Edited Copy of Final Proposal -To Print

PREVALENCE OF PERSONALITY DISORDERS AMONG SUBSTANCE ABUSERS IN DRUG REHABILITATION CENTRES IN KENYABY DR. ONGERI LINNET K. A THESIS PROPOSAL PRESENTED IN PART FULFILLMENT FOR THE REQUIREMENT FOR THE AWARD OF THE DEGREE OF MASTER OF MEDICINE IN PSYCHIATRY IN THE UNIVERSITY OF NAIROBI SUPERVISORS, DR. KURIA W. DR. OWITI F. DECLARATION I declare that this proposal entitled “ prevalence of personality disorder among substance abusers in drug rehabilitation centers in Kenya” is the result of my own work and that it has not been submitted either wholly or in part to or any other university for the award of any degree or diploma. Department of Psychiatry Dated 29/10/10 Signed___________________________ Linnet Ongeri (candidate) SUPERVISORS’ APPROVAL This proposal has been submitted for examination with our approval as the university supervisors. Dr. Mary W. Kuria MBCHB (Nairobi), M.Med Psych (Nairobi), PhD (Nairobi), Lecturer Department of Psychiatry, UON Signed____________________________ Date______________________________ Dr. F.R. Owiti MBCHB (Nairobi), M.R.C. Psych (UK), Lecturer Department of Psychiatry, UON Signed___________________________ Date_____________________________ ACKNOWLEDGEMENT The development of the concept and proposal owes much to the support and encouragement which my supervisors Dr. Kuria and Dr. Owiti have so generously supplied throughout. Further gratitude goes to my colleagues for their support and input in the preparation of this study. 2 Table of Contents Title Page .i Declaration……………………………………………………………………….………………..ii Acknowledgment…………………………………………………………………………………iii Table of Contents iv List of figures and tables …………………………………………………………………………vi Abbreviations……………………………………………………………………………………vii Definition of terms ……………………………………………………………………………..viii Abstract 1.1 1.2 1.3 1.4 2.1 ix CHAPTER I...................................................................................................................1 Clusters of Personality Disorders................................................................................1 Background..........................................................................................................2 Statement of the Problem..........................................................................................4 Justification for Study..............................................................................................5 Overview.............................................................................................................6 CHAPTER 2..................................................................................................................6 2.1.1 The Behavioural Disinhibition Pathway..........................................................................6 2.1.2 Stress Reactivity Pathway...........................................................................................7 2.1.3 Reward Sensitivity Pathway........................................................................................7 2.2 Epidemiology........................................................................................................9 2.2.1 Regional Studies.......................................................................................................9 2.2.2 The Rest of the World................................................................................................9 CHAPTER THREE........................................................................................................13 3.1 3.2 3.3 3.4 3.5 4.1 4.2 4.3 Research Questions...............................................................................................13 Aim..................................................................................................................13 Specific Objectives...............................................................................................13 Null Hypothesis...................................................................................................13 Alternative Hypothesis...........................................................................................13 Study design.......................................................................................................14 Study Area......................................................................................................14 Study Population...............................................................................................15 2 CHAPTER FOUR..........................................................................................................14 ........................................................................46 Appendix 8: ASSIST Questionnaire................6 4.............................9 Inclusion Criteria......................................................................................................................................................................................16 Sampling...............................................1 4.......................45 Appendix 7: Socio-demographic Questionnaire...................................................................................................3..........................................................................................................................................................................5 4..................................................40 Appendix 1: Flow Chart illustrating methodology...........................................................................................................................................5 Figure 2: Stress Reactivity Pathway.........16 Data Analysis and Presentation..............44 Appendix 6: Consent Form.................................................................................................................17 Study Implementation........................................................................43 Appendix 5: Fomu ya Maelezo ya Maridhiano....................8 4.............................................................................................................6 Figure 3: Reward Sensitivity Pathway.........48 Appendix 9..................................15 Exclusion Criteria.....................................................4........15 Sample Size.............................................4 4............................17 Ethical Considerations.............................................................................2 4....................................................................................................................................................................................16 Study Instruments.41 Appendix 3: Budget (Kenya Shillings).......................6 Tables Table 1: Co-morbidity of personality disorders and substance use disorders accounted for by distinct causal or developmental pathways to addiction............42 Appendix 4: Informed consent Explanation........3..........7 4....7 1 ....................................................40 Appendix 2: The Time Schedule................................................................51 Appendix 9 LIST OF FIGURES AND TABLES Figures Figure 1: Behavioural Disinhibition Pathway........................................................18 REFERENCES.......36 APPENDICES......................................................................................... KNH: Kenyatta National Hospital P. SPSS: Statistical Package for Social Sciences. STI: Sexually Transmitted Infection U.ABBREVIATIONS ASSIST: Alcohol Smoking and Substance Involvement Screening Test DSM: Diagnostic Statistical Manual HIV: Human Immunodeficiency Virus ICD: International Classification of Diseases.D: Personality Disorder SCID II: Structured Clinical Interview for DSM-IV Axis II Personality Disorders SDQ: Social Demographic Questionnaire.O.N: University Of Nairobi PDQR: Personality Diagnostic Questionnaire-Revised MCMI: Millon Clinical Multiaxial Inventory 2 . was published in 2000. what they do and their innate tendencies and preferences. as they involve what person’s value. Numerous studies in both population and clinic based settings show a higher prevalence of personality disorders among individuals with substance use disorders than among the general population. feeling. These problems must occur recurrently during the same12-month period. integral to each person’s sense of self. Substance Dependence: A syndrome manifested by a behavioural pattern in which the use of a given psychoactive drug. Axis I Disorders: Clinical Disorders. and skilled escape from unconditioned punishment. behaving and relating to others. Comorbidity: The presence of any distinct clinical entity that has existed or that may occur during the clinical course of a patient who has the index disease under study.DEFINITION OF TERMS Addiction: a persistent. Axis II Disorders: Personality disorders and mental retardation. Personality Disorder is defined in DSM-IV-TR as an enduring pattern of inner experiences and behaviour that deviates markedly from the expectations of the individual’s culture. is given a much higher priority than other behaviours that once had higher value. including major mental disorders. compulsive dependence on a behaviour or substance. Personality: A characteristic manner of thinking. Very little information is available on the co-occurrence of different personality disorders (PDs) and drug use disorders among treatment seeking substance abusers in the Kenyan population. DSM-IV-TR: A “Text Revision” of the DSM-IV. ABSTRACT Introduction: Personality disorders play a potential role in vulnerability to substance misuse and dependence. The diagnostic categories and the vast majority of the specific criteria for diagnosis were unchanged. active avoidance of conditioned signals of punishment.e. is stable over time and leads to distress or impairment. is pervasive and inflexible. approach to signals of reward.. and thinking about oneself and the environment” (i. relating to. Novelty Seeking: Reflects a heritable bias in the initiation or activation of appetitive approach in response to novelty. 2 . and learning disorders. Personality Trait: The DSM defines personality traits as “enduring patterns of perceiving. The text sections giving extra information on each diagnosis were updated. Personality disorder effects can have important clinical implications. as were some of the diagnostic codes in order to maintain consistency with the ICD. The high individual and social costs of drug use highlight the need to study factors related to such behaviours. Substance Abuse: DSM-IV defines the essential features of substance abuse as follows: A maladaptive pattern of substance use manifested by recurrent and significant adverse consequences related to the repeated use of substances. with particular prominence of antisocial and borderline personality disorder. other people and the world as a whole). or class of drugs. has an onset in adolescence or early adulthood. Red Hill Rehabilitation Centre. Data Analysis: Descriptive and inferential analysis will be done using the Statistical Package for Social Sciences (SPSS) version 12. Study site: The study will be conducted in the following drug rehabilitation centres in Kenya: Mathari Hospital Rehabilitation Centre. SCID II will be used to assess for axis II diagnosis of personality disorder. Informed consent will be sought from the patients. The present study shall contribute to this line of research by examining personality disorders associated with substance abuse. Asumbi Treatment Centres. and Jorgs Ark Rehabilitation Centre. Method: A sample of 263 patients admitted in drug rehabilitation centres in Kenya will be assessed within a period of three months. Script Resource Centre. Aim: The aim of the study is to establish the prevalence of personality disorders among substance abusers and to identify factors associated with the presence of personality disorders. tables and charts. the results will be presented in narratives. individual screening at each facility will then follow and recruitment will be done for patients who meet the inclusion criteria. The ASSIST instrument will be administered to assess for the specific substances used in the study population. 