Out‐patient behaviour therapy in alcoholism: impact of personality disorders and cognitive impairments

Abstract

Objective: We investigated whether alcoholic patients with comorbid personality disorders and those with cognitive impairments would benefit in a different way from different behaviour therapy strategies. Method: After detoxification, 120 alcoholics were assigned randomly to one of three out‐patient treatment programmes comprising ‘coping skills training’, ‘cognitive behaviour therapy’ or unspecific supportive control therapy. Personality disorders and cognitive impairments were assessed at the beginning of the 6‐month treatment period. Results: The impact of concomitant personality disorders or cognitive impairments was generally only moderate and mainly independent from treatment condition. However, alcoholic patients relapsing within 6 months after detoxification showed a higher rate of personality disorders (especially antisocial and borderline) and slightly more cognitive deficits (especially in verbal memory and visuomotor functions) than abstainers even before therapy. Conclusion: The high amount of early relapses and drop‐outs probably hindered larger differentiated treatment effects. Hypotheses will be retested in treatment completers using forthcoming follow‐up data.

Personality Disorders among Alcoholic Outpatients: Prevalence and Course in Treatment

“…Another notable finding was our sample's unexpectedly low rate of ASPD (5% of total sample), comparable to the general population rate of 3.6% found in the NESARC 42 but lower than the 7% to 23% rate reported in most clinical samples of alcoholics. 3,6,[8][9][10]13,14 This lower than expected rate in our study may be because eligible study subjects were voluntarily treatment-seeking, treatable on an outpatient basis and having no comorbid substance dependence other than nicotine, as well as because care was taken to exclude drug-or alcohol-influenced behaviours from PD criteria.…”

“…Moreover, there have been few attempts to clarify the differential impact of the seemingly more prevalent Cluster B PDs in this population. 7,9,12,14 While some studies find greater addiction severity and poorer treatment outcomes among alcoholics with Cluster B PDs, 6,7,11,14 others suggest that alcoholics with ASPD and other Cluster B PDs may fare as well in treatment as patients with no PD. 7,26,27 Thus there is no clear consensus regarding the relation between alcoholism and the different PD diagnoses.…”

“…21 In terms of clinical presentation, a concurrent PD diagnosis is associated with an earlier age of onset of alcohol-related problems, 6,7,10,11 increased addiction severity, 6,11 more secondary drug use, 7,9,10,12 more psychological distress, 6,7,9 and greater impairment in social functioning. 10 As for course in addiction treatment, a concurrent PD diagnosis has been associated with premature discontinuation of treatment, 10,13 earlier relapse, 9,12,13 poorer treatment response, 8,14 and worse long-term outcome. 5,25 However, few studies have looked at the impact of individual PD diagnoses (other than ASPD) on the course of alcoholism, or on the outcome of alcohol treatment.…”

“…In clinical settings, the rates of concurrent PDs among alcoholics range from 22% to 78%, [1][2][3][4][5][6][7][8][9][10][11][12][13][14] with most estimates around 60%. 3,5,6,8,[11][12][13][14] The variability in prevalence rates may be partly explained by differences in sample selection, treatment settings (residential, compared with outpatient), assessment instruments (self-report, compared with semi-structured interviews), and time of PD diagnosis (ongoing substance use, compared with remission). Nonetheless, prevalence rates for PDs in alcoholics are consistently higher than the estimated 9% to 16% PD lifetime rates in the general population, [15][16][17][18][19] and appear even greater than the 45% PD rate in a psychiatric sample.…”

Variables predictivas del alta terapéutica entre pacientes con patologia dual grave atendidos en una comunidad terapéutica de drogodependencias con unidad psiquiátrica

“…Los trastornos de personalidad no han sido, sin embargo, muy estudiados en las comunidades terapéuticas (Fernández-Montalvo et al, 2004), aunque un indeterminado pero numeroso grupo de pacientes con este trastorno recibe tratamientos en recursos para drogodependencias (Gunderson, 2001) y en general la presencia de un trastorno de personalidad se asocia con una menor adhesión al tratamiento (Hunter et al, 2000;Wölver, Burtscheid, Redner, Schwartz y Gaebel, 2001) y con el abandono prematuro del mismo aunque algunos autores (Linehan et al, 2006) ofrecen resultados esperanzadores respecto a la eficacia de la terapia dialéctico-comportamental. Un metaanálisis sobre 41 estudios en Trastorno Límite (Barnicot, Katsakou, Marougka y Priebe, 2011) obtienen cifras muy variables de cumplimiento terapéutico, que van desde el 36,0% al 100,0%, con una tasa global del 71,0%.…”