Facultad de Psicología, Universidad del País Vasco, Avda. de Tolosa, 70, 20018 San Sebastián, España and 1 Medicina Psico-Orgánica, S. L. Bilbao España
* Author to whom correspondence should be addressed at: Enrique Echeburúa, Facultad de Psicología, Universidad del País Vasco, Avda. de Tolosa, 70, 20018 San Sebastián, España. Tel.: +34 943 018329; Fax: +34 943 015670; E-mail:eecheburua{at}ss.ehu.es
(Received 20 October 2004; first review notified 25 November 2004; in revised form 11 March 2005; accepted 13 March 2005)
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ABSTRACT |
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INTRODUCTION |
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On the other hand, prevalence rates for personality disorders (PDs) in the adult community range from a low of 2.8% to a high of 11% (Zimmerman and Coryell, 1989; Weissman, 1993
; Alarcón et al.,1998
; Tyrer, 2002
). Prevalence figures are even more varied when mental health settings are considered. This fluctuation depends on the type of sample (e.g. general population or psychiatric patients), method of diagnosis (e.g. self-report personality inventory or structured interview) and the type of research design (e.g. retrospective chart review, cross-sectional or longitudinal). Accurate diagnosis of PDs is still viewed as a complex and challenging task (Segal and Coolidge, 1998
).
These factors have also hampered studies of the association of PDs with alcohol dependence, where the prevalence of PDs is reported as ranging from as low as 2438% (Zimmerman and Coryell, 1989; Powell and Peveler, 1996
; Driessen et al., 1998
; Pettinati et al., 1999
; Grant et al., 2004
) to as high as 5878% (De Jong et al., 1993
; Nurnberg et al., 1993
; Morgenstern et al., 1997
; Fernández-Montalvo et al., 2002
). A meaningful comparison of previous and recent data is difficult because of large discrepancies.
Similarly, the types of PDs found in the literature are very heterogeneous. The most relevant in the clinical trials have been histrionic and dependent (De Jong et al., 1993; Grant et al., 2004
), paranoid (Nurnberg et al., 1993
), borderline (Powell and Peveler, 1996
), antisocial (Morgenstern et al., 1997
; Grant et al., 2004
), narcissistic and avoidant (Pettinati et al., 1999
) or passiveaggressive (Fernández-Montalvo et al., 2002
). Once again, available current data are inconsistent and not conclusive.
The diagnostic disparity and the lack of consistency in the literature with respect to the number and types of PDs associated with alcohol dependence are related to the different assessment tools, to the different severity of alcoholism considered (abuse or dependence) and to the different mental health settings (inpatients or outpatients) (Sher et al., 1999).
The purpose of this study was to contribute to a better knowledge of comorbidity and types of PDs in alcoholics by using accurate assessment tools [International Personality Disorder Examination (IPDE) and Millon Clinical Multiaxial Inventory-II (MCMI-II)] and comparing alcoholics with non-addict psychiatric patients and normal population (Fernández-Montalvo and Landa, 2003).
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SUBJECTS AND METHOD |
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The alcohol-dependent group (n = 30) was recruited from consecutive attenders aged 18 years who met the diagnostic criteria of DSM-IV-TR (American Psychiatric Association, 2000
) for alcohol dependence and who scored
11 in the Munich Alcoholism Test (MALT) (Feuerlein et al., 1977
). All of them were seeking treatment for problems related to drinking. To be included, the primary diagnosis was alcohol dependence, without other addictive disorders or evidence of psychosis. They had to be able to give informed consent.
The clinical control group (n = 30), also aged 18 years and able to give informed consent, was drawn consecutively from among non-addict, non-psychotic subjects seeking treatment for various mental disorders, the most frequent of which were generalized anxiety disorder, panic disorder, social phobia, obsessivecompulsive disorder, major depression and dysthymic disorder.
The normative group (n = 31) were people without mental disorders of Axis I, found among workers at a university (clerks; n = 14) and in a canning factory (n = 17) who were asked to collaborate in research and were motivated to do so by offering them feedback on their personality test results. A selection was made to achieve a group who matched the clinical groups in terms of age, gender and social class, the clinical groups having by chance turned out to be reasonably matched on these measures. All assessments were made during 2003.