2 . A socio demographic questionnaire will be administered to collect socio demographic information on the subjects recruited in the study.Research on the correlates of drug addiction provides insights for understanding aetiology and informs prevention and cessation programs. Study design: A cross-sectional descriptive study. The history and validity of the concept of personality disorders has been the subject of authoritative reviews. schizoid and Schizotypal personality disorders. histrionic and narcissistic disorders. borderline. It often involves severe symptoms. eccentric and aloof behaviour. Only rarely do people with Cluster A disorders self present for treatment. The initial clinical presentation of the Cluster B patient is typically crisis-related and chaotic. histrionic. dependent and avoidant. doctor shopping or following recommended treatment. and conflicts with family members.1 Researchers may suspect personality disorders could affect. This group is characterised by a general distrust of others. B and C. Such people have difficulty maintaining interpersonal relationships (e.3 Cluster A includes personality disorders in which people exhibit odd. These personality disorders are classified into 3 clusters according to the behaviours exhibited by patients: Cluster A. unpredictable. odd or idiosyncratic beliefs and a tendency towards social isolation. One distinction has been the extent to which individuals are responsible for their own actions. narcissistic. It has long been recognized that there are individuals who have problems which are broadly psychiatric in nature but which appear to represent extensions of the usual range of character variations. The personality disorders classified here include antisocial. as it demonstrably affects the response to treatment of a range of other problems such as anxiety and depression. antisocial.g. Awareness of Cluster B personality 1 . The key features of personality disorders are that the personality pattern is formed by adolescence or early adult years. without other superimposed disturbances. 3 The cluster A personalities are paranoid. and is maladaptive. borderline. employers or the health care system.2 1. The initial presentation of Cluster A personality disorders: the underlying mistrust and unusual ideas usually become apparent over time.CHAPTER I INTRODUCTION Personality disorders refer to personality attributes which are sufficiently problematic to cause distinct impairments in areas such as social functioning or personal relationships.1 Clusters of Personality Disorders Personality disorder subtypes classified in DSM-IV are: schizotypal. unlikable or impulsive. paranoid. obsessive compulsive.3 Cluster B personalities are characterized by dramatic. schizoid. substance abuse. for instance the outcome of drug use. which is regarded as greater in those with personality disorder than with “formal” mental illness. is characteristic across different situations. misinterpretation of other’s actions. Such people are characterised as labile. with health care providers) and often have a history of discharge against medical advice. erratic and impulsive behaviour. compulsive disorders and alcohol dependence. In the Epidemiologic Catchment Areas Study10. given the considerable social. timid. some of which will be integral to a patient’s self-image. Although sometimes initially reluctant to engage in medical or psychiatric treatment. even marginal reductions in symptomatology can represent quite significant and meaningful public health care.3 1. maladaptive personality traits are often the focus of clinical attention. alcohol use disorders and all other DSM-III non alcohol substance use disorders were more strongly associated with antisocial personality than with any axis I disorders examined in the survey. medical and other costs that are engendered by such personality disorders as the antisocial and borderline. dependent and obsessive compulsive personality disorders.6 One of the mistaken assumptions or expectations of Axis II is that personality disorders are untreatable. perfectionist. semi 2 .10. but clinically and socially meaningful change to personality structure and functioning does occur. They include avoidant. they may become highly attached because they have few other important relationships and have difficulty disengaging at the appropriate time. Patients are often anxious. Cluster C personality types exhibit anxious and fearful behaviour. Nevertheless. 6 Treatment of a personality disorder is unlikely to result in the development of a fully healthy or ideal personality structure. Personality disorders are among the more difficult of mental disorders to treat as they involve entrenched behavior patterns.2 Background Across studies involving different samples. In fact. Presentation is frequently triggered by depression. social and clinical benefits in patients with comorbid substance abuse disorder. there is compelling empirical support to indicate that meaningful response to psychosocial and pharmacologic treatment does occur.8 and in the general population9. more than half of the treated substance abusers have at least one personality disorder. Before the developmental of standardized.6 The association of a variety of specific substance use disorders with antisocial personality disorders has been observed in clinical and forensic settings 7.disorder may help the practitioner to anticipate such problems and to undertake treatment in a more sophisticated way3. settings and method of assessment.4 Estimates of the prevalence of personality disorder within clinical settings is typically above 50%. In fact. or somatic complaints. and conflict avoidant. occupational. 5 Although the comorbid presence of a personality disorder is likely to have an important impact on the course and treatment of an Axis I disorder the prevalence of personality disorder is generally underestimated in clinical practice due in part to the failure to provide systematic or comprehensive assessments of personality disorder symptomatology. 0% in treated addicts(median 56. institutionalization. it its reasonable to expect that a broader perspective on diagnosis of personality disorder might uncover a more extensive pattern on co morbidity. 11. disability. In another study. and in both groups personality disorders are about four times more prevalent than among individuals from the general population. instruments were available only for antisocial personality disorders.11 However. family disruption. and society is substantial.8 to 73. personality disorders are comparably prevalent among psychiatric and addicted patients. medical and judicial recidivism. Thus a perception was created that substance use disorder and personality disorder co morbidity was limited to antisocial personality. Because the latter conclusion has also been found to be true among non patient substance abusers the observed co morbidity cannot be attributed to referral bias. self-injurious behavior. Substance use disorder co occur with personality disorders at rates far exceeding those predicted by chance alone.structured interviews for all axis II disorders.3 Statement of the Problem The total impact of personality disorders on the individual. However. and from 34. suggesting that addiction and personality are somehow causally linked in co morbid individuals. Ruegg and Francis15 nicely summarized the impact: PDs are associated with crime.5%) from 45. several studies have refuted potential artefacts in Axis II diagnoses.5%) were found.5 An important ongoing controversy concern the question whether and to what extent Axis II diagnoses in alcoholics and drug addicts are substance-related artefacts. malpractice suits. poverty. family. Thus. homelessness.0 to 14. underemployment.2 to 80% in psychiatric patients (median 60. illegitimacy. assaults. dissatisfaction with and disruption of psychiatric treatment settings. misdiagnosis and mistreatment of medical and psychiatric disorder.4%). Verheul et al 14 found that remission of the substance use disorder is not significantly associated with remission of the personality pathology. 15 2 . STDs. substance abuse. delayed recovery from Axis I and medical illness.12 In a recent literature review.8% in normal subjects (median 13. 5 A study by Skodol et al 13 found the prevalence rate of personality disorder to be similar among those with a current diagnosis of substance use disorder compared with those with a past diagnosis of substance disorder.5 1. secondary to the addictive problems rather than true personality disorders with early onset and an enduring course independent of Axis I symptoms. Verheul 5 compared the prevalence rates typically found in the general population and psychiatric samples with those reported in studies of substance users. Estimates of the overall Axis II prevalence range from 10. child abuse and neglect. underachievement. suicide attempts. increased need for medical care. suggesting that the two conditions follow an independent course. and dependency on public support. Reflecting transient conditions. since impulsive tendencies may underlie other personality disorders. As economic conditions worsen and the trend toward family breakdown continues. Diagnosing additional problems. Hence personality disorders are commonly overlooked co morbidities in the management of patients with substance use disorder. is important in planning and implementing treatment for patients in drug rehabilitation centres. we can predict an increase in the incidence of personality disorder.19 In Kenya a study done on personality disorders focused on its prevalence among patients admitted in a psychiatric hospital with axis I disorder diagnosis. 20No subsequent study has been done since. F. among the patients with substance use disorder 66% were found to have a co morbid personality disorder. and effective treatment interventions for this under served population16. According to P. “Personality disorders historically have received less attention from clinicians and researchers than other psychiatric disorders such as depression and schizophrenia” 17 Regardless of the controversy. there is increasing empirical evidence of the likelihood that a personality disorder diagnosis suggests that another clinical disorder will also be present and that it will likely be the reason for treatment. Kernberg et al. This study will provide local data on the prevalence of personality disorders among treatment seeking substance abusers and offer further information to an earlier study on personality disorders in a Kenyan Psychiatric hospital. 3 . and is also important in evaluating treatment outcome.5%. and for antisocial personality disorder alone. the Axis II personality disorders are the most common co-occurring disorders in treated substance abusers.4 Justification for Study Despite substantial evidence clearly showing that personality and personality pathology are involved in the aetiology and course of substance use disorders. estimates range from 7% to 55%. 