INTRODUCTION
There is substantial comorbidity between alcohol use disorders and personality disorders (PDs). National Epidemiologic Survey on Alcohol and Related Conditions, a large nationwide study in the United States, reported that more than one-fourth of patients with alcohol use disorder had at least one PD.[ 1 ] A more recent review reported that more than half the patients with certain PDs (antisocial PD and borderline PD) have alcohol use disorder.[ 2 ] Similarly, about half the patients with alcohol use disorder have comorbid PDs.[ 3 ] Patients with alcohol use disorder and comorbid PD are difficult to retain in treatment and they tend to drink more frequently.[ 3 ] The heterogeneity in the prevalence of personality disorders in alcohol use disorder populations is attributed to problems in the tools used for diagnosis.[ 3 ]
A few Indian studies have studied the comorbidity between PD and alcohol use disorder. A hospital-based Indian study found that the prevalence of PDs in alcohol dependence patients was about 30% using International Personality Disorder Examination.[ 4 ] Another Indian study that used Millon Clinical Multiaxial Inventory-III found that depressive, narcissistic, and paranoid PDs were prominent in the alcohol dependence group.[ 5 ] Determination of the prevalence of PDs in alcohol-dependent individuals using a clinician-administered semi-structured diagnostic interview will be a valuable addition to the literature from India. In the above context, the present study was conducted to estimate the prevalence of personality disorders in individuals with alcohol dependence syndrome undergoing inpatient treatment and to determine the sociodemographic and clinical correlates of personality disorders in these patients.
METHODS
The participants for this cross-sectional observational study were drawn from the in-patient ward of the department of psychiatry in a tertiary care–teaching hospital in South India using a consecutive sampling technique. In our setting, patients with alcohol dependence syndrome who present to the outpatient or emergency services with alcohol dependence syndrome are offered admission along with one caregiver. The patients undergo thorough medical and psychiatric evaluation. Benzodiazepines and multivitamin supplementation are initiated. Once the withdrawal symptoms subside, the patients are started on individual psychotherapy addressing the alcohol dependence syndrome and its consequences. Occupational therapy and other psychosocial interventions are initiated as per the need of the patient.
The study was approved by Institute Ethics Committee Reference number RC/18/86. Male patients in the age group of 18-60 years admitted to the psychiatry ward with a Diagnostic and statistical manual of mental disorders fourth edition, Text Revision (DSM-IV TR) diagnosis of alcohol dependence syndrome were eligible to participate in the study. Critically ill patients and patients with psychotic syndrome or hearing impairment were excluded. Eligible participants who provided a written informed consent underwent further assessments.
The assessments were conducted after the resolution of alcohol withdrawal symptoms (based on a consistent score of less than 8 on Clinical Institute Withdrawal Assessment–Alcohol revised scale). The sociodemographic (age, marital status, education, occupation, and socio-economic status) and clinical details (including details of alcohol use–age at first drink, duration of alcohol consumption, duration of alcohol dependence, amount of alcohol consumed per day) were collected using a semistructured proforma. The presence of Axis I psychiatric disorders was evaluated based on a clinical interview with the patient and the informant. The severity of alcohol dependence was assessed using Severity of Alcohol Dependence Questionnaire.[ 6 ] The presence of personality disorders was assessed using Structured Clinical Interview for DSM IV Axis II Personality disorders (SCID II).[ 7 ] The information obtained from the patient was corroborated by the informants and ward observations. The data collection was done from November 2018 to July 2020.
Tools used
The 20-item Severity of Alcohol Dependence Questionnaire is a reliable and valid instrument to measure the severity of alcohol dependence in various clinical settings.[ 6 ] This self-report tool takes about five minutes to complete. Each item is scored on a 4-point scale with a score of 0 to 3. The total score can range from 0 to 60. A score of less than 16, 16-30, and more than 30 indicates mild, moderate, and severe alcohol dependence, respectively.
SCID-II[ 7 ] is a semistructured instrument to diagnose personality disorders based on DSM IV criteria. It is a clinician-rated instrument and the trained interviewer clarifies and confirms the presence of acknowledged symptoms by asking for examples. This gives a reliable and valid assessment of the presence of various PDs based on DSM IV criteria. In addition to covering the 10 standard DSM-IV Axis II PDs, SCID II assesses for the presence of depressive PD and passive-aggressive PD.
Assuming the prevalence of PDs in individuals with alcohol-dependence syndrome to be 40% based on previous reports and an acceptable deviation of 10%, a sample of 96 participants would be required to estimate a similar prevalence at a confidence level of 95%. The statistical analysis was carried out using Statistical Package for Social Sciences software version 20 (IBM Corp., Armonk, NY, USA). Sociodemographic and clinical variables were summarized using frequency and percentage for categorical variables and mean and standard deviation for continuous variables. Chi-squared test/Fisher’s exact test was used to evaluate the association between various sociodemographic parameters and the presence of personality disorders. Student t -test was used to determine whether alcohol-related clinical variables differed between the two groups namely participants with and without PDs. A two-tailed P value <.05 was considered to be statistically significant.
