Rottoli Chiara

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Personality structure predicts early dropout in patients with substance-

related disorders and comorbid personality disorders

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

Fabio Madeddu1

1. Department of Psychology, ni!ersity of Milano"#icocca, Pia$$a dell%&teneo 'uo!o 1,

()1(*, Milano, +taly

(. Casa di Cura -CRES/, Pia$$ale #aracca 1, ()1(0, Milano, +taly.


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Riassunto

uesto studio si propone di indagare i fattori preditti!i di un precoce dropout in pa$ienti con doppia

diagnosi, prendendo in esame !ariabili socio"demografiche, diagnostiche e di struttura della

personalit2.

&bbiamo ipoti$$ato che la struttura di personalit2 del pa$iente dimostrasse capacit2 preditti!e

migliori rispetto alle !ariabili descritti!e per ci3 che concerne l4abbandono precoce del trattamento.

& 5uarantasette pa$ienti rico!erati consecuti!amente in una comunit2 residen$iale per doppia

diagnosi sono stati somministrati la Structured +nter!ie6 of Personality 7rgani$ation 8S+P79, la

Structured Clinical +nter!ie6 for &:is ++ Disorders 8SC+D ++9, la Response E!aluation Measure ;1

8REM;19, la Symptom Chec< =ist >)?R 8SC=>)"R9 e infine la #orderline Personality Disorder

Chec< =ist 8#PDC=9.

Differen$e significati!e sono emerse tra il gruppo dropout 8coloro che hanno abbandonato la

comunit29 e il non"dropout@ problemi negli in!estimenti e nella coren$a del sA 8S+P79 erano piB

ele!ati nel gruppo dropout nello stesso gruppo un numero significati!amente alto di pa$ienti

mostra un4organi$$a$ione di personalit2 borderline 8.>9. + risultati sostengono l4uso di inter!iste

che indagano la struttura della personalit2 nella !aluta$ione di pa$ienti con doppia diagnosi.

Parole chiave :

disturbi di personalit2 disturbi correlati alle sostan$e doppia diagnosi assessment struttura di

personalit2


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Abstract

his study aims at in!estigating the predicti!e factors of early dropout in dual diagnosis patients,

considering socio"demographic, diagnostic and personality structure !ariables.

e hypothesi$ed that the personality structure of the patient 6ill sho6 better predicti!e properties

on dropout compared 6ith descripti!e !ariables. Forty"se!en patients consecuti!ely admitted in a

dual diagnosis residential treatment unit 6ere administered the Structured +nter!ie6 of Personality

7rgani$ation 8S+P79, the Structured Clinical +nter!ie6 for &:is ++ Disorders 8SC+D ++9, the

Response E!aluation Measure ;1 8REM;19, the Symptom Chec< =ist >)?R 8SC=>)"R9 and the

#orderline Personality Disorder Chec< =ist 8#PDC=9.

Significant differences emerged bet6een the dropout and no"dropout group@ in!estments and self"

coherence problems 8S+P79 6ere higher among dropouts moreo!er, in the dropout group a

significantly higher number of patients sho6ed a borderline personality organi$ation 8.>9.

Results support the use of structural inter!ie6s 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


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1. Introduction

he term -dual diagnosis/ has been introduced to describe the phenomenon in 6hich substance

abuse or dependence co"occurs 6ith other psychiatric disorders. 6o of the most commonly co"

occurring diagnoses are personality disorders 8PD9 and substance use disorders 8SD9. erheul,

an den #rin< and Gartgers 81>>H9 found that II of people 6ith alcohol use disorders and ;;

of people 6ho abuse opiates 6ould meet the criteria for a PD, identifying cluster # disorders as

those most commonly associated 6ith SD. Moreo!er, studies about patients 6ith PDs confirm the

relationship 6ith substance use@ rull, Sher, Min


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a higher personality organi$ation 8as the neurotic one9. Con!ersely, an immature defense style is

more rigid, maladapti!e and can interfere 6ith adapti!e functioning. Reality testing refers to the

process of relating one%s self to the e:ternal 6orld and distinguishing bet6een inner and outer

reality. hree other factors are contemplated in ernberg%s model@ 5uality of obKect relations,

