months of admission, with a non-dropout group. More specifically, we sought to:
1. Compare the two groups on a number of socio-demographic variables;
2. Compare the two groups in terms of diagnostic features (including the prevalence of personality
disorders and clinical data on substance use);
3. Compare the two groups in terms of structural variables of personality functioning.
We hypothesized that the personality structure of the patient will show better predictive properties
on dropout compared with descriptive variables.

2. Matherials and methods

2.1 Sample

Participants consisted of 47 patients consecutively admitted to a Dialectical-Behavioral Therapyoriented inpatient dual diagnosis treatment service between January 2011 and March 2013. All
patients received a diagnosis of substance abuse or dependence, and most of them (45
participants) had at least one personality disorder.
The inclusion criteria were as follows:
age greater than 18 years;
absence of cognitive deficits or cognitive impairment;
absence of any psychotic disorders.
The mean age of the study patients was 35.4 years (SD = 9.51 years, range 18-49); 33
participants were male (70.2%) and 14 were female (29.8%). The mean age of patients first
contact with any substance was 17.21 years (SD = 5.9 years, range 12-41). In our study
population, 34% (16) were students or workers, while 51% (24) were unemployed. Twentysix
participants (55.3%) reported a high level of education (high school or above), whereas 31.9% (15)
reported a low level of education. Finally, 16 participants (34%) reported a family history of
psychiatric disorders.

Cocaine was the main substance of abuse (72.3%), followed by alcohol (66%), cannabis (29.8%),
opioids (25.5%), hallucinogens (8.5%) and psychotropic drugs (1.8%). A total of 32 patients
(68.1%) were polysubstance abusers and 15 (31.9%) were single substance abusers. Nineteen
patients (40.4%) had an abuse diagnosis and 21 patients (44.7%) had a dependence diagnosis.
Eight patients reported one or more diagnoses on Axis I: 4 patients were diagnosed with mood
disorders, 2 with eating disorders, 2 with anxiety disorders and one with schizoaffective disorder.
After six months, 23 of the 47 patients (51.1%) quit treatment against medical advice.

2.2 Instruments

We reviewed the files of all 47 patients for the following information:


Medical history of substance use: substance(s) of use, age of onset, single substance abuse or
polysubstance abuse, abuse or dependence.
Case history data: demographic characteristics (age and gender), prevalence and number of Axis
I disorders.

We administered 2 clinical interviews:


Structured Clinical Interview for DSM-IV Axis II disorders (SCID-II, First, Spitzer, Gibbon,
Williams & Benjamin 1997): a 140-item, semi-structured interview designed to provide categorical
assessment of DSM-IV-TR personality disorders. The SCID-II interview was preceded by the
administration of its self-report screening questionnaire.
Structured Interview of Personality Organization (STIPO, Clarkin et al., 2007; Stern et al., 2010):
a 100-item, semi-structured interview that provides a dimensional assessment of the domains of
functioning central to Kernbergs theory of personality organization including: identity consolidation,
quality of object relations, use of primitive defenses, quality of aggression, adaptive coping versus
character rigidity, moral values and reality testing. The STIPO explores both the patient's
behavioral world and inner world. The STIPO is scored by the interviewer while it is administered:
each item is rated on a 0-2 scale, with zero reflecting the absence of pathology, two reflecting the
clear presence of pathology, and one representing an intermediate status. In addition, the

interviewer also completes a 5-point rating for each domain, which defines the range of health and
pathology for each section being rated. The 5-point ratings are highly correlated with the mean-ofitem scores.

Finally, we administered 3 self-reports:


Symptom Check List 90 R (SCL-90-R, Derogatis, 1977): a 90 item, multidimensional self
report inventory designed to assess psychological symptom patterns. It provides measures of
current psychological symptom status within nine primary symptom dimensions (Somatization,
Obsessive-Compulsive, Interpersonal Sensitivity, Depression, Anxiety, Hostility, Phobic Anxiety,
Paranoid Ideation and Psychoticism), as well as a Global Severity Index (GSI). The nine
dimensions show good levels of reliability (Cronbachs alpha ranging from .794 to .920), as did the
GSI (Cronbachs alpha = .979).
Borderline Personality Disorder Check List (BPDCL, Prunas, Sarno, Capizzi & Madeddu, 2006):
a 47-item, self-report instrument designed to assess the patients burden of complaints about
borderline personality disorder symptoms in the previous month according to DSM-IV-TR criteria.
The test shows good levels of reliability on all DSM criteria subscales (Cronbachs alpha ranging
from .692 to .897) as did the global score (Cronbachs alpha = .960).
Response Evaluation Measure (REM-71, Steiner, Araujo & Koopman 2001): a 71-item, self-report
questionnaire that allows for the evaluation of 21 defenses (Cronbachs alpha ranging from .217
to .886). Two factors are used to divide these defenses into two styles: Factor 1 ( = .828) contains
14 defenses that distort reality in accordance with expected outcomes leading to less adaptive
functioning, and Factor 2 ( = .605) contains 7 defenses that attenuate unwelcome reality, allowing
for more adaptive functioning.

