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Original Article |

Co-occurrence of 12-Month Alcohol and Drug Use Disorders and PersonalityDisorders in the United States:  Results From the National Epidemiologic Survey on Alcohol and RelatedConditions FREE

Bridget F. Grant, PhD, PhD; Frederick S. Stinson, PhD; Deborah A. Dawson, PhD; S. Patricia Chou, PhD; W. June Ruan, MA; Roger P. Pickering, MS
[+] Author Affiliations

From the Laboratory of Epidemiology and Biometry, Division of IntramuralClinical and Biological Research, National Institute on Alcohol Abuse andAlcoholism, National Institutes of Health, Department of Health and HumanServices, Bethesda, Md.


Arch Gen Psychiatry. 2004;61(4):361-368. doi:10.1001/archpsyc.61.4.361.
Text Size: A A A
Published online

Background  Very little information is available on the co-occurrence of different personality disorders (PDs) and alcohol and drug use disorders in the US population.

Objective  To present national data on sex differences in the co-occurrence of Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) alcohol and drug use disorders and 7 of the 10 DSM-IV PDs.

Design  Face-to-face interviews conducted in the 2001-2002 National Epidemiologic Survey on Alcohol and Related Conditions (N = 43 093).

Setting  The United States and the District of Columbia, including Alaska and Hawaii.

Participants  Household and group-quarters residents, aged 18 years and older.

Results  Among individuals with a current alcohol use disorder, 28.6% (95% confidence interval [CI], 26.7-30.6) had at least 1 PD, whereas 47.7% (95% CI, 43.9-51.6) of those with a current drug use disorder had at least 1 PD. Further, 16.4% (95% CI, 15.1-17.6) of individuals with at least 1 PD had a current alcohol use disorder and 6.5% (95% CI, 5.7-7.3) had a current drug use disorder. Associations between PDs and alcohol and drug use disorders were overwhelmingly positive and significant (P < .05). Overall, alcohol use disorders were most strongly related to antisocial (odds ratio [OR], 4.8; 95% CI, 4.1-5.6), histrionic (OR, 4.7; 95% CI, 3.8-5.8), and dependent (OR, 3.0; 95% CI, 1.9-4.8) PDs. Drug use disorders also were more highly associated with antisocial (OR, 11.8; 95% CI, 9.7-14.3), histrionic (OR, 8.0; 95% CI, 6.0-10.7), and dependent (OR, 11.6; 95% CI, 7.1-19.1) PDs. Associations between obsessive-compulsive, histrionic, schizoid, and antisocial PDs and specific alcohol and drug use disorders were significantly stronger (P < .04) among women than men, whereas the association between dependent PD and drug dependence was significantly greater (P < .04) among men than women.

Conclusions  The co-occurrence of PDs with alcohol and drug use disorders is pervasive in the US population. Results highlight the need for further research on the underlying structure of these disorders and the treatment implications of these disorders when comorbid.

Numerous studies have addressed the prevalence of personality disorders(PDs), especially antisocial PD, among alcohol and drug abusers.1 Theyshow a high but variable rate of a broad range of PDs in alcohol and drugabusers, and several among them have demonstrated the adverse effect of thesedisorders on duration of stay in treatment and outcome.29 Studiesof alcohol and drug use disorders among patients seeking treatment for personalitypsychopathology are rare. A recent study,10 however,has found high prevalences of alcohol and drug use disorders in patients seekingtreatment for PDs. With few exceptions, psychiatric comorbidity in these clinicalstudies did not differentiate between alcohol and drug use disorders, andthese studies were conducted in predominantly male samples. That this literaturehas paid little attention to sex differences is surprising considering thatthe importance of distinguishing men and women is firmly established in thefield of substance use disorder research.

From an epidemiological perspective, however, a more serious problemwith research on comorbidity in clinical studies is that the samples of subjectsdo not represent the underlying populations. Because of this problem, it isnecessary to turn to general population samples for more accurate and preciseinformation on the comorbidity of PDs and alcohol and drug use disorders.However, large epidemiologic surveys conducted in the United States duringthe past 2 decades have focused exclusively on the prevalence and comorbidityof antisocial PD and alcohol and drug use disorders.11,12 Withthe exception of antisocial PD, we have very limited knowledge of the comorbiditybetween the range of PDs and alcohol and drug use disorders and whether theseassociations differ between men and women. The fact that accurate data onthe sex-specific prevalences of a broad range of PDs have not been availablein general population surveys of the United States reflects a major gap inour understanding of the processes underlying the comorbidity of PDs and alcoholand drug use disorders. The present study was designed, in part, to addressthis gap and provide the information.

Accordingly, this article presents nationally representative data onthe prevalence and co-occurrence of alcohol and drug use disorders and 7 ofthe 10 PDs defined in the Diagnostic and Statistical Manualof Mental Disorders, Fourth Edition (DSM-IV)13 assessed in the 2001-2002 National Institute on AlcoholAbuse and Alcoholism (NIAAA) National Epidemiologic Survey on Alcohol andRelated Conditions (NESARC).14 The NESARC isthe largest comorbidity survey ever conducted (N = 43 093). The samplesize allows for accurate estimation of current or past-year co-occurrenceof both alcohol and drug use disorders and avoidant, dependent, obsessive-compulsive,histrionic, paranoid, schizoid, and antisocial PDs among men and women.

NESARC SAMPLE

The Wave 1 NESARC is a nationally representative face-to-face surveyof 43 093 respondents, aged 18 years and older, conducted by the NIAAAin 2001 through 2002. (A second wave will be conducted in 2004-2005.)14 The target population of the Wave 1 NESARC is thecivilian, noninstitutionalized population residing in the United States andthe District of Columbia, including Alaska and Hawaii. The housing-unit samplingframe of the NESARC was the US Census Bureau Census 2000 Supplementary Survey, 14 a national survey of more than 78 000 householdsper month conducted in 2000 through 2001. The NESARC also included a group-quarterssampling frame derived from the Census 2000 Group Quarters Inventory.14 The group-quarters sampling frame captures importantsubgroups of the population with heavy substance use patterns (eg, collegehousing) not often included in general population surveys. The sampling frameresponse rate was 99%, the household response rate was 89%, and the personresponse rate was 93%, yielding an overall survey response rate of 81%, substantiallyhigher than other surveys of this kind.

Information on race and ethnicity collected in the Census 2000 SupplementarySurvey in 2000 through 2001 was used to oversample African American and Hispanichouseholds. The oversampling procedure increased the percentage of non-Hispanic,African American households in the sample from 12.3% to 19.1% (n = 8245) andthe percentage of Hispanic households from 12.5% to 19.3% (n = 8308). Onesample person from each household or group-quarters unit was randomly selectedfor interview, and young adults, aged 18 to 24 years, were oversampled ata rate of 2.25 times that of other members in the household.

The NESARC data were weighted to reflect the probabilities of the selectionof primary sampling units (PSUs) within strata and for the selection of housingunits within the sample PSUs. The PSUs are mutually exclusive categories ofpersons or units of interest identified in the first stage of the multistageNESARC sample. The PSUs consisted of geographic units representing the entireUnited States defined in terms of sociodemographic criteria. The data alsowere weighted: (1) to account for the selection of 1 sample person from eachhousehold; (2) to account for oversampling of young adults; (3) to adjustfor nonresponse at the household level and person level; and (4) to reducethe variance arising from selecting 2 PSUs to represent an entire stratum.The weighted data were then adjusted to be representative of the US civilian,noninstitutionalized population for a variety of socioeconomic variables includingregion, age, sex, race, and ethnicity using the 2000 Decennial Census of Populationand Housing14 and statistics on births, deaths,immigration and emigration, and the size of the Armed Forces.

INTERVIEWER TRAINING AND FIELD QUALITY CONTROL

Approximately 1800 experienced lay interviewers from the US Census Bureauadministered the NESARC using laptop computer–assisted software thatincluded built-in skip, logic, and consistency checks. On average, the interviewershad 5 years' experience working on census and other health-related nationalsurveys. All NESARC interviewers completed a 5-day self-study at home andparticipated in a standardized 5-day in-class training session at 1 of thebureau's 12 regional offices. The NESARC training supervisors from each regionaloffice also were required to complete the home study and to attend a centralizedtraining session prior to fielding of the survey, where they completed thein-class training under the direction of NIAAA sponsors and Census Field andDemographics Survey Division headquarters staff.

