Antisocial alcoholic patients show as much improvement at 14-month follow-up as non-antisocial alcoholic patients

Schema therapy for patients with borderline personality disorder and comorbid alcohol dependence: A multiple-baseline case series design study

This study tested the effectiveness of schema therapy (ST) for borderline personality disorder (BPD) and comorbid alcohol dependence (AD). Twenty patients participated in a case series study with multiple baselines. The baseline phase consisted of treatment as usual. It was followed by a case conceptualization phase, an experiential techniques phase and a behavioural change phase. Patients showed a significant decrease in BPD and AD symptoms; change was mainly accomplished in the experiential techniques phase, with medium to large effect sizes. Three months after termination of therapy, 68% of the patients had remitted from BPD, and the number of drinking days decreased clearly. This study shows that, although treatment is challenging in this group of patients, meaningful change can be obtained in patients with BPD and AD using ST.

A Novel Graphical Method for Data Presentation in Alcohol Systematic Reviews: The Interactive Harvest Plot

AIMS

To demonstrate a novel method for presenting and exploring data in systematic reviews of the alcohol literature.

METHODS

Harvest plots are a graphical method for displaying data on the overall pattern of evidence from a systematic review. They can display the direction of effects and risk of bias within studies for multiple outcomes in a single graphical chart. Using data from our previous meta-analysis on the association between personality disorder and alcohol treatment outcome, we extended the application of harvest plots by developing an interactive online harvest plot application.

RESULTS

Studies included in the review were heterogeneous in design. There were many different primary outcomes, and similar outcomes were often defined differently across studies. The interactive harvest plot allows readers to explore trends in the data across multiple outcomes, including the impact of within-study bias and year of publication. In contrast, meta-analysis on the same data was hampered by a lack of consistency in the way outcomes were measured, and incomplete reporting of effect sizes and their variance. This meant many studies included in the systematic review could not be meta-analysed.

CONCLUSIONS

Interactive harvest plots are a novel graphical method to present data from systematic reviews. They can supplement or even replace meta-analysis when the studies included in a systematic review use heterogeneous designs and measures, as is often the case in the alcohol literature.

Personality disorder and alcohol treatment outcome: systematic review and meta-analysis

BackgroundPersonality disorders commonly coexist with alcohol use disorders (AUDs), but there is conflicting evidence on their association with treatment outcomes.AimsTo determine the size and direction of the association between personality disorder and the outcome of treatment for AUD.MethodWe conducted a systematic review and meta-analysis of randomised trials and longitudinal studies.ResultsPersonality disorders were associated with more alcohol-related impairment at baseline and less retention in treatment. However, during follow-up people with a personality disorder showed a similar amount of improvement in alcohol outcomes to that of people without such disorder. Synthesis of evidence was hampered by variable outcome reporting and a low quality of evidence overall.ConclusionsCurrent evidence suggests the pessimism about treatment outcomes for this group of patients may be unfounded. However, there is an urgent need for more consistent and better quality reporting of outcomes in future studies in this area.

Behavioral Couple Therapy in the Treatment of a Female Alcohol-Dependent Patient With Comorbid Depression, Anxiety, and Personality Disorders

Behavioral Couple Therapy (BCT) has shown to be effective in the treatment of alcohol dependence. However, it is still unclear whether this intervention is effective in severe caseswith comorbid other conditions. The aim of the present study is to illustrate the assessment, case conceptualization, prioritizing of interventions and treatment in a female “treatment resistant” alcohol-dependent patient, with comorbid depression, anxiety, personality disorders, andmarital problems, using a BCT manual. In total, the treatment consisted of 19 sessions, during a 7-month period. Results show BCT to be successful in treating alcohol dependence and to some extent increasing marital satisfaction. At posttreatment the patient did no longer meet criteria for major depressive disorder. At 3-month follow-up she had been abstinent for 51/2 months, with a 2-day lapse, and her depressive disorder was still in full remission. This case demonstrates—even with severe comorbid conditions—that targeting the drinking problem is the treatment of choice. However, we stress the importance of a thorough assessment of other Axis I and II disorders.

BAP updated guidelines: evidence-based guidelines for the pharmacological management of substance abuse, harmful use, addiction and comorbidity: recommendations from BAP

The British Association for Psychopharmacology guidelines for the treatment of substance abuse, harmful use, addiction and comorbidity with psychiatric disorders primarily focus on their pharmacological management. They are based explicitly on the available evidence and presented as recommendations to aid clinical decision making for practitioners alongside a detailed review of the evidence. A consensus meeting, involving experts in the treatment of these disorders, reviewed key areas and considered the strength of the evidence and clinical implications. The guidelines were drawn up after feedback from participants. The guidelines primarily cover the pharmacological management of withdrawal, short- and long-term substitution, maintenance of abstinence and prevention of complications, where appropriate, for substance abuse or harmful use or addiction as well management in pregnancy, comorbidity with psychiatric disorders and in younger and older people.