1. such as personality disorders. As a broad diagnostic group. developing clear theoretical models. no local studies have been carried out to establish the prevalence of personality disorders among substance abusers in rehabilitation centres.20 The information will also aid in sensitizing clinicians on the need for diagnosing and managing comorbid personality disorders among substance abusers. This development underscores the urgency of developing the science of personality. obtaining epidemiological findings concerning the prevalence. 18 Reviews of western studies of the co-occurrence of personality disorders and substance abuse disorders provide estimates of prevalence of any personality disorder diagnosis range from 34% to 100%. using the current dominant diagnostic system of classification (DSM). that focuses specifically on patients with substance use disorders in the drug rehabilitation facilities within our country. 1Median prevalence rates of personality disorder among patients with alcohol and substance use disorders in prospective studies including more than 100 subjects was found to be at 56. 2 times more likely to have a co-morbid antisocial personality disorder than those without. they recruited a large sample from the general population and found that those with a substance use disorder were 17. These pathways were defined as: 1. High relative co-morbidity is observed between substance use disorders and Axis I and Axis II disorders from the impulse control spectrum.1 The Behavioural Disinhibition Pathway BEHAVIOURAL DISINHIBITION SERETONIN DEFICIENCY DEFICIENT SOCIALIZATION ADDICTION Figure 2. and low on constraint and harm avoidance have lower threshold to deviant behaviours such as alcohol and drug abuse.1 The Behavioural Disinhibition Pathway The behavioural disinhibition pathway to addiction predicts that individuals scoring high on traits such as anti sociability and impulsiveness.CHAPTER 2 LITERATURE REVIEW 2. The stress reduction pathway 3. The reward sensitivity pathway 2. The behavioural disinhibition pathway 2.1. This was evidenced by a study done by Zimmerman M and his colleagues21 who studied personality disorder diagnoses in a non patient sample. 1 .1 Overview In a recent review by Verheul et al 5it was suggested that at least three different causal or developmental pathways to addiction can be distinguished in which personality factors are likely to be an important aetiological factor. 22 2.2 Stress Reactivity Pathway Stressed life events STRESS REACTIVITY ANXIETY AND MOOD INSTABILITY SUBSTANCE USE AS SELF-MEDICATION thr GABAergic glutaminergic dysregulation Figure 2. some longitudinal studies have shown that novelty-seeking as a temperamental trait in childhood predicts later substance use and related problems .3 The Reward Sensitivity Pathway The reward sensitivity pathway predicts that individuals scoring high on traits such as noveltyseeking.2.23. in turn. Retrospective accounts of the order of onset have shown that anxiety disorders precede the substance use disorder in large portions of co-morbid subjects. extraversion and gregariousness will be motivated to substance intake for its positive reinforcing properties. anxiety sensitivity. and neuroticism are vulnerable to stressful life events.1.The Stress Reduction Pathway The stress reduction pathway to addiction predicts that individuals scoring high on traits such as stress reactivity.24 3 . reward-seeking. Consistent with this hypothesis.2. can become a motive for substance use as self medication. These individuals typically respond to stress with anxiety and mood instability that.3 Reward Sensitivity Pathway Excessive substance use Sensitization processes Addiction REWARD SENSITIVITY Dopaminergic/opioidergic hyperreactivity Figure 2.1. 6%).7%. heroine. 66. Co morbidity of personality disorders in individuals with substance use disorders. The above three respective pathways are likely to differ with respect to their relevance across different psychoactive substances. European Psychiatry 2001:16: 274-82.3% with majority of these patients having a cluster B personality disorder (86. predicts alcohol dependence at age 30. narcissistic Substances Cocaine. she found psychiatric co morbidity 1 . Among those with personality disorders. Pathway Behavioural disinhibition pathway Stress reduction pathway Reward sensitivity pathway Axis II disorders Antisocial.7% had a diagnosis of substances abuse or dependence.0). Another local study by Karanja W. He found a prevalence rate of 20.2. Schizotypal. amphetamines Alcohol. borderline Histrionic. A study by Mc Gue et al 26 on personality and substance use disorders reported alcoholism to be primarily associated with negative emotionality but not low constraint.2 Epidemiology 2. whereas other drug use disorders showed the reversed pattern. A recent study on personality factors and drugs of choice in female addicts by Gerdner et al 27 reported a higher association of alcoholics and benzodiazepine addicts with cluster C personality disorder (37. at least among those without a family history of alcoholism. dependent.M20 investigated prevalence of personality disorder among in patients at Mathari Hospital with Axis I diagnosis. benzodiazepines Most substances Table 1: Co-morbidity of personality disorders and substance use disorders accounted for by distinct causal or developmental pathways to addiction. Source: Verheul R.5).1 Regional Studies A local Kenyan study by Thuo J. borderline Avoidant. The patients with a mood disorder and a comorbid personality disorder were 46.M28 investigated prevalence of Axis I diagnosis among substance abusers admitted in drug rehabilitation centres. 2.A study by Morgenstern et al 25on co morbidity of alcoholism and personality disorders in a clinical population furthermore suggests that students’ scores of extraversion. Amphetamine addicts had a greater association with Cluster B personality disorder (50. and dependent PD(0.3%) followed by paranoid and obsessive-compulsive personality disorders (10%). The study found that 40% of alcohol dependent patients met the DSMIV-TR diagnostic criteria for a personality disorder.1%).5%). found that the most prevalent PD in the general population was obsessive-compulsive PD (7.4%).2 The Rest of the World A study in USA by Grant et al 30 on a general population sample. mean 31 yrs than the group without personality disorders mean.6% and 47. There were no significant differences in gender between the groups with and without personality disorders.4% with cluster A and B personality disorder most commonly co-occurring with substance disorders (16. respectively. Among these borderline personality disorder had the highest prevalence of 30% followed by paranoid personality disorder (12%).7%). had at least 1 PD. and paranoid PD (10.3%). The prevalence of antisocial PD (12. histrionic PD(1. The personality disorder group was significantly younger.6%).4% respectively) 2.4%). 30 alcohol dependent patients attending an outpatient clinic were compared with 30 psychiatric patients with non addictive disorders and 31 subjects from the general population.8%.6% of the non addict patients and 6.9%). The personality disorder group was less likely to be married 68% than the group without personality disorders 51%. A study in South Africa by Suliman et al29 on personality disorders and their Axis I correlates found the prevalence rate estimate for any personality disorder in the community sample to be 6. The subjects with personality disorders had significantly less education than the group without personality disorders.7% of respondents with a 12-month alcohol use disorder and drug use disorder. avoidant PD (2.1%) followed by anxiety disorders (19. 38 years. antisocial PD (3. The prevalence of a personality disorder with any substance use disorder was found to be at 18.prevalence rate of 56% with depression being the commonest (20. A study in Spain by Echeburia et al32 on co-morbidity of alcohol dependence and personality disorders.1%). obsessive-compulsive PD (12. These also were the most prevalent PDs among respondents with any drug use disorder but the rates were much higher. In the same study dependent personality disorders were most prevalent (13. Another American study by Nace et al31 on Axis II co-morbidity among substance abusers in an inpatient substance abuse program found 57% of the admitted patients had at least one personality disorder.8%).2.2%) were the highest among respondents with an alcohol use disorder. 2 . followed by paranoid PD(4. schizoid PD (3. 28.4% of the normative control. compared with 16. histrionic personality disorder (10%) and antisocial personality disorder at (5%).7% and 49. 2 . A study by Brandell et al41 in Norway among alcoholics using SCID II tool. A diagnosis within cluster B was made in 55. Cluster B was diagnosed in almost half of the subjects (48.1%. A study in Spain by Haro et al36 found the prevalence rate of personality disorders among opiate abusers admitted in treatment facilities to be 58. Saxon et al 40 in the USA studied personality disorders among outpatient cocaine and opioid addicts using the MCMI tool.8%). The study showed a higher prevalence of personality disorders among the cocaine users than among the alcohol dependent (55% vs. Among the substance abusers a prevalence rate of 18% had co morbid personality disorders. The predominant personality disorder among cocaine user was antisocial (21.8%) Pettinati et al35 studied prevalence of personality disorders among cocaine and alcohol dependent patients in a New Jersey treatment facility.6%). found a prevalence rate of 58% with at least one personality disorder. followed by dependent and paranoid personality disorder at 13% each.5%.Skodol et al 33 did a study in two treatment settings in New York State and found a prevalence rate of 46% of at least one personality disorder.2%) and Borderline (37. anxiety and substance use disorder found a prevalence of 54% having at least one personality disorder . The most common personality disorders were from cluster B (borderline 28. with a high frequency of Antisocial (39. 35%).8% of the subjects had a personality disorder according to SCID II interview.5%) type of personality disorder. Cluster C personality disorders were predominant in three Axis I disorders. No significant difference existed in prevalence rate among the cocaine and opioid addicts.4% of subjects. while among alcohol users the disorder most predominant was avoidant personality disorder. Another study in Spain by Gutierrez et al37 among drug dependent patients admitted to a treatment facility found 60. Mean age of subjects was 28 years and 82. The most frequent diagnoses were borderline and avoidant personality disorder at 15% each. Heroin was the main substance of abuse (89. A study in Norway by Kantojarvi et al38 in a community sample among patients with mood. Antisocial Personality Disorder being the most prevalent (33. He found a prevalence rate of 22% with at least one personality disorder.5%) A clinic based sample study in Greece by Kokkevi et al 34found a prevalence of Axis II personality disorders of 59.8%) disorders. Sex was not a statistically significant parameter among these patients. Borderline personality disorder was the most prevalent (23%).5 % ) and cluster C (avoidant 21. A study by Montalvo et al39 in Spain among treatment seeking substance abusers found personality disorders among 22% of the participants. The most prevalent personality disorder were the Avoidant personality disorder (10%) followed by Borderline (6%).3% male subjects. Cannabis and inhalant use disorders were the most frequent among substance use. less likely to be married. Patients with personality disorders were on average younger than the other patients. The average age of first alcohol use was 15yrs and the average age of first other substance use was 14.6% of the sample followed by antisocial PD (14. A study by Vanhorn et al44 in the USA on 334 substance abusers in a dependency unit using SCID II found 71. obsessive-compulsive PD (13. Subjects with Axis II were also less likely to be married and to have more than secondary education.6% respectively.9 yrs. to live alone and to be unemployed. No significant differences in age. marital status or employment status among the group was found.3% had at least one cluster B disorder and 38. 