اختلال شخصیت ضد اجتماعی نتایج درمان متامفتامین در بی خانمان ها، مردان وابسته به مواد در رابطه جنسی با مردان را پیش بینی می کند

Abstract One-hundred-thirty-one homeless, substance-dependent MSM were enrolled in a randomized controlled trial to assess the efficacy of a contingency management (CM) intervention for reducing substance use and increasing healthy behavior. Participants were randomized into conditions that either provided additional rewards for substance abstinence and/or health-promoting/prosocial behaviors (“CM-full”; n = 64) or for study compliance and attendance only (“CM-lite”; n = 67). The purpose of this secondary analysis was to determine the affect of ASPD status on two primary study outcomes: methamphetamine abstinence, and engagement in prosocial/health-promoting behavior. Analyses revealed that individuals with ASPD provided more methamphetamine-negative urine samples (37.5%) than participants without ASPD (30.6%). When controlling for participant sociodemographics and condition assignment, the magnitude of this predicted difference increases to 10% and reached statistical significance (p < .05). On average, participants with ASPD earned fewer vouchers for health-promoting/prosocial behaviors than participants without ASPD ($10.21 [SD = $7.02] versus $18.38 [SD = $13.60]; p < .01). Participants with ASPD displayed superior methamphetamine abstinence outcomes regardless of CM schedule; even with potentially unlimited positive reinforcement, individuals with ASPD displayed suboptimal outcomes in achieving health-promoting/prosocial behaviors.

1. Introduction 1.1. Antisocial personality disorder and substance abuse Antisocial personality disorder (ASPD) is an Axis-II personality disorder present in approximately 0.6% of the United States population (Lenzenweger, Lane, Loranger, & Kessler, 2007) characterized by near-constant pursuit of personal gratification and the pervasive disregard for the rights of others, often manifesting as the eschewal of social norms, deceit, aggression, and lack of empathy/remorse (American Psychiatric Association, 2000). ASPD often first manifests itself as an aggressive childhood behavior (Schaeffer, Petras, Ialongo, Poduska, & Kellam, 2003), an antecedent occurrence also common to drug abuse disorders (Petras et al., 2008). Previous studies have demonstrated that a diagnosed psychiatric illness increases risk for a comorbid substance use disorder, and ASPD comes with one of the highest such increases in risk (Compton et al., 2005 and Mueser et al., 2006). Diagnosis of ASPD is associated with use of alcohol and illegal drugs (Trull, Jahng, Tomko, Wood, & Sher, 2010), with nearly half of all substance abusers meeting the criteria for diagnosis with ASPD (Messina et al., 2003 and Messina et al., 2001). ASPD the most common comorbid personality disorder among substance abusers (Craig, 2000, Fridell et al., 2006a and Verheul, 2001), and people with ASPD have more current and lifetime substance use than people without ASPD (Mueser et al., 2006). Additionally, diagnosis of ASPD is associated with heavier methamphetamine use among users (Lecomte et al., 2010), and among individuals who do seek treatment for their substance abuse, individuals with ASPD are more likely to recidivate into heavy drug use after treatment (Fridell, Hesse, & Billsten, 2006).

3. Results At baseline, participants' self-reported substance use in the previous month revealed no significant differences between those with or without ASPD. The most frequently used substances were marijuana, alcohol, and methamphetamine. Table 2 contains four analyses. Both analyses along the top are bivariate, while both analyses along the bottom are multivariate. Analyses on the left compare methamphetamine abstinence rates across ASPD statuses, while analyses on the right compare health-promoting/prosocial behavior earnings across ASPD statuses. All multivariate models control for race/ethnicity, age, HIV status, educational attainment, and (where necessary) condition assignment. Table 2. Associations between ASPD status and intervention response variables. Methamphetamine abstinence (N = 131) Behavior earnings (CM-full only; n = 64) Bivariate Z-test for differences in proportions Bivariate Student's t-test (unequal variances) ASPD (n = 45) Non-ASPD (n = 86) p-Value ASPD (n = 17) Non-ASPD (n = 47) p-Value 37.5% methamphetamine-metabolite free urine samples 30.6% methamphetamine-metabolite free urine samples ns $10.21 average/earned per behavior [SD = 7.02] $18.38 average/earned per behavior [SD = 13.60] .003 Multivariate Ordinary least squares (OLS) regressiona Multivariate Random intercept longitudinal OLS regressionb Predictor Coef. (SE) p-Value Predictor Coef. (SE) p-Value ASPD 0.10 (0.05) .04 ASPD −$7.80 ($3.20) .02 All significance tests two-tailed. a Controls: race/ethnicity, age, education, HIV status, condition assignment. b Controls: race/ethnicity, age, education, HIV status. Table options As shown in Table 2, participants diagnosed with ASPD at baseline provided an average of 37.5% methamphetamine metabolite-free urine samples during the course of the intervention, compared to 30.6% provided by participants without ASPD, a non-significant difference. When controlling for participant sociodemographics and condition assignment, however, ASPD status was significantly positively associated with methamphetamine abstinence (coefficient = 0.1 [SE = 0.05]; p < .05), with the magnitude of the difference at the multivariate level increasing from 7% to an estimated 10%. As was reported elsewhere ( Reback et al., 2010), the “CM-full” escalating rewards schedule also produced significant increases in participant abstinence. Separate analyses were carried out to explore the importance of an interaction effect between ASPD status and CM condition. In no instance was the additional interaction effect significant; it was excluded from final analyses to avoid issues of collinearity. Participants achieved a similar number health-promoting/prosocial behaviors regardless of ASPD diagnosis (MASPD = 28 versus MNon-ASPD = 23, ns). However, participants with ASPD earned fewer vouchers for health-promoting/prosocial behaviors during the course of the study than participants without ASPD ($221.47 in vouchers [SD = $145.84] versus $365.53 in vouchers [SD = $493.38], p = .077), implying that, on average, the behaviors enacted by participants with ASPD were of a smaller magnitude than those achieved by participants without ASPD. Thus, to best capture the variance in both the number of behaviors achieved as well as the relative importance of any given behavior, final analyses were conducted on event-level earning data (i.e., actual daily participant voucher earnings throughout the study). As shown in Table 2, at the bivariate level, participants with ASPD earned on average significantly less per behavior than participants without ASPD ($10.21 in vouchers [SD = $7.02] versus $18.38 in vouchers [SD = $13.60]; p < .01). When controlling for participant sociodemographics, ASPD status retained its significant negative association with health-promoting/prosocial behavior earnings (coefficient = −$7.80 [SE = $3.20]; p < .05).