the coping styles of alcoholics with axis ii disorders

Journal of Substance Abuse, 7(4), 425-435 (1995)

The Coping Styles of Alcoholics With Axis II Disorders

Nancy J. Smyth Research Institute on Addictions and University at Buffalo,

State University of New York

Richard C. Washousky Erie County Medical Center and Erie County Community College

This study investigated the drinking triggers and coping styles of alcoholics with

coexisting personality disorders (PDs). Forty-eight outpatients in alcohol treatment

(75% men) were assessed with a structured interview for PD diagnoses and were divided into two groups: those with one or more PD diagnoses (n = 29) and those with no personality disorder (NPD) diagnoses (n = 19). Relative to NPD participants, PD participants had greater alcoholism severity and were more likely to have another Axis I psychiatric diagnosis. All subsequent analyses used these variables as covariates. Utilizing

analyses of covariance (ANCOVAs), the groups were compared on triggers for heavy

drinking and coping styles. The PD group was more likely to report negative emotions,

interpersonal conflict, and testing personal control as triggers for heavy drinking, as well as having an emotion-oriented coping style. There were no differences in task or avoidant

coping styles.

Although comorbid mental disorders among alcoholics have been a topic of clinical and research interest, relatively little is known about Axis II diagnoses among alcoholics other than antisocial personality disorder (ASPD) and borderline personality disorder (BPD). The few studies that have investigated the full spectrum of personality disorders (PDs) among alcoholics have found that prevalence rates are high for several other PD diagnoses (DeJong, van den Brink, Harteveld, & van der Wielen, 1993; Nurnberg, Rifkin, & Doddi, 1993), including paranoid, avoidant, histrionic, dependent, obsessive-compulsive, and passive-aggressive.

In inpatient treatment populations, prevalence rates for ASPD have been reported at 20% to 49% (V.M. Hesselbrock, Meyer, & Keener, 1985; Liskow, Powell, Nickel, & Penick, 1991; Ross, Glaser, 8c Germanson, 1988), although rates are

We thank the following individuals for their work on the project Deborah Deiboldt, Lori Reyes, Marcy Brimo-Walle, Linda Macahrso, Hope Jay, Donna Leigh, Pat Malone, and the staffof the Downtown Clinic, especially Joan Moslow.

This research was supported by a BR8G grant (No. 908-E083G) through the Research Institute on Addictions. Preliminary findings from this study were presented as a poster session at the International Conference on the Treatment of Addictive Behavior in January 1993, in Santa Fe, NM.

Correspondence and requests for reprints should be sent to Nancy J. Smyth, Research Institute on Addictions, 1021 Main Street, Buffalo, NY 14203, or through E-mail:<[email protected]>.

425

426 N.J. Smyth and R.C. Washousky

higher for men than for women (V.M. Hesselbrock, Meyer, et al., 1985; Ross, Glaser, 8c Stiasny, 1988). Rates for BPD have been reported at 21% in inpatient alcoholics and 13% when alcohol-related diagnostic items were eliminated (Nate, Saxon, & Shore, 1983). Unfortunately, there has been little research on the full range of PDs among alcoholics and substance abusers. In a study of the full range of PD comorbidity among alcoholics, Nurnberg et al. (1993) found that 64% of a sample of outpatients had at least one PD diagnosis, and the diagnoses with the greatest prevalence were paranoid (44%)) ASPD (20%)) avoidant (20%), passive-aggressive (180/o), and BPD (16%). DeJong et al. (1993) reported that 78% of their sample of inpatient alcoholics in the Netherlands qualified for at least one PD diagnosis. The most common diagnoses were histrionic (34%)) dependent (29%)) avoidant (19%)) obsessive-compulsive (19%), and BPD (17%). Nate, Davis, and Gaspari (1991) conducted a similar study among U.S. substance abuse inpatients and found that 57% had at least one PD diagnosis.