24% had features of at least 1 personality disorder. race.7% of the sample with at least one personality disorder. followed by Cluster B at 35% and finally Cluster C at 9%. and35. Borderline was the commonest overall at 12%. 25% had at least one cluster A personality disorder. Men and women were equally likely to be diagnosed as having a personality disorder as compared to subjects without personality disorders. Another study by Powell et al46 in the UK among 104 inpatient alcoholics in a treatment facility sought to find personality disorder prevalence using SCID II tool. 75%. 4 . paranoid PD (40%).antisocial PD(24. 67.2%).4%. gender.A study by Uzun et al42 in Turkey focused on substance use disorders in men with antisocial personality disorder. Antisocial PD was next commonest and restricted to males. The most prevalent such disorder was borderline PD diagnosed in 18. alcohol. Subjects with Axis II diagnoses were younger mean age (39. with a higher prevalence among females than males. In this study. A study by Verheul et al45 in Denmark among 187 alcoholics in a treatment setting using PDQR tool found 45.4 % had at least one cluster C disorder. The most common diagnoses identified were the borderline PD (40%).5% met criteria for at least one specific personality disorder. and more likely to be divorced. Cluster C disorders were the most prevalent in 49% of the sample.9%) and avoidant PD (13%).5%).4%) and narcissistic PD (22. A different study by Sonne et al43 in the USA using the SCID II tool among cocaine dependent individuals found a prevalence rate of 51% with at least one personality disorder. 31.2yrs). CHAPTER THREE RESEARCH SCOPE 3.1 Research Questions The following research questions arise:1.3 Specific Objectives 1 To determine the prevalence of personality disorders among substance abusers admitted in drug rehabilitation centres in Kenya. Is there a pattern of substance use among substance abusers with co morbid personality disorders? 3. 3. 1 . 2 3 To determine the socio-demographic characteristics of substance abusers with co-morbid personality disorders. Are there any socio demographic correlates of personality disorders in substance abusers? 3. What is the prevalence of personality disorders among substance abusers admitted in drug rehabilitation centres in Kenya? 2.4 Null Hypothesis There is no co-morbid personality disorder among patients admitted in drug rehabilitation centres in Kenya.5 Alternative Hypothesis There is co-morbid personality disorder among patients admitted in drug rehabilitation centres in Kenya. To determine the pattern of substance use among substance abusers with co morbid personality disorders.2 Aim To establish the prevalence of personality disorders in patients with substance use disorder at drug rehabilitation centres in Kenya. 3. 3. Blessed Talbot recovery centre. Counselling/psychotherapy.1 Study design The study is a descriptive cross sectional study. 7. Nyanza. Asumbi Treatment Centre.and out-patient treatment to drug users using a multidisciplinary approach. Raphaelites (Red Hill). 4. 8. Asumbi Treatment Centre. Homabay. Nairobi. Asumbi 1 . The centre also makes use of outreach services through community nursing department. Treatment for other mental illnesses is not provided in these institutions but where necessary. 2. 5. describing the prevalence and pattern of personality disorders among in-patient substance abusers in drug rehabilitation centres in Kenya. a psychiatrist’s review is sought or patients referred accordingly. Drug Rehabilitation Unit.2 Study Area 1. 3. Limuru.CHAPTER FOUR METHODOLOGY 4. Participating institutions will include Mathari Hospital Rehabilitation Centre. 6. Script resource centre. recreational activities and guidance are provided. 4. Ridgeway’s. Mathari Hospital. Asumbi Treatment Centre. Kenya The only public rehab established in 2003 in order to provide drug abuse treatment and rehabilitation services with the aim to become a centre of excellence for treatment. training and research. Trained psychiatry community nurses refer patients in need of rehabilitation to the facility from the different outreach clinics. Maisha Rehabilitation Centre.Homabay under the Catholic Diocese. The main objectives of the centre are provision of in. occupational therapy. Kiserian.. Kiserian In these centres the therapeutic community is based on Alcoholic Anonymous and Narcortic Anonymous programme and a well designed and implemented after-care support through a fellowship for alcoholics and addicts. Karen. Nairobi. Asumbi Treatment Center is one of the oldest drug rehabilitation centers in East Africa having been started way back in 1978 in Asumbi. Kiambu. The center offers in patient rehabilitation services to substance abusers. Asumbi Homabay. 4. It was established in April 2001 and has a capacity of 32 patients admitting both male and females. Those less than 18 years of age. It offers drug free residential treatment for a period of between 3 to 6 months depending on the substance of abuse. 4. Those who decline to give consent. Asumbi Karen and Asumbi Ridgeways. Red Hill is located in Limuru. 2.3 Sample Size The sample size shall be calculated using the Fisher formula: N=Z²pq d2 Where n is the sample size Z is the standard normal deviation usually set at 1. Maisha Rehabilitation Center is located in Ongata Rongai town. Those above 18 years of age. Script Resource center (formerly St. Martins) is a residential facility in Kiserian. It has a capacity of 30 inpatients and admits both male and female. The Asumbi treatment centre Homabay is located inside Asumbi Teachers College approximately 24kms from Kisii town. treatment of alcohol dependence is 3 months while for other drugs like cannabis and heroin is 6 months. It offers drug free rehabilitation services and for some recovering addicts also provides a half way house services. It also embraces a spiritual approach in the counseling. Those who have given consent.3. 2km from Kiambu town.currently has three centers.3. about 800metres from the Karen shopping centre while that in Ridgeways is located 2kms off Kiambu road. 4. off Limuru road.3 Study Population The study population consists of inpatients at the participating drug rehabilitation centers that will fulfill the inclusion criteria. all male. 2 . The admission period in the rehabilitation centers ranges between 3-6 months depending on the substance of abuse. The Karen centre is located in Nairobi along Langata road. 3. 4. Blessed Talbot Recovery Center is located in Ndenderu. It has a capacity of 30 inpatients. about 35 km from Nairobi. In most facilities. The centers are all residential drug free treatment facilities focusing on spiritual and personal growth through group and individual counseling. Those admitted for non drug rehabilitation. 2.1 Inclusion Criteria 1. Ngong.96 which corresponds to 95% confidence interval.1 Exclusion Criteria 1. It has a capacity to accommodate 14 patients. II. This instrument begins with a brief overview that characterises the subject’s typical behaviour and relationships and elicits information about the subject’s capacity for self-reflection. The SCID-II is preceded by the administration of the personality questionnaire and this allows the interviewer to follow up on the items endorsed on the screen. 4. Social Demographic Questionnaire (SDQ). level of education. religion. and personality disorder not otherwise specified. 2 . The researcher will be trained by Dr.300 patients during the study period.962 x . Since the total number of recovering substance abusers in the rehabilitation centres is estimated to range from 250.4 Sampling The sampling method used to select the rehabilitation centres will be purposive. N=1. marital status.05(5%) Therefore substituting the values as follows.052 =263 4. This will be a researcher designed and researcher administered questionnaire. gender. occupation. passive-aggressive personality disorder.p is the hypothesized prevalence level 22% from similar prevalence study (Montalvo et al 2006)39 Q is 1-p D is the degree of precision set at 0. Participating rehabilitation centres will be selected from well established and registered centres in the country. reliable and accurate diagnoses of the 10 DSM-IV Axis II personality disorders as well as depressive personality disorder. previous admissions in rehabilitation centres and other socio demographic data.22 x. Structured Clinical Interview for DSM-IV Axis-II Personality Disorders (SCID II). Wangari Kuria on how to implement this tool. all in-patients meeting the inclusion criteria are expected to be enrolled to the study. III. smoking and substance involvement screening test (ASSIST).78 0. Alcohol.5 Study Instruments I. It shall collect data on age. SCID II is a user-friendly instrument that helps to make standardized. This is a tool developed by the World Health Organization (WHO) in 1997 to detect and manage substance use and related problems in primary and general medical care settings. ASSIST and lastly the SCID II. University of Nairobi and clearance obtained from Ethics and research committee at KNH. A written informed consent will be sought from participants after having explained the purpose of the study in detail.9 Ethical Considerations Approval to carry out the study will be obtained from Department of Psychiatry. problems related to substance use.8 Study Implementation The researcher will set 5 days in a week (Monday to Friday) to interview the patients over a period of 9wks. No invasive procedures will be used and participants shall not be posed any risk. Permission to carry out research will be obtained from the administrators of the various drug rehabilitation centers. Those who will not meet the criteria will be thanked and excluded from the study. At the end of the interview the patient will be thanked and the interview terminated. 4. the risk of current or future harm. About 6 patients will be interviewed per day and about 60minutes will be spent in each interview. Confidentiality will be assured. the substances they have used in the past 3 months.7 Data Analysis and Presentation Descriptive and inferential analysis will be done using the statistical package for social sciences (SPSS) version 12. dependence and injecting drug use. Study instruments will be administered in the order of socio demographic questionnaire. The total number anticipated for the stated period of the study will be 263 which is the total number of the estimated sample size. The ASSIST provides information on the substances which subjects have ever used in their lifetime. will be explained about the study and an informed consent will be signed. serial numbers instead of names will be assigned to participants to ensure anonymity. No material gain is expected from the study. For those who will be eligible and willing to participate in the study. tables and charts. 