RESULTS
One hundred male patients with alcohol dependence syndrome were recruited for the study. The mean age of the participants was 41.16 ± 8.91 years. Most participants were married and belonged to Hindu religion. Unskilled, semiskilled, and skilled workers together constituted about half of the participants [Table 1 ]. Half of the participants had moderate alcohol dependence and more than one-fourth had severe alcohol dependence. The mean duration of alcohol dependence was 9.62 ± 6.3 years [Table 2 ]. A past history of withdrawal seizures was reported by 43 (43%) patients, while 29 (29%) patients had a past history of delirium tremens.
Table 1: Sociodemographic details of the participants
Table 2: Alcohol-related variables in the study participants
In our study, 48 (48%) participants had at least one PD. Antisocial and avoidant PDs were the most common PDs in the study population [Table 3 ]. Chi-squared test/Fisher’s exact test was used to evaluate the association between the sociodemographic parameters (religion, marital status, education, occupation, and socioeconomic status) and presence of any PD. No association was noted between any of the above parameters and the presence of PD in the study population. Similarly, there was no association between comorbid smoking, oral tobacco use, cannabis use, and the presence of PDs. Alcohol dependent individuals with comorbid PD were noted to have lower age at first drink and higher daily alcohol consumption compared to those without comorbid personality disorder . Other alcohol-related variables like duration of alcohol consumption, duration of alcohol dependence, and severity of alcohol dependence were not different between these two groups [Table 4 ].
Table 3: Prevalence of personality disorders in treatment-seeking alcohol-dependent individuals
Table 4: Comparison of alcohol-related variables in alcohol-dependent individuals with and without any personality disorder
DISCUSSION
About half of the treatment-seeking male patients with alcohol dependence syndrome had at least one PD in the present study. Antisocial and avoidant PDs were the most commonly diagnosed PDs in this population. Paranoid, borderline, and obsessive-compulsive PDs were also present in about one-tenth of the individuals in the present study. The reported prevalence of PDs in alcohol use disorders varies considerably in previous studies.[ 2 ] Our findings are broadly similar to previous studies conducted in Canada and Germany.[ 8 , 9 ] Using SCID-II, Zikos et al .[ 8 ] found that 59% of alcohol use disorder patients had at least one PD and cluster B PDs were the most common subtype. Similarly, Preuss et al .[ 9 ] reported a 60% PD prevalence in alcohol-dependent inpatients. They found obsessive-compulsive and borderline PDs to be most common in their study population. An earlier multicentric study from the United States also reported a 58% prevalence of PDs in participants with alcohol dependence syndrome with antisocial, borderline, and paranoid PDs being the most commonly identified disorders.[ 10 ] A multicentric study from the United Kingdom reported a PD prevalence of 53% in alcohol service sample.[ 11 ] A Spanish study[ 12 ] also reported a similar PD prevalence of 44.3% in treatment-seeking alcohol-dependent subjects. Obsessive-compulsive PD was the most commonly diagnosed personality disorder in this study.
The prevalence of PD found in our study is clearly higher than an earlier Indian study[ 4 ] which reported a 30% prevalence in a hospital-based population of alcohol dependence subjects using the International Personality Disorder Examination. This study also found obsessive-compulsive and antisocial PDs to be the most prevalent PDs in this population. Antisocial PD was found in 21% of alcohol-dependent subjects in another Indian study[ 13 ] that used the Present Status Examination as the study tool. The variations in the prevalence rates of PDs in the present study and previous studies may be partially attributed to the differences in the prevalence rates in the general population in the different catchment areas. Alternatively, the nature of study tools (structured vs. semi-structured; self-report vs. clinician administered), the timing of assessment during the course of alcohol withdrawal, the degree of substance use comorbidity, and the sample size could influence the prevalence reported.
Several hypotheses have been put forward to explain the greater prevalence of PDs in alcohol use disorders. Among them, the four models that have been supported by empirical literature are predisposition/vulnerability, complication/scar model, exacerbation, and spectrum models.[ 14 , 15 ]
Age at first drink and average alcohol consumption per day were associated with the presence of PD in the present study. Surprisingly, the severity of alcohol dependence was not associated with the presence of PD. Preuss et al .[ 9 ] found that different PDs were associated with age at first drink and severity of alcoholism in their study population. An earlier study linked the presence of antisocial PD and borderline PD to more severe alcoholism.[ 10 ] Zikos et al .[ 8 ] reported that Cluster B PD group achieved alcohol milestones at a younger age and they had more severe psychosocial problems. Several sociodemographic and clinical factors were found not to be associated with prevalence of PDs in the present study. Our study was probably underpowered to detect these associations as we calculated the sample size based on our primary objective. The analysis regarding associated factors should be considered exploratory in nature.
Despite the high prevalence of PDs in individuals with alcohol dependence syndrome, it is not a usual practice to systematically evaluate treatment seekers for the presence of PDs. Several reports have highlighted the role of PDs in the treatment outcome of alcohol-dependent patients.[ 2 , 3 , 16 ] One recent meta-analysis[ 17 ] did not find any difference in treatment outcomes of alcohol-dependent patients with and without PDs. However, the authors have reported the quality of evidence of all the included studies to be low or very low.