aggression, coping strategies and moral !alues. he neurotic level is the healthiest le!el of

personality organi$ation and is characteri$ed by intact reality testing, an integrated identity and a

generally mature defense style. People at this le!el ha!e a consistent sense of purpose and life

goals. hey are also able to deeply commit to and care about other people, as 6ell as !ie6 them

accurately. &t the borderline level , reality testing is generally intact, but people ha!e a fragmented

and inconsistent sense of self and others. his fragmented sense of self is the most significant and

defining feature of the borderline le!el and results in se!ere and repetiti!e problems 6ith

interpersonal relationships. People 6ith borderline personality organi$ation also tend to rely on

primiti!e defense mechanisms, especially splitting. his defense mechanism is characteri$ed by a

tendency to !ie6 the 6orld and other people in a polari$ed manner, as Nall goodN or Nall badN,

flipping bac< and forth bet6een these t6o e:tremes based on moment"to"moment perceptions. &t

the opposite end of the personality organi$ation dimension is the psychotic level , characteri$ed by

compromised reality testing, an inconsistent sense of self and others and an immature defense

style.

Comorbid personality pathology in patients 6ith a SD has been related to poor treatment

outcomes. 7ne of the most important problems in dual diagnosis treatment is the high rate of

dropout 8lac< of adherence9 a substantial proportion 8ranging from 10 to 019 of indi!iduals 6ho

see< treatment for a SD do not complete treatment 8Daughters et al., ())H 9. Researchers ha!e

become increasingly interested in e:amining potential predictors of treatment dropout. o9 found that appro:imately 0OI of patients 6ith a

substance use disorder also ha!e a PD 8specifically antisocial, paranoid and a!oidant personality

disorders9 and that they prematurely abandon treatment more often compared to those 6ho do not

ha!e a PD. Comorbid patients also appear to ha!e more psychological, social, familial and medical

problems, and 6orse pretreatment conditions ho6e!er, they respond to therapy as much as non"

comorbid patients, e!en if some areas remain problematic at follo6 up after se!en months


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8Cacciola, &lterman, Rutherford, Mcay Mul!aney, ())19. Comorbidity 6ith an &:is ++ disorder

appears to be the best predictor of early dropout 8Pettinati, Pierce, #elden Meyers, 1>>>9.

Samuel, =aPaglia, Maccarelli, Moore and #all 8()119 found that antisocial and histrionic personality

disorders are predicti!e of an earlier dropout, 6hereas #PD became a significant predictor of

dropout 6hen considering nine months of treatment.

& small number of studies ha!e e:amined the effect of #PD on dropout from residential substance

abuse treatment programs, and the results are mi:ed. hereas MartQne$"Raga, Marshall, eaney,

#all and Strang 8())(9 found that SD patients 6ith #PD 6ere more li9 failed to find any significant association bet6een #PD and

residential substance abuse treatment completion, most li


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Cocaine 6as the main substance of abuse 8;(.09, follo6ed by alcohol 8**9, cannabis 8(>.9,

opioids 8(H.H9, hallucinogens 8.H9 and psychotropic drugs 81.9. & total of 0( patients

8*.19 6ere polysubstance abusers and 1H 801.>9 6ere single substance abusers. 'ineteen

patients 8I).I9 had an abuse diagnosis and (1 patients 8II.;9 had a dependence diagnosis.

Eight patients reported one or more diagnoses on &:is +@ I patients 6ere diagnosed 6ith mood

disorders, ( 6ith eating disorders, ( 6ith an:iety disorders and one 6ith schi$oaffecti!e disorder.

&fter si: months, (0 of the I; patients 8H1.19 5uit treatment against medical ad!ice.

2.2 Instruments

e re!ie6ed the files of all I; patients for the follo6ing information@

Medical history of substance use@ substance8s9 of use, age of onset, single substance abuse or

polysubstance abuse, abuse or dependence.

Case history data@ demographic characteristics 8age and gender9, pre!alence and number of &:is

+ disorders.

e administered ( clinical inter!ie6s@

Structured Clinical Interview for DSM-IV Axis II disorders SCID-II! "irst! Spit#er! $ibbon!