Although prevalence rate information is useful, there is a need to investigate additional clinical characteristics that may be associated with comorbid psychiatric disorders in alcoholics, particularly clinical characteristics that can guide the selec- tion of appropriate treatment methods. Prior research has documented several differences among alcoholics with and without comorbid PDs. For example, Nate et al. (1983) reported that alcoholics with a BPD diagnosis, relative to the alcoholics without that comorbid diagnosis, were younger and more likely to have a history of drug abuse, suicide attempts, and accidents. Jonsdottir-Baldursson and Horvath (1987) reported similar results: Inpatient alcoholics with BPD were younger and more likely to abuse drugs than their non-BPD counterparts. No differences in severity of alcoholism symptoms were found. Similarly, alcoholics with ASP report earlier onset of drinking problems, more years of problem drinking and more alcohol-related problems than alcoholics without ASPD (V.M. Hesselbrock, Hessel- brock, & Stabenau, 1985). As with the findings related to BPD, alcoholics with ASPD are more likely to abuse drugs than alcoholics without ASPD (M.N. Hesselbrock et al., 1984).

Only a few studies have investigated current antecedents (or triggers) for alcohol and other drug use or current coping skills among alcoholics and substance abusers with comorbid personality disorders. Kruedelbach, McCormick, Schulz, and Grueneich (1993) compared substance abusers with BPD to substance abusers without BPD. The BPD substance abusers had higher levels of impulsivity, abused a greater number of substances, and more often reported craving and substance use triggered by negative emotional states, negative physical states, social rejection, and tension. In addition, the BPD participants utilized avoidance coping mechanisms more often and problem-solving and positive appraisal coping strategies less often. Nate et al. (1991) reported similar findings in their study of substance abusers with comorbid PDs. The comorbid substance abusers were more likely than their non-PD counterparts to use alcohol to manage mood. Con- flicting results were reported by V.M. Hesselbrock, Hesselbrock, and Workman- Daniels (1986) in the only study of drinking antecedents among alcoholics with PDs; they found no differences in drinking antecedents for alcoholics with and without ASPD.

Comorbid Axis II Disorders 427

Only one of the aforementioned studies investigated the drinking antecedents or coping skills for the full range of PDs, and that study (Nate et al., 1991) examined an inpatient substance abuse population. Our study investigated the coping styles and drinking antecedents associated with PD diagnoses in a sample of alcoholics in outpatient treatment. The hypothesis was that alcoholics with PDs would more often report that triggers for heavy drinking were unpleasant emotions and interpersonal conflict than would alcoholics without PDs. In addition, it was expected that the comorbid group would report greater use of avoidant and emotion coping styles and less use of task coping styles. These hypotheses were based on the assumption that alcoholics with comorbid PD diagnoses, by virtue of the personality disorder, would have greater deficits in interpersonal functioning, management of emotions, and general coping ability than alcoholics without PD diagnoses, and that these deficits would increase the likelihood that alcohol use would be triggered by situations involving interpersonal conflict and unpleasant emotions.

Although the hypothesized differences theoretically would be more prevalent in specific PD diagnostic categories rather than others, practically, once people qualify for one PD diagnosis, they usually qualify for several (Gunderson, Links, & Reich, 1991). This creates difficulties isolating characteristics associated with only one PD diagnosis, particularly with smaller samples. Given our small sample size, we limited our hypotheses and analyses to the investigation of the presence or absence of any PD diagnosis.

METHOD

Sample

Forty-eight participants were recruited from the adult clients of a large, public, metropolitan alcoholism outpatient clinic; 29 participants were from a standard outpatient program and 19 were from an intensive outpatient program. Ninety percent of the sample qualified for a Diagnostic and Statistical Manual of Mental

Dismden (3rd ed., rev. [DSM-III-R]; American Psychiatric Association, 1987) diagnosis of alcohol dependence and 10% qualified for an alcohol abuse diagnosis; 76% of the sample qualified for another DSM-III-Rpsychoactive substance use diagnosis, primarily cannabis and cocaine dependence.

The mean age of the participants was 34 years old (SD = 8.4). Seventy-five percent of the sample consisted of men. The mean number of days since last use of alcohol or drugs was 60 (SD = 10.3)) ranging from 0 to 270 days (many of the clients had already started treatment). The racial and ethnic group breakdown was 54% African Ameri- can, 38% European American, 4% Hispanic American, and 4% Native American.

Procedure

The study was described to clients in treatment groups; interested participants approached the interviewers regarding participation. Data were collected by research assistants in one 3 to 4hour interview, half of which involved a semistruc- tured clinical interview to obtain DSM-III-R Axis I and Axis II diagnoses. The

428 NJ. Smyth and R.C. Washousky

remainder of the assessment consisted of a battery of questionnaires. Participants were divided into one of two groups: PD and NPD, based on the presence or absence of at least one DSM-III-R PD.

