Using Personality Assessment to Inform Comorbid Addiction Diagnosis

Screening and Assessment of Personality Disorders in Addiction Treatment Settings

Shelley McMain & Michael Ellery

Received: 25 February 2007 /Accepted: 2 April 2007 / Published online: 20 July 2007 # Springer Science + Business Media, LLC 2007

Abstract Given the high rates of overlap between personality disorders and substance use disorders and the associated high levels of disability, a thorough diagnostic assessment involving screening for personality pathology should be routinely done with people seeking treatment for addiction problems. Evaluating whether a person meets diagnostic criteria for an Axis II disorder is essential, since specific diagnoses, such as borderline personality disorder, are linked to preferred treatment approaches. Screening is integral to the detection and treatment of problems faced by people with concurrent personality disorders and substance use disorders. However, as screens tend to overestimate the presence of personality disorder traits, diagnostic assessment is necessary to accurately determine the presence or absence of a personality disorder and to specify the contribution of a concurrent personality disorder to the problems being experienced by someone with a substance use disorder. This paper reviews the psychometrics of several instruments for the screening and diagnosis of personality disorders, which may be useful in addiction treatment settings.

Keywords Screening . Assessment . Personality disorders . Substance abuse treatment

Introduction

According to the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), a personality disorder is a serious illness that involves “an enduring pattern of inner experience and behaviour that deviates markedly from the expectations of the individual’s culture, is pervasive and inflexible, has an onset in adolescence or early adulthood, is stable over time, and leads to distress or impairment”(American Psychiatric Association 1994). People with personality disorders (PDs) can be identified by severe impairments in

Int J Ment Health Addiction (2008) 6:20–31 DOI 10.1007/s11469-007-9093-5

S. McMain (*) Centre for Addiction and Mental Health, 33 Russell Street, Toronto, ON, Canada M5S 2S1 e-mail: [email protected]

M. Ellery Dalhousie University, Halifax, Nova Scotia, Canada

functioning in at least two of the following areas: impulsivity, interpersonal functioning, affectivity, and cognition.

Clinicians in the addiction treatment field have, until recently, paid little attention to the diagnosis and treatment of PDs. Some have viewed symptoms of personality disturbance as a variant of substance abuse, or as having little clinical meaning. In the past decade, however, as more has been learned about PDs, there has been an increased focus on their co-occurrence with substance use disorders (SUDs), with several studies documenting high rates of overlap between these disorders. The management of these patients is an important issue in addiction treatment, as they typically pose greater challenges and often do not respond well to traditional approaches. Effective management of these patients requires clinicians in the addiction treatment system to be well trained in the detection and assessment of personality pathology.

This paper highlights concerns about the co-occurrence of PDs and SUDs, and addresses the prevalence and consequences of this co-occurrence. Practical issues related to the screening and assessment of people with PDs in addiction settings are discussed; a number of assessment tools are recommended; and empirical findings relevant to the treatment of comorbid PDs and SUDs are reviewed.

Prevalence of Co-occurring Personality Disorders and Substance Use Disorders

Several studies have found rates of PDs among substance abusers around 60%, with an association of 61% between PDs and drug use disorders and of 59% between PDs and alcohol use disorders (Brooner et al. 1997; Grant et al. 2004; Hasin et al. 2006; Malow et al. 1989; Nace et al. 1991; Skodol et al. 1999; Verheul et al. 1995; Weiss et al. 1993a). High rates of PDs have been found across diverse groups of substance abusers, including alcoholics (DeJong et al. 1993; Nace et al. 1983; Vaglum and Vaglum 1985), heroin users (Darke et al. 2003; 2004; Kosten et al. 1989), and cocaine users (Weiss et al. 1993b).

The most common PDs seen in people with SUDs are identified in Cluster B; specifically, antisocial personality disorder (ASPD), borderline personality disorder (BPD), and histrionic personality disorder (HPD). This is followed by PDs identified in Cluster C, including dependent personality disorder (DPD; Malow et al. 1989; Verheul et al. 1995; Weiss et al. 1993a). In the Epidemiological Catchment Area study, 83.6% of individuals with ASPD were identified with a substance abuse disorder. ASPD was found to be more strongly associated with alcohol and drug use disorders than any other Axis I disorder (e.g., anxiety, affective, schizophrenia) (Regier et al. 1990). In a recent review of studies investigating the extent to which BPD occurred amongst samples of substance abusers, Trull et al. (2000) found the prevalence rate to range from 5.2% to 67%. Variability across studies can be attributed to differences in the study populations, settings, and assessment procedures. The observed high rates of Cluster B PDs, particularly ASPD and BPD, are not unexpected, since impulse control problems are a particular concern for these groups of patients. Although impulsivity (e.g., substance abuse) is a diagnostic criterion for BPD and ASPD, high rates of comorbidity exist even after adjusting for symptom overlap (Brooner et al. 1997; Dulit et al. 1990).