%illia&s ' (en)a&in *++,@ a 1I)"item, semi"structured inter!ie6 designed to pro!ide categorical

assessment of DSM"+"R personality disorders. he SC+D"++ inter!ie6 6as preceded by the

administration of its self"report screening 5uestionnaire.

Structured Interview of .ersonality /rgani#ation S0I./! Clar1in et al2! 344,5 Stern et al2! 34*4 @

a 1))"item, semi"structured inter!ie6 that pro!ides a dimensional assessment of the domains of

functioning central to ernberg%s theory of personality organi$ation including@ identity consolidation,

5uality of obKect relations, use of primiti!e defenses, 5uality of aggression, adapti!e coping !ersus

character rigidity, moral !alues and reality testing. he S+P7 e:plores both the patient4s

beha!ioral 6orld and inner 6orld. he S+P7 is scored by the inter!ie6er 6hile it is administered@

each item is rated on a )"( scale, 6ith $ero reflecting the absence of pathology, t6o reflecting the

clear presence of pathology, and one representing an intermediate status. +n addition, the


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inter!ie6er also completes a H"point rating for each domain, 6hich defines the range of health and

pathology for each section being rated. he H"point ratings are highly correlated 6ith the mean"of"

item scores.

Finally, 6e administered 0 self"reports@

Sy&pto& Chec1 6ist 7 +4 7 R SC6-+4-R! Derogatis! *+,,@ a >) item, multidimensional self

report in!entory designed to assess psychological symptom patterns. +t pro!ides measures of

current psychological symptom status 6ithin nine primary symptom dimensions 8Somati$ation,

7bsessi!e"Compulsi!e, +nterpersonal Sensiti!ity, Depression, &n:iety, Gostility, Phobic &n:iety,

Paranoid +deation and Psychoticism9, as 6ell as a $lobal Severity Index 8JS+9. he nine

dimensions sho6 good le!els of reliability 8Cronbach%s alpha ranging from .;>I to .>()9, as did the

JS+ 8Cronbach%s alpha .>;>9.

(orderline .ersonality Disorder Chec1 6ist (.DC6! .runas! Sarno! Capi##i ' Madeddu! 3448@

a I;"item, self"report instrument designed to assess the patient%s burden of complaints about

borderline personality disorder symptoms in the pre!ious month according to DSM"+"R criteria.

he test sho6s good le!els of reliability on all DSM criteria subscales 8Cronbach%s alpha ranging

from .*>( to .>;9 as did the global score 8Cronbach%s alpha .>*)9.

Response 9valuation Measure R9M-,*! Steiner! Arau)o ' :oop&an 344* @ a ;1"item, self"report

5uestionnaire that allo6s for the e!aluation of (1 defenses 8Cronbach%s alpha ranging from .(1;

to .*9. 6o factors are used to di!ide these defenses into t6o styles@ Factor 1 8T .(9 contains

1I defenses that distort reality in accordance 6ith e:pected outcomes leading to less adapti!e

functioning, and Factor ( 8T .*)H9 contains ; defenses that attenuate un6elcome reality, allo6ing

for more adapti!e functioning.

2.3 Data analyses

Preliminary analyses 6ere conducted to pro!ide information about the participants 8demographic

!ariables, substances used, age of onset and diagnosis of personality disorders9. 'o differences

6ere found bet6een male and female patients on demographic and diagnostic !ariables, apart


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from a higher pre!alence of employment in the male sample 8UV I.*, df 1, p W ).)H, 1I males

and ( females9, antisocial PD in the male sample 8UV I.)H, df 1, p W ).)H, 1; males and (

females9, and depressi!e PD in the female sample 8UV H.>0, df 1, p W ).)H, ( males and ;

females9.

he subKects 6ere then di!ided into t6o groups@ the dropout group 8DR79 and the nondropout

group 8'7DR79 comparisons bet6een the t6o groups 6ere conducted using continuity corrected

chi"s5uare tests for categorical !ariables and Student%s t"test for continuous !ariables.

. Results

3.1 Prevalence of personality disorders

+n our study, IH of the I; patients had at least one personality disorder 8as sho6n in table +9 the

most common PD 6as antisocial personality disorder, follo6ed by PD not other6ise specified

8'7S9, #PD and narcissistic PD. he mean number of personality disorder diagnoses 6as 1.;;

1.0(.

