Patients with addiction and personality disorder: treatment outcomes and clinical implications Louisa M.C. van den Bosch a and Roel Verheul b,c

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1 Patients with addiction and personality disorder: treatment outcomes and clinical implications Louisa M.C. van den Bosch a and Roel Verheul b,c Purpose of review The present review examines the outcomes of treatments focusing on substance abuse, on personality disorders, and on both the foci simultaneously. Clinical guidelines for the treatment of dually diagnosed patients are described. Recent findings Recent studies continued the tradition of examining the importance of factors such as the chronicity of substance abuse and the impact of sex with regard to the prognosis of the treatment of substance abuse and the development of effective treatment programs. Overall, the multifaceted and risky nature of dual problems is stressed, and as a logical consequence, an early detection of dual problems is promoted. Several studies show the risk of suicidal and harmful behavior associated with this population, even when the treatment for substance abuse has been successful. For the first time, the issue of dropout is studied from the client s perspective. Summary Knowledge about the effectiveness of dually focused treatments is emerging. Results show that the treatment of dually diagnosed patients with severe problems needs to include both the foci because it leads to enormous gains for the patients when personality disorders are also addressed. Yet, integrated treatment programs are lacking and research is still too limited. Keywords addiction, antisocial, borderline, personality disorders, substance abuse, substance use disorders Curr Opin Psychiatry 20: ß 2007 Lippincott Williams & Wilkins. a Forensic Psychiatric Institute Oldenkotte, Rekken, The Netherlands, b University of Amsterdam, Department of Clinical Psychology, Amsterdam, The Netherlands and c Viersprong Institute for Studies on Personality Disorders (VISPD), Center of Psychotherapy De Viersprong, Halsteren, The Netherlands Correspondence to Dr Louisa M.C. van den Bosch PhD, Forensic Psychiatric Institute Oldenkotte, Kienvenneweg 18, 7157 CC Rekken, The Netherlands Tel: ; fax: ; wiesvdbosch@planet.nl Current Opinion in Psychiatry 2007, 20:67 71 Abbreviations ASPD antisocial personality disorder BPD borderline personality disorder DFST Dual Focus Schema Therapy 12FT 12-Step Facilitation Therapy SUD substance use disorders ß 2007 Lippincott Williams & Wilkins Introduction Since the introduction of Diagnostic and Statistical Manual of Mental Disorders, Third Edition (DSM-III) in 1980, there has been a growing interest in the study of Axis II comorbidity among patients with substance use disorders (SUD). The driving force behind this study has been, and still is, the high comorbidity, along with the overall clinical pessimism about the prognosis, and the difficulties in the clinical management of the dually diagnosed patients. Although the evaluation of co-occurring personality disorders has been the subject of numerous studies by addiction researchers, very little attention is paid on the co-occurrence of substance abuse by personality disorder researchers. This state of affairs is difficult to understand when one considers that substance abuse and personality disorders are by far the most common forms of dual diagnosis. Treatment outcomes Studies will be discussed according to the point of departure they take in examining the treatment of dually diagnosed patients: pharmacotherapy, substance abuse, personality disorders, and dual focus treatments. pharmacotherapy Pharmacotherapy can have an important role in the treatment of dually diagnosed patients. Medications may ameliorate some personality disorder symptoms while improving the outcome of SUD. It should be noted, however, that the co-occurrence of these disorders is also associated with high rates of noncompliance and an increased risk of lethal overdose, as well as a potential for dependence on the medication. Surprisingly, the number of studies focusing on pharmacotherapy of dually diagnosed patients is very limited. In the last 2 years, only one study has been published. In a study on the treatment outcome of buprenorphine in heroin-dependent patients with personality disorders, Gerra et al. [1 ] showed that high doses of buprenorphine predict a better outcome in terms of negative urines but not in terms of retention. substance abuse In the early 1990s, it was generally believed that personality pathology is significantly related to poor treatment 67