Assessment measures
The Structured Clinical Interview is an instrument aimed at assessing, in an initial interview, mental disorders according to the diagnostic criteria of DSM-IV-TR. The content of the interview is related to the most relevant information: current difficulties, current mental disorder, antecedents, family, education, work, social relationships, alcohol and drugs consumption, hobbies, etcetera.
Two personality assessment tools were used. The MCMI-II (Millon, 1997; Spanish version of TEA, 2000
) is a self-report questionnaire with 175 true/false items. Thirteen clinical scales assess personality patterns that relate to DSM-III-R Axis II disorders. There are 10 clinic personality pattern scales (schizoid, avoidant, dependent, histrionic, narcissistic, antisocial, aggressivesadistic, compulsive, passiveaggressive and self-defeating), as well as three severe personality pathology scales (schizotypal, borderline and paranoid). In this study, additional clinical syndrome scales of Axis I were not taken into account because they were not relevant to the purpose of this research.
Raw scores on scales were weighted and converted to base rates scores. The base rate scores reflect the prevalence of a particular personality disorder. According to the conservative criteria of Weltzler (1980), a base rate score >84 is considered to be significant. Although the MCMI-II offers good internal consistency, it has only a modest accuracy for assigning patients to diagnostic groups across a variety of clinical criteria.
The IPDE (Loranger, 1995; Spanish version of López-Ibor et al., 1996
) is a semi-structured diagnostic interview designed to assess PDs. The IPDE covers all the criteria for the 11 Axis II disorders of DSM-IV. In order to establish reliable diagnoses, the behavior or trait must be present for at least 5 years and the criterion must be met before the age of 25 years. A self-administered IPDE screening questionnaire is available before the interview to assist in identifying personality disorders that might be of focus in the interview. Inter-rater reliability of the IPDE (median kappa = 0.73), as well as testretest reliability (median = 0.87) (Blanchard and Brown, 1998
) is generally good.
The MALT (Feuerlein et al., 1977; Spanish version of Rodríguez-Martos and Suárez, 1984
) is a screening test aimed to identify alcoholics in an early contact phase. The test consists of two parts: a self-rating questionnaire (26 items) and a physician-rating score (7 items). This instrument has been used for a confirmation of the diagnosis of alcoholism in clinical studies.
The MALT is interpreted through the use of cut-off scores. The total score ranges from 0 to 54. Scores from 0 through 5 indicate no or minimal alcoholism; scores from 6 to 10 indicate a risk of alcoholism; and scores from 11 through 54 indicate severe alcoholism.
Procedure
Once the total sample was selected according to the previously indicated criteria, the pre-treatment assessment was conducted in two sessions. In the first one, data related to psychopathological characteristics were collected and the MCMI-II and the IPDE screening test were carried out. And in the second session, the presence of personality disorders identified in the previous IPDE screening test was accurately assessed with the IPDE interview. The time interval between assessment occasions was 1 week. Patients had to be sober at the time of both interviews.
In order to control the inter-rater reliability, a clinical psychologist (R.B.M.) and a psychiatrist (J.A.), sitting in on the same interview and providing independent rating, carried out together the clinical diagnosis of alcoholism/other mental disorders (with the structured clinical interview) and personality disorders (with the IPDE). With respect to the diagnosis of alcoholism/other mental disorders, the coincidence degree between both professionals was 100%. In the case of personality disorders, the inter-rater reliability in joint interviews was quite high (kappa = 0.83).
In this study, the analyzed data have been the following ones: (i) the overall prevalence rate of personality disorders among the different samples; and (ii) the PDs profile among the different groups.
Non-parametric tests were used for statistical analysis. All the comparisons between groups were analyzed using the KruskalWallis H test. The MannWhitney U-test was used as a post-hoc procedure.
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RESULTS |
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Finally, with respect to the number of PDs showed by affected patients, the most frequent was to show one PD. There were only four patients who showed two PDs. There were not any statistically significant differences among the different groups.