Personality disorders among alcoholic outpatients: prevalence and course in treatment

OBJECTIVE

To determine the prevalence of concurrent personality disorders (PDs) among alcoholic men and women seeking outpatient treatment, and to examine their effect on the course of alcohol treatment.

METHOD

Patients with alcohol use disorders (n = 165) were assessed by clinical and semi-structured interviews, as well as self-report scales, to measure levels of psychological distress, impulsivity, social functioning, and addiction severity at treatment intake. PD diagnoses were assessed using the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Personality Disorder (SCID-II). Course in treatment was monitored prospectively for 12 weeks.

RESULTS

Using the results of the SCID-II (n = 138), the sample was divided into 3 groups-that is, no PD 41% (n = 57), Cluster B PD 32% (n = 44), and other PD 27% (n = 37). The 3 groups did not differ in their alcohol use severity at intake. However, the Cluster B PD group achieved alcohol milestones at a younger age. Subjects with a PD had more severe psychological and social problems at intake. The Cluster B PD group showed significantly higher levels of impulsivity at intake, greater likelihood of early treatment dropout, and quicker times to first slip and to relapse.

CONCLUSIONS

This study supports the high prevalence of concurrent PDs, particularly Cluster B PDs, among treatment-seeking alcoholics. The relation between observed high levels of impulsivity and worse course in early alcohol treatment among people with a Cluster B PD merits further investigation.

Antisocial personality disorder as a predictor of criminal behaviour in a longitudinal study of a cohort of abusers of several classes of drugs: relation to type of substance and type of crime

Mixed findings have been made with regard to the long-term predictive validity of antisocial personality disorder (ASPD) on criminal behaviour in samples of substance abusers. A longitudinal record-linkage study of a cohort of 1052 drug abusers admitted 1977-1995 was undertaken. Subjects were recruited from a detoxification and short-term rehabilitation unit in Lund, Sweden, and followed through criminal justice registers from their first treatment episode to death or to the year 2004. In a ML multinomial random effects regression, subjects diagnosed with antisocial personality disorders were 2.16 times more likely to be charged with theft only (p<0.001), and 2.44 times more likely to be charged committing multiple types of crime during an observation year (p<0.001). The findings of the current study support the predictive validity of the DSM-III-R diagnosis of ASPD. ASPD should be taken seriously in drug abusers, and be targeted in treatment to prevent crime in society.

Axis I and II disorders as long-term predictors of mental distress: a six-year prospective follow-up of substance-dependent patients

BACKGROUND

A high prevalence of lifetime psychiatric disorders among help-seeking substance abusers has been clearly established. However, the long-term course of psychiatric disorders and mental distress among help-seeking substance abusers is still unclear. The aim of this research was to examine the course of mental distress using a six-year follow-up study of treatment-seeking substance-dependent patients, and to explore whether lifetime Axis I and II disorders measured at admission predict the level of mental distress at follow-up, when age, sex, and substance-use variables measured both at baseline and at follow-up are controlled for.

METHODS

A consecutive sample of substance dependent in- and outpatients (n = 287) from two counties of Norway were assessed at baseline (T1) with the Composite International Diagnostic Interview (Axis I), Millon's Clinical Multiaxial Inventory (Axis II), and the Hopkins Symptom Checklist (HSCL-25 (mental distress)). At follow-up (T2), 48% (137/287 subjects, 29% women) were assessed with the HSCL-25, the Alcohol Use Disorders Identification Test, and the Drug Use Disorders Identification Test.

RESULTS

The stability of mental distress is a main finding and the level of mental distress remained high after six years, but was significantly lower among abstainers at T2, especially among female abstainers. Both the number of and specific lifetime Axis I disorders (social anxiety disorder, generalized anxiety disorder, and somatization disorder), the number of and specific Axis II disorders (anxious and impulsive personality disorders), and the severity of substance-use disorder at the index admission were all independent predictors of a high level of mental distress at follow-up, even when we controlled for age, sex, and substance use at follow-up.

CONCLUSION

These results underscore the importance of diagnosing and treating both substance-use disorder and non-substance-use disorder Axis I and Axis II disorders in the same programme.

A Critical Look at Dual-Focused Cognitive-Behavioral Treatments for Comorbid Substance Use and Psychiatric Disorders: Strengths, Limitations, and Future Directions

Several large-scale studies examining outcome predictors across various substance use treatments indicate a need to focus on psychiatric comorbidity as a very important predictor of poorer SUD treatment involvement and outcome. We have previously argued that current cognitive-behavioral treatments (CBT) approaches to SUD treatment do not focus on the necessary content in treatment in order to effectively address specific forms of psychiatric comorbidity, and thus only provide clients with generic coping strategies for managing psychiatric illness (as would be achieved in other SUD treatment approaches; Conrod et al., 2000). Furthermore, following our review of the literature on dual-focused CBT treatment programs for concurrent disorders in this article, we argue that combining CBT-oriented SUD treatments with specific CBT treatments for psychiatric disorders is not as straightforward as one would think. Rather, it requires very careful consideration of the functional relationship between specific disorders, patient reactions to specific treatment components, and certain barriers to treatment in order to achieve an integrated dual-diagnosis focus in treatment that is meaningful and to which clients can adhere.