2 68 Personality disorders and neuroses response and outcome in patients with substance abuse. The studies available at that time, however, suffered from many methodological and interpretative problems, making it difficult to draw conclusions. A number of more recent studies have yielded results that provide somewhat more clarity. Overall, the multifaceted nature of the problems is stressed. For example, comorbidity of personality disorders with alcohol use disorders seems to be less destructive than that with heroin or cocaine use disorders [2]. Several studies convincingly show that personality pathology is associated with pretreatment and posttreatment problem severities, but is not a robust predictor of the amount of improvement. Cacciola et al. [3] examined the relationship of comorbid nonsubstance use psychiatric disorders with preadmission problem status and treatment outcomes in 278 methadone-maintenance patients. Across substance use and psychosocial domains, participants showed significant and comparable levels of improvement regardless of comorbidity, although psychiatric comorbidity was associated with poorer psychosocial and medical status at the time of admission and follow-up. Participants with the combination of Axes I and II comorbidities had the most severe problems, a finding that was confirmed by Westermeyer and Thuras [4 ]. In an examination of 606 voluntary patients aged 18 years and older, it was found that despite the many similarities in SUD among those with and without antisocial personality disorder (ASPD), the comorbidity in patients with ASPD, as measured by the number and types of substance-related problems, was considerably greater. Ball et al. [5 ] assessed the reasons for dropout from the client s perspective in a group of 24 clients. He found no relation between the reasons for dropout and the frequency or duration of use, prior treatment, or the extent of addiction-related psychosocial impairment. Dropout reasons, however, appeared to be associated with lost motivation or hope for a change and interpersonal problems with the program staff. One study directly focused on the effect of enhancing motivation. Carroll et al. [6 ] found that participants assigned to motivational interviewing had significantly better retention rates although no significant effects on the outcomes of substance use were found. The question as to whether staff functioning or attitude contributes to an early dropout is still unanswered although several authors have suggested that these factors play a significant motivational role [6,7]. Chronicity of addiction also could play an important role. In a prospective 4-year study, Krampe et al. [8 ] found that chronicity and the presence of a personality disorder are independently associated with a decrease in cumulative 4-year abstinence probability. Another possible explanation for this apparent discrepancy is that patients without personality pathology improve to a level of problem severity that no longer leaves them at a risk of relapse, whereas patients with personality pathology are at a risk of relapse despite their improvement. Consistently, Darke et al. [9 ] found that although participants with borderline personality disorder (BPD) showed reductions in the use of heroin and other drugs similar to other patients, they continued to exhibit higher levels of risk and harm across a range of outcomes. Furthermore, Fridell and Hesse [10 ] showed that even if treating psychiatric problems has modest effects on abstinence, effective treatment of psychiatric symptoms in substance abusers might be life saving because it decreases mortality. Miller et al. [11] points out that specific personality disorders, such as paranoid personality disorder, are a predictor of dropout. Verheul et al. [12] show that the comorbidity of ASPD/BPD and SUD specifically leads to early attrition and higher relapse rates. An alternative explanation of the available data with respect to the prognosis of ASPD and comorbid SUD is that the ASPD criteria set identifies a heterogeneous group of patients that includes both individuals with only antisocial behaviors and individuals with ASPD, including traits such as shallow affect, grandiosity, and lack of empathy and remorse. The latter group might be more at risk of poor treatment response and outcome, as shown by Marmorstein and Iacono [13 ]. This study also shows how significant the impact of sex is in the treatment of patients with comorbid problems. In a population-based sample of twins, the course of antisocial behavior with persisting (beginning by early adolescence and continuing through late adolescence) and desisting (stopping by midadolescence) antisocial behavior was examined in terms of a risk of later substance dependence and other background risk factors. Late-onset antisocial behavior has many of the same negative correlates as those of persisting antisocial behavior but significantly includes more women. Although youths are excluded from the diagnosis of ASPD, they have clinically significant problems similar to those who undergo this diagnosis. In this respect, it creates hope that there is a growing body of studies on the adequate detection of comorbidity among adolescents and young adults aiming at the development of early specific interventions [14 16 ]. personality disorder Little is known about the impact of substance abuse on the treatment outcome of patients undergoing treatment for their personality problems. Patients with comorbid SUD are often excluded from studies examining the efficacy of treatments designed to target personality disorder symptoms, although several studies have shown