Clinical Implications of Comorbid Personality Disorders and Substance Use Disorders

Several studies have found evidence that the co-occurrence of PDs and SUDs is associated with a more severe clinical profile than that seen with SUDs alone (Kosten et al. 1989;

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Nace et al. 1991; Skodol et al. 1999). Compared to substance abusers without personality pathology, those with PDs exhibit greater dysfunction, which can complicate their treatment prognosis. They have been found to have poorer school performance, lower levels of education, higher rates of unemployment, and more legal problems (Brooner et al. 1997; Cacciola et al. 1996; Links et al. 1995a, c; Thomas et al. 1999), as well as higher levels of psychopathology, increased psychiatric risk, and a higher need for psychiatric services (van den Bosch et al. 2001; Kosten et al. 1989; Nace et al. 1991). Additionally, individuals with comorbid PDs and SUDs have been found to have a more severe substance abuse profile and a range of increased risks associated with their substance abuse. Several studies have found that compared to people with SUDs alone, they report heavier patterns of drug and alcohol use (Cacciola et al. 1996; Nace et al. 1991), have higher rates of polydrug use (Kosten et al. 1989; Nace et al. 1983), and are at a greater risk of relapse (Kosten et al. 1989; Pettinati 1991; Thomas et al. 1999).

With respect to BPD, substance abusers with comorbid BPD have been found to have higher rates of suicidal behaviours, including suicide attempts, and non-suicidal self-injurious behaviours (Inman et al. 1985; Links et al. 1995a, b, c; Nace et al. 1991; van den Bosch et al. 2001; Verheul et al. 1995), and higher rates of completed suicides (Stone 1990), compared to non-BPD substance abusers. In a study of heroin users, Darke et al. (2003) found that the presence of BPD was associated with a history of polydrug use, increased risk of overdosing, and increased risk-taking behaviours with respect to needle use. In another study, a comparison of BPD patients with and without SUDs revealed that the addition of substance abuse problems was associated with higher levels of sexual promiscuity and higher rates of prostitution (Miller et al. 1993). Although several studies have found that the presence of ASPD is associated with increased levels of harm (Brooner et al. 1997; Rutherford et al. 1994), one study found that increased risk associated with an ASPD diagnosis was not apparent when the presence of a BPD diagnosis was taken into account (Darke et al. 2004).

As difficult as the treatment of PDs and SUDs is separately, the overlap of these two conditions is often even more complicated. Several studies have shown that there is a poorer prognosis for patients with both a PD and an SUD (Cacciola et al. 1996; Nace et al. 1991; 1983; Thomas et al. 1999). Links et al. (1995a, b, c) found that people with concurrent BPD and SUDs were twice as likely as those with BPD alone to meet the criteria for BPD seven years after their index admission. In a study of opiate-dependent individuals, Kosten et al. (1989) found that the co-occurrence of BPD predicted more severe psychiatric problems and higher rates of alcoholism at follow-up.

General Issues in Screening and Assessment

Given the high rates of overlap between PDs and SUDs and the associated high levels of disability, a thorough diagnostic assessment involving screening for personality pathology should be routinely done with people seeking treatment for addiction problems. A number of issues must be considered when developing an efficient and comprehensive screening and assessment protocol. One consideration is the type of data that are relevant to treatment planning. There are two main approaches to gathering and organising information about a patient: 1) a consideration of diagnostic issues and 2) an assessment of severity of presentation. Evaluating whether a person meets diagnostic criteria for an Axis II disorder based on the DSM-IV (1994) is essential, since specific diagnoses, such as BPD, are linked to preferred treatment approaches. It is also important to obtain information about current

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and lifetime Axis I disorders and medical disorders, since patients with personality pathology often present with multiple problems.