Measurement

PD Diagnoses Diagnoses were assigned by research interviewers using the Structured Clinical

Interview II for the DSM-III-R (SCID II; Spitzer, Williams, Gibbon, 8c First, 1990a), after using the SCID II prescreening personality questionnaire to eliminate unnec- essary questions. Consistent with methodology used in similar research (V.M. Hes- selbrock et al., 1986; Rounsaville, Dolinsky, Babor, & Meyer, 1987)) DSM-III-R Axis

II criteria for ASPD and BPD were modified so that criteria relating directly to alcohol and other drug use (e.g., driving while intoxicated, impulsive use of alcohol and other drugs) were not included as PD criteria. In addition, the SCID II interviews were structured to identify personality traits that did not occur exclusively in relation to Axis I symptomatology. Primary Axis II diagnoses were assigned based on the interviewer’s assessment of the severity of the impact of each Axis II diagnosis on psychosocial functioning over the past year (a scale included with the SCID II), with the diagnosis with the most severe impact taking precedence. Research interviewers received 20 hours of training in administration of the SCID; the training involved viewing SCID demonstration interviews, reviewing each question, and role-playing SCID interviews with constructive feedback.

Alcohol and Drug Use Measures Psychoactive substance use disorder diagnoses were assigned by research inter-

viewers using the Structured Clinical Interview I for the DSM-III-R (SCID I; Spitzer, Williams, Gibbon, 8c First, 1990b). Alcohol and drug-use history (e.g., age of onset, number of years of problem drinking, last use of alcohol and other drugs) was gathered through use of a self-report questionnaire, and the Alcohol Dependence Scale (ADS; Horn, Skinner, Wanberg, & Foster, 1984) was used to assess the severity of alcohol dependence. The ADS measures the alcohol dependence syndrome, a key component of which is impaired control over alcohol.

Triggers for heavy drinking were measured with the loo-item Inventory of Drink- ing Situations (IDS; Annis, 1986), an instrument that assesses situations in which a person drank heavily. It includes eight categories of drinking situations: five that involve personal states (unpleasant emotions, physical discomfort, pleasant emotions, testing personal control, and urges and temptations to drink) and three that involve interactions with other people (conflict with others, social pressure to drink, and pleasant times with others). It is based on Marlatt and Gordon’s (1980) research on relapse situations.

Coping Measure The Coping Inventory for Stressful Situations (CISS; Endler & Parker, 1990), a

48item self-report measure, was administered to assess three coping styles: (a) avoidanceoriented, (b) emotionoriented, and (c) task-oriented. Participants indi-


cate the extent to which they use various coping strategies when they are under stress. Sample items for each coping style include ‘Think about how I have solved similar problems” (task), “Blame myself for having gotten into this situation” (emotion), and ‘Try to go to sleep” (avoidance).

RESULTS

Sixty percent of the sample qualified for at least one PD diagnosis, giving the PD group 29 participants and the NPD group 19. There were no significant differences between the PD group and the NPD group on age, ethnic and racial breakdown, education, or gender.

Prevalence Rates

Although our sample size did not allow for statistical analyses at the level of specific PD diagnoses, we examined the prevalence rates for these specific diagnoses so that our results can be compared more readily with those of other studies. Because participants could receive more than one PD diagnosis, two types of prevalence rates are reported: general and primary diagnoses. The general prevalence rates represent the percentage of participants who met the criteria for each PD diagnosis. The primary diagnosis rates represent the percentage of participants who qualified for a given diagnosis as their principal PD diagnosis. As was noted earlier, assignment of the primary diagnosis was made based on interviewers’ assessment of severity of impair- ment in the past year. Both types of prevalence rates are displayed in Table 1. As indicated in Table 1, the diagnoses with the greatest general prevalence rates were paranoid (31%), BPD (31%), and avoidant (29%). The most prevalent primary diagnosis was BPD (17%). The mean number of PD diagnoses per person (in the PD group) was 3.2 (SD = 2.0)) the range was 1 to 7, and the mode was 1.