Regional supervisors recontacted a random 10% of all respondents forquality-control purposes. In these quality-control interviews, a series ofquestions were reasked to verify that respondents had received the entireinterview and that the questionnaire had been administered properly. Therewas no case in which it was determined that the interview had been conductedin any manner that was inconsistent with the interviewer's extensive training.In addition, 2657 respondents were randomly selected to participate in a reinterviewstudy after completion of their NESARC interview. Each respondent was readministered1 to 3 sections of the survey assessment instrument. These interviews notonly served as an additional check on survey data quality but formed the basisof a test-retest reliability study of new modules of the survey instrument.15

ALCOHOL AND DRUG USE DISORDER ASSESSMENT

Diagnoses presented in this article were made by the NIAAA Alcohol UseDisorder and Associated Disabilities Interview Schedule–DSM-IV Version (AUDADIS-IV),16 a state-of-the-artstructured diagnostic interview designed to be used by lay interviewers. TheAUDADIS-IV included an extensive list of symptom questions that separatelyoperationalized DSM-IV criteria for alcohol and drugabuse and dependence including 10 classes of drugs: sedatives, tranquilizers,opiates (other than heroin or methadone), stimulants, hallucinogens, cannabis,cocaine (including crack cocaine), inhalants/solvents, heroin, and other drugs.Consistent with the DSM-IV, current (in the last12 months) dependence diagnoses required the respondent to satisfy at least3 of the 7 DSM-IV criteria for dependence duringthe last year. The withdrawal criterion of the alcohol-dependence diagnosiswas measured as a syndrome, requiring at least 2 positive symptoms of withdrawalas defined in the DSM-IV alcohol-withdrawal category.The AUDADIS-IV diagnoses of alcohol abuse required a respondent to meet atleast 1 of the 4 criteria defined for abuse in the 12-month period precedingthe interview and not meet criteria for dependence. The drug-specific diagnosesof abuse and dependence were derived using the same algorithm and were aggregatedto produce measures of any drug use disorder, any drug abuse, and any drugdependence.

The reliability of AUDADIS-IV alcohol and drug use disorder measureswas assessed in several large test-retest studies conducted in clinical andgeneral population samples.1721 Thereliability of alcohol and drug abuse and dependence in these studies wasexcellent, exceeding κ = 0.74 for alcohol diagnoses and κ = 0.79for drug diagnoses. The discriminant, concurrent, convergent, construct, andpopulation validities of the AUDADIS-IV alcohol and drug use disorder diagnosesalso have been well documented,2235 includingin the World Health Organization/National Institutes of Health Reliabilityand Validity Study.3640 Inthese studies,33 alcohol and drug use disorderdiagnoses were found to be significantly and highly correlated with importantvalidators, including substance use, social/occupational dysfunction and disability,and family history (convergent validity),2426,3234 andthese results were shown to generalize to other populations (population validity).27 These studies also demonstrated that abuse and dependencediagnoses also were related to different sets of validators (discriminantvalidity). Alcohol and drug use disorder diagnoses defined by DSM-III, DSM-III-R, DSM-IV, and the International Classification of Diseases,10th Revision (ICD-10)41 criteria alsowere shown to be highly concordant (convergent validity).22,23,2830,37 Concordancebetween AUDADIS-IV alcohol and drug use disorders and those assessed withthe Schedule for Clinical Assessment in Neuropsychiatry42 was high (concurrent validity),36,39 and the construct validity of thesediagnoses has been supported by both exploratory and confirmatory factor analyses.32,35,38

PERSONALITY DISORDER ASSESSMENT

The diagnosis of PDs requires an evaluation of the individual's long-termpatterns of functioning.13(p630) Diagnosesof PDs made using the AUDADIS-IV were made accordingly. Respondents were askeda series of personality symptom questions about how they felt or acted mostof the time throughout their lives regardless of the situation or whom theywere with. They were reminded on 20 occasions throughout the PD section notto include times when they were depressed, manic, anxious, drinking heavily,using medicines or drugs, experiencing withdrawal symptoms (defined earlierin the AUDADIS-IV), or times when they were physically ill.

To receive a DSM-IV diagnosis, respondentsneeded to endorse the requisite number of DSM-IV symptomitems for the particular PD and at least 1 positive symptom item must havecaused social or occupational dysfunction. Multiple symptom items were usedto operationalize the more complex criteria associated with certain PDs. Thefollowing number of symptom items were used to assess each PD: avoidant (n= 7); dependent (n = 8); obsessive-compulsive (n = 10); paranoid (n = 9);schizoid (n = 10); histrionic (n = 11); and antisocial (n = 30). Because oftime and space constraints, not all DSM-IV PDs wereassessed in the Wave 1 NESARC. The decision to exclude borderline, schizotypal,and narcissistic PDs was based on the larger number of symptom items requiredto operationalize the disorders relative to those PDs assessed in Wave 1 (ie,borderline, 18 items; schizotypal, 16 items; and narcissistic, 19 items).However, in the follow-up Wave 2 of the NESARC, borderline, schizotypal, andnarcissistic PDs will be included.

The reliability of AUDADIS-IV PDs was assessed in a test-retest studyconducted as part of the NESARC survey proper.15 Arandom subsample of 282 respondents was reinterviewed with the antisocialPD module, and another subsample of 315 respondents was reinterviewed withthe AUDADIS-IV modules containing the remaining PD measures. These reinterviewswere conducted approximately 10 weeks after the NESARC interviews. The reliabilityof the PD diagnoses in these community samples ranged from fair to good, from κ= 0.40 for histrionic PD to κ = 0.67 for antisocial PD. Reliabilitiesof the AUDADIS-IV PD diagnoses are as good as or better than those found forsemistructured personality interviews in short-term test-retest studies conductedin treated samples of patients.43

The validity of AUDADIS-IV PDs was assessed in a series of linear regressionanalyses, using the NESARC data, that examined the associations between eachPD and 3 Short Form 12v244 disability scores,controlling for age, all other PDs, and 12-month comorbid DSM-IV substance use disorders and anxiety and mood disorders. TheShort Form 12v2, a reliable and valid measure of generic quality of life usedin large population surveys, yields 10 component summary and profile scoresassessing various dimensions of disability and impairment. In the presentanalyses, the focus was on 3 Short Form 12v2 scores: the mental componentsummary score; the social functioning score, reflecting limitations in socialfunctioning; and the role emotional function score, measuring role impairmentdue to emotional problems. All PDs, except histrionic, were shown to be highlysignificant (P < .01 to P <.001) predictors of the mental component summary, social functioning, androle emotional scores. Respondents with those PDs had significantly greaterdisability and social/occupational dysfunction than respondents who did nothave the PD.

STATISTICAL ANALYSIS

Cross-tabulations were used to calculate prevalences and comorbidityrates of PDs and alcohol and drug use disorders. A series of univariate logisticregression analyses was used to study associations between PDs and alcoholand drug use disorders. The β coefficients from these analyses were transformedinto odds ratios (ORs) for ease of interpretation. Differences in the associationsof PDs and alcohol and drug use disorders between men and women were examinedby comparing sex-specific β coefficients derived from the logistic regressionanalyses. Because of the complex survey design of the NESARC, variance estimationprocedures that assume simple random sampling cannot be used. The stratificationof the NESARC sample will result in standard errors much larger than thosethat would be obtained with a simple random sample of equal size. To takeinto account this NESARC sample design component, all standard errors and95% confidence limits (CIs) presented here were generated using SUDAAN (ResearchTriangle Institute, Research Triangle Park, NC),45 asoftware program that uses appropriate statistical techniques to adjust forsample design characteristics.

PREVALENCE OF ALCOHOL AND DRUG USE DISORDERS AND PDs

The 12-month prevalences of any alcohol use disorder and any drug usedisorder were 8.5% and 2.0%, respectively (Table 1). Rates of abuse exceeded those for dependence for bothalcohol and drug use disorders. The most prevalent PD in the general populationwas obsessive-compulsive PD (7.9%), followed by paranoid PD (4.4%), antisocialPD (3.6%), schizoid PD (3.1%), avoidant PD (2.4%), histrionic PD (1.8%), anddependent PD (0.5%).