2.3 Data analyses

Preliminary analyses were conducted to provide information about the participants (demographic
variables, substances used, age of onset and diagnosis of personality disorders). No differences
were found between male and female patients on demographic and diagnostic variables, apart

from a higher prevalence of employment in the male sample ( = 4.86, df = 1, p < 0.05, 14 males
and 2 females), antisocial PD in the male sample ( = 4.05, df = 1, p < 0.05, 17 males and 2
females), and depressive PD in the female sample ( = 5.93, df = 1, p < 0.05, 2 males and 7
females).
The subjects were then divided into two groups: the dropout group (DRO) and the nondropout
group (NODRO); comparisons between the two groups were conducted using continuity corrected
chi-square tests for categorical variables and Students t-test for continuous variables.

3. Results

3.1 Prevalence of personality disorders

In our study, 45 of the 47 patients had at least one personality disorder (as shown in table I); the
most common PD was antisocial personality disorder, followed by PD not otherwise specified
(NOS), BPD and narcissistic PD. The mean number of personality disorder diagnoses was 1.77
1.32.

3.2 Dropout Group and Non-Dropout Group: descriptive variables

Considering the socio-demographic and Axis I variables, no significant differences were found
between the two groups. With regards to personality disorder diagnoses, the DRO group showed a
significantly higher rate of narcissistic personality disorder (7 in DRO vs 2 in NODRO, = 4.47, df
= 1, p < .05). Neither the number of diagnoses nor the PD cluster subdivision had a different
distribution between the two groups.

The results of the comparison between the two groups on the Symptom Check List-90-R global
index and its nine scales did not show any significant differences.

The last descriptive instrument, the Borderline Personality Disorder Check List, did not show

significant differences between the two groups.

3.3 Dropout Group and Non-Dropout Group: structural variables

Regarding the STIPO interview, the DRO group reported higher scores on the domains of
Investments (t = - 2.392, df = 38, p < .05) and Coherence and continuity (t = - 2.771, df = 38, p < .
005), two identity subscales. We then categorized patients into two diagnostic subgroups
according to Kernberg model of personality pathology (Kernberg, 1984): patients were classified as
Neurotics if they showed scores lower than 3 on both Identity and Primitive Defenses dimensions
and patients who reported scores higher than 3 on these two dimensions were classified as
Borderline. In this regard, significant differences emerged: in the DRO group, a significantly higher
presence of Borderline subjects was found ( = 6.825, df = 1, p < .05).

The last comparison between the two groups was on Response Evaluation Measure-71 variables.
Our analysis did not detect any differences among global factors (immature defense style and
mature defense style). The only significant difference was found in the use of splitting in patients:
the NODRO group appears to make more use of splitting (t = 2.25, df = 42, p < .05).

4. Discussion

Consistent with previous research, we found a high prevalence of personality disorders in our
substance use disorders sample, in particular, those who belong to Cluster B: antisocial
(40.4%) and borderline (25.5%) personality disorders, as reported by Martnez-Raga et al. (2002)
and Samuel et al. (2011). When considering demographic variables, no differences emerged
between our two groups; however, previous literature has reported that younger patients have a
higher risk of dropping out of treatment (Kokkevi et al. 1998; Martnez-Raga et al. 2002; Madeddu
et al. 2005). Similarly, we did not find any significant differences concerning other predictive
variables associated with substance abuse, such as an early onset substance abuse or
polysubstance abuse. Variables connected to Axis I comorbid disorders showed no predictive