Current and lifetime Axis I psychiatric diagnoses also were assessed. There was a trend for the PD group to have a greater prevalence of lifetime Axis I psychiatric diagnoses (74% vs. 26%), x2( 1, N = 48) = 3.36, p I .lO, and the PD group had significantly more current (past 30 days) diagnoses than the NPD group (87% vs. 13%, respectively), x2( 1, N = 48) = 6.27, p 5 .05. Because a current Axis I psychiatric diagnosis may account for the differences in characteristics between the PD and NPD groups, all subsequent analyses controlled for this difference.

Alcohol and Drug Use

Table 2 presents the results of an analysis of covariance (ANCOVA) for a variety of alcohol and drug variables for each group, controlling for current Axis I psychiatric diagnosis. The PD group had significantly higher ADS scores, earlier age of onset of a drinking problem, more years of problem drinking, and more times in treatment for alcohol and drug abuse (excluding the current treatment episode). Although the PD group had a higher percentage of participants with drug diagnoses than did the NPD group (83% vs. 63%), this difference was not statistically significant. There were no significant differences between the two groups in number of

430 NJ. Smyth and RX. Washousky

Table 1. Diagnoses: Numbers and Percentages Qualifying for Each PD Diagnosis and for

Each Primary Diagnosis (n = 48)

PD Diagnosis

Prevalence

N %

Primary Diagnosis

N %

Paranoid 15 31 3 6 Schizoid 1 2 0 0 Schizotypal 3 6 1 2 Histrionic 3 6 0 0 Narcissistic 7 15 2 4 Borderline 15 31 8 17 Antisocial 7 15 3 6 Avoidant 14 29 3 6 Dependent 6 13 3 6 Obsessive-Compulsive 6 13 2 4 Passive-Aggressive 9 19 1 2 Not Otherwise Specified 3 6 3 6 No Diaenosis 19 40 19 40

Note. PD = personality disorder.

days since admission to the current treatment environment or in numbers of days since the last use of alcohol and other drugs.

Heavy Drinking Triggers and Coping Style

Because severity of alcoholism and current Axis I psychiatric diagnosis could explain other differences between the two groups, all subsequent analyses controlled for alcoholism severity and the presence of a current Axis I psychiatric diagnosis. Due to the small sample size, each of the three alcoholism severity control variables was run separately (in conjunction with the presence of an Axis I psychiatric diagnosis) using ANCOVA procedures. Number of times in treatment was not used

Table 2. Comparison of Alcoholics with and without PD Diagnoses on Alcohol and Drug

Use Variables, Controlling for Current Axis I Psychiatric Diagnosis (ANCOVA)

PD” NPDb

Alcohol and Drug Variables M SD M SD F c5”

Days Since Last Used 54.3 72.4 69.9 48.8 .8 2, 37 Times in Treatment 4.4 4.2 1.6 2.1 6.7 2,45* Days Since Admission 57.3 53.9 72.5 36.0 1.4 2, 45 Alcohol Dependence Scale 22.6 9.1 12.8 11.0 5.9 2,45* Years of Alcohol Problem’ 13.2 8.3 5.9 6.3 6.7 2,42* Age of Onset of Alcohol Problem’ 19.1 4.9 24.3 a.2 8.5 2,42*

Note. PD = personality disorder; NPD = no personality disorder. VI = 29. bn = 19. cDegrees of freedom vary due to missing data on some variables. dPD = 26, NPD = 14. ePD = 29, NPD = 16.

*p zz .Ol , two-tailed.


Table 3. Comparison of Alcoholics With and without PD Diagnoses on Mean IDS and

Mean CISS Variables, Controlline: for Axis I Psychiatric Dkosis and the ADS (ANCOVA)

Dimensions

PD h?PP

M SD M SD F(@= 3,43)

IDS Personal States Pleasant Emotions Unpleasant Emotions Testing Control

Urges and Temptations

Physical Discomfort

IDS Interpersonal Situations Conflict With Others Pleasant Times With Others

Social Pressure

CISS Subscales Avoidant Emotion Task

59.5 23.6 47.0 24.7 .36 61.3 21.5 26.2 25.3 7.49*

56.3 20.7 26.7 23.4 7.34*

51.7 20.8 32.0 22.3 1.21

40.5 23.5 20.7 23.2 .51

50.1 20.4 16.9 20.0 11.79**

59.8 20.6 48.1 22.6 .06

59.7 18.8 47.8 21.5 .99

44.2 10.9 42.5 13.7 .12

44.2 11.6 32.8 8.4 9.50*

51.2 9.9 50.9 15.7 .08

Note. PD = personality disorder; NPD = no personality disorder; IDS = Inventory of Drinking Situations; CISS = Coping Inventory for Stressful Situations; ADS = Alcohol Dependency Scale.