4. 4. Serial numbers will be assigned instead of names. Participants will be informed that participation in the study would be voluntary and information collected during the study will be used only for purposes of the study. The result will be presented in narratives. Upon arrival at the rehabilitation center. permission to conduct the study will be obtained from the rehab administrator and if granted then patients will be sorted out for inclusion criteria. 1 . 2% and 17. The age range was between 18 years to 60 years.5%. Socio-demographic correlates of personality disorders in substance abusers v. Patterns of substance abuse and co-morbid personality disorders Socio-demographic characteristics of participants Age of substance abusers The average age of the 207 substance abusers admitted in the rehabilitation centers and recruited in this study was 33. Prevalence of personality disorders among substance abusers iii. The findings of this analysis are presented by study objectives and organized into the following sections: i. Types of substances abused and problems associated with substance abuse (ASSISST tool) iv. Most of the patients were aged between 18 years and 34 years of age with 44. Socio-demographic characteristics of participants ii. Of 208 patients who met the study inclusion criteria and were recruited into the study. 207 were successfully enrolled and interviewed and were entered into the analysis resulting in a study response rate of 99.7). Figure 1. Figure 1: Distribution of substance abusers in drug rehabilitation centers by age category 1 . shows the age distribution of the patients by 10-year age groups. respectively.CHAPTER FOUR: RESULTS Introduction This chapter presents the results of this study on prevalence of personality disorders among substance abusers in Kenyan drug rehabilitation centers.4 (SD 9.5% of all participants being in the age groups 25 to 34 years and 18 to 24 years. Figure 2: Pie chart of gender distribution of substance abusers in drug rehabilitation centers Education level Table 1 presents the level of formal education reported by study participants.9%) and divorced (0. The other marital status included separated (9.6 71.7 1 .5 3. There was only a single patient (0.7% of the substance abusers recruited in the study.0 100 The marital status of the substance abusers in the study is presented in Table 2.8%) out of the 207 substance abusers were male.3 38. widowed (1.9 24. This was followed by married participants who accounted for 38. Otherwise. 71% of all participants reported having attained tertiary level education. One hundred and ninety (91. Approximately one-half (49.5%) who reported not having attended any formal education and 3.97%) participants. As shown in Figure 2. the ratio of female to male substance abusers in the study was 1: 11.2%).9% had primary level education. Table 1: Reported level of formal education attained by substance abusers in drug rehabilitation centers Level of education None Primary Secondary Tertiary Total Marital status Frequency (n) 1 8 51 147 207 Percent 0.Gender of substance abusers Figure 2 shows the gender of substance abusers in the study.3%) of all substance abusers in this study were single. Table 2: Marital status of substance abusers in drug rehabilitation centers Marital status Single Married Frequency (n) 102 80 Percent 49. 8% of participants were Catholics. Muslim comprised 3.2%) of the participants were engaged in formal employment.1 3. respectively.9% of all participants. Figure 3: Religious affiliation of drug abusers in drug rehabilitation centers Occupation The participants in this study engaged in various occupation and these are summarized in Table 3 below.97 100 Figure 3 shows the distribution of participants by their religious affiliations.2 19. Approximately one-third (37.Separated Widowed Divorced Total Religion 19 4 2 207 9.4 100 Prevalence of personality disorders among substance abusers Overall prevalence of personality disorders 1 . More than one-half (52. and 35.9 0.5 14 11. The remaining 7.8% of the sample.7% of the sample reported that they practiced “other” religious beliefs including traditional religions. This group was followed by participants involved in business who formed 19. Students and unemployed participants comprised 14.2 1.7%) of all participants professed Protestant religious belief. Table 3: Occupation of drug abusers admitted in drug rehabilitation centers in Kenya Occupation Formal employment Business Student Unemployed Informal Multiple Frequency (n) 77 41 30 29 23 7 207 Percent 37.5% and 14% of the sample.8 14. 3%) of the substance abusers.0 10. the following personality disorders were infrequently diagnosed: schizotypal (1. Ninety-two (44.5%).9%) had more than one personality disorder.97%) and depressive personality disorder (0.3 6.5%).48%). histrionic (0. The most commonly diagnosed type of personality disorders was avoidant personality disorder which occurred among 44 (21.7 7.9 1. Prevalence of personality disorders by DSM-IV clusters 1 .7%) patients had a single personality disorder and 35 (16.1% of substance abusers.1 8.3 14. n = 29) and paranoid personality disorder in 10.48 As shown in Table 4.The overall prevalence of personality disorders among substance abusers admitted in drug rehabilitation centers in Kenya with at least one personality disorder was 55. dependent (1.5 1.5 0.9%). 80 (38.3 6.3 1.97 0. followed by obsessive compulsive personality disorder (14%.4%) patients did not have any diagnosis of a personality disorder. Prevalence of specific personality disorders Table 4 below shows the frequency of diagnosis of specific personality disorders among substance abusers admitted in drug rehabilitation centers in Kenya. schizoid (1.7% (115 out of 207). Table 4: Prevalence of specific personality disorders diagnosed among substance abusers admitted to drug rehabilitation center in Kenya Personality disorder Avoidant Obsessive Paranoid Antisocial Passive-Aggressive Narcissistic Borderline Schizotypal Dependent Schizoid Histrionic Depressive Frequency (n) 44 29 21 18 15 13 13 4 3 3 2 1 Percent 21. 6 – 25. The other important substances of abuse in terms of frequency of abuse were tobacco products abused by 168 1 . 31.4 25 182 207 12. Almost all the patients (95.9) and 12.7 62.1 – 85.3 82.3 – 68.9 74. The prevalence of Cluster C disorders was significantly higher than both cluster B and A disorders which had prevalence of 19.1 – 44.0 Frequency (n) Percent 95% CI Types of substances abused and problems associated with substance abuse (ASSIST tool) Types of substances abused Alcohol.3). 14.17.97 .3 100 31.The prevalence of personality disorders by clusters is presented in Table 5.1 87. Tobacco and cannabis were the most frequently reported substances of abuse among the patients undergoing rehabilitations in the centers recruited in this study.1 – 44.8% (95% CI.7 .7 55. 7.2 100 14. Personality disorders classified in cluster C had the highest prevalence and were diagnosed in 37.7%) of the substance abusers undergoing rehabilitation. respectively.17.97 . Table 5: Prevalence of DSM-IV clusters of personality disorders among substance abusers admitted to drug rehabilitation centers in Kenya Personality disorder cluster Cluster A Yes No Total Cluster B Yes No Total Cluster C Yes No Total 78 129 207 37.92. Table 6 lists all the substances of abuse reported by the study participants.1% (95% CI.6 – 25.9 100 7.7% (95%CI.8 80.2%) reported that they had abused alcoholic beverages.9 41 166 207 19. n = 2).2%) patients.4%. Only a single patient reported having abused other drugs apart from those listed above and in Table 6.5 10.8%) participants reported that they had experienced a health problem related to their first drug of choice.6 99 28 22 19 17 11 6 1 47. Figure 4 shows the frequency of reported health problems for the first four substances of choice among the substance abusers.3 2. This frequency reduced for subsequent drugs of choice: second (23. Figure 4: Frequency of health problems reported by substance abusers in drug rehabilitation centers 2 . opioids. sedatives or sleeping pills.out of the 207 (81. caffeine. cannabis abused by 54.6% of patients and amphetamine type stimulants abused by 47.2 54.2 5.2 81. At least 159 out of the 207 (76.8 13. third (3. n = 49).6 9. Problems associated with substance abuse a.5 The remaining drugs listed in Table 6 were less frequently used with less than 15% of participants reporting that they had ever abused cocaine. inhalants or hallucinogens.7%. n = 7) and fourth (1%.8% of the substance abusers.9 0. Table 6: Substances of abuse among 207 patients admitted in drug rehabilitation centers in Kenya Substance of abuse Alcoholic beverages Tobacco products Cannabis Amphetamine type stimulants Cocaine Caffeine Sedatives or sleeping pills Opioids Inhalant Hallucinogens Others Frequency (n) 197 168 113 Percent 95. Health problems The substance abusers commonly reported that they had ever had health problems related to use of the substance of abuse of choice.2 8. 8% of substance abusers reported ever having injected themselves with substances of abuse.3% (95%CI.1-6. respectively (Figure 6). Figure 5 below shows the frequency of patients reports of social problems related to their substance abuse. p = 0. Legal problems Legal problems related to substance abuse occurred less frequently compared to social and health problems.3% . A further seventeen participants and five participants had experienced legal problems related to abuse of their second and third drugs of choice. Overall.4. Figure 7: Prevalence of use of injectable drugs of abuse among patients in drug rehabilitation centers Socio-demographic correlates of personality disorders in substance abusers Substance abusers’ socio-demographics versus presence of personality disorder Analysis of the ages of substance abuser showed that participants with personality disorders were significantly younger than those who abused drugs but did not have personality disorders (t-test. 1. 1 . 2. 95% CI.0059) The average age of substance abusers developing personality disorders was 31. Figure 5: Frequency of social problems reported by substance abusers in drug rehabilitation centers c.The most commonly reported drugs of first and second choice in Figure 4 above were alcoholic beverages. Figure 6: Frequency of legal problems reported by substance abusers in drug rehabilitation centers Use of injections to administer drugs of abuse Figure 7 shows the frequency of use of injections to administer substances of abuse among patients admitted for rehabilitation. tobacco products and cannabis.2) years compared to 35. 0.3%) of patients had injected themselves within the last 3 months while 1. b.4).7 years. One-half of the substance abusers (105 out of 207) reported having had legal problems related to their first drug of choice. At least 85% (176 out of 207) of substance abusers reported they had experienced social problems related to the use of their first drug of choice.8 (SD 9. However. Social problems Social problems were the most commonly reported problems and were more frequent than health or legal problems. A further 25% (52 out of 207) had had social problems related to their use of their second drug of choice and fewer cases had problems with their third (6 out of 207) and fourth (1 out of 207) drugs of choice.9.5% (95%CI. Figure 6 shows that a significant number of substance users still reported that they had experienced legal problems related to their use of drugs.5 (SD 10) years among those without personality disorders (mean difference = 3.1%) of patients had ever injected themselves but had not used injections to administer drugs of abuse in the last 3 months.7% . 