Clinical Textbook of Addictive Disorders 3rd ed - R. Frances, S. Miller, A. Mack (Guilford, 2005) WW

254 IV. SPECIAL POPULATIONSAntisocial Personality DisorderThe risk of ASPD among drug-dependent individuals in community samples is29 times that of the general population, and rates of ASPD among IDUs rangebetween 35 and 71% (Darke et al., 2004; Dinwiddie et al., 1996; Regier et al.,1990). ASPD appears to be a risk factor for multiple substance dependence. Forexample, patients who meet dependence criteria for both cocaine and alcoholhave higher psychiatric severity and are more likely to have ASPD thanpatients with cocaine dependence only (Cunningham, Corrigan, Malow, &Smason, 1993). Among clinical populations, sociopathy among substance abusersis associated with high treatment dropout and poorer treatment outcome(Leal, Ziedonis, & Kosten, 1994; Woody, McLellan, Luborsky, & O’Brien,1985). Tómasson and Vaglum (2000) followed 100 treatment-seeking alcoholicswith ASPD for 28 months in a European study: Forty-seven percent of thecohort had multiple SUDs and more prior admissions, and they were more frequentlyinvolved in fights. The route of drug administration also is associatedwith elevated risk of ASPD. Compared to non-IDUs with a substantial drug usehistory, rates of ASPD are elevated in IDUs (Dinwiddie et al., 1996). Increasedsocial deviance is a factor that likely increases risk of access to hard drugs. However,the specific contribution of ASPD to SUD risk is less clearly delineated.Recent family genetics studies suggest that familial aggregation of SUD islargely independent of ASPD (Bierut et al., 1998; Merikangas et al., 1998).Borderline Personality DisorderAlthough ASPD has been the personality disorder that is traditionally diagnosedin patients with SUDs and is typically believed to be responsible for thehigher risk of self- and other-harmful behaviors in this population, recent evidencesuggests that some proportion of the risk for multiple substance use, aswell as suicide attempts and psychiatric severity, is associated with BPD (Darkeet al., 2004). Trull, Sher, Minks-Brown, Durbin, and Burr (2000) reviewed 26studies of the comorbidity of BPD and SUD, and found rates of BPD thatranged from 5 to 65%. Much of the variability between studies was due to differentinstruments used and populations studied. However, the rate across studieswas 57.4%; thus, it is clear that the prevalence of BPD is elevated amongpatients with SUDs (Trull et al., 2000). BPD is present in 18–34% of cocaineabusers in treatment settings and among 46% of injection heroin users in andout of treatment (Darke et al., 2004; Kleinman et al., 1990; Kranzler, Satel, &Apter, 1994; Marlowe et al., 1995). In a recent study of injection heroin users,46% of the sample met criteria for BPD, including 38% who also met criteriafor comorbid ASPD, yet there appeared to be little increased risk for harmfulbehaviors among IDUs with ASPD compared to those without ASPD (Darkeet al., 2004).