% = 29. ?a = 18 (one participant was dropped due to missing data). *p 5 .Ol, two-tailed. **p 5 .OOl, two-tailed.

as a control variable because this variable could be caused by either severity of alcoholism or by the presence of a comorbid psychiatric disorder.1 Because the results at the .05 level were the same regardless of the alcoholism control variable utilized, only the results utilizing ADS scores and Axis I psychiatric diagnoses as covariates are presented. We chose ADS scores because they are the most direct measure of severity of alcohol dependence.

Table 3 displays the results of the ANCOVA results for the two groups on triggers for heavy drinking. As can be seen, the PD group had a greater frequency of drinking heavily when experiencing unpleasant emotions, testing personal control, and experiencing conflict with others.

The coping style results are also presented in Table 3. The PD group reported greater use of an emotion-oriented coping style than the NPD group, but not of avoidant or task-oriented coping styles.

DISCUSSION

The majority of alcoholics in this sample met the criteria for a PD diagnosis. Indeed, 60% of the participants qualified for at least one PD diagnosis. These results

When number of times in treatment was run as a control variable with presence of a current Axis I diagnosis, the results for the CISS were identical. Results for the IDS were that all subscales were

significantly (p 5 .05) greater for the PD group, with the exception of the following subscales: physical discomfort, pleasant times with others, and social pressure.


are consistent with those of Nurnberg et al. (1993), who reported a similar prevalence of 64% among outpatient alcoholics. We also found a great deal of overlap among PDs. Furthermore, we found high prevalence of participants who were paranoid, avoidant, passive-aggressive, and BPD. However, the prevalence of antisocial PD in our sample was surprisingly low.

As reported in previous research (V.M. Hesselbrock et al., 1985), the alcoholics with PD diagnoses in this study exhibited more severe alcoholism symptomatology than their noncomorbid counterparts, as noted by younger onset, more years of problem drinking, and greater severity of alcohol dependence syndrome. Unlike previous research (M.N. Hesselbrock et al., 1984; Jonsdottir-Baldursson 8c Horvath, 1987; Nate et al., 1983), the comorbid group was not more likely to have a drug problem, although given that there were differences in the same direction, this finding may have been a function of small sample size.

The hypothesis regarding difference in triggers for heavy drinking was supported, and is similar to the findings of Nate et al. (1991) and Kruedelbach et al. (1993). Participants with Axis II diagnoses reported greater frequency of drinking heavily when experiencing unpleasant emotions and interpersonal conflict than those without these diagnoses, even when severity of alcoholism was controlled. It may be that the behavioral problems and deficits associated with a comorbid PD influence the pattern of drinking, such that heavy drinking functions as a coping skill. We also found that the PD participants reported more heavy drinking triggers connected to testing personal control. Testing personal control may be greater in alcoholics with PDs due to their unwillingness to give up a method of coping (a characteristic of the generally decreased flexibility and adaptability indicative of a PD diagnosis), particularly when they are called on to give up a substance (alcohol) that has served a positive function. At the least, this situational drinking pattern may place the alcoholic with a comorbid PD at high risk for relapse in these specific situations. Unlike Kruedelbach et al., we did not find physical discomfort significantly different. This difference may be due, in part, to population differences (Kruedelbach et al., 1993, limited their study to BPD) or to the fact that we controlled for severity of alcoholism, whereas they did not. Our findings conflict with those of V.M. Hesselbrock et al. (1986) who did not find any differences in drinking antecedents among alcoholics with and without ASPD. The differences in these findings may be attributed to diEerences in the populations studied (their sample had high prevalence-49% for men and 20% for women-of ASP, whereas ours was 14%) or in the type of measure used to identify drinking antecedents.