The use of SCID-II which is a reliable and valid instrument to assess PDs is a major strength of the present study. SCID-II being a semistructured interview administered by a trained clinician is superior to fully structured instruments used in several previous studies.
The findings of the present study have to be interpreted with the following limitations in mind. The study was done on male patients with alcohol dependence syndrome in an inpatient setting. Outpatients and nontreatment seekers were not included and hence the findings cannot be generalized to all patients with alcohol dependence syndrome. Inclusion of only treatment-seeking individuals might have overestimated the prevalence of PDs (Berkson’s bias).
CONCLUSION
About half of male patients with alcohol dependence syndrome undergoing inpatient treatment had at least one PD. Antisocial and avoidant PDs were the most common PDs in this population. Individuals with comorbid PD had a lower age at first drink and higher daily alcohol consumption.
In future, studies conducted on a representative sample from the community, outpatients, and inpatients are required to estimate the prevalence of PDs in patients with alcohol dependence syndrome in various settings. The role of PD on the pattern and clinical correlates of relapse and its implication in treatment outcomes merit further study. Considering the high prevalence of PDs noted in patients with alcohol dependence, evaluation of the same using validated tools can be incorporated as part of standard care of management of these patients.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
REFERENCES
1. Grant BF, Stinson FS, Dawson DA, Chou SP, Ruan WJ, Pickering RP. Co-occurrence of 12-month alcohol and drug use disorders and personality disorders in the United States:Results from the National Epidemiologic Survey on Alcohol and Related Conditions. Arch Gen Psychiatry 2004;61:361–8.
2. Newton-Howes G, Foulds J.
Personality disorder and alcohol use disorder:An overview. Psychopathology 2018;51:130–6.
3. Newton-Howes G, Foulds J.
Personality disorder and treatment outcome in alcohol use disorder. Curr Opin Psychiatry 2018;31:50–6.
4. Chaudhury S, Saini R, Kumar S, Dewan C, Goyal E, Kadiani A. Prevalence of personality disorders in alcohol dependence:A control study. Glob J Addict Rehabil Med 2017;3:106–10.
5. Prakash O, Sharma N, Singh AR, Sengar KS, Chaudhury S, Ranjan JK.
Personality disorder , emotional intelligence, and locus of control of patients with alcohol dependence. Ind Psychiatry J 2015;24:40–7.
6. Stockwell T, Murphy D, Hodgson R. The severity of alcohol dependence questionnaire:Its use, reliability and validity. Br J Addict 1983;78:145–55.
7. First M, GIbson M, Spitzer R, Williams J, Benjamin L. User's Guide for the Structured Clinical Interview for DSM-IV Axis II Personality Disorders. Washington, DC: American Psychiatric Press; 1997.
8. Zikos E, Gill KJ, Charney DA. Personality disorders among alcoholic outpatients:Prevalence and course in treatment. Can J Psychiatry Rev Can Psychiatr 2010;55:65–73.
9. Preuss UW, Johann M, Fehr C, Koller G, Wodarz N, Hesselbrock V, et al. Personality disorders in alcohol-dependent individuals:Relationship with alcohol dependence severity. Eur Addict Res 2009;15:188–95.
10. Morgenstern J, Langenbucher J, Labouvie E, Miller KJ. The comorbidity of alcoholism and personality disorders in a clinical population:Prevalence rates and relation to alcohol typology variables. J Abnorm Psychol 1997;106:74–84.
11. Bowden-Jones O, Iqbal MZ, Tyrer P, Seivewright N, Cooper S, Judd A, et al. Prevalence of
personality disorder in alcohol and drug services and associated comorbidity. Addict Abingdon Engl 2004;99:1306–14.
12. Echeburúa E, De Medina RB, Aizpiri J. Comorbidity of alcohol dependence and personality disorders:A comparative study. Alcohol Alcohol 2007;42:618–22.
13. Heramani Singh N, Sharma SG, Pasweth AM. Psychiatric co-morbidity among alcohol dependants. Indian J Psychiatry 2005;47:222–4.
14. Krueger RF, Tackett JL. Personality and psychopathology:Working toward the bigger picture. J Personal Disord 2003;17:109–28.
15. Helle AC, Watts AL, Trull TJ, Sher KJ. Alcohol use disorder and antisocial and borderline personality disorders. Alcohol Res Curr Rev 2019 40: arcr. v40.1.05.
16. Soundararajan S, Narayanan G, Agrawal A, Murthy P. Personality profile and short-term treatment outcome in patients with alcohol dependence:A study from South India. Indian J Psychol Med 2017;39:169–75.
17. Newton-Howes GM, Foulds JA, Guy NH, Boden JM, Mulder RT.
Personality disorder and alcohol treatment outcome:Systematic review and meta-analysis. Br J Psychiatry J Ment Sci 2017;211:22–30.