The diagnostic assessment process is complicated by the difficulty of distinguishing substance-induced symptoms from true personality traits. For example, reckless and risky behaviour, unstable affect, and disrupted interpersonal relationships may be symptomatic of ASPD or BPD, but could also be a consequence of drug use, including symptoms of intoxication or withdrawal from psychoactive substances. The clinical challenge is to identify whether the symptoms warrant an independent personality disorder diagnosis. Structured assessment protocols can improve the reliability of the diagnostic assessment.

While categorizing symptoms in terms of DSM-IV diagnoses provides useful information, relying exclusively upon diagnostic categories to inform treatment planning has its limitations. A major problem is that the diagnostic classification system lacks precision with regard to the severity and pattern of problems. People who meet diagnostic criteria for concurrent PDs and SUDs often represent a heterogeneous group of individuals with a wide range of presenting problems; and to obtain a comprehensive clinical picture, it is necessary to consider the severity of mental health and addiction problems and the patient’s level of functioning. This involves considering any diagnoses within a broad context, as symptoms can be exhibited across a continuum from mild to more severe clinical presentations. At one end, severely impaired patients often lead chaotic lives, have little structure and limited interpersonal ties, and often rely heavily on social and treatment services; while those at the milder end of the spectrum may evidence less impulsivity and disturbed coping, and may be better able to make use of treatment services. The severity of illness has been shown to be the best predictor of treatment response (Shane et al. 2003). Severity is reflected in the type of presenting problems, pervasiveness of problems, complexity of problems, degree of disability or impairment, and presence of imminent risk to self or others. Indicators of severity may include: homelessness, involvement in the criminal justice system, lack of productive activity, sexually risky behaviours, high utilisation of health care services, early onset of substance use, polydrug dependence, and low self-efficacy to resist psychoactive substance use.

There is no agreed-upon methodology or body of well-tested instruments for capturing the severity of illness in patients with concurrent PDs and SUDs. The most widely used measure of overall functioning is the Global Assessment of Functioning (GAF) score, a facet of the DSM-IV multiaxial diagnostic system which involves an estimate of a person’s psychological, social, and occupational functioning on a hypothetical continuum of mental illness. The GAF is a single score that reflects the degree to which symptoms interfere with optimal functioning across school, work, and social activities. It may, however, have limited value for clinicians since it is a global score and does not capture the details of the full clinical picture.

No gold-standard instrument is currently available that captures the extensive life issues in patients with concurrent PDs and SUDs. Clinicians are advised to elicit information about as many areas of functioning as is feasible. It is advisable to use a straightforward, direct, and nonjudgemental inquiry to assess the extent and severity of problems in the following areas:

a. Life-Threatening Behaviours: Suicidal behaviour, non-suicidal self-injurious behav- iours, urges to suicide and self-harm, aggressive and violent behaviours, hostility, dangerous behaviours, urges to harm others

b. Treatment Compliance Problems: Premature withdrawal from treatments, discharge from treatments, failure to show for appointments, lateness, lying

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c. Quality of Life Problems: Extensive health care utilisation, involvement with the criminal justice system, severe anger, significant interpersonal problems, unstable housing, unemployment, prostitution, hygiene and health problems, lack of productive activity

Screening and assessment measures need to be matched to the treatment setting. Settings that do not have ready access to a physician or a psychologist may have difficulty conducting diagnostic assessments. If a diagnostic assessment is not feasible, an assessment of indicators of severity of illness may be conducted to less directly detect the presence of a concurrent personality problem. The availability of staff resources and time will also influence the selection of assessment procedures. Finally, assessments conducted for the purpose of clinical treatment planning, compared to those conducted within the context of research trials, will have different standards. Generally speaking, standards of test reliability and validity are lower for instruments used in test construction and other basic research, and are higher when the instruments are used clinically or for clinical research purposes.

A comprehensive assessment should be done prior to the onset of treatment, but in practice, assessment is often an ongoing process. Patients who are extremely guarded may be reticent to disclose critical information until a treatment alliance is established. Another practical consideration is the validity and reliability of patients’ self-reports, which clinicians should corroborate with collateral information gained from previous assessment and treatment reports, as well as from friends and family members.