6. Comparison of self injection rates by the most recent period of injection showed that 5. 58. At least 40% of participants in each type of occupation had a personality disorder but this prevalence varied from 43% to 77% depending on the specific occupation that participants reported to be involved in. The proportion of patients in the various marital status who also had a diagnosis of a personality disordered varied from 25% to 100% as shown in Table 7. p = 0. The remaining socio-demographic factors were not significantly associated with the diagnosis of personality disorders in substance abusers undergoing rehabilitation.1.4. These factors included gender. p = 0. The lowest prevalence of personality disorders was reported among patients engaging in multiple occupations (43%). level of formal education χ2 = 1. p = 0.02 (Table 7).75 and religion χ2 = 5.05. n (%) Gender Male Female Marital status Single Married Separated 66(65) 37(46) 11(58) 36(35) 43(53) 8(42) 9.5. The marital status of substance abusers was significantly associated with a diagnosis of personality disorder.08 No. p = 0.Findings of the chi square tests comparing prevalence of personality disorders among patients with different levels of socio-demographic factors are presented in Table 7. This prevalence gradually increased in the following occupations: formal employment (45%). Secondly. More specifically.1(1) 0. Table 7: Chi square tests of association between the prevalence of personality disorders and socio-demographics of substance abusers Diagnosis of personality disorder Yes. business (49%). unemployed participants (72%) and students (77%). χ2 = 9.4(4) 0. personality disorders also showed a significant relationship with occupation that the study participants engaged in. informal employment (57%). n (%) Chi square (df) P value 1 . 25% of widowed patients had personality disorders compared to 46% of married. p = 0. 65% of single and 100% of divorced substance abusers. χ2 = 13. 58% of separated.04.16 (Table 7). χ2 = 3.08.04 109(57) 6(35) 81(43) 11(65) 3. 58(3) 0.75 35(45) 20(49) 23(77) 21(72) 13(57) 3(43) 42(55) 21(51) 7(23) 8(28) 10(43) 4(57) 13. Two factors: 1 .05(3) 0.Divorced Widowed Level of education None Primary Secondary Tertiary Occupation Formal Business Student Unemployed Informal Multiple Religion Protestant Catholic Muslim Others 2(100) 1(25) 0 3(75) 0 4(50) 30(59) 81(55) 1(100) 4(50) 21(41) 66(45) 1.02 59(54) 38(51) 5(62) 13(81) 50(46) 36(49) 3(38) 3(19) 5.16 Substance abusers’ socio-demographics versus clusters of personality disorders Table 8 presents results of the chi square tests between the socio-demographic characteristics of substance abusers and the clusters of personality disorders.1(5) 0. 75 153(92) 13(8) 115(89) 18(11) 0.58 1(0. Table 8: Chi square tests of association between the clusters of personality disorders and socio-demographics of substance abusers Cluster A personality disorder Cluster B personality disorder Yes.6) 6(4) 44(27) 115(69) 0 3(4) 22(28) 53(68) 0.8) 3(2.77 61(47) 50(39) 14(11) 1(0.8) 5(4) 29(22) 94(73) .3) 1(0. n (%) No. n (%) Gender Male Female Chi square p value Marital status Single Married Separated Divorced Widowed Chi square p value Level of education None Primary Secondary Tertiary Chi square p value 0 2(8) 6(24) 17(68) 0.32 86(47) 47(41) 17(9) 2(1) 3(2) 25(61) 7(17) 7(17) 2(5) 0 0.6) 6(3) 45(25) 130(71) 0 2(5) 7(17) 32(78) 0. n (%) No.43 168(92) 14(8) 37(90) 4(10) 0. n (%) No.51 2 Cluster C personality disorder Yes. n (%) 22(88) 3(12) 0.001** 77(46) 73(44) 12(7) 0 4(3) 41(53) 30(38) 5(6) 1(1) 1(1) 0.occupation and marital status showed statistically significant associations with cluster B personality disorders.77 1(0. n (%) Yes.11 75(96) 3(4) 16(64) 6(24) 2(8) 0 1(4) 0. 014). p = 0.Occupation Formal Business Student Unemployed Informal Multiple Chi square p value Religion Catholic Protestant Muslim Others 9(36) 12(48) 1(4) 3(12) 65(36) 97(53) 7(4) 13(7) 11(27) 22(54) 2(5) 6(15) 0. Patterns of substance abuse and co-morbid personality disorders Table 9 presents findings of chi square tests examining association between personality disorder clusters and the common type of substances abused by study participants: alcohol.2 26(14) 69(38) 21(12) 38(21) 21(12) 7(4) 15(37) 9(22) 6(15) 4(10) 7(17) 0 < 0. Table 9: Chi square tests of association between the clusters of personality disorders and type of substance abused Cluster A personality disorder Cluster B personality disorder Cluster C personality disorder 1 .0001** 15(9) 68(41) 17(10) 37(22) 22(13) 7(4) 12(15) 26(33) 8(10) 15(19) 14(18) 3(4) 0. p = 0.19 63(38) 87(52) 6(4) 10(6) 26(33) 42(54) 3(4) 7(9) 0.92 48(37) 67(52) 5(4) 9(7) 4(16) 8(32) 2(8) 3(12) 8(32) 0 0.003).82 18(14) 51(40) 15(12) 26(20) 15(12) 4(3) Chi square p value 0.05 level There were no significant associations between clusters A disorders or cluster C disorders and substance abusers’ socio-demographic factors (Table 8). tobacco. cannabis and amphetamine like drugs. Similarly these cluster of personality disorders were more common in participant who abused amphetamine like substances compared to those who did not abuse amphetamine (66% versus 34%.73 **significant at the 0. Cluster B personality disorders occurred more frequently in participants who abused cannabis compared to those who did not abuse cannabis (76% versus 24%. n (%) Yes.014** 72(43) 94(57) 42(54) 36(46) 0. n (%) No.2 96(53) 86(47) 31(76) 10(24) 0. n (%) Alcoholic beverages Yes No Chi square p value Tobacco products Yes No Chi square p value Cannabis Yes No Chi square p value Amphetamine Yes No 15(60) 10(40) 84(46) 98(54) 27(66) 14(34) 0. n (%) Yes. Similarly tobaccos use was also not significantly associated with any cluster of personality disorders. n (%) No.05).77 69(53) 60(47) 22(88) 3(12) 0.61 172(95) 10(5) 41(100) 0 0.21 156(94) 10(6) 73(94) 5(6) 0.003** 82(49) 84(51) 44(56) 34(44) 0. In fact all the patients with cluster A and B personality disorders also abused alcohol and 94% of participants with cluster C disorders also abused alcohol.5 124(96) 5(4) Chi square p value 0.198 57(44) 72(56) 17(68) 8(32) 0.43 146(80) 36(20) 35(85) 6(15) 0. 1 .91 105(81) 24(19) 25(100) 0 0.51 133(80) 33(20) 63(80) 15(20) 0.05 level There was no significant association between alcohol abuse and any of the three clusters of personality disorders (all p values > 0. n (%) No.20 **significant at the 0.Yes. This differs from other studies. personality disorder (37. The study found the prevalence of these disorders using SCID II to be at 55. In a study by Pettinati et al35 in a New Jersey treatment facility compared personality disorders among cocaine and alcohol users.8%) and lastly Cluster A (12. Guittierez et al37 in Spain also found similar results of antisocial PD being the highest disorder at 39. whereby Cluster C were the most prevalent disorders in 49% of the sample.7%) followed by cluster B (19. anxiety and substance use disorder found Cluster C personality disorders predominant in all three Axis I disorders.3%) followed by obsessive compulsive PD(12.3% followed by obsessive compulsive PD at 14%.8). This prevalence rate is comparable to similar studies done in the rest of the world.2% followed by borderline (37.8%) while among the alcohol users the disorder most predominant was avoidant personality disorder.1%.1%) . A study by Nace et al31 found borderline PD to have the highest prevalence at (30%) followed by paranoid PD (12%).1%). This study found the predominant personality disorder to be avoidance PD at 21. 1 . the most prevalent personality disorder among the cocaine users was antisocial (21. A study by Brandell et al41 in Norway found this prevalence at 58% while in Spain Haro et al36 found one of 58. followed by Cluster B at 35% and finally Cluster A at 9%. This was similar to a study by Vanhorn et al44 in the USA on 334 substance abusers in a dependency unit using SCID II.CHAPTER 5: DISCUSSION This study was carried out to establish the prevalence of personality disorders among substance abusers admitted in drug rehabilitation centers in Kenya. This could explain the high prevalence rate of avoidance PD in my study as majority of the participants in my study were alcohol users. A similar study in Norway by Kantojarvi et al38 in a community sample among patients with mood. In the USA Nace et al31 found a prevalence of 57% of admitted participants with at least one personality disorder while Sonne et al43 found the prevalence to be at 51% in a similar study.7%. Grant et al30 in USA found antisocial PD highest (12. In one study by Montalvo et al39 in Spain among inpatient alcoholics similar results to my study were found with avoidant PD being the highest disorder at 10% followed closely by borderline(6%). Nate et al31 found a similar finding whereby the personality disorder group was significantly younger. In the study amphetamine addicts had a greater association with cluster B personality disorder. Association between clusters of personality disorders and common type of substance abused found a significant association of Cluster B with Cannabis and amphetamine like products. Marital status also had a significant association with personality disorder (p=0. This is consistent with the findings of a similar study by Nace et al31 that found no significant differences in gender between the groups with and without personality disorders. STUDY LIMITATIONS. 38 years. This results were also found in a similar study by Gerdner et al27. • Data was obtained by subject interview only and collateral interviews were not used. Presence of a personality disorder in the participants also had a significant relationship with occupation (P=0. Another similar study by Vanhorn et al44 also found the subjects with Axis II diagnoses were younger mean age (39. Hence subjects in the study were also more highly educated and had higher rates of recent employment. This similar finding was replicated by Vanhorn et al44 as well as by Nace et al31. hence a lack of external validation of subjects’ self reported past substance use behavior. less likely to be married and more likely to be unemployed. hence any association observed between substance dependence and personality disorder may be a consequence of referral bias.The study found that participants with personality disorder were significantly younger than those who abused drugs but did not have a personality disorder (t-test p=0.0059). mean 31 years than the group without personality disorders mean. level of formal education and religion.02). These group and setting characteristics may explain the high rate of avoidant personality disorder and lower rate of antisocial personality disorder that I found. This study found no significant association with in gender. The group with personality disorder was more likely to be unemployed compared to the group without personality disorder.04) with participants with personality disorder less likely to be married. The following limitations were encountered during the study: • Difficulties in distinguishing behaviors that may be secondary to the effects of the dependence syndrome especially in participants with a very early and chronic substance abuse. CHAPTER 6 CONCLUSIONS AND RECOMMENDATIONS 1 .2yrs). • Present results were based solely upon a clinical sample. For example the study excludes the homeless or people belonging to a lower class who in Kenya tend to underutilize the health care resources. This is similar to a study by Powell et al46 in the Uk that found patients with personality disorders were on average younger than the other patients. Carey. P. Need for longitudinal studies in the substance abuse field as little information is available to treatment providers regarding treatment modifications associated with improved outcomes. 