Table Graphic Jump LocationTable 1. 12-Month Prevalence of Alcohol and Drug Use Disorders andPrevalence of Personality Disorders (PDs)
THE PREVALENCE OF PDs AMONG RESPONDENTS WITH 12-MONTH ALCOHOL AND DRUGUSE DISORDERS

As indicated in the top row of Table2, 28.6% and 47.7% of respondents with a 12-month alcohol use disorderand drug use disorder, respectively, had at least 1 PD. Rates of any PD weregreater among respondents with any drug abuse (37.8%) and any drug dependence(69.5%) than among respondents with alcohol abuse (19.8%) and alcohol dependence(39.5%). The prevalence of antisocial PD (12.3%), obsessive-compulsive PD(12.1%), and paranoid PD (10.2%) were the highest among respondents with analcohol use disorder. These also were the most prevalent PDs among respondentswith any drug use disorder, but the rates were much higher. The prevalenceof specific PDs was much greater among respondents with dependence on alcohol(2.5%-18.3%) or drugs (10.1%-39.5%) compared with respondents with alcoholabuse (0.3%-9.5%) or any drug abuse (2.0%-22.3%).

Table Graphic Jump LocationTable 2. Prevalence of Personality Disorders (PDs) Among RespondentsWith a 12-Month Alcohol or Drug Use Disorder*
PREVALENCE OF 12-MONTH ALCOHOL AND DRUG USE DISORDERS AMONG RESPONDENTSWITH PDs

As indicated in Table 3,16.4% of the respondents with at least 1 PD met criteria for a current alcoholuse disorder and 6.5% met criteria for a current drug use disorder. The prevalenceof any alcohol use disorder was greatest among respondents with histrionic(29.1%), antisocial (28.7%), dependent (21.6%) and paranoid (19.5%) PDs. Similarly,the rate of any drug use disorder was greatest among respondents with dependent(18.5%), antisocial (15.2%), and histrionic (12.8%) PDs. Prevalences of alcoholabuse (2.5%-9.5%) and drug abuse (2.0%-8.4%) were consistently lower amongrespondents with specific PDs than the corresponding rates for alcohol dependence(7.4%-21.3%) and any drug dependence (2.3%-12.9%). The only exception to thispattern was among respondents with antisocial PD, where the prevalence ofany drug abuse (8.4%) exceeded the rate for any drug dependence (6.8%).

Table Graphic Jump LocationTable 3. Prevalence of 12-Month Alcohol and Drug Use Disorders AmongRespondents With a Personality Disorder (PD)*
ASSOCIATIONS BETWEEN ALCOHOL AND DRUG USE DISORDERS AND PDs

Associations between alcohol and drug use disorders and PDs are shownin Table 4 in the form of ORs.The overall pattern of ORs is overwhelmingly positive, with 88% of the disorder-specificORs being positive and statistically significant. The association betweenany PD and any alcohol use disorder (OR, 2.6) was weaker than the associationfound for any drug use disorder (OR, 5.5), a pattern also found when specificPDs were examined. Specific PDs were more strongly related to alcohol dependence(ORs, 2.2-7.5) and drug dependence (ORs, 4.8-26.0) than to alcohol abuse (ORs,0.5-2.2) or drug abuse (ORs, 1.5-8.2). Although histrionic PD (OR, 1.7) andantisocial PD (OR, 2.2) were significantly associated with alcohol abuse,the associations between alcohol abuse and avoidant, dependent, obsessive-compulsive,paranoid, and schizoid PDs were not significant. All specific PDs, however,were strongly and consistently related to any alcohol use disorder (ORs, 1.7-4.8)and any drug use disorder (ORs, 2.4-11.8). Dependent, histrionic, and antisocialPDs were more strongly related to both alcohol and drug use disorders thanany of the other PDs.

Table Graphic Jump LocationTable 4. Odds Ratio (ORs) of Personality Disorders (PDs) and Alcoholand Drug Use Disorders*
ASSOCIATIONS BETWEEN ALCOHOL AND DRUG USE DISORDERS AND PDs BY SEX

Similar to the pattern observed in the total sample, the associationsbetween current alcohol and drug use disorders and PDs among men and womenwere overwhelmingly significant and positive, with the exception of the associationsbetween avoidant, dependent, obsessive-compulsive, paranoid, and schizoidPDs and alcohol abuse (Table 5).With respect to any drug use disorder, drug abuse, and drug dependence, associationsremained the strongest for antisocial, histrionic, and dependent PDs amongmen and women. The same pattern was observed for any alcohol use disorderand alcohol dependence among men and women.

Table Graphic Jump LocationTable 5. 12-Month Odds Ratios (ORs) of Personality Disorders (PDs)and Alcohol and Drug Use Disorders by Sex*

Significant sex differences in the associations between alcohol anddrug use disorders and PDs also were observed. The relationship between obsessive-compulsive(P < .02), histrionic (P <.04), and antisocial (P < .006) PDs and alcoholdependence was significantly greater for women than men. With regard to anydrug abuse, the associations with obsessive-compulsive (P < .03), schizoid (P < .009), histrionic(P < .02), and antisocial (P < .002) PDs were greater for women than for men. In contrast,the association between drug dependence and dependent PD was significantlygreater (P < .04) among men than women.

The co-occurrence of DSM-IV current alcoholand drug use disorders and DSM-IV PDs is pervasivein the US population. Among individuals with a current alcohol or drug usedisorder, 28.6% and 47.7%, respectively, had at least 1 PD. While the proportionof individuals with a PD who also had an alcohol or drug disorder was lower,a considerable proportion of those with PDs did meet criteria for alcoholor drug abuse or dependence. Overall, 16.4% of individuals in the generalpopulation with at least 1 PD had a current alcohol use disorder, and 6.5%had a current drug use disorder. The strong associations between most PDsand alcohol and drug use disorders were generally consistent when examinedseparately among men and women. Consistent with clinical research on comorbidityof Axis II disorders and alcohol and drug use disorders,1 thisstudy found greater associations between PDs and drug use disorders comparedwith alcohol use disorders.

Comorbidity in the general population is often lower than comorbidityin treated samples since individuals with more than 1 disorder have a greaterprobability of seeking treatment (ie, Berkson bias). However, a striking findingin this study was that the prevalence of any PD and antisocial PD (one ofthe most extensively studied PDs in treated samples) among individuals withcurrent alcohol and drug use disorders was similar to the median rates observedin samples of patients receiving treatment for alcohol and/or drug use disorders,as assessed with other standardized assessment instruments (ie, the Structured Clinical Interview for DSM-III-R Personality Disorders [SCID-II]46 andthe Diagnostic Interview Schedule).47 For example,the median rate of any PD among patients receiving treatment for an alcoholuse disorder assessed with the SCID-II48,49 was39.0% compared with 39.5% found among individuals in this study with currentalcohol dependence. The median rate of any PD among patients receiving treatmentfor drug use using the SCID-II4,7,10,4957 was59.0% compared with the 69.5% rate found among individuals with current drugdependence. The prevalence of antisocial PD among respondents with currentdrug dependence was 39.5%, a figure midway between the median rates foundin studies of drug treatment samples using the semistructured SCID-II,50,52,53,55,5860 (21.0%)and the fully structured Diagnostic Interview Schedule6164 (49.0%)assessment instruments. The rate of antisocial PD among individuals with currentalcohol dependence was 18.3%, somewhat lower than the median rate of 37.5%found among patients in alcohol treatment settings using the Diagnostic InterviewSchedule.6572 Itis likely that the prevalences of PDs among individuals with alcohol and druguse disorders in this study would have been greater if all DSM-IV PDs had been assessed. If all PDs had been assessed, we mightexpect the reported rates of PDs using the fully-structured AUDADIS-IV tohave slightly exceeded the rates presented earlier for semistructured interviews,as would be predicted by the literature.