3 Patients with addiction and personality disorder Bosch and Verheul 69 a lack of differences in clinical characteristics and/or etiological background between patients with and without SUD [17,18]. Implementation of integrated treatment is still slow. This differential approach illustrates the limitations specific to a mental health system and a research policy oriented toward the treatment of single rather than multiple disorders, even when the integrated treatment of comorbid psychiatric disorders is prioritized as one of the nine core treatment principles of the National Institute on Drug Abuse [19]. To the best of our knowledge, there is only one study that has investigated the impact of substance abuse on the outcome of a treatment focusing on Axis II comorbidity. In their randomized trial of Dialectical Behavior Therapy (DBT) among Dutch women with borderline disorders, Verheul et al. [20] and van den Bosch et al. [21 ] found no differences in the effectiveness of treatment between patients with and without SUD. Outcomes of dual focus treatments Two psychotherapies, namely Schema Focused Therapy and DBT developed for the treatment of personality disorders have been modified to meet the specific needs of dually diagnosed patients. The only documented integrated dual focus treatment for a broad range of Axis II comorbidity is Dual Focus Schema Therapy (DFST) developed by Ball [22]. DFST is a 24-week, manual-guided individual therapy, consisting of a set of core topics that integrate symptom-focused relapse prevention and coping skill techniques and schema-focused techniques for maladaptive schemas and coping styles. A randomized pilot study [23] of 30 methadone-maintenance patients, comparing DFST with 12-Step Facilitation Therapy (12FT) has given some preliminary empirical support. In patients assigned to DFST, substance use frequency reduced more rapidly over the 24-week treatment than in patients assigned to 12FT. Furthermore, patients undergoing DFST reported an improvement from a good early therapeutic alliance to a very strong alliance over the subsequent months of treatment, whereas those undergoing 12FT demonstrated no such improvement. Consistent with this finding, DFST therapists reported a feeling of a stronger working alliance with patients than did 12FT therapists. Ball et al. [24 ] also implemented DFST as a lower demand psychotherapeutic contact on-site for a sample of 52 predominantly homeless men within a homeless drop-in center. The patients could be characterized as a group with all the persistent and pervasive deficits that define personality disorder in combination with substance abuse. Examination of the effect of DFST compared with the standard group substance abuse counseling (SAC) showed a better use of the individual DFST than the group SAC. For the clients with greater personality pathology, the use of SAC, however, was higher than that of DFST, whereas no difference was found in the retention rate. The second dual focus treatment involves a modified, intensified, and extended version of the standard DBT [25], targeting substance abuse: DBT-S. DBT-S includes the standard treatment modules and a number of added elements: application of dialectics to abstinence issues, new strategies to keep difficult-to-engage and easily lost patients, the addition of six new and modified skills, and increased emphasis on using natural and arbitrary reinforcers for the maintenance of abstinence. In a randomized trial, Linehan et al. [26] compared DBT-S with Treatment as Usual (TAU). Participants assigned to DBT-S had significantly lower dropout rates and showed significantly greater reductions in drug abuse throughout the treatment year and at 16-month follow-up than the control subjects. No differences were, however, reported in the medical or psychiatric inpatient treatments received by DBT-S and control subjects, or in the rates of parasuicidal behavior. A second randomized trial [27] compared DBT with Comprehensive Validation Therapy with 12-Step (CVT þ 12S), a manual approach that provided the major acceptance-based strategies used in DBT in combination with participation in 12-Step programs. Both the treatment conditions were effective in reducing opiate use relative to baseline. DBT participants maintained the reductions in the mean opiate use through 12 months of active treatment, whereas those assigned to CVT þ 12S significantly showed increased opiate use during the last 4 months of treatment. The retention rate in DBT participants was, however, lower than that in CVT þ 12S participants. No difference in reduction in the level of psychopathology relative to baseline was found for both the conditions. Clinical implications In general, clinical guidelines for the treatment of personality disorders recommend psychotherapy whenever possible, complemented by symptom-targeted pharmacotherapy whenever necessary or useful. Literature gives us no reasons to substantially deviate from this recommendation in dually diagnosed patients although effective treatment of these patients often requires modifications in traditional programs and methods. We, however, wish to mention some essential ingredients of effective treatment of patients with both SUD and personality disorders. In the treatment of comorbid patients, a risk assessment always needs to take place and should be a crucial focus of the treatment efforts [28,29, 30,31,32 ].

