Abstract
This prospective study examines the association of DSM-III-R Axis II comorbidity with (time to) relapse since the end of treatment in a sample of 105 outpatient and 82 inpatient alcoholics. Furthermore, this study addresses the role of motivation for change, time in program, and working alliance in the mechanism underlying the association between Axis II and relapse. We found that Axis II comorbidity in alcoholics is a robust predictor of relapse following treatment, while the effect is strongest in outpatients with low motivation for change and/or short time in program. Motivation for change and time in program did not mediate the association of Axis II with relapse. We also found poor working alliance to be related to personality pathology among inpatients, and from our findings it can be hypothesised that poor working alliance is part of the mechanism underlying the observed impact of Axis II on treatment outcome in outpatients. A preliminary model of the role of personality pathology in the mechanism of relapse is proposed.
Results
The total sample comprised 105 outpatient and 82 inpatient alcoholics. The proportion of males was not significantly different among outpatients (74.7%) compared with inpatients (67.7%). However, outpatients were on average somewhat younger than inpatients (40.2 ± 9.3 years vs. 42.0 ± 9.1; F = 1.06, df = 539, p = .027). Within the outpatient sample, 60.4% met criteria for at least one specific personality disorder, 30.4% for at least one Cluster A personality disorder (i.e., paranoid, schizotypal, schizoid), 43.9% for at least one Cluster B personality disorder (i.e., borderline, antisocial, narcissistic, histrionic), and 48.6% for at least one Cluster C personality disorder (dependent, avoidant, obsessive-compulsive, passive-aggressive). Within the inpatient sample, these rates were 45.5%, 25.0%, 31.3%, and 38.4%, respectively. The outpatient and inpatient samples differed with regard to the prevalence of any Cluster B disorder (43.9% vs. 31.3%; χ2 = 4.32, df = 1, p = .038) and the overall prevalence (59.5% vs. 45.5%; χ2 = 4.97, df = 1, p = .026). Finally, outpatients were somewhat less motivated for change than inpatients (mean scores on CMRS subscale: 44.5 ± 6.6 vs. 48.3 ± 6.6; F = 1.21, df = 258, p < .001).
Table 1 shows the ORs and 95% CIs for the association between personality disorders and relapse at 3-month follow-up. These analyses could be performed only in patients who left treatment at least 3 months before follow-up assessment (n = 167) but not in those who left treatment recently (n = 20). The results show that patients with at least one Axis II diagnosis were 3.4 times (CI 1.5–7.7) more likely to be relapsed at 3-month follow-up than patients without Axis II comorbidity. The analyses at the cluster level reveal that the association was nonspecific across the three clusters. The associations (for any Axis II diagnosis) were even stronger in the outpatient sample (OR 5.9; CI 2.0–17.7) but could not be observed within the inpatient sample (OR 1.1; CI 0.3–4.3). Additional analyses (not reported in the tables) revealed that, within the outpatient sample, 45.7% of those with at least one Axis II disorder had relapsed at 3-month follow-up, whereas only 12.5% of those without a personality disorder had done so. Within the inpatient sample, these rates were 11.4% and 10.6%, respectively.