Substantial decrease of psychiatric comorbidity in chronic alcoholics upon integrated outpatient treatment - results of a prospective study

It is far from clear how comorbidity changes during alcoholism treatment. This study investigates: (1) the course of comorbid Axis I disorders in chronic alcoholics over 2 years of controlled abstinence in the outpatient long-term intensive therapy for alcoholics (OLITA) and (2) the effect of comorbid Axis I and II disorders in this group of patients on subsequent drinking outcome over a four-year follow-up. This prospective treatment study evaluates psychiatric variables of 89 severely affected chronic alcohol dependent patients on admission (t(1)), month 6 (t(2)), 12 (t(3)) and 24 (t(4)). Drinking outcomes have been analyzed from 1998 to 2002. On admission, 61.8% of the patients met criteria for a comorbid Axis I disorder, 63.2% for a comorbid personality disorder. Axis I disorders remit from t(1) (59.0% ill), t(2) (38.5%), t(3) (28.2%) to t(4) (12.8%) (p < 0.0001). Anxiety disorders remit more slowly from t(1) (43.6%) to t(3) (20.5%, p = 0.0086), whereas mood disorders remit early between t(1) (23.1%) and t(2) (5.1%, p = 0.0387) with a slight transient increase at t(3) (10.3%). During the four-year follow-up, the cumulative probability of not having relapsed amounts to 0.59. Two predictors have a strong negative impact on abstinence probability: number of inpatient detoxifications (p = 0.0013) and personality disorders (p = 0.0106). The present study demonstrates a striking remission of comorbid Axis I disorders upon abstinence during comprehensive long-term outpatient alcoholism treatment. The presence of an Axis II rather than an Axis I disorder on admission strongly predicts drinking outcome over a four-year follow-up.

A comparison between dually diagnosed inpatients with and without Axis II comorbidity and the relationship to treatment outcome

The presence of a personality disorder (PD) has been associated with certain types of poor treatment outcomes in patients with substance use disorders (SUDs). The purpose of this study was to determine the prevalence of comorbid PDs in psychiatrically hospitalized adults with both non-SUD Axis I disorders and SUDs, and to assess the relationship between Axis II psychopathology and degree of pretreatment addiction severity and treatment outcome.

METHOD

One hundred consecutive inpatients admitted to a mixed dual diagnosis inpatient unit were assessed using semistructured interviews for SUDs, non-SUD Axis I disorders, and PDs. Pretreatment severity was assessed using a modified version of the Addiction Severity Index (ASI). Outcome measures were assessed both during hospitalization and at an initial follow-up appointment after discharge. Statistical analyses were performed comparing dually diagnosed patients with and without Axis II psychopathology.

RESULTS

A significant number (53%) of the patients met criteria for at least one personality disorder. Of the PDs, Cluster B PDs were the most prevalent, particularly borderline personality disorder (74%) and antisocial personality disorder (66%). Dually diagnosed patients without an Axis II diagnosis had less severe pretreatment severity measures. During hospitalization, patients with Axis II disorders had higher levels of psychopathology on the Brief Symptom Inventory (BSI) subscales of sensitivity and hostility. However, there was no difference in overall degree of global improvement during hospitalization. During follow-up, patients with Axis II disorders were significantly less likely to be compliant in attending their initial follow-up appointment.

CONCLUSIONS

Dual diagnosis inpatients with PDs appear to improve as much as patients without PDs during their inpatient hospitalizations; however, they appear to be less likely to be compliant with attending their initial follow-up appointment.

Co-morbidity of personality disorders in individuals with substance use disorders

This review summarizes the recent literature about personality disorders among substance abusers. First, it will be shown that personality disorders are highly prevalent co-morbid conditions among addicted individuals. Second, it is argued that this co-morbidity is likely to be accounted for by multiple complex etiological relationships. Finally, the clinical relevance of routine assessment of (maladaptive) personality traits in individuals admitting for substance abuse treatment will be discussed.

Sociopathy, gender, and treatment outcome among outpatient substance abusers

Antisocial personality disorder (ASPD) may predict poor prognosis but gender/sociopathy relationships to prognosis remain unclear. This study investigated the effects of ASPD upon psychiatric and substance-related outcomes among 235 addiction treatment center outpatients. Prevalence rates for ASPD were similar for males (16%) and females (22%). At baseline, women and ASPD patients displayed greater substance-related and psychiatric severity. At 6-month follow-up, ASPD patients had greater severity on both measures than did patients without ASPD, but women now had equivalent psychiatric severity to men. After controlling for initial severity, ASPD was related to worse substance-related outcomes, but not to worse psychiatric outcomes.