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DISCUSSION |
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A limitation is that participants in this study only represent alcohol-dependent patients in outpatient treatment. This study does not deal with the homeless or people belonging to the lower strata of society with many psychosocial problems (no job, no partnership, no home, etc.) who are usually not represented in the help-seeking populations in Spain. This study relates to more integrated patients, although it includes some with severe alcohol dependence.
The most salient finding is that 40% of the alcoholics met DSM-IV-TR diagnostic criteria for a personality disorder compared with 16.6% of the non-addict patients and 6.4% of the normative controls. Previous studies found that PDs were very common in alcoholics (Cuadrado, 1998,Cuadrado 1999
; De Jong et al., 1993
; Nurnberg et al., 1993
; Powell and Peveler, 1996
; Morgenstern et al., 1997
; Driessen et al., 1998
; Pettinati et al., 1999
; Grant et al., 2004
). But the contribution of this study is to have proven that this high rate of comorbidity with PDs is different from and much higher in alcohol dependence than in other Axis I mental disorders, such as mood and anxiety disorders.
Unlike other studies, where the average number of PD diagnoses is generally 24 (Driessen et al., 1998), the average number of diagnosed PDs for each subject in our study was one. PDs found in alcoholics tended to be within the cluster C category, such as dependent (13.3%) and obsessivecompulsive (10%), except in the case of paranoid PD (10%). These findings are consistent with those found by other studies (Driessen et al., 1998
), but not with others (De Jong et al., 1993
; Nurnberg et al., 1993
), in which the prevalence rate of PDs in alcoholics, as well the average number of PDs for each subject, were higher. Unlike other studies (Lewis et al., 1985
; Grant et al., 2004
), antisocial or borderline PDs were not prevalent in our sample. This lack of consistency with these studies could be related to our sample (drawn only from outpatients) or to the different assessment tools (IPDE and MCMI-II together) used in our study to diagnose a PD. The accuracy of the self-reports, such as MCMI, by themselves, can be expected to be poor. However, further research is required to find out if antisocial PD and borderline PD were overdiagnosed in the previous literature.
The main difference between alcoholics and non-addict patients was that the alcoholics showed 2.5 times more PDs than the latter. There were no specific differences between the groups with respect to the type of PDs. In turn, non-addict patients showed nearly 2.5 times PDs more than the subjects of the normative control group.
The purpose of this paper was to understand the role played by the psychiatric comorbidity (referred, in this case, to PDs) in alcoholism and to help identify different kinds of patients. Personality processes must be integrated to forward our understanding of alcoholism (Sher et al., 1999). This information could be helpful in alerting the clinician to potential obstacles and difficulties early in therapy, thereby increasing treatment compliance and guiding treatment decisions based on the patient's personality pattern. Further research on the underlying structure of PDs and the treatment implications of these disorders when comorbid is needed.
However, much remains to be achieved. This is a pilot study with the sample size not being large enough to generate generalizable and reliable findings. This is only the preliminary point of an ongoing work about the frequency of personality disorders in alcoholism and according to the epidemiological literature (Alarcón et al.,1998; Tyrer, 2002
), it may be an underestimation of the prevalence of PDs.
In this study, according to the diagnostic philosophy contained within DSM-IV-TR, PDs have been considered as categorical. However, a dimensional approach to personality disorder diagnosis may yield more precise information (Ullrich et al., 2001) to plan interventions within a promising individual therapy model that focuses both on alcohol abuse and maladaptive schemas and coping styles (Ball and Cecero, 2001
). Moreover it would be interesting, according to the typology based on indicators of vulnerability and severity (Litt et al., 1992
), not to consider alcoholism as an only construct, but to study the application of this empirically-derived typology to treatment matching. And, finally, specific gender differences should be dealt with in further research in order to test some preliminary conclusions (obsessivecompulsive, histrionic, schizoid and antisocial PDs, more frequent in alcoholic women; dependence, more frequent in men) (Grant et al., 2004
).
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