3.2 Dropout Group and Non-Dropout Group: descriptive variables

Considering the socio"demographic and &:is + !ariables, no significant differences 6ere found

bet6een the t6o groups. ith regards to personality disorder diagnoses, the DR7 group sho6ed a

significantly higher rate of narcissistic personality disorder 8; in DR7 !s ( in '7DR7, UV I.I;, df

1, p W .)H9. 'either the number of diagnoses nor the PD cluster subdi!ision had a different

distribution bet6een the t6o groups.

he results of the comparison bet6een the t6o groups on the Symptom Chec< =ist">)"R global

inde: and its nine scales did not sho6 any significant differences.

he last descripti!e instrument, the #orderline Personality Disorder Chec< =ist, did not sho6


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significant differences bet6een the t6o groups.

3.3 Dropout Group and Non-Dropout Group: structural variables

Regarding the S+P7 inter!ie6, the DR7 group reported higher scores on the domains of

Invest&ents 8t " (.0>(, df 0, p W .)H9 and Coherence and continuity 8t " (.;;1, df 0, p W .

))H9, t6o identity subscales. e then categori$ed patients into t6o diagnostic subgroups

according to ernberg model of personality pathology 8ernberg, 1>I9@ patients 6ere classified as

'eurotics if they sho6ed scores lo6er than 0 on both +dentity and Primiti!e Defenses dimensions

and patients 6ho reported scores higher than 0 on these t6o dimensions 6ere classified as

#orderline. +n this regard, significant differences emerged@ in the DR7 group, a significantly higher

presence of #orderline subKects 6as found 8UV *.(H, df 1, p W .)H9.

he last comparison bet6een the t6o groups 6as on Response E!aluation Measure";1 !ariables.

7ur analysis did not detect any differences among global factors 8immature defense style and

mature defense style9. he only significant difference 6as found in the use of splitting in patients@

the '7DR7 group appears to ma


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!alue, 6hich 6as different from other studies 8erheul, an den #rin< Gartgers, 1>> homas,

Melchert #an>> o Pettinati et al. 1>>> MartXne$"Raga et al. ())(9.

Descripti!e data from the SC=">)"R also failed to detect differences bet6een the DR7 and

'7DR7 groups this finding contrasts 6ith the findings of o9, 6ho identified

high scores in somati$ation and hostility scales as dropout predictors. +n our sample, not e!en the

global scale 6as predicti!e of early dropout. he &:is ++ profiles of the t6o subgroups 6ere similar.

he only personality disorder that sho6ed a significantly different distribution is narcissistic

personality disorder. +n psychodynamic theory, narcissistic and antisocial personality disorders are

intimately linI

Jabbard, ());9. 7ther studies sho6ed a higher pre!alence of antisocial and borderline PD 8ull

Jrat$, ()1(9. +n our study, these results are partially confirmed by the #PDC=, 6here 6e found 0

nearly significant trends@ mean !alues on measures of Self"mutilation?Parasuicide 8Hth criteria of

#PD according to the DSM"+"R t " 1.>0(, df I(, p .)*9, Mood 8* th criteria t " 1.>00, df

I(, p .)H09 and Paranoid?Dissociation 8>th criteria t " 1.>*, df I(, p .)H*9 are higher in the

DR7 group.

hese three results can be interpreted as general se!erity indicators 6ith regard to personality

pathology 8o, Cacciola et al., ())1 MartXne$"Raga et al., ())(9 and, more

specifically, borderline personality pathology 8Samuel et al., ()119.

7n the other hand, 6e found that a structural approach to personality diagnosis can gi!e important

information that differentiates the dropout group from the non"dropout group. +n fact, the S+P7

dimensions of Invest&ents and Coherence and Continuity , belonging to the +dentity domain, note a

6ea


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predictor of ele!ated ris< of therapy dropout. hus, the S+P7 results confirm that a greater

se!erity of personality pathology, represented by borderline personality organi$ation, is a trigger to

early dropout 8o MartXne$"Raga et al., ())(9.