The PDs most strongly associated with alcohol and drug use disorderswere antisocial, dependent, and histrionic PDs. The degree of diagnostic overlapbetween DSM-IV PDs has long been recognized,73,74 and it may be responsible for thestrong relationship observed between histrionic, antisocial, and dependentPDs and alcohol and drug use disorders. For example, individuals with antisocialPD share certain tendencies with individuals with histrionic PD to be impulsive,seductive, superficial excitement seeking, reckless, and manipulative, butindividuals with histrionic PD do not characteristically exhibit antisocialbehaviors.13 Individuals with dependent PDand histrionic PD are excessively dependent on others for praise, guidance,and nurturance, but individuals with dependent PD do not characteristicallydemonstrate the flamboyant emotional features of histrionic PD. Although multivariatestudies7577 havebeen conducted on item-level criteria of DSM PDsin search of the factor structure underlying PD diagnoses, the findings ofthis study suggest that this search be expanded to include criteria of AxisI substance use disorders along with the components of PDs that are most closelyassociated with them. The results of these future studies might elucidatesubtypes of alcohol and drug use disorders, refine the classification of bothtypes of disorder, and increase our understanding of the pathological processesunderlying their comorbidity.

A number of the PDs examined in this study were more strongly associatedwith alcohol and drug use disorders among women, including antisocial PD.However, a stronger association between dependent PD and drug dependence wasobserved among men. Although reasons for these observed sex differences areunknown, these findings highlight the need to examine a broader set of factorsthat affect the prevalence and co-occurrence of PDs and alcohol and drug usedisorders, including age, socioeconomic status, and, importantly, primarysubstance of abuse. In the current study, the stronger associations observedbetween antisocial PD and alcohol and drug use disorders among women may bethe result of differential mortality or incarceration. That is, men who arehighly comorbid for antisocial PD and alcohol and drug use disorders are morelikely to die young or be incarcerated than women and thus less likely tobe represented in general population surveys. This explanation is consistentwith the findings that men are overrepresented in jail and prison populationsand that substance use disorders occur in about 90% of individuals with antisocialPD who are incarcerated.78

In light of the extensive comorbidity between PDs and alcohol and druguse disorders found in this study, there would appear to be great value inassessing a broad range of PDs among substance abuse patients. This more comprehensiveassessment can guide treatment planning. For example, patients with comorbidalcohol and drug use disorders and PDs can be expected to require treatmentthat is more extensive and of longer duration. In this regard, modified psychoanalyticpsychotherapy focused or targeted on particular features of PDs might holdgreat promise for successful recovery among comorbid individuals.7981 The trend towardintegrating 12-step programs into rehabilitation programs also appears promisingin that 12-step programs require individuals to examine their relationshipto others, overcome feelings of helplessness, gain an internal locus of control,encourage self-examination, address defects in character, and promote honestrelationships.82,83 More clinicalresearch is needed to examine the role of these and other approaches targetedat treating substance use disorders (eg, contingency management, motivationalenhancement therapy, cognitive behavior therapy) in improving the chancesof recovery and the lives of individuals with comorbid alcohol and drug usedisorders and PDs. This work will be formidable, because some of these componentsof treatment are on uncertain grounds in terms of efficacy and mechanismsof action (eg, 12-step programs and psychoanalytic treatments). Attentionin this clinical work on the effects of sex, substance of choice, and otherfactors that affect treatment outcome and eventual recovery might furtherrefine treatment planning.

This national study of comorbidity represents a landmark study in thearea of PDs. Previous psychiatric epidemiology studies were too small to addressthese important relationships in detail. Personality disorders are not onlypervasive and associated with substantial disability,44 theyare very common among those with alcohol and drug use disorders. Further workin many directions is indicated by the results of this study, including adissection of the components of the 2 types of disorders that are most closelyassociated, the factors giving rise to the associations, and the treatmentand prevention implications of these disorders when comorbid.

Corresponding author and reprints: Bridget F. Grant, PhD, PhD, Laboratoryof Epidemiology and Biometry, Division of Intramural Clinical and BiologicalResearch, Room 3077, National Institute on Alcohol Abuse and Alcoholism, NationalInstitutes of Health, MS 9304, 5635 Fishers Ln, Bethesda, MD 20892-9304 (e-mail: bgrant@willco.niaaa.nih.gov).

Submitted for publication August 25, 2003; final revision received October31, 2003; accepted November 19, 2003.

The views and opinions expressed in this article are those of the authorsand should not be construed to represent the views of any of the sponsoringorganizations, agencies, or the US government.

