Personality disorders associated with substance use among American and Greek adolescents

Adolescence, Winter, 2002 by Nina Serman, Jeffrey G. Johnson, Pamela A. Geller, Ruth E. Kanost, Helen Zacharapoulou

Substantial research has focused on the association between personality disorders and substance abuse among adults. In a number of studies, researchers have found that adults with certain types of personality disorders are at elevated risk for developing substance use disorders (Khantzian & Treece, 1985) and that adult patients diagnosed with substance use disorders are likely to have comorbid personality disorders (DeJong, van den Brink, Harteveld, & van der Wielen, 1993; Nace, Davis, & Gaspari, 1991; Ross, Glaser, & Germanson, 1988). Numerous studies have indicated that patients in treatment for substance use disorders are likely to have co-occurring personality disorders (O'Boyle, 1993). For example, DeJong, van den Brink, Harteveld, and van der Wielen (1993) found that nine out of ten inpatients with polydrug addiction met criteria for at least one personality disorder, and eighty percent met criteria for at least two personality disorders. Similarly, Weiss et al. (1993) found that in a sample of 50 patie nts hospitalized for cocaine dependence, 74% met diagnostic criteria for at least one personality disorder and retained these diagnoses even when drug-free.

Evidence from adult studies indicates that certain personality diagnoses seem to be particularly associated with substance abuse. Nace, Davis, and Gaspari (1991) examined 100 inpatients in a substance abuse treatment program and found that 57% had at least one personality disorder; borderline, histrionic, and passive-aggressive personality disorders were the most prevalent, and patients with personality disorders were more extensively involved in substance abuse than those without personality disorders. DeJong et al. (1993) found that the most common personality disorders associated with polydrug addiction were as follows: borderline, histrionic, passive-aggressive, antisocial, schizotypal, and dependent. Other researchers also found that individuals participating in inpatient treatment programs had high prevalences of borderline, histrionic, and antisocial personality disorders (Brooner et al., 1992; Dulit et al., 1990; Oldham et al., 1995).

While most research on the relationship between personality disorders and substance use among adults has been conducted using patient samples, a few studies have examined community samples. In one such study, Johnson et al. (1996) reported that among 107 HIV seropositive and seronegative gay men in the community, those with high levels of personality disorder symptomatology were more likely than those with fewer personality disorder symptoms to be diagnosed with subsequent substance use disorders (46% as compared to 14%). Unfortunately, almost all of the studies that have examined the relationship between personality disorders and substance abuse in the community have been conducted with adult samples. Thus, an area in particular need of investigation is the association between personality disorders and substance abuse among adolescent' in the community.

Further highlighting this need is the fact that, even when clinical studies are considered, little research has investigated substance abuse among adolescents with personality disorders. This lack of research is likely due in part to the fact that, until recently, it was widely considered inappropriate to diagnose adolescents with personality disorders (Rey, 1996). However, a number of studies have examined the link between an array of personality factors and the onset or continuation of substance use during adolescence. Several studies have indicated that, among adolescents in the community, personality factors such as rebelliousness, impaired emotional well-being, low academic aspirations, low self-esteem, and impulsiveness are associated with substance use (e.g., Adger, 1991; Shedler & Block, 1990; Teichman, Barnea, & Rahav, 1989). Research has also indicated that the risk for comorbid substance use disorder is substantial among adolescents identified with serious emotional disturbances, and that adolescen ts with serious emotional problems tend to have higher prevalence rates for substance abuse and greater mental health service utilization (see Greenbaum et al., 1991).

Numerous studies have examined the comorbidity of substance abuse and Axis I psychiatric disorders, such as conduct (e.g., DeMilio, 1989), anxiety, and eating disorders (e.g., Bukstein, Brent, & Kaminer, 1989), among adolescents referred for inpatient substance abuse treatment. A smaller number of studies conducted with community samples have yielded findings indicating that substance use is strongly associated with psychiatric disorders, particularly conduct disorder, among adolescents in the general population (e.g., Boyle & Offord, 1991; Neighbors, Kempton, & Forehand, 1992). Because conduct disorder is associated with high risk of continuation into adult life in the form of antisocial personality disorder, these findings are consistent with findings indicating that adults with antisocial personality disorder are likely to abuse drugs. In a recent study, it was found that daily cigarette use, weekly alcohol consumption, and any illicit substance use in the past year were each independently associated with an increased likelihood of anxiety, disruptive behavior, mood, and substance use disorders (Kandel et al., 1997). Although little research has investigated the relationship between adolescent personality disorders and substance abuse, Johnson et al. (1995) reported that in a sample of 18-and 19-year-olds, heavy substance users reported significantly greater antisocial, borderline, and overall personality disorder symptomatology than did adolescents who reported little or no substance use. Further, adolescents diagnosed with personality disorders were more than twice as likely as those without personality disorders to be heavy users of alcohol, marijuana, or tobacco.