Diagnostic Screening and Assessment

With respect to the assessment and treatment of concurrent mental health and SUDs in addiction treatment settings, the Health Canada (2002) recommendation for best practice is to apply Level I and Level II screening procedures. Level I screening involves the assessor being mindful of an “index of suspicion”, by asking a few direct and nonjudgemental questions about possible problems. In the case of PDs, this may involve noticing any indicators of the types of problems listed above: i.e., life-threatening behaviours, treatment compliance problems, or quality of life problems. For example, indices of suspicion may include previous history of premature withdrawal from treatment and poor compliance with treatment, history of chronic self-harm or suicidal behaviours, extensive involvement with the criminal justice system, or extensive utilisation of health care resources. If problems in one or more of these areas are noted, the assessor would proceed to Level II screening, which consists of the administration of one or more personality disorder screening instruments (usually a questionnaire or an interview). If the Level II results suggest the possible presence of a PD, then a structured or semi-structured diagnostic interview could be conducted by a trained diagnostician in order to verify the presence or absence of a PD.

For the most part, screening tools require little time to administer and little expertise; however, they tend to have a high rate of false positives. Below, we review several instruments for identifying people with PDs. Many of these tools are in the public domain and freely available. Those that are recommended for research on PDs and SUDs are identified with an asterisk.

The Personality Assessment Inventory (PAI; Morey 1991) is a self-report question- naire used in the detection of traits related to BPD and ASPD, both of which have a high co-occurrence with SUDs. The subscale for BPD consists of 24 items, each scored zero to three, assessing affective instability, identity problems, poor relationships, and self-harm. It

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has very good to excellent overall internal consistency (Cronbach’s alpha estimates of .88 to .91; Boone 1998). Its subscales have good internal consistency, with Cronbach’s alpha estimates for each subscale as follows: affective instability, .70 to .81; identity problems, .76 to .77; negative relationships, .55 to .68; and self-harm, .73 to .76 (Boone 1998). The subscale for ASPD also has very good overall internal consistency (Cronbach’s alpha of .84 to .86; Boone 1998). Its subscales have adequate to good internal consistency, with Cronbach’s alpha estimates as follows: antisocial behaviours, .75 to .80; egocentricity, .52 to .63; and stimulus seeking, .72 to .75 (Boone 1998). Since it is a self-report questionnaire, the PAI does not require a clinician interview to administer, which may make it particularly useful in certain settings.

Another self-report instrument to screen for the presence of a PD, is the Personality Diagnostic Questionnaire (PDQ; Hyler et al. 1988). The developers report that, in its revised version, the PDQ-R was very sensitive to possible presence of PDs, i.e., sensitivities greater than .80, but not very specific, i.e., specificities as low as .60 (Hyler et al. 1990; 1992). The PDQ-R resulted in many false positives but very few false negatives (Hyler et al. 1990; 1992), reflecting its utility as a screening instrument. As with most screens, it is too sensitive to be used diagnostically. Currently in its fourth edition, the PDQ-4 includes 100 dichotomous (i.e., true or false) items and yields information concordant with DSM-IV Axis II personality disorders. The PDQ-4 is brief, i.e., it can be completed in 20 to 30 minutes, making it ideal for clinical settings. Both paper-and-pencil and computer assisted formats of the PDQ-4 are available.

A screening interview that was developed to detect the possible presence of PD traits is the Personality Interview Questionnaire II (PIQ II; Widiger and Frances 1987). It can be administered by assessors with very little training, which makes it desirable in settings where training is less available. However, its results are likely to be less reliable than those obtained from an assessment conducted by a trained and experienced clinician (Zimmerman 1994).

Several other instruments require somewhat more training. The Revised Diagnostic Interview for Borderlines* (DIB-R; Zanarini et al. 1989) is a semi-structured interview that was originally designed to differentiate BPD from other Axis II diagnoses. The authors’ report that while the DIB-R was able to accurately differentiate BPD in 80% of cases, it was overly sensitive, and is better used as screen for possible BPD, as it cannot be used to diagnose. The Borderline Personality Disorder Severity Index (BPDSI; Arntz et al. 2003), is a semi-structured interview designed to assess both the frequency and intensity of BPD symptoms, as defined by the DSM-IV, over the course of three months. Inter-rater reliability and internal consistency of the BPDSI are excellent (intraclass correlation=.97 and Cronbach’s alpha=.93). It is useful for discriminating BPD from other Axis II disorders and for detecting clinical improvement after six months of therapy.

A commonly used self-report screen for traits related to ASPD is Hare’s Self-Report Psychopathy II (SRP-II) scale. It is the latest revision of the Self-Report Psychopathy scale (Hart et al. 1995) originally developed as a self-administered version of the Psychopathy Checklist, which is itself currently in a revised edition (PCL-R; Hare 2003). The SRP-II consists of 40 self-report items, scored on a 1 to 7 Likert-type scale. Like most screens, it is a sensitive measure that should not be relied upon to provide definitive evidence for the presence of psychopathy. A result that suggests the presence of psychopathy should be followed up with a more in-depth assessment.