Verheul  Rvan den Brink  WHartgers  C Prevalence of personality disorders among alcoholics and drug addicts:an overview. Eur Addict Res. 1995;1166- 177
Link to Article
Cacciola  JSRutherford  MJAlterman  AIMcKay  JRSnider  EC Personality disorders and treatment outcome in methadone maintenancepatients. J Nerv Ment Dis. 1996;184234- 239
PubMed Link to Article
Kosten  TAKosten  TRRounsaville  BJ Personality disorders in opiate addicts show prognostic specificity. J Subst Abuse Treat. 1989;6163- 168
PubMed Link to Article
Kranzler  HRSatel  SApter  A Personality disorders and associated features in cocaine-dependentinpatients. Compr Psychiatry. 1994;35335- 340
PubMed Link to Article
Marlowe  DBKirby  KCFestinger  DSHusband  SDPlatt  JJ Impact of comorbid personality disorders and personality disorder symptomson outcomes of behavioral treatment for cocaine dependence. J Nerv Ment Dis. 1997;185483- 490
PubMed Link to Article
Movalli  MGMadeddu  FMaffei  FC Personality disorders (DSM-III-R, DSM-IV):prevalence in alcoholics and influence on dropout from treatment [in Italian]. Alcologia. 1996;847- 52
Nurnberg  HGRifkin  ADoddi  S A systematic assessment of the comorbidity of DSM-III-R personality disorders in alcoholic outpatients. Compr Psychiatry. 1993;34447- 454
PubMed Link to Article
Pettinati  HMJensen  JMTracy  JISamuels  DMeyers  K Cocaine vs alcohol dependence: axis II and outcome.  Paper presented at: Annual Meeting of the Research Society on Alcoholism June 19, 1991 Marco Island, Fla.
Thomas  VHMelchert  TPBanken  JA Substance dependence and personality disorders: comorbidity and treatmentoutcome in an inpatient treatment population. J Stud Alcohol. 1999;60271- 277
PubMed
Skodal  AEOldham  JMGallaher  PE Axis II comorbidity of substance use disorders among patients referredfor treatment of personality disorders. Am J Psychiatry. 1999;156733- 738
PubMed
Kessler  RCWalters  EE The National Comorbidity Survey. Tsaung  MTTohen  MedsTextbook in PsychiatricEpidemiology. 2 New York, NY John Wily & Sons2002;343- 362
Robins  LNedRegier  DSed Psychiatric Disorders in America: The EpidemiologicCatchment Area Study.  New York, NY Free Press1991;
American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, FourthEdition.  Washington, DC American Psychiatric Association1994;
Grant  BFMoore  TCShepard  JKaplan  K Source and Accuracy Statement: Wave 1 National EpidemiologicSurvey on Alcohol and Related Conditions (NESARC).  Bethesda, Md National Institute on Alcohol Abuse and Alcoholism2003;
Grant  BFDawson  DAStinson  FSChou  PSKay  WPickering  R The Alcohol Use Disorder and Associated Disabilities Interview Schedule-IV(AUDADIS-IV): reliability of alcohol consumption, tobacco use, family historyof depression and psychiatric diagnostic modules in a general population sample. Drug Alcohol Depend. 2003;717- 16
PubMed Link to Article
Grant  BFDawson  DAHasin  DS The Alcohol Use Disorder and Associated DisabilitiesInterview Schedule-DSM-IV Version.  Bethesda, Md National Institute on Alcohol Abuse and Alcoholism2001;
Canino  GJBravo  MRamfrez  RFebo  VFernandez  RHasin  D The Spanish Alcohol Use Disorder and Associated Disabilities InterviewSchedule (AUDADIS): reliability and concordance with clinical diagnoses ina Hispanic population. J Stud Alcohol. 1999;60790- 799
PubMed
Grant  BFHarford  TCDawson  DAChou  PSPickering  R The Alcohol Use Disorder and Associated Disabilities Interview Schedule(AUDADIS): reliability of alcohol and drug modules in a general populationsample. Drug Alcohol Depend. 1995;3937- 44
PubMed Link to Article
Hasin  DCarpenter  KMMcCloud  SSmith  MGrant  BF The Alcohol Use Disorder and Associated Disabilities Interview Schedule(AUDADIS): reliability of alcohol and drug modules in a clinical sample. Drug Alcohol Depend. 1997;44133- 141
PubMed Link to Article
Vrasti  RGrant  BFChatterji  SUstun  BTMager  DOlteanu  IBodoi  M Reliability of the Romanian version of the alcohol module of the WHOAlcohol Use Disorder and Associated Disabilities Interview Schedule--Alcohol/Drug-Revised(AUDADIS-ADR). Eur Addict Res. 1998;4144- 149
PubMed Link to Article
Chatterji  SSaunders  JBVrasti  RGrant  BFHasin  DSMager  D The reliability of the Alcohol Use Disorder and Associated DisabilitiesInterview Schedule-Alcohol/Drug-Revised (AUDADIS-ADR) in India, Romania andAustria. Drug Alcohol Depend. 1997;47171- 185
PubMed Link to Article
Grant  BF DSM-III-R and proposed DSM-IV alcohol abuse and dependence, United States, 1988: a nosologicalcomparison. Alcohol Clin Exp Res. 1992;161068- 1075
PubMed Link to Article
Grant  BF DSM-IV, DSM-III-R and ICD-10 alcohol and drug abuse/harmful use and dependence,United States, 1992: a nosological comparison. Alcohol Clin Exp Res. 1996;201481- 1488
PubMed Link to Article
Grant  BF The relationship between ethanol intake and DSM-III-R alcohol dependence: results of a national survey. J Subst Abuse. 1993;5257- 267
PubMed Link to Article
Grant  BFHarford  TC The relationship between ethanol intake and DSM-III-R alcohol dependence. J Stud Alcohol. 1990;51448- 456
PubMed
Grant  BFHarford  TC The relationship between ethanol intake and DSM-III-R alcohol use disorders: a cross-perspective analysis. J Subst Abuse. 1988-1989;1231- 252
PubMed Link to Article
Harford  TCGrant  BF Prevalence and population validity of DSM-III-R alcoholabuse and dependence: the 1998 National Longitudinal Survey on Youth. J Subst Abuse. 1994;637- 44
PubMed Link to Article
Hasin  DSGrant  BF Draft criteria for alcohol use disorders: comparison to DSM-III-R and implications. Alcohol Clin Exp Res. 1994;181348- 1353
PubMed Link to Article
Hasin  DSGrant  BF Nosological comparisons of DSM-III-R and DSM-IV alcohol abuse and dependence in a clinical facility:comparison to National HIS88 results. Alcohol Clin Exp Res. 1994;18272- 279
PubMed Link to Article
Hasin  DLi  QMcCloud  SEndicott  J Agreement between DSM-III, DSM-III-R and DSM-IV and ICD-10 alcohol diagnoses in a US community-sample of heavy drinkers. Addiction. 1996;911517- 1527
PubMed Link to Article
Hasin  DSMuthen  BGrant  BF The dimensionality of DSM-IV alcohol abuseand dependence: factor analysis in a clinical sample. Vrast  RedAlcoholism: New Research Perspectives. Gottingen, Germany Hogrefe & Hubner1997;27- 39
Hasin  DSPaykin  A Alcohol dependence and abuse diagnoses: concurrent validity in a nationallyrepresentative sample. Alcohol Clin Exp Res. 1999;23144- 150
PubMed
Hasin  DSchuckit  MMartin  CSGrant  BFBucholz  KKHelzer  JE The validity of DSM-IV alcohol dependence:what do we know and what do we need to know. Alcohol Clin Exp Res. 2003;27244- 252
PubMed Link to Article
Hasin  DSVan Rossem  RMcCloud  SEndicott  J Alcohol dependence and abuse diagnoses: validity in a community sampleof heavy drinkers. Alcohol Clin Exp Res. 1997;21213- 219
PubMed
Muthen  BGrant  BFHasin  DS The dimensionality of alcohol abuse and dependence: factor analysisof DSM-III-R and proposed DSM-IV criteria in the 1988 National Health Interview Survey. Addiction. 1993;881079- 1090
PubMed Link to Article
Cottler  LBGrant  BFBlaine  JMavreas  VPull  CBHasin  DCompton  WMRubio-Stipee  MMager  D Concordance of DSM-IV alcohol and drug usedisorder criteria and diagnoses as measured by AUDADIS-ADR, CIDI and SCAN. Drug Alcohol Depend. 1997;47195- 205
PubMed Link to Article
Hasin  DGrant  BFCottler  LBlaine  JTowle  LUstun  BSartorius  N Nosological comparisons of alcohol and drug diagnoses: a multisite,multi-instrument international study. Drug Alcohol Depend. 1997;47217- 226
PubMed Link to Article
Nelson  CBRehm  JUstun  BGrant  BFChatterji  S Factor structure of DSM-IV substance disordercriteria endorsed by alcohol, cannabis, cocaine and opiate users: resultsfrom the World Health Organization Reliability and Validity Study. Addiction. 1999;94843- 855