4 70 Personality disorders and neuroses The treatment requires special and professional attention to both the foci from the very beginning, that is, the program should consist of an integrated package of these elements. Particular emphasis on motivational interviewing and validation [5,6,33] during the admission phase and the entire treatment process may be necessary for these dually diagnosed patients. In addition to the regular program modules, intensive individual counseling is recommended to establish a working alliance and to prevent these patients from leaving the treatment early. Furthermore, findings of a review by McKay [34 ] indicate that maintaining therapeutic contact for extended periods appears to promote better long-term outcomes. Direct therapeutic attention to maladaptive personality traits may increase cognitive and coping skills, and especially when facilities or resources are limited, it may improve symptomatology and reduce the risk of relapse. Yet, psychotherapy for patients with both SUD and personality disorders is likely to have greater success, only if it is provided in the context of a relatively long-term treatment program that provides sufficient structure and safety (e.g., day hospital, residential treatment, or methadone-maintenance program) and is combined with a skill-training or relapse prevention program. Patients with SUD and severe personality disorders consume a disproportionate amount of the staff time. They tend to be admitted repeatedly for the treatment and exhaust the resources of one counselor after the other. Therapists treating these dual disorders should be professional and highly skilled with extensive education and training in psychotherapy, psychopathology, personality disorders, and addiction. Given the challenges of treating this population, all therapists should be obliged to take part in some forum for supervision or consultation. Several studies [5 ] suggest that because impaired coping and social functioning, and low motivation or readiness to change are associated with higher rates of low attrition caused by the treatment, motivational, interpersonal, and perceptional problems need to be considered as core features in the treatment of dually diagnosed patients. Treatment programs, therefore, should integrate targeted behavior therapy interventions with empirical support for their use with specific disorders found in substance abusers, particularly those with antisocial [35] and borderline [25,36] disorders. Finally, participation in an appropriate aftercare program is highly recommended. Conclusion We have seen that: (a) personality pathology has a strong impact on the course of the addictive problems after discharge from addiction treatment; (b) individuals with SUD are usually, without a proper theoretical or empirical basis, excluded from Axis II treatments; and (c) some preliminary data are supportive of treatments with a dual focus. Together, these data provide strong support for the current movement toward treatment approaches, such as DFST and DBT/DBT-S, that pay simultaneous attention to both addictive and personality problems. We, however, need more empirical evidence to show that these treatments really have improved effectiveness over existing approaches. All therapies remain experimental, and the studies are too few and too small to inspire full confidence in their results. Attention to the feasibility issue is also required. As they have been recently developed, DFST and DBT-S require additional or separate clinical training over the standard programs they are derived from. The focus on one target seems to be a common characteristic of the different DBT programs. The question is to what extent is this approach useful for common clinical practice, which includes treatment of patients who suffer from multiple symptoms. It would therefore be worthwhile to examine the possibility of integrated, multitargeted treatment programs, rather than separate symptom-specific programs. This might imply that the therapists are trained to address a range of symptomatic manifestations of personality pathology in the impulse control spectrum, including suicidal and self-damaging behaviors, binge eating, and substance abuse. References and recommended reading Papers of particular interest, published within the annual period of review, have been highlighted as: of special interest of outstanding interest Additional references related to this topic can also be found in the Current World Literature section in this issue (pp ). 