1. B. British Journal of Psychiatry. a uniform approach to substance abuse treatment may be inadequate. Recommendations 1. Ferguson. Following the significant differences between the substance abusers with and without personality disorders. P. Personality disorders in perspective. Further studies on the prevalence of personality disorders in the general population should be carried out. REFERENCES... 3. Active screening for personality disorders in substance abusers with longer term follow up and support for such patients. Tyrer. 2.Conclusions The prevalence of personality disorders among substance abusers admitted in treatment facilities in Kenya is comparable to the median prevalence rate calculated over numerous similar studies done around the world. 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Pickering.R. and co morbidity. W. Zimmerman. (2000)... 27. Dawson. 30. Oxford University Press 2000. B. Journal of Personality Disorders. Journal of Abnormal Psychology. Journal of Personality Disorder 1997. Psychopathology. M. 2002.. Seedet.R. Tyrer.A. T. 1997. A. Lopez-Ibor. 12: 494-505. M. S. Gerdner. W. The relation between alcohol problems and anxiety disorders. Iacano.M. J. S. N. Kernberg. W. Windle.. F. R. 26. Morgenstern.. S. J. K.G. 106 : 74-84. M. American Journal of Psychiatry. Personality Disorders in drug abusers: Prevalence and their Association with Axis I Disorders as Predictors of Treatment Retention. Jarvelin. Castellano.. 34.. Relationship of Axis II Personality Disorder to other known Predictors of Addiction Treatment Outcome. Doruk.P.. R. Echeburua. Goni.25(9):1037-1047. 1999. Valdervere. Anxiety And Substance Abuse Disorders In A Young Adult Population. L.148:118-120. Torrens. E. Skodol. M. A. Davis. 37.344-359.. F. Gallaher.. Lorea. Addictive Behaviours.M.. I. Sangorrin. Axis II co morbidity of substance use disorders Among Patients Referred for Treatment of Personality Disorders.. A. Kokkonen. Herva.. Gaspari. Co morbidity of alcohol dependence and personality disorders a comparative study.United States: Results from the National Epidemiological Surveys on Alcohol Related Conditions.156: 733-738. Anastasopoulou. Martinez-Raga. G. Substance use disorders in men with antisocial personality disorders: A study in Turkish Sample. Journal of Clinical Psychiatry.. P.. J. P. Belden. J. 236: 841-853.. Nace. Perdeci.. E. H. C.M. 1998. Torres.E. Z. 1990... Laksy. The role of personality disorders on drug dependence treatment outcomes following inpatient detoxification.. P.A. J. Turbay. Calsyn... Saxon. 19: 187-192. 32. International Journal of Addiction. 2 . Kokkevi. J.. Cerversera. M. Veijola. J. Jokelainen.. 2004. 38. 42. Gutierrez.C. 1999.. Karvonen.P. J. J. 31: 1442-1448. Nord J Pschiatry.L.D. O.. 65: 948-958. Brandell. K.D. 49: 389-392. A. T.. J. American Journal of Addictions. 41. C. Oldham. M.2006. Addictive Behaviours 2006.. Personality disorders in alcoholics.. 16(4). Mateu. L. E. K.W. M. J. 20(1) 102-112 39. Haro. 31.T. J. R. Measuring the core features of personality disorders in substance abusers using the temperament and clinical inventory (TCI). Axis II Comorbidity in Substance Abusers. Pierce. J..41: 1171-1178. X.. J.. Aizpiri. Bravo de Medina. J. 1991.. Journal of Personality Disorder. 36. Mayers. Personality disorders in alcoholics: A risk factor for suicide. 33.. Uzun. Alcohol and Alcoholism. Landa. American Journal of Psychiatry. 8: 136–147. A. 40... G..E. 1995. 35. Kostogianni. Co-Occurrence Of Personality Disorders With Mood. Pettinati. A. Kantojarvi. Personality Disorders Among Cocaine and Opiod Addicts Using the Millon Clinical Multiaxial Inventory. C. N. 2004.. A..42: 618622. 2007. European Psychiatry.. Montalvo..F. Martin-Santos. Journal of Personality Disorders:2002. 2006. and Joukamaa. Substance Use and Misuse. Ekselius. 45.S.K. 5(3):305314. 46.. Brady. Addictive Behaviours. Brink. Frank. 7:1-6.. Hartgers. Powell.A. Sonne. 23:(6)869-882.J Drug Alcohol Abuse. W.1996.. Nature and prevalence of personality disorders amongst patients receiving treatment for alcohol dependence. 1998. American Journal of Addiction. Personality disorders predict relapse in alcoholic patients. AM. 44. T. Verheul. C. ADMINISTER ASSIST MANAGE THANK PATIENT TERMINATE INTERVIEW ANALYSIS OF DATA APPLY THANK AND EXCLUDE THANK AND EXCLUDE 1 . APPENDICES Appendix 1: Flow Chart illustrating methodology MEET PATIENTS AT REHABILITATION CENTRES EXCLUSION CRITERIA DO NOT APPLY EXPLAIN AND OBTAIN CONSENT SIGNS CONSENT ADMINISTER SOCIODEMOGRAPHIC QUESTIONNARE ADMINISTER SCID II.. Journal of Mental Health.43. H.D. Vanhorn. F. C. R. Peveler. 24:(3)395-404. 1998. 1998.. G.K. Diagnosis of personality disorders in cocaine-dependent individuals. Substance use situations and abstinence predictions in substance abusers with and without personality disorders. R. September 2010 October 2010 November.Appendix 2: The Time Schedule Activity Proposal Development Approval by department Ethical committee clearance Data collection Data analysis Report Writing Presentation Time Frame May.January 2010 February – April 2011 May 2011 June 2011 July 2011 1 . (Kiswahili or English) 1 .000 50.000 10.000 15.000 Appendix 4: Informed consent Explanation To be read and questions answered in a language in which the subject is fluent.Appendix 3: Budget (Kenya Shillings) Stationery.000 120.000 10. 20.000 20. printing and Photocopy services Internet access/ computer services Local transport Telephone services Data analysis Miscellaneous Total Funding will be sourced from personal savings. Huu ni utafiti wa kitabibu na unahitaji kuelewa mambo yafuatayo ambayo hutumika katika tafiti zote za namna hii. Unaweza kusitisha ridhaa yako ya kushiriki wakati wowote. please feel free to ask any questions that will allow you to understand clearly the nature of the study. Pia nitakuuliza maswali 3 . Chuo kikuu cha Nairobi.O BOX 20723.” The purpose of the study is to establish the magnitude of Personality Disorder co morbidity among this group of patients. Ongeri. legal or financial problems. University of Nairobi. All information obtained from this study will remain confidential and your privacy will be upheld. Huu utafiti utafanywa na mimi mwenyewe chini ya usimamizi wa Dr Mary Kuria na Dr Owiti ambao wote ni wahadhiri katika kitengo cha magojwa ya akili. After you read the explanation. University of Nairobi. Nitakuuliza maswali yanayohusu vile unajisikia. Kukataa kwako kushiriki haita athiri kwa namna yoyote ile huduma zako za kiafya unazotakiwa kupewa. Ongeri nasoma shahada udhamini ya magonjwa ya akili chuo kikuu cha Nairobi. social. (Kiingereza au Kiswahili) Mimi ni daktari na jina langu ni Linnet K. cannabis. Nafanya utafiti unaojulikana kama “Personality disorders among substance abusers in drug rehabilitation centres in Kenya”. thoughts and behavior . The research will be carried out by me under the supervision of Dr Fred Owiti and Dr Mary Kuria who are all Lecturers in the Department of Psychiatry. mafikira na pia tabia yako.I. which apply to all in medical research. leading to the implementation of better interventions and comprehensive care for patients with substance use problems. Dhumuni la utafiti huu nikujua ukubwa wa tatizo la Personality disorders kati ya kundi hili la wagonjwa. Your participation is entirely voluntary. Nairobi. Baada ya kusoma maelezo usisite kuuliza maswali endapo utahitaji ufafanuzi. I hope that information generated by this study will be of benefit. If you have any questions you can contact me on telephone number 0722615999 or my lead supervisor Dr Owiti at the Department of Psychiatry. Dr Linnet K. No invasive procedure such as drawing of blood will be involved. khat and others and whether their use has led to any health. The procedure will involve my asking you questions concerning your feelings. This is a Medical research study and you are required to understand the following general principles. Refusal to participate will not lead to any penalty or benefit to which you are otherwise entitled. tobacco. Appendix 5: Fomu ya Maelezo ya Maridhiano Isomwe na maswali yajibiwe kwa lugha ambayo inaeleweka na mshiriki wautafiti. Identification will be by number only. You can also forward any concerns to the KNH/ UON Ethics and Research Committee at Kenyatta Hospital on telephone number 726300-9 or P. no names will be used in this study or in its future publications. You may withdraw from the study at any time. wish to do a study entitled “Prevalence of Personality Disorders among substance abusers in drug rehabilitation centers in Kenya. Kushiriki kwako ni kwa hiari.I will also ask you questions concerning your history of use of substances such as alcohol. bangi. Signature ____________________Date_______________________ Serial number ______________________________________________________ Signature___________________________Date_______________________ (Dr Linnet K. Natumaini taarifa zitakazopatikana katika utafiti huu zitakuwa za manufaa na zitasaidia katika kuboresha utoaji wa huduma za kiafya miongoni mwa wagonjwa wa madawa ya kulevya.P 20723. kijamii au kiuchumi. Endapo utakuwa na maswali yoyote kuhusiana na utafiti huu tafadhali nipigie katika namba zangu za simu ambazo ni 0722615999 au unaweza kuwasiliana na msimamizi wangu mkuu Dr Owiti katika kitengo cha afya na magonjwa ya akili chuo kikuu cha Nairobi. pombe. na itatumika namba badala ya jina lako katika kukutambua.. Appendix 6: Consent Form I. Habari zitakazopatikana katika utafiti huu zitabakia kuwa siri.yanayohusu historia yako ya matumizi ya madawa ya kulevya kama vile sigara. Hakutakuwa na utolewaji damu katika utafiti. Unaweza pia kuwasilisha dukuduku zako kwa KNH/ UON Ethics and Research Committee at Kenyatta Hospital kwenye namba 726300-9 au S. miraa na nyinginezo nakujua endapo matumizi ya madawa haya yamekusababishia matatizo mbali mbali kama vile ya kiafya. Ongeri) 2 .L. Nairobi. Ongeri I understand that all information gathered will be used for the purposes of this study only. the undersigned do hereby Volunteer to participate in this study. The nature and purpose have been fully explained by Dr Linnet K. Highest level of education. Marital status. Student ii. Unemployed vi. Married iii. Separated iv. Formal employment iii. More than 1category specify_________________ Others specify_________ (tick where appropriate) 6.Appendix 7: Socio-demographic Questionnaire Date_____________________________ Serial number______________________ 1. Age in years_______________________ 2. Catholic ii. Muslim 1 . Widowed v. No formal education ii. Religion i. Occupation i. Single ii. i. Primary iii. Sex Male Female 3. Divorced v. Cohabiting 4. Secondary iv. Informal employment iv. Tertiary (College/University 5. Protestant iii. Business person v. i. hash. (kumi kumi) c) Caffeine d) Cannabis (marijuana. Duration of Previous admissions in rehabilitation center 1-7 days 1 week 8-14 days 2 weeks 15-21 days 3 weeks 22-29 days 1 month 30-60 days 2 month > 61 >2month 9. PCP.iv. which of the following substance have you 0= 1= Yes Ever used? No a) Tobacco products ( cigarettes. etc) h) Sedatives or sleeping pills ( valium. cigars etc) b) Alcoholic beverages ( beer. chewing tobacco. Others specify ______ 7. Previous admissions in rehabilitation center If Yes. etc) f) Amphetamine type stimulants (speed. diet pills. petrol. cigars etc) b) Alcoholic beverages ( beer. In your life. crack. bhang) e) Cocaine (coke. grass. wine. Family history of substance abuse (Yes) 10. khat/ Miraa) g) Inhalants (nitrous. (kumi kumi) c) Caffeine d) Cannabis (marijuana. SMOKING AND SUBSTANCE INVOLVEMENT SCREENING TEST (ASSIST) 1. pot. chewing tobacco. 