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Cross sectional study.
Households and group housing in the USA and District of Columbia, including Hawaii and Alaska; recruited 2001–2002.
43 093 people aged over 18 years randomly sampled from the general population. African-American, Hispanic and young adults aged 18–24 years were oversampled.
Trained interviewers conducted face to face interviews as part of the National Epidemiological Survey on Alcohol and Related Conditions. Alcohol and drug use disorders were assessed with the structured diagnostic Alcohol Use Disorder and Associated Disabilities Interview Schedule-DSM-IV (AUDADIS-IV). Current dependence required participants to satisfy at least three of seven DSM-IV criteria for dependence in the preceding 12 months. Alcohol abuse required at least one of four DSM-IV criteria for abuse, but not dependence. Drug specific abuse and dependence were derived in the same way. Personality disorders were also diagnosed by AUDADIS-IV. Participants were required to answer personality symptom questions about their lives, excluding times when they were ill, using drugs or medication, drinking heavily, experiencing withdrawal, anxious, depressed, or manic. Three of the 10 personality disorders defined by DSM-IV criteria were not assessed (borderline, schizotypal, and narcissistic).
Alcohol or drug use disorder and personality disorder (AUDADIS-IV).
In the general population, the 12 month prevalence of alcohol use disorder was 8.5% and drug use disorder was 2.0%. Overall, 29% of people with a current alcohol use disorder and 48% of people with a current drug use disorder had at least one personality disorder (see http://www.ebmentalhealth.com/supplemental for table). Among people who had at least one personality disorder, 16% had current alcohol use disorder and 7% had current drug use disorder. Antisocial, dependent, and histrionic personality disorders were most strongly associated with alcohol and drug use disorders. There was a greater association between personality and drug use disorders than between personality and alcohol use disorders. Antisocial personality disorders were most strongly associated with alcohol and drug use disorders in women (alcohol: OR 6.2, 95% CI 4.7 to 8.2; drug: OR 17.9, 95% CI 12.5 to 25.5). Dependent personality disorders were most strongly associated with drug dependence in men (OR 48.4, 95% CI 20.6 to 113.5).
Personality disorders commonly occur together with alcohol and drug use disorders in the general population. Antisocial, dependent, and histrionic personality disorders are most strongly associated with alcohol and drug use.
There is some degree of DSM-IV diagnostic overlap between antisocial, dependent, and histrionic personality disorders, which may explain why all three are strongly associated with alcohol and drug use disorders. Men with antisocial personality disorders who have drug and alcohol use disorders may be underrepresented in the study as they are more likely to be in prison or die younger than women.
Researchers and clinicians are aware that alcohol and drug problems are prevalent in both clinical and community samples. Further, the comorbidity between substance use disorders and other Axis I disorders (for example, mood and anxiety disorders) is generally recognised by mental health professionals. In contrast, less attention has been focused on the prevalence of personality disorders (PDs) in the population as well as on the comorbidity of substance use disorders and Axis II PDs (the one exception being antisocial PD).
Grant et al make several unique and important contributions to the field. Firstly, their prevalence estimates of PDs and the comorbidity rates between PDs and substance use disorders in the general population were based on an extremely large and representative sample of US residents. Prevalence and comorbidity estimates using clinical samples are biased and can lead to faulty conclusions about corresponding rates in the general population. Secondly, unlike previous epidemiological studies, this study assessed a range of PDs in addition to antisocial PD. Finally, this study examined whether prevalence rates and comorbidity patterns differed as a function of gender.
There are several important clinical and public health implications that can be drawn from this study. Firstly, PDs are relatively prevalent in the population; 15% of the sample met criteria for at least one of the PDs assessed (borderline, narcissistic, and schizotypal PD were not assessed but will be assessed in a follow up survey). Because of the significant disability associated with PDs, clinicians and researchers should routinely screen for these conditions. Secondly, PDs were quite prevalent among those with substance use disorders, especially dependence syndromes. Treatment providers need to be trained to recognise and treat PDs because their comorbidity could complicate treatment efforts and presage poorer outcomes. This can be a significant challenge because many substance use treatment programmes are staffed by specialists with minimal training in personality pathology. Finally, many of the associations between PDs and substance use disorders were stronger for women than for men. This highlights the need to consider PDs an important part of the clinical picture when treating substance dependent women, perhaps indicating specialised treatment approaches.
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For correspondence: Bridget Grant, Laboratory of Epidemiology and Biometry, Division of Intramural Clinical and Biological Research, National Institute for Alcohol Abuse and Alcoholism, National Institutes of Health, Bethesda, MD, USA;
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