1 Gerra G, Leonardi C, D Amore A, et al. Buprenorphine treatment outcome in dually diagnosed heroin dependent patients: a retrospective study. Prog Neuropsychopharmacol Biol Psychiatry 2006; 30: [Epub 2005 Nov 23]. This article describes that severe dually diagnosed opiod-dependent male and female patients can benefit form the use of buprenorphine in getting abstinent, but unfortunately, the study has a retrospective design and was carried out in a nonexperimental setting. 2 Ross S, Dermatis H, Levounis P, Galanter M. A comparison between dually diagnosed inpatients with and without Axis II comorbidity and the relationship to treatment outcome. Am J Drug Alcohol Abuse 2003; 29: Cacciola JS, Alterman AI, Rutherford MJ, et al. The relationship of psychiatric comorbidity to treatment outcomes in methadone maintained patients. Drug Alcohol Depend 2001; 61: Westermeyer J, Thuras P. Association of antisocial personality disorder and substance disorder morbidity in a clinical sample. Am J Drug Alcohol Abuse 2005; 31: This article shows that a large population makes results reliable. 5 Ball SA, Carroll KM, Canning-Ball M, Rounsaville BJ. Reasons for dropout from drug abuse treatment: symptoms, personality, and motivation. Addict Behav 2006; 31: This article describes dropout from the patients perspectives and directs attention toward the (motivational effect of the) relationship with program staff. 6 Carroll KM, Ball SA, Nich C, et al. Motivational interviewing to improve treatment engagement and outcome in individuals seeking treatment for substance abuse: a multisided effectiveness study. Drug Alcohol Depend 2006; 81: This article shows the importance of motivating patients. 7 Claus RE, Kindleberger LR. Engaging substance abusers after centralized assessment: predictors of treatment entry and dropout. J Psychoactive Drugs 2002; 34:25 31.

5 Patients with addiction and personality disorder Bosch and Verheul 71 8 Krampe H, Wagner T, Stawicki S, et al. Personality disorder and chronicity of addiction as independent outcome predictors in alcoholism treatment. Psychiatr Serv 2006; 57: A prospective study with patients coming from inpatient and outpatient settings. 9 Darke S, Ross J, Williamson A, Teesson M. The impact of borderline personality disorder on 12-month outcomes for the treatment of heroin dependence. Addiction 2005; 100: This study clearly shows that focusing on drug abuse alone in dually diagnosed patients still leaves the patient with high levels of risk and harm. 10 Fridell M, Hesse M. Psychiatric severity and mortality in substance abusers: a 15-year follow-up of drug users. Addict Behav 2006; 31: This study clearly shows that focusing on drug abuse alone in dually diagnosed patients still leaves the patient with high levels of risk and harm. 11 Miller S, Brown J, Sees C. A preliminary study identifying risk factors in dropout from a prison therapeutic community. J Clin Forensic Med 2001; 11: Verheul R, van den Bosch LMC, Ball SA. Substance abuse. In: Oldham J, Skodol AE, Bender DS, editors. Textbook of personality disorders. Washington, DC: American Psychiatric Publishing; pp Marmorstein NR, Iacono WG. Longitudinal follow-up of adolescents with lateonset antisocial: a pathological yet overlooked group. J Am Acad Child Adolesc Psychiatry 2005; 44: Results are very important in the treatment planning of women diagnosed with lateonset antisocial behavior. 14 Carballo JJ, Oqendo MA, Giner L, et al. Impulsive-aggressive traits and suicidal adolescents and young adults with alcoholism. Int J Adolesc Med Health 2006; 18: Importance of impulsivity as a characteristic that links alcohol-related problems and suicidal behavior in adolescents. 15 Carballo JJ, Oqendo MA, Garcia-Moreno M, et al. Demographic and clinical features of adolescents and young adults with alcohol-related disorders admitted to the psychiatric emergency room. Int J Adolesc Med Health 2006; 18: Detection of alcohol-related problems among adolescents who are admitted for acute psychiatric care can be life saving, especially for women. 16 Stepp SD, Trull TJ, Sher KJ. Borderline personality features predict alcohol use problems. J Personal Disord 2005; 19: A study that stresses the important role of impulsivity as a dimensional characteristic of BPD and alcohol abuse on a large, nonclinical population. 17 Westermeyer J, Thuras P, Carlson G. Association of antisocial personality disorder with psychiatric morbidity among patients with substance use disorder. Subst Abus 2006; 26: Careful examination of a large population of substance abusers shows that ASPD SUD patients and non-aspd SUD patients are very similar, except for the comorbidity in the ASPD population. 