Findings on coping-style differences were mixed. The greater use of an emotion coping style by the PD group was expected. This finding supports the notion that the comorbid group has a general coping style reflecting greater difficulty with negative emotions. Participants with a comorbid PD diagnosis more frequently endorsed emotion subscale items (e.g., “blame myself for having gotten into this situation, n “become very upset,” or “feel anxious about not being able to cope”) when asked how they usually respond to a stressful situation. However, contrary to expectations, the comorbid participants did not differ in their use of task and avoidant coping styles. This lack of significant differences on task or avoidant coping styles between the two groups suggests that either the overuse of an emotion coping


style or an inability to shift away from this focus may interfere with the effectiveness of the other two coping styles. It also is possible that another measure, such as the Ways of Coping Scale (Lazarus & Folkman, 1984), which was utilized by Kruedel- bath et al. (1993)) would yield different results.

Although our findings persisted when controlling for alcoholism severity, a few cautions must be presented regarding their interpretation, particularly as they pertain to the etiology of coexisting PD diagnoses among this population. The reason for high rates of PD diagnoses among alcoholics and substance abusers is unclear. Some people advocate that high rates are a function of the high risk of alcohol and other drug abuse that is associated with the PDs, whereas others propose that the symptoms of the PD are a consequence of many years of substance abuse (O’Malley, Kosten, 8c Renner, 1990; Sederer, 1990).* Ultimately, this debate centers around whether or not these PD diagnoses are reflective of “true” PDs or are an artifact of years of substance abuse. One problem with this question is that it assumes that there are people with true PDs out there. However, many people are questioning the validity of these diagnoses and of the categorical model of PDs, particularly because comorbidity of Axis II diagnoses seems to be the norm (Gun- derson et al., 1991). Furthermore, research on new interventions for PDs, such as Dialectical Behavior Therapy for people diagnosed with BPD (Linehan, Armstrong, Suarez, Allmon, & Heard, 1991), point to the possibility of significant behavioral change after 1 to 2 years of therapy, again calling into question our assumptions about what these diagnoses mean.

Ultimately, although the aforementioned issues regarding etiology are important in their own right, they may be of less immediate importance to the practitioner working in alcoholism treatment. Clients who qualify for these diagnoses are experiencing similar long-standing behavioral problems at the point of assessment (ac- cording to the behavioral diagnostic criteria), regardless of etiology.3 From the perspective of both the client and the practitioner, these behavioral problems must be addressed in a treatment plan, particularly as they relate to recovery from alcohol and other drug abuse, regardless of whether they represent a true disorder or the consequence of many years of addiction. Although practitioners may want to avoid formally applying Axis II diagnostic labels to these clients (because of very real concerns about the impact of labeling), this does not preclude targeting, for systematic intervention, those behaviors that are associated with a PD diagnosis.

In light of this (and in the event that subsequent research confirms our results), we think our findings have important implications for treatment and treatment outcome research. The differences in drinking triggers and coping style may place the alcoholic with a PD diagnosis at high risk of relapse in situations involving unpleasant emotions, interpersonal conflict, and testing personal control. This suggests the need for explicitly targeting these behavioral deficits, ideally early in treatment, so that clients can develop alternate skills to manage feelings, tolerate distress, manage interpersonal situations, and challenge thinking that contributes

sA third possibility is that people with these coexisting diagnoses are more likely to seek treatment than people who have only an alcohol or other drug problem (Sederer, 1990).

‘This perspective on Axis II disorders is most consistent with that of behavioral or social learning theorists.


to testing control. One existing treatment package for alcohol dependence already includes several modules addressing these areas of functioning (Monti, Abrams, Kadden, & Cooney, 1989); additional mood management modules have been added to this intervention by clinical researchers involved with a national treatment study (Kadden et al., 1992). In addition, mental health interventions that include skills modules in emotion management, distress tolerance, and interpersonal effectiveness (i.e., see Linehan, 1993) hold promise and could be adapted for alcoholism treatment.

Interpreting findings from any one study, particularly one with a small sample, must be done with caution because results may not generalize to the population of interest. Although the data support the existence of differences in coping styles and drinking triggers between alcoholics with and without comorbid PD diagnoses, the small sample size necessitates further study. Further research is needed to replicate these findings with other samples and to determine if these findings extend to drug use antecedents. In addition, although the small sample size in this study precluded examining gender and ethnic differences, investigation into these areas may prove fruitful.

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the coping styles of alcoholics with axis ii disorders

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