In contrast with the self-report version, the Psychopathy Checklist: Screening Version (PCL:SV) is designed as a clinician-scored instrument to screen for psychopathy in forensic as well as other settings (Hart et al. 1995). The PCL:SV contains 12 items taken from the 20-item PCL-R (Hare 2003) that screen for emotional detachment (including traits such as

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superficiality, grandiosity, deceit, absence of remorse, absence of empathy, lack of acceptance of responsibility) and antisocial behaviour (including traits such as impulsivity, poor behavioural control, absence of goals, irresponsibility, antisocial behaviour in ado- lescence, and antisocial behaviour in adulthood). Scores less than 13 are thought to reflect an absence of psychopathy; scores ranging from 13 to17 are thought to indicate the possible presence of psychopathy; and scores of 18 or more are thought to reflect a strong probable presence of psychopathy. Estimates of inter-rater reliability and internal consistency for the PCL:SV are good (kappa=0.66 and Cronbach’s alpha=0.87, respectively), which recom- mends its use in clinical and research settings for the detection of possible psychopathy.

As impulsiveness is common to both BPD and ASPD (American Psychiatric Association 1994), it is recommended to screen for this trait as well. The Barratt Impulsiveness Scale* (BIS 11) is designed to measure impulsivity in the motor, non-planning, and attentional domains, and is the most current version of the BIS (Barratt 1959) and the BIS-10 (Barratt 1985). Like the PAI and the SRP-II, the BIS 11 is a self-report measure, consisting of 30 items that are scored on a four-point Likert scale. It is primarily a research instrument, with good internal consistency (Cronbach’s alpha ranging from .79 to .83), and has been validated across a number of populations, including patient, nonpatient, and forensic (Patton et al. 1995; Suris et al. 1995; Stanford et al. 1995). While it is less a clinical than a research instrument, it may provide data about impulsivity as an index of functional impairment and suggest behavioural targets for therapy.

The most definitive method of determining the presence or absence of co-occurring SUD and PD is the use of a structured or semi-structured diagnostic interview administered by a trained diagnostician. Two of these interviews are described below. The Structured Clinical Interview for DSM (SCID; Spitzer et al. 1992) was originally developed to determine the presence or absence of criteria for Axis I disorders as outlined in the revised third edition of the DSM (DSM-III-R; American Psychiatric Association 1987). When the fourth edition, DSM-IV (American Psychiatric Association 1994), became available, the instrument was revised to reflect the changes in diagnostic criteria. A multi-site study of the SCID for DSM-III-R revealed that the instrument yielded acceptably reliable diagnoses, with kappa values greater than .60 for test–retest reliability within a sample of clients (Williams et al. 1992). However, when used with non-clients, its reliability fell below acceptable levels (Williams et al. 1992). Another study examined the appropriateness of using the SCID for DSM-III-R specifically with clients having a substance use disorder (Kranzler et al. 1996). In this study, the authors used the SCID for Axis I diagnoses (SCID-I; Spitzer et al. 1992) and the ASPD section of the SCID for Axis II (SCID-II; First et al. 1995). They found that the SCID-I was useful for detecting and differentiating other SUDs and major depression among clients with a substance use disorder, but that anxiety disorders tended to be misdiagnosed. They also found that the ASPD section of SCID-II was useful for accurately diagnosing ASPD among clients with a substance use disorder (Kranzler et al. 1996). The results highlighted a primary drawback of the SCID, which is that it requires a trained and experienced clinician to use it accurately (Kranzler et al. 1996).

The International Personality Disorders Examination* (IPDE; Loranger 1995); is a semi-structured interview, designed to be compatible with DSM-III-R (American Psychiatric Association 1987) classifications of PDs as well as with the classifications of the World Health Organization’s International Statistical Classification of Diseases and Related Health Problems, Tenth Revision (ICD-10; World Health Organization 1990). Like the SCID, the IPDE has also been evaluated in an international multisite study to examine its reliability (Loranger et al. 1994). The authors found kappa values estimating inter-rater reliability for the diagnosis of antisocial personality disorder (ASPD) on the IPDE to be

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about .73, indicating good inter-rater reliability for this diagnosis. Kappa values estimating the test–retest reliability of the ASPD diagnosis ranged from .59 to .62, demonstrating acceptable temporal stability. For the diagnosis of BPD, the authors found kappa values estimating inter-rater reliability on the IPDE to range from .76 to .80, indicating very good agreement among raters for this diagnosis. Kappa values estimating the test–retest reliability of the BPD diagnosis ranged from .70 to .72, demonstrating good temporal stability for the diagnosis of BPD using this instrument (Loranger et al. 1994). The IPDE has a drawback similar to that of the SCID in that it requires a good deal of training to administer and interpret accurately. However, its psychometric strengths have contributed to its use in specialized treatment settings and its wide acceptance as the current standard for the assessment of PDs in research settings.