PubMed Link to Article
Pull  CBSaunders  JBMavreas  VCottler  LBGrant  BFHasin  DSBlaine  JMager  DUstun  B Concordance between ICD-10 alcohol and druguse disorder criteria and diagnoses as measured by the AUDADIS-ADR, CIDI andSCAN: results of a cross-national study. Drug Alcohol Depend. 1997;47207- 216
PubMed Link to Article
Ustun  BCompton  WMager  DBabor  TBaiyewu  OChatterji  SCottler  LGogus  AMavreas  VPeters  LPull  CSaunders  JSmeets  RStipic  MRVrasti  RHasin  DSRoom  RVan Den Brink  WRegier  DBlaine  JGrant  BSartorius  N WHO study on the reliability and validity of the alcohol and drug usedisorder instruments: overview of methods and results. Drug Alcohol Depend. 1997;47161- 170
PubMed Link to Article
World Health Organization, International Classification of Diseases, 10th Revision(ICD-10).  Geneva, Switzerland World Health Organization1992;
World Health Organization, Schedule for Clinical Assessment in Neuropsychiatry.  Geneva, Switzerland World Health Organization1997;
Zimmerman  M Diagnosing personality disorders: a review of issues and research methods. Arch Gen Psychiatry. 1994;51225- 245
PubMed Link to Article
Ware  JEKosinski  MTurner-Bowker  DMGandek  B How to Score Version 2 of the SF-12 Health Survey.  Lincoln, RI Quality Metric2002;
 Software for Survey Data Analysis (SUDAAN) [computer program] Version8.2.  Research Triangle Park, NC Research Triangle Institute2002;
Spitzer  RWilliams  J Structured Clinical Interview for DSM-III-R PersonalityDisorders (SCID-II).  New York New York State Psychiatric Institute, Biometrics ResearchDepartment1985;
Robins  LNHelzer  JECroughan  JLRatcliff  K National Institute of Mental Health Diagnostic Interview Schedule:its history, characteristics and validity. Arch Gen Psychiatry. 1981;38381- 389
PubMed Link to Article
Peninati  H Diagnosing Personality Disorders in Substance Abusers.  Bethesda, Md National Institute on Drug Abuse1991;236- 242
Thevos  AKBrady  KTGrice  DDustan  LMalcolm  R A comparison of psychopathology in cocaine and alcohol dependence. Am J Addict. 1993;2279- 286
Link to Article
Brooner  RKHerbst  JHSchmidt  CWBigelow  GECosta  PT  Jr Antisocial personality disorder among drug abusers: relations to otherpersonality diagnoses and the five factor model of personality. J Nerv Ment Dis. 1993;181313- 319
PubMed Link to Article
DeJong  CAJvan den Brink  WHarteveld  FMvan der Wielen  EGM Personality disorders in alcoholics and drug addicts. Compr Psychiatry. 1993;3487- 94
PubMed Link to Article
Kleinman  PHMiller  ABMillman  RBWoody  GETodd  TKemp  JLipton  DS Psychopathology among cocaine abusers entering treatment. J Nerv Ment Dis. 1990;178442- 447
PubMed Link to Article
Malow  RMWest  JAWilliams  JLSutker  PB Personality disorders classification and symptoms in cocaine and opioidaddict. J Consult Clin Psychol. 1989;57765- 767
PubMed Link to Article
Marlowe  DBHusband  SDLamb  RJKirby  KCIquchi  MYPlatt  JJ Psychiatric comorbidity in cocaine dependence: diverging trends, AxisII spectrum, and gender differentials. Am J Addict. 1995;470- 81
Link to Article
Nace  EPDavis  CWGaspari  JP Axis II comorbidity in substance abusers. Am J Psychiatry. 1991;148118- 120
PubMed
Rutherford  MJCacciola  JSAlterman  AI Relationships of personality disorders with problem severity in methadonepatients. Drug Alcohol Depend. 1994;3569- 76
PubMed Link to Article
Weiss  RDMirin  SMGriffin  MLGunderson  JGHufford  C Personality disorders in cocaine dependence. Compr Psychiatry. 1993;34145- 149
PubMed Link to Article
Brady  KTGrice  DEDuston  LRandall  L Gender differences in substance use disorders. Am J Psychiatry. 1993;1501707- 1711
PubMed
Lehman  AFMeyers  CPThompson  JWCorty  E Implications of mental and substance use disorders: a comparison ofsingle and dual diagnosis patients. J Nerv Ment Dis. 1993;181365- 370
PubMed Link to Article
Rounsaville  BJFoley  ASCarrol  KBudde  DPrusoff  BAGavin  F Psychiatric diagnoses of treatment-seeking cocaine abusers. Arch Gen Psychiatry. 1991;4843- 51
PubMed Link to Article
Hasin  DSGrant  BF Psychiatric diagnosis of patients with substance abuse problems: acomparison of two procedures, the DIS and SADS-L. J Psychiatr Res. 1987;217- 22
PubMed Link to Article
Muntaner  CNagoshi  CJaffe  JHWalter  DHaertzen  CFishbein  D Correlates of self-reported early childhood aggression in subjectsvolunteering for drug studies. Am J Drug Alcohol Abuse. 1989;15383- 402
PubMed Link to Article
Ross  HEGlaser  FBStiasny  S Sex differences in the prevalences of psychiatric disorders in patientswith alcohol and drug problems. Br J Addict. 1988;831179- 1192
PubMed Link to Article
van Limbeek  JWouters  LKaplan  CDGeerlings  PJvan Alem  V Prevalence of psychopathology in drug-addicted Dutch. J Subst Abuse Treat. 1992;943- 52
PubMed Link to Article
Cadoret  RTroughton  EWidmer  R Clinical differences between antisocial and primary alcoholics. Compr Psychiatry. 1984;251- 8
PubMed Link to Article
Helzer  JEPryzbeck  TR The co-occurrence of alcoholism with other psychiatric disorders inthe general population and its impact on treatment. J Stud Alcohol. 1988;49219- 224
PubMed
Herz  LRVolicer  LD'Angelo  NGadish  D Additional psychiatric illness by Diagnostic Interview Schedule inmale alcoholics. Compr Psychiatry. 1990;3172- 79
PubMed Link to Article
Hesselbrock  VMHesselbrock  MNStabenau  JR Alcoholism in men patients subtyped by family history and antisocialpersonality. J Stud Alcohol. 1985;4659- 64
PubMed
Hesselbrock  MNMeyer  REKeener  JJ Psychopathology in hospital alcoholics. Arch Gen Psychiatry. 1985;421050- 1055
PubMed Link to Article
Malloy  PNoel  NLongabaugh  RBeattie  M Determinants of neuropsychological impairment in antisocial substanceabusers. Addict Behav. 1990;15431- 438
PubMed Link to Article
Ross  HEGlaser  FBGermanson  T The prevalence of psychiatric disorders in patients with alcohol andother drug problems. Arch Gen Psychiatry. 1988;451023- 1031
PubMed Link to Article
Yamamoto  JSilva  JASasao  TWang  CNguyen  L Alcoholism in Peru. Am J Psychiatry. 1993;1501059- 1062
PubMed
Francis  AJ Categorical and dimensional systems of personality disorder diagnoses. Compr Psychiatry. 1982;23516- 527
PubMed Link to Article
Livesley  JW Diagnostic dilemmas in classifying personality disorder. Phillips  KAFirst  MBPincus  HAedsAdvancingDSM: Dilemmas in Psychiatric Diagnosis. Washington, DC American PsychiatricAssociation2003;153- 189
Austin  EJDeary  IJ The "Four As": a common framework for normal and abnormal personality? Pers Individ Dif. 2000;28977- 996
Link to Article
Livesley  WJJang  KLVernon  PA The phenotypic and genetic architecture of traits delineating personalitydisorder. Arch Gen Psychiatry. 1998;55941- 948
PubMed Link to Article
Mulder  RTJoyce  PR Temperament and the structure of personality disorder symptoms. Psychol Med. 1997;2799- 106
PubMed Link to Article
Regier  DFarmer  MERae  DSLocke  BZKeith  SJudd  LLGoodwin  FK Comorbidity of mental disorders with alcohol and other drug abuse:results from the Epidemiologic Catchment Area (ECA) study. JAMA. 1990;2642511- 2518
PubMed Link to Article
Coccaro  EF Psychopharmacologic studies in patients with personality disorders:review and perspective. J Personal Disord. 1993;7suppl181S- 192S
Gordon  CBeresin  E Conflicting treatment models for inpatient management of borderlinepatients. Am J Psychiatry. 1983;140979- 983
PubMed
Linehan  MM Cognitive-Behavioral Treatment of Borderline PersonalityDisorder.  New York, NY Guilford1993;
Chappel  JNGottheill  ENace  EP Alcoholism Update for Psychiatrists.  Port Washington, NY American College of Psychiatrists1988;
Nace  EP Personality disorders in the alcoholic patient. Psychiatr Ann. 1989;19256- 260
Link to Article