18 van den Bosch LMC, Verheul R, van den Brink W. Substance abuse in borderline personality disorder: clinical and etiological correlates. J Person Disord 2001; 15: Libby AM, Riggs PD. Integrated substance use and mental health treatment for adolescents: aligning organizational and financial incentives. J Child Adolesc Psychopharmacol 2005; 15: Verheul R, van den Bosch LMC, Koeter MWJ, et al. Efficacy of dialectical therapy: a Dutch randomized controlled trial. Br J Psychiatry 2003; 182: van den Bosch LMC, Koeter M, Stinjen T, et al. Sustained efficacy of dialectical therapy for borderline personality disorder. Behav Res Ther 2005; 43: This study is the first to show that treatment of BPD SUD patients with standard DBT seems to have a sustained effect on some of the core symptoms of BPD, in terms of lower levels of impulsive and self-mutilating behaviors and of alcohol problems. 22 Ball SA. Manualized treatment for substance abusers with personality disorders: Dual Focus Schema Therapy. Addict Behav 1998; 23: Ball SA, Young JE, Rounsaville BJ, et al. Dual Focus Schema Therapy vs. 12- Step Drug Counseling for personality disorders and addiction: randomized pilot study. Paper presented at the ISSPD 6th International Congress on the Disorders of Personality, Geneva, Switzerland, Ball SA, Cobb-Richardson P, Connolly AJ, et al. Substance abuse and personality disorders in homeless drop-in center clients: symptom severity and psychotherapy retention in a randomized clinical trial. Compr Psychiatry 2005; 46: Although several factors prohibit generalizing the findings (very low retention rates, small size of sample, study attrition, predominantly male sample, disproportionate rates of A and C), it must be concluded that the study is very important in the sense that it shows that adding low-intensity psychotherapies in dually diagnosed populations, even in the homeless, is effective in enhancing the utilization of the treatment offered to the patients. 25 Linehan MM. Cognitive behavioral therapy of borderline personality disorder. New York: Guilford Press; Linehan MM, Schmidt H, Dimeff LA. Dialectical behavior therapy for patients with borderline personality disorder and drug-dependence. Am J Addict 1999; 8: Linehan MM, Dimeff LA, Reynolds SK, et al. Dialectical therapy versus comprehensive validation therapy plus 12-step for the treatment of opioid dependent women meeting criteria for borderline personality disorder. Drug Alcohol Depend 2002; 67: Preuss UW, Koller G, Barnow S, et al. Suicidal in alcohol-dependent subjects: the role of personality disorders. Alcohol Clin Exp Res 2006; 30: Another study that shows the risk of suicide among dually diagnosed BPD patients, but this study specifically stresses the pattern of characteristics of the patients who deserve special attention. 29 Sher L. Alcoholism and suicidal: a clinical overview. Acta Psychiatr Scand 2006; 113: This clinical overview of the literature on suicidality and alcoholism especially stresses the interrelatedness of especially partner-relationship disruptions with suicidal behavior in patients with alcoholism. 30 Cottler LB, Campbell W, Krishna VA, et al. Predictors of high rates of suicidal ideation among drug users. J Nerv Ment Dis 2005; 193: This is another study confirming the risk of suicide/self-harm in dually diagnosed patients. 31 Zanarini MC, Frankenburg FR, Hennen J, et al. Axis I comorbidity in patients with borderline personality disorder: 6-year follow-up and prediction of time to remission. Am J Psychiatry 2004; 161: Tidemalm D, Elofsson S, Stefansson CG, et al. Predictors of suicide in a community-based cohort of individuals with severe mental disorder. Soc Psychiatry Psychiatr Epidemiol 2005; 40: A study of a large community-based cohort shows that BPD is a very strong predictor of suicide. 33 Martino S, Carroll K, Kostas D, et al. Dual Diagnosis Motivational Interviewing: a modification of motivational interviewing for substance-abusing patients with psychotic disorders. J Subst Abuse Treat 2002; 23: McKay JR. Is there a case for extended interventions for alcohol and drug use disorders? Addiction 2005; 100: Although this article reviews the evidence for the feasibility and effectiveness of extended interventions for SUD only, it clearly shows what is needed when treating patients with severe problems. 35 Messina N, Farabee D, Rawson R. 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