In sum, there are several options available for screening and assessing personality pathology among people presenting to addiction treatment services. The specific approach selected will be determined by a consideration of several factors. At a minimum, asking questions across several areas of life functioning is important. More desirable is the use of one or more brief screening tools (e.g., PDQ). If more time and resources are available, then the administration of one or more comprehensive instruments would be ideal (e.g., IPDE).

Treatment

Over the past two decades, increased attention has been paid to the implications of co- occurring mental health and addiction disorders. However, much more has yet to be understood about how to effectively treat this client population, and to date, there is a dearth of integrated treatment approaches. Dialectical Behaviour Therapy (DBT), an integrative approach that blends cognitive behavioural therapy and acceptance strategies, is one of only a few treatments that has been specially adapted and evaluated for this population (Linehan 1993a, b). DBT was developed originally to treat chronically suicidal patients with borderline personality disorder (BPD), and was later adapted for the treatment of comorbid BPD and SUDs. Several additional features were incorporated into standard DBT for the treatment of BPD and SUDs in order to facilitate the treatment of substance abuse. Adaptation involved the inclusion of a conceptual framework for understanding the overlap between BPD and SUDs, treatment goals related to addictive behaviour, a modified treatment target hierarchy that included a focus on substance abuse, and a set of attachment strategies to increase treatment engagement.

A few studies provide empirical support for the effectiveness of DBT for the treatment of BPD and SUDs. To date, four randomized controlled trials have been conducted. In the first study, Linehan et al. (1999) evaluated the effectiveness of DBT compared to a community treatment-as-usual (TAU) control condition in a sample of 28 substance- dependent women with BPD. Findings revealed that DBT was more effective than TAU in reducing drug abuse and retaining subjects in treatment. In a second study, Linehan et al. (2002) evaluated the effectiveness of DBT in the treatment of comorbid opiate dependence and BPD. Twenty-three women were randomized to DBT or a control condition combining Comprehensive Validation Therapy (CVT) with a Twelve Step approach. Results indicated that both treatments were effective in reducing opiate use during the first eight months of active treatment, but patients in the control group significantly increased their opiate use during the last four months. By four months post treatment, however, there were no between-group differences. In a study conducted in the Netherlands by researchers independent of the treatment developer (Verheul et al. 2003), the effectiveness of DBT

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was compared to TAU in a sample of 58 women with BPD with or without substance abuse problems. Findings supported the superiority of DBT on improving treatment retention, reducing self-mutilation, and reducing self-damaging impulsive behaviours (including substance misuse). In an unpublished trial (McMain et al. 2004), 27 women with concurrent SUD and BPD were randomly assigned to DBT or to TAU control treatment. Although the differences between groups were not significant, the results favoured the DBT group on reduction of alcohol consumption and self-harm behaviours.

In sum, results of studies on DBT indicate that this approach may hold promise in the treatment of individuals with co-occurring SUDs and BPD. Preliminary findings suggest that while DBT may be equivalent to nonspecialized treatments on drug use outcomes, it may have an added advantage of effecting change on other symptoms associated with BPD, such as self-harm behaviours. While some progress is under way on the development and evaluation of treatments for co-occurring PDs and SUDs, there is a critical need for more attention to this area.

Summary

The prevalence of PDs among people with an SUD is high, and the clinical presentation of these patients is often more complex than that of their non-PD counterparts. Given this complexity, screening is integral to the detection and treatment of problems faced by people with concurrent PDs and SUDs. However, as screens tend to overestimate the presence of PD traits, diagnostic assessment is necessary to accurately determine the presence or absence of a PD and to specify the contribution of a concurrent PD to the problems being experienced by someone with an SUD. Research on the treatment of concurrent PDs and SUDs is in its infancy. An important future direction is the development and empirical testing of treatments specifically designed for this population.

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