Figures

Tables

Table Graphic Jump LocationTable 1. 12-Month Prevalence of Alcohol and Drug Use Disorders andPrevalence of Personality Disorders (PDs)
Table Graphic Jump LocationTable 2. Prevalence of Personality Disorders (PDs) Among RespondentsWith a 12-Month Alcohol or Drug Use Disorder*
Table Graphic Jump LocationTable 3. Prevalence of 12-Month Alcohol and Drug Use Disorders AmongRespondents With a Personality Disorder (PD)*
Table Graphic Jump LocationTable 4. Odds Ratio (ORs) of Personality Disorders (PDs) and Alcoholand Drug Use Disorders*
Table Graphic Jump LocationTable 5. 12-Month Odds Ratios (ORs) of Personality Disorders (PDs)and Alcohol and Drug Use Disorders by Sex*

References

Verheul  Rvan den Brink  WHartgers  C Prevalence of personality disorders among alcoholics and drug addicts:an overview. Eur Addict Res. 1995;1166- 177
Link to Article
Cacciola  JSRutherford  MJAlterman  AIMcKay  JRSnider  EC Personality disorders and treatment outcome in methadone maintenancepatients. J Nerv Ment Dis. 1996;184234- 239
PubMed Link to Article
Kosten  TAKosten  TRRounsaville  BJ Personality disorders in opiate addicts show prognostic specificity. J Subst Abuse Treat. 1989;6163- 168
PubMed Link to Article
Kranzler  HRSatel  SApter  A Personality disorders and associated features in cocaine-dependentinpatients. Compr Psychiatry. 1994;35335- 340
PubMed Link to Article
Marlowe  DBKirby  KCFestinger  DSHusband  SDPlatt  JJ Impact of comorbid personality disorders and personality disorder symptomson outcomes of behavioral treatment for cocaine dependence. J Nerv Ment Dis. 1997;185483- 490
PubMed Link to Article
Movalli  MGMadeddu  FMaffei  FC Personality disorders (DSM-III-R, DSM-IV):prevalence in alcoholics and influence on dropout from treatment [in Italian]. Alcologia. 1996;847- 52
Nurnberg  HGRifkin  ADoddi  S A systematic assessment of the comorbidity of DSM-III-R personality disorders in alcoholic outpatients. Compr Psychiatry. 1993;34447- 454
PubMed Link to Article
Pettinati  HMJensen  JMTracy  JISamuels  DMeyers  K Cocaine vs alcohol dependence: axis II and outcome.  Paper presented at: Annual Meeting of the Research Society on Alcoholism June 19, 1991 Marco Island, Fla.
Thomas  VHMelchert  TPBanken  JA Substance dependence and personality disorders: comorbidity and treatmentoutcome in an inpatient treatment population. J Stud Alcohol. 1999;60271- 277
PubMed
Skodal  AEOldham  JMGallaher  PE Axis II comorbidity of substance use disorders among patients referredfor treatment of personality disorders. Am J Psychiatry. 1999;156733- 738
PubMed
Kessler  RCWalters  EE The National Comorbidity Survey. Tsaung  MTTohen  MedsTextbook in PsychiatricEpidemiology. 2 New York, NY John Wily & Sons2002;343- 362
Robins  LNedRegier  DSed Psychiatric Disorders in America: The EpidemiologicCatchment Area Study.  New York, NY Free Press1991;
American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, FourthEdition.  Washington, DC American Psychiatric Association1994;
Grant  BFMoore  TCShepard  JKaplan  K Source and Accuracy Statement: Wave 1 National EpidemiologicSurvey on Alcohol and Related Conditions (NESARC).  Bethesda, Md National Institute on Alcohol Abuse and Alcoholism2003;
Grant  BFDawson  DAStinson  FSChou  PSKay  WPickering  R The Alcohol Use Disorder and Associated Disabilities Interview Schedule-IV(AUDADIS-IV): reliability of alcohol consumption, tobacco use, family historyof depression and psychiatric diagnostic modules in a general population sample. Drug Alcohol Depend. 2003;717- 16
PubMed Link to Article
Grant  BFDawson  DAHasin  DS The Alcohol Use Disorder and Associated DisabilitiesInterview Schedule-DSM-IV Version.  Bethesda, Md National Institute on Alcohol Abuse and Alcoholism2001;
Canino  GJBravo  MRamfrez  RFebo  VFernandez  RHasin  D The Spanish Alcohol Use Disorder and Associated Disabilities InterviewSchedule (AUDADIS): reliability and concordance with clinical diagnoses ina Hispanic population. J Stud Alcohol. 1999;60790- 799
PubMed
Grant  BFHarford  TCDawson  DAChou  PSPickering  R The Alcohol Use Disorder and Associated Disabilities Interview Schedule(AUDADIS): reliability of alcohol and drug modules in a general populationsample. Drug Alcohol Depend. 1995;3937- 44
PubMed Link to Article
Hasin  DCarpenter  KMMcCloud  SSmith  MGrant  BF The Alcohol Use Disorder and Associated Disabilities Interview Schedule(AUDADIS): reliability of alcohol and drug modules in a clinical sample. Drug Alcohol Depend. 1997;44133- 141
PubMed Link to Article
Vrasti  RGrant  BFChatterji  SUstun  BTMager  DOlteanu  IBodoi  M Reliability of the Romanian version of the alcohol module of the WHOAlcohol Use Disorder and Associated Disabilities Interview Schedule--Alcohol/Drug-Revised(AUDADIS-ADR). Eur Addict Res. 1998;4144- 149
PubMed Link to Article
Chatterji  SSaunders  JBVrasti  RGrant  BFHasin  DSMager  D The reliability of the Alcohol Use Disorder and Associated DisabilitiesInterview Schedule-Alcohol/Drug-Revised (AUDADIS-ADR) in India, Romania andAustria. Drug Alcohol Depend. 1997;47171- 185
PubMed Link to Article
Grant  BF DSM-III-R and proposed DSM-IV alcohol abuse and dependence, United States, 1988: a nosologicalcomparison. Alcohol Clin Exp Res. 1992;161068- 1075
PubMed Link to Article
Grant  BF DSM-IV, DSM-III-R and ICD-10 alcohol and drug abuse/harmful use and dependence,United States, 1992: a nosological comparison. Alcohol Clin Exp Res. 1996;201481- 1488
PubMed Link to Article
Grant  BF The relationship between ethanol intake and DSM-III-R alcohol dependence: results of a national survey. J Subst Abuse. 1993;5257- 267
PubMed Link to Article
Grant  BFHarford  TC The relationship between ethanol intake and DSM-III-R alcohol dependence. J Stud Alcohol. 1990;51448- 456
PubMed
Grant  BFHarford  TC The relationship between ethanol intake and DSM-III-R alcohol use disorders: a cross-perspective analysis. J Subst Abuse. 1988-1989;1231- 252
PubMed Link to Article
Harford  TCGrant  BF Prevalence and population validity of DSM-III-R alcoholabuse and dependence: the 1998 National Longitudinal Survey on Youth. J Subst Abuse. 1994;637- 44
PubMed Link to Article
Hasin  DSGrant  BF Draft criteria for alcohol use disorders: comparison to DSM-III-R and implications. Alcohol Clin Exp Res. 1994;181348- 1353
PubMed Link to Article
Hasin  DSGrant  BF Nosological comparisons of DSM-III-R and DSM-IV alcohol abuse and dependence in a clinical facility:comparison to National HIS88 results. Alcohol Clin Exp Res. 1994;18272- 279
PubMed Link to Article
Hasin  DLi  QMcCloud  SEndicott  J Agreement between DSM-III, DSM-III-R and DSM-IV and ICD-10 alcohol diagnoses in a US community-sample of heavy drinkers. Addiction. 1996;911517- 1527
PubMed Link to Article
Hasin  DSMuthen  BGrant  BF The dimensionality of DSM-IV alcohol abuseand dependence: factor analysis in a clinical sample. Vrast  RedAlcoholism: New Research Perspectives. Gottingen, Germany Hogrefe & Hubner1997;27- 39
Hasin  DSPaykin  A Alcohol dependence and abuse diagnoses: concurrent validity in a nationallyrepresentative sample. Alcohol Clin Exp Res. 1999;23144- 150
PubMed
Hasin  DSchuckit  MMartin  CSGrant  BFBucholz  KKHelzer  JE The validity of DSM-IV alcohol dependence:what do we know and what do we need to know. Alcohol Clin Exp Res. 2003;27244- 252
PubMed Link to Article
Hasin  DSVan Rossem  RMcCloud  SEndicott  J Alcohol dependence and abuse diagnoses: validity in a community sampleof heavy drinkers. Alcohol Clin Exp Res. 1997;21213- 219
PubMed
Muthen  BGrant  BFHasin  DS The dimensionality of alcohol abuse and dependence: factor analysisof DSM-III-R and proposed DSM-IV criteria in the 1988 National Health Interview Survey. Addiction. 1993;881079- 1090
PubMed Link to Article
Cottler  LBGrant  BFBlaine  JMavreas  VPull  CBHasin  DCompton  WMRubio-Stipee  MMager  D Concordance of DSM-IV alcohol and drug usedisorder criteria and diagnoses as measured by AUDADIS-ADR, CIDI and SCAN. Drug Alcohol Depend. 1997;47195- 205
PubMed Link to Article
Hasin  DGrant  BFCottler  LBlaine  JTowle  LUstun  BSartorius  N Nosological comparisons of alcohol and drug diagnoses: a multisite,multi-instrument international study. Drug Alcohol Depend. 1997;47217- 226