Defensi!e functioning of patients assessed through the REM";1 did not lead to significantly

different results bet6een the t6o groups. he only difference detected by the REM";1 6as the use

of splitting splitting 6as more fre5uent in the '7DR7 group of patients. his result can be partly

accounted for by the self"report nature of this instrument the REM";1 single defense scales, in

fact, sho6 poor reliability 8Steiner et al., ())1 Prunas et al., ())>9.

Furthermore, the S+P7 defense subscale did not detect differences bet6een the t6o groups

results on this topic in the literature are mi:ed@ 6hereas no differences emerge in terms of

defensi!e functioning bet6een dropout and non"dropout patients 8Madeddu et al., ())H9, e:ler

and De=eon%s study 81>;;9 on the other hand found a more primiti!e defensi!e style in dropout

patients.

7ur results are in line 6ith proposals for the DSM"H in terms of e!aluating the le!els of personality

functioning. Section +++ of the DSM"H proposes to assess personality pathology considering se!erity

as the most important single predictor of concurrent and prospecti!e dysfunction and that

personality disorders might be best characteri$ed by a general personality se!erity continuum 6ith

additional specification of prototypical elements 8&P&, ()109.

+n conclusion, early structural diagnosis appears to represent an essential part of successful and

enduring therapeutic treatment. +n this study, the most predicti!e !ariables appear to be more

easily identified through instruments that detect the structural characteristics of patients, such as

the S+P7 inter!ie6 that recogni$es borderline and neurotic groups, in line 6ith ernberg%s theory.

Despite our finding that no specific personality disorders indicate a ris< factor for early dropout,

contrary to 6hat 6as found by Samuel et al. 8()119, patients 6ho abandoned treatment at si:

months are characteri$ed by greater identity fragility and are situated at a borderline le!el,

follo6ing ernberg%s model. herefore, it is necessary to 6or< on identity consolidation, the

creation of more stable and meaningful relationships, affecti!e stability, and stress tolerance to

pre!ent early dropout.

he main limitation of this study is its retrospecti!e nature@ part of data collection 6as based on the


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medical records of the patients selected. he sample si$e is rather limited, 6hich may ha!e

reduced the predicti!e po6er of some !ariables. E!en the use of self"report may constitute a

further limitation, in terms of social desirability.


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Re#erences

&merican Psychiatric &ssociation, 8()))9. Diagnostic and Statistical Manual of Mental Disorders

8Ith ed., te:t re!.9. ashington, DC@ &uthor.

&merican Psychiatric &ssociation, 8()109. Diagnostic and Statistical Manual of Mental Disorders

8Hth ed.9. &rlington, &@ &merican Psychiatric Publishing.

Cacciola, L. S., &lterman, &. +., Rutherford, M. L., Mcay, L. R., Mul!aney, F. D. 8())19. he

relationship of psychiatric comorbidity to treatment outcomes in methadone maintained patients.

Drug and Alcohol Dependence! 8*, (;1").

Clar


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Psychiatric Press.

Jabbard, J. 7. 81>>)9. .sychodyna&ic psychiatry in clinical practice. ashington, DC@ &merican

Psychiatric Press.

ernberg, 7. F. 81>I9. Severe personality disorders. 'e6 Ga!en@ Yale ni!ersity Press.

oealth and Substance ?se! "0;;.


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Prunas, &., Sarno, +., Capi$$i, S., Madeddu, F. 8())*9. =a !ersione italiana del #orderline

Personality Disorder Chec< =ist. Minerva .sichiatrica! >9. &:is ++ comorbidity of substance use

disorder among patients referred for treatment of personality disorder. A&erican ;ournal of

.sychiatry! *B8 , ;00";0.

Steiner, G., &rauKo, . #., oopman, C. 8())19. he Response E!aluation Measure 8REM";19@ &

ne6 instrument for the measurement of defences in adults and adolescents. A&erican ;ournal of

.sychiatry! *B , I*;"I;0.

Stern, #. =., Caligor, E., Clar


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disorder and substance use disorders@ & re!ie6 and integration. Clinical .sychology Review! 34 ,

(0H"(H0.

ull, M. ., Jrat$, . =. 8()1(9. he impact of borderline personality disorder on residential

substance abuse treatment dropout among men. Drug and Alcohol Dependence! *3*, >;"1)(.

erheul, R., an den #rin

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