value, which was different from other studies (Verheul, Van den Brink & Hartgers, 1998; Thomas,
Melchert & Banken, 1999; Kokkevi et al. 1998; Pettinati et al. 1999; Martnez-Raga et al. 2002).
Descriptive data from the SCL-90-R also failed to detect differences between the DRO and
NODRO groups; this finding contrasts with the findings of Kokkevi and coll. (1998), who identified
high scores in somatization and hostility scales as dropout predictors. In our sample, not even the
global scale was predictive of early dropout. The Axis II profiles of the two subgroups were similar.
The only personality disorder that showed a significantly different distribution is narcissistic
personality disorder. In psychodynamic theory, narcissistic and antisocial personality disorders are
intimately linked in a continuum that spans between narcissism and psychopathy (Kernberg, 1984;
Gabbard, 2007). Other studies showed a higher prevalence of antisocial and borderline PD (Tull &
Gratz, 2012). In our study, these results are partially confirmed by the BPDCL, where we found 3
nearly significant trends: mean values on measures of Self-mutilationParasuicide (5th criteria of
BPD according to the DSM-IV-TR; t = - 1.932, df = 42, p = .06), Mood (6 th criteria; t = - 1.933, df =
42, p = .053) and ParanoidDissociation (9th criteria; t = - 1.96, df = 42, p = .056) are higher in the
DRO group.
These three results can be interpreted as general severity indicators with regard to personality
pathology (Kokkevi et al. 1998, Cacciola et al., 2001; Martnez-Raga et al., 2002) and, more
specifically, borderline personality pathology (Samuel et al., 2011).

On the other hand, we found that a structural approach to personality diagnosis can give important
information that differentiates the dropout group from the non-dropout group. In fact, the STIPO
dimensions of Investments and Coherence and Continuity, belonging to the Identity domain, note a
weakness in identity of the DRO group. Patients who drop out of treatment have a more fragile
identity, placing themselves at a borderline level of personality organization. These dimensions
indicate that it is necessary to take into account traits, such as chronic feelings of emptiness,
contradictory behaviors and superficial visions of self and others (Kernberg, 1984), as variables
that can potentially lead to early treatment dropout.
Additionally, the categorization of patients into the two levels of personality structure proposed by
Kernberg (neurotic and borderline), allows us consider the borderline level of organization as a

predictor of elevated risk of therapy dropout. Thus, the STIPO results confirm that a greater
severity of personality pathology, represented by borderline personality organization, is a trigger to
early dropout (Kokkevi et al., 1998; Martnez-Raga et al., 2002).
Defensive functioning of patients assessed through the REM-71 did not lead to significantly
different results between the two groups. The only difference detected by the REM-71 was the use
of splitting; splitting was more frequent in the NODRO group of patients. This result can be partly
accounted for by the self-report nature of this instrument; the REM-71 single defense scales, in
fact, show poor reliability (Steiner et al., 2001; Prunas et al., 2009).
Furthermore, the STIPO defense subscale did not detect differences between the two groups;
results on this topic in the literature are mixed: whereas no differences emerge in terms of
defensive functioning between dropout and non-dropout patients (Madeddu et al., 2005), Wexler
and DeLeons study (1977) on the other hand found a more primitive defensive style in dropout
patients.
Our results are in line with proposals for the DSM-5 in terms of evaluating the levels of personality
functioning. Section III of the DSM-5 proposes to assess personality pathology considering severity
as the most important single predictor of concurrent and prospective dysfunction and that
personality disorders might be best characterized by a general personality severity continuum with
additional specification of prototypical elements (APA, 2013).
In conclusion, early structural diagnosis appears to represent an essential part of successful and
enduring therapeutic treatment. In this study, the most predictive variables appear to be more
easily identified through instruments that detect the structural characteristics of patients, such as
the STIPO interview that recognizes borderline and neurotic groups, in line with Kernbergs theory.
Despite our finding that no specific personality disorders indicate a risk factor for early dropout,
contrary to what was found by Samuel et al. (2011), patients who abandoned treatment at six
months are characterized by greater identity fragility and are situated at a borderline level,
following Kernbergs model. Therefore, it is necessary to work on identity consolidation, the
creation of more stable and meaningful relationships, affective stability, and stress tolerance to
prevent early dropout.
The main limitation of this study is its retrospective nature: part of data collection was based on the

medical records of the patients selected. The sample size is rather limited, which may have
reduced the predictive power of some variables. Even the use of self-report may constitute a
further limitation, in terms of social desirability.

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