PubMed Link to Article
Nelson  CBRehm  JUstun  BGrant  BFChatterji  S Factor structure of DSM-IV substance disordercriteria endorsed by alcohol, cannabis, cocaine and opiate users: resultsfrom the World Health Organization Reliability and Validity Study. Addiction. 1999;94843- 855
PubMed Link to Article
Pull  CBSaunders  JBMavreas  VCottler  LBGrant  BFHasin  DSBlaine  JMager  DUstun  B Concordance between ICD-10 alcohol and druguse disorder criteria and diagnoses as measured by the AUDADIS-ADR, CIDI andSCAN: results of a cross-national study. Drug Alcohol Depend. 1997;47207- 216
PubMed Link to Article
Ustun  BCompton  WMager  DBabor  TBaiyewu  OChatterji  SCottler  LGogus  AMavreas  VPeters  LPull  CSaunders  JSmeets  RStipic  MRVrasti  RHasin  DSRoom  RVan Den Brink  WRegier  DBlaine  JGrant  BSartorius  N WHO study on the reliability and validity of the alcohol and drug usedisorder instruments: overview of methods and results. Drug Alcohol Depend. 1997;47161- 170
PubMed Link to Article
World Health Organization, International Classification of Diseases, 10th Revision(ICD-10).  Geneva, Switzerland World Health Organization1992;
World Health Organization, Schedule for Clinical Assessment in Neuropsychiatry.  Geneva, Switzerland World Health Organization1997;
Zimmerman  M Diagnosing personality disorders: a review of issues and research methods. Arch Gen Psychiatry. 1994;51225- 245
PubMed Link to Article
Ware  JEKosinski  MTurner-Bowker  DMGandek  B How to Score Version 2 of the SF-12 Health Survey.  Lincoln, RI Quality Metric2002;
 Software for Survey Data Analysis (SUDAAN) [computer program] Version8.2.  Research Triangle Park, NC Research Triangle Institute2002;
Spitzer  RWilliams  J Structured Clinical Interview for DSM-III-R PersonalityDisorders (SCID-II).  New York New York State Psychiatric Institute, Biometrics ResearchDepartment1985;
Robins  LNHelzer  JECroughan  JLRatcliff  K National Institute of Mental Health Diagnostic Interview Schedule:its history, characteristics and validity. Arch Gen Psychiatry. 1981;38381- 389
PubMed Link to Article
Peninati  H Diagnosing Personality Disorders in Substance Abusers.  Bethesda, Md National Institute on Drug Abuse1991;236- 242
Thevos  AKBrady  KTGrice  DDustan  LMalcolm  R A comparison of psychopathology in cocaine and alcohol dependence. Am J Addict. 1993;2279- 286
Link to Article
Brooner  RKHerbst  JHSchmidt  CWBigelow  GECosta  PT  Jr Antisocial personality disorder among drug abusers: relations to otherpersonality diagnoses and the five factor model of personality. J Nerv Ment Dis. 1993;181313- 319
PubMed Link to Article
DeJong  CAJvan den Brink  WHarteveld  FMvan der Wielen  EGM Personality disorders in alcoholics and drug addicts. Compr Psychiatry. 1993;3487- 94
PubMed Link to Article
Kleinman  PHMiller  ABMillman  RBWoody  GETodd  TKemp  JLipton  DS Psychopathology among cocaine abusers entering treatment. J Nerv Ment Dis. 1990;178442- 447
PubMed Link to Article
Malow  RMWest  JAWilliams  JLSutker  PB Personality disorders classification and symptoms in cocaine and opioidaddict. J Consult Clin Psychol. 1989;57765- 767
PubMed Link to Article
Marlowe  DBHusband  SDLamb  RJKirby  KCIquchi  MYPlatt  JJ Psychiatric comorbidity in cocaine dependence: diverging trends, AxisII spectrum, and gender differentials. Am J Addict. 1995;470- 81
Link to Article
Nace  EPDavis  CWGaspari  JP Axis II comorbidity in substance abusers. Am J Psychiatry. 1991;148118- 120
PubMed
Rutherford  MJCacciola  JSAlterman  AI Relationships of personality disorders with problem severity in methadonepatients. Drug Alcohol Depend. 1994;3569- 76
PubMed Link to Article
Weiss  RDMirin  SMGriffin  MLGunderson  JGHufford  C Personality disorders in cocaine dependence. Compr Psychiatry. 1993;34145- 149
PubMed Link to Article
Brady  KTGrice  DEDuston  LRandall  L Gender differences in substance use disorders. Am J Psychiatry. 1993;1501707- 1711
PubMed
Lehman  AFMeyers  CPThompson  JWCorty  E Implications of mental and substance use disorders: a comparison ofsingle and dual diagnosis patients. J Nerv Ment Dis. 1993;181365- 370
PubMed Link to Article
Rounsaville  BJFoley  ASCarrol  KBudde  DPrusoff  BAGavin  F Psychiatric diagnoses of treatment-seeking cocaine abusers. Arch Gen Psychiatry. 1991;4843- 51
PubMed Link to Article
Hasin  DSGrant  BF Psychiatric diagnosis of patients with substance abuse problems: acomparison of two procedures, the DIS and SADS-L. J Psychiatr Res. 1987;217- 22
PubMed Link to Article
Muntaner  CNagoshi  CJaffe  JHWalter  DHaertzen  CFishbein  D Correlates of self-reported early childhood aggression in subjectsvolunteering for drug studies. Am J Drug Alcohol Abuse. 1989;15383- 402
PubMed Link to Article
Ross  HEGlaser  FBStiasny  S Sex differences in the prevalences of psychiatric disorders in patientswith alcohol and drug problems. Br J Addict. 1988;831179- 1192
PubMed Link to Article
van Limbeek  JWouters  LKaplan  CDGeerlings  PJvan Alem  V Prevalence of psychopathology in drug-addicted Dutch. J Subst Abuse Treat. 1992;943- 52
PubMed Link to Article
Cadoret  RTroughton  EWidmer  R Clinical differences between antisocial and primary alcoholics. Compr Psychiatry. 1984;251- 8
PubMed Link to Article
Helzer  JEPryzbeck  TR The co-occurrence of alcoholism with other psychiatric disorders inthe general population and its impact on treatment. J Stud Alcohol. 1988;49219- 224
PubMed
Herz  LRVolicer  LD'Angelo  NGadish  D Additional psychiatric illness by Diagnostic Interview Schedule inmale alcoholics. Compr Psychiatry. 1990;3172- 79
PubMed Link to Article
Hesselbrock  VMHesselbrock  MNStabenau  JR Alcoholism in men patients subtyped by family history and antisocialpersonality. J Stud Alcohol. 1985;4659- 64
PubMed
Hesselbrock  MNMeyer  REKeener  JJ Psychopathology in hospital alcoholics. Arch Gen Psychiatry. 1985;421050- 1055
PubMed Link to Article
Malloy  PNoel  NLongabaugh  RBeattie  M Determinants of neuropsychological impairment in antisocial substanceabusers. Addict Behav. 1990;15431- 438
PubMed Link to Article
Ross  HEGlaser  FBGermanson  T The prevalence of psychiatric disorders in patients with alcohol andother drug problems. Arch Gen Psychiatry. 1988;451023- 1031
PubMed Link to Article
Yamamoto  JSilva  JASasao  TWang  CNguyen  L Alcoholism in Peru. Am J Psychiatry. 1993;1501059- 1062
PubMed
Francis  AJ Categorical and dimensional systems of personality disorder diagnoses. Compr Psychiatry. 1982;23516- 527
PubMed Link to Article
Livesley  JW Diagnostic dilemmas in classifying personality disorder. Phillips  KAFirst  MBPincus  HAedsAdvancingDSM: Dilemmas in Psychiatric Diagnosis. Washington, DC American PsychiatricAssociation2003;153- 189
Austin  EJDeary  IJ The "Four As": a common framework for normal and abnormal personality? Pers Individ Dif. 2000;28977- 996
Link to Article
Livesley  WJJang  KLVernon  PA The phenotypic and genetic architecture of traits delineating personalitydisorder. Arch Gen Psychiatry. 1998;55941- 948
PubMed Link to Article
Mulder  RTJoyce  PR Temperament and the structure of personality disorder symptoms. Psychol Med. 1997;2799- 106
PubMed Link to Article
Regier  DFarmer  MERae  DSLocke  BZKeith  SJudd  LLGoodwin  FK Comorbidity of mental disorders with alcohol and other drug abuse:results from the Epidemiologic Catchment Area (ECA) study. JAMA. 1990;2642511- 2518
PubMed Link to Article
Coccaro  EF Psychopharmacologic studies in patients with personality disorders:review and perspective. J Personal Disord. 1993;7suppl181S- 192S
Gordon  CBeresin  E Conflicting treatment models for inpatient management of borderlinepatients. Am J Psychiatry. 1983;140979- 983
PubMed
Linehan  MM Cognitive-Behavioral Treatment of Borderline PersonalityDisorder.  New York, NY Guilford1993;
Chappel  JNGottheill  ENace  EP Alcoholism Update for Psychiatrists.  Port Washington, NY American College of Psychiatrists1988;
Nace  EP Personality disorders in the alcoholic patient. Psychiatr Ann. 1989;19256- 260
Link to Article

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