4=Daily 0 1 2 3 4 or Almost daily 1. how often have you used the substance you mentioned? a) Tobacco products ( cigarettes. In the past 3months. codeine. pot. morphine. Serepax. Rohypnol) i) Hallucinogens (LSD. 3=Weekly. paint thinner. mushrooms. wine. 2= Monthly. ecstasy. spirits changaa. bhang) 1 . Age of onset of substance abuse <10yrs 10-18yrs >18yrs (No) Appendix 8: ASSIST Questionnaire THE ALCOHOL. acid. Special K) j) Opioids ( heroin. glue. 1= once or twice. spirits changaa. Brown sugar) k) Other-specify Q2 – Q5 tick: 0= Never. hash. Number of previous admissions 1 2 >2 (Yes) (No) 8. grass. Brown sugar) k) Other-specify 1. diet pills. chewing tobacco. mushrooms. (kumi kumi) c) Caffeine d) Cannabis (marijuana. cigars etc) b) Alcoholic beverages ( beer. Special K) Opioids ( heroin. khat/ Miraa) Inhalants (nitrous. morphine. pot. etc) h) Sedatives or sleeping pills ( valium. codeine. morphine. etc) Amphetamine type stimulants (speed. glue. petrol. Brown sugar) Other-specify 1. substance you have mentioned in Q1 how often have you had a strong desire a) Tobacco products ( cigarettes.e) f) g) h) i) j) k) Cocaine (coke. etc) f) Amphetamine type stimulants (speed. glue. mushrooms. PCP. ecstasy. khat/ Miraa) g) Inhalants (nitrous. paint thinner. and social. PCP. bhang) e) Cocaine (coke. legal. grass. hash. spirits changaa. During the past 3 months. acid. Serepax. acid. petrol. crack. diet pills. codeine. Special K) j) Opioids ( heroin. paint thinner. etc) Sedatives or sleeping pills ( valium. crack. Rohypnol) i) Hallucinogens (LSD. wine. how often has your use of drugs mentioned in question 1 led to health. Serepax. Rohypnol) Hallucinogens (LSD. During the past 3 months. or financial problems? (Specify the four leading drugs) Health problems ( specify the four leading drugs Drug i) Drug ii) Drug iii) Drug iv) Social problems ( specify the four leading drugs Drug i) Drug ii) Drug iii) Drug iv) Legal problems ( specify the four leading drugs Drug i) Drug ii) Drug iii) Drug iv) 2 . ecstasy. 2. During the past 3 months, how often have you failed to do what was normally expected of your Because of your use of: (Specify the four leading drugs) Drug i) Drug ii) Drug iii) Drug iv) Q6 – Q8 0=No, Never, 1= Yes, but in the past 3 months , or 2= yes in the past 3 months 3. Has a friend or relative or anyone else never expressed concern about your use of drug ( if yes Specify the four leading drugs) Drug i) Drug ii) Drug iii) Drug iv) 4. Have you ever tried to control, cut down or stop using drug ( if yes Specify the four leading drugs) Drug i) Drug ii) Drug iii) Drug iv) 5. Have you ever used any drug by injection (non-medical use only( if yes Specify the four leading drugs) Drug i) Drug ii) Drug iii) Drug iv) 0 1 2 3 Appendix 9 Structured Clinical Interview for DSM-IV Axis-II Personality Disorders (SCID-II) SCID-II SUMMARY SCORESHEET Personality Disorder Number of Items Coded “3” (Boxed numbers indicate threshold required for a diagnosis.) 01 Avoidant 02 Dependent 03 Obsessive -Compulsive 04 Passive-Aggressive 05 Depressive 06 Paranoid 07 Schizotypal 08 Schizoid 09 Histrionic 10 Narcissistic 11 Borderline 12 Antisocial 13 Not Otherwise Specified (NOS) PRINCIPAL AXIS II DIAGNOSIS (i.e., the Personality Disorder that is – or should be – The main focus of clinical attention). Enter code number from left of diagnosis above: ___ ___ Note: Enter 99 if no Axis II disorder. 1 1 1 1 1 1 1 1 1 1 1 1 1 2 2 2 2 2 2 2 2 2 2 2 2 3 3 3 3 3 3 3 3 3 3 3 3 4 4 4 4 4 4 4 4 4 4 4 4 5 5 5 5 5 5 5 5 5 5 5 6 6 6 6 6 6 6 6 6 6 6 7 7 7 7 7 7 7 7 7 7 7 7 8 8 8 9 9 8 9 8 8 5 6 1 OVERVIEW FOR PERSONALITY DISORDERS Now I am going to ask you some questions about the kind of person you are – that is, how you generally have felt or behaved. IF A CIRCUMSCRIBEED OR EPISODIC AXIS I DISORDER HAS BEEN PRESENT: I know that there have been times when you have been [AXIS I SYMPTOMS]. I am not talking about those times; you should try to think of how you usually are when you are not [AXIS I SYMPTOMS]. Do you have any questions about this? How would you describe yourself as a person (before [AXIS I SYMPTOMS])? IF CAN’T ANSWER, MOVE ON. How do you think other people would describe you as a person (before [AXIS I SYMPTOMS])? Who have been the important (IF MENTIONS ONLY FAMILY: What about friends?) How have you gotten along with them? Do you think that the usual way that you react to things or behave with people has caused you problems with anyone? (At home? At school? At work?) (In what way?) What kinds of things have you done that other people might have found annoying? How do you spend your free time? If you could change your personality in some ways, how would you want to be different? IF PERSONLITY QUESTIONNAIRE HAS BEEN COMPLETED: Now I want to go over the questions to which you answered “yes” on the questionnaire. IF PERSONLAITY QUESTIONNAIRE HAS NOT BEEN COMPLELTLED: Now I want to ask you some more specific questions. ? = inadequate information 1 = absent or false 2 = subthreshold 3 = threshold or true AVOIDANT PERSONALITY DISORDER 1 What was the reason that you avoided these [LIST JOBS OR TASKS]? (Have you ever refused a promotion because it would involve dealing with more people than you would be comfortable with?) 2. You’ve said that [Do] you avoid getting involved with people ? 1 2 3 ? 1 2 3 unless you are certain they will like you. as smart. You’ve said that [Do] you find it hard to be “open” even with ? 1 2 3 people you are close to. or as attractive as most other people. Give me some examples. 7. Why is this? (Are you afraid of being made fun of or embarrassed?) 4. If you don’t know whether someone likes you. You’ve said that you have [Have you] avoided jobs or tasks that involved having to deal with a lot of people. or not good enough?) 6. You’ve said that {Do ] you believe that you’re not as good. Tell me about that. AT LEAST FOUR ITEMS ARE CODED “3” 1 3 ? 1 2 3 ? 1 2 3 ? 1 2 3 ? 1 2 3 AVOIDANT PERSONALITY DISORDER DEPENDENT PERSONALITY DISORDER 8. You’ve said that you’re [Are you] afraid to try new things. Give me some examples.1. You’ve said that you’re [Are you] usually quite when you meet new people Why is that? (Is it because you feel in some way inadequate. Do you spend a lot of time worrying about this? 5. You’ve said that [Do] you need a lot of advice or reassurance from others before you can make everyday decisions – like 1 ? 1 2 3 . You’ve said that [Do] you often worry about being criticized or rejected in social situations. would you ever make the first move? 3. Is that because you are afraid of being embarrassed? Give me some examples. Give me some examples. You’ve said that [Do] you worry a lot about being left alone ? 1 2 3 to take care of yourself. You’ve said that you have [Have you] often volunteered to do things that are unpleasant. You’ve said that [Do] you usually feel uncomfortable when you are by yourself. Give me some examples. You’ve said that [Do] you find it hard to disagree with people even when you think they are wrong. (Have you reacted this way almost always when close relationships have ended?) ? 1 2 3 ? 1 2 3 ? 1 2 3 ? 1 2 3 ? 1 2 3 ? 1 2 3 15.what to wear or what to order in a restaurant. child care or living arrangements. do you] feel you immediately have to find someone else to take care of you. You’ve said that you [Do you] depend on other people to handle important areas in your life such as finances. Why is that? (Is it because you need someone to take care of you?) 14. Why is that? (Is this because you are not sure you can do it right?) 12. Are there often times when you keep worrying abut this? Do you have periods when you worry about this all the time? 1 . Give me some examples of when you’ve found it hard to disagree? What are you afraid will happen if you disagree? 11. You’ve said that when a close relationship ends you [When a close relationship ends. Can you give me some examples of the kinds of decisions you would ask for advice or reassurance about? (Does this happen most of the time?) 9. Tell me about that. You’ve said [Do] you find it hard to start or work on tasks when there is no one to help you. Give me some examples of these kinds of things. Why is that? 13. (Is this more than just getting advice from people?) (Has this happened with MOST important areas of your life?) 10. You’ve said that it is [Is it] hard for you to let other people help you unless they agree to do things exactly 3 ? 1 2 3 ? 1 2 3 . (Do you follow rules to the letter of the law. Tell me about it. You’ve said that you or other people feel that you [Do you ? 1 2 3 ? 1 2 3 ? 1 2 3 or other people feel that you] are so devoted to work (or school) that you have no time left for anyone else or for just having fun. You’ve said that [Do] you have very high standards about what is right and what is wrong. Give me some examples of your high standards. (How often does this happen?) 18. 19. Give me some examples Do you sometimes get so caught up with [EXAMPLES] that you lose sight of what you are trying to accomplish? (…Like you can’t see the forest for the trees?) (Does this happen often?) 17. no matter what?) IF GIVES RELIGIOUS EXAMPLES: Do even people who share your religious views say you’re too strict about right and wrong? ? 1 2 3 20. You’ve said that you are [Are you] the kind of person who focuses on details. You’ve said that [Do] you have trouble finishing jobs because you spend so much time trying to get things exactly right. (How cluttered does your place get because you don’t throw things out?) 21.AT LEAST FIVE ITEMS ARE 1 CODED “3” 3 DEPENDENT PERSONLITY DISORDER OBSESSIVE-COMPULSIVE PERSONALITY DISORDER 16. order. Give me some examples of things that you’re unable to throw out. and organization or likes to make lists and schedules. Give me some examples. You’ve said that [Do] you have trouble throwing things out because they might come in handy some day. (Does this happen often?) (Do you often end up doing things yourself to make sure they are done right?} 22. Give me some examples of this. Tell me about that. You’ve said that you are [Are you] often so sure you are right that it doesn’t matter what other people say. 1 . you [When someone asks you to do something that you don’t want to do. Tell me about that AT LEAST FOUR ITEMS ARE CODED “3” 1 3 OBSESSIVE COMPULSIVE PERSONALITY DISORDER PASSIVE-AGGRESSIVE PERSONALITY DISORDER 25. You’ve said that other people have told you [Have other ? 1 2 3 ? 1 2 3 ? 1 2 3 people told you] that you are stubborn or rigid. You’ve said that when someone asks you to do something ? 1 2 3 that you don’t want to do. 23. 24.the way you want. Why? (Is this because you’re worried about not having enough in the future when you really need it?) Tell me about some things you haven’t spent money on because you have to save for the future. do you] say yes” but then work slowly or do a bad job. Tell me about it. You’ve said that it is [Is it] hard for you to spend money on yourself and other people even when you have enough. You’ve said that [Do] you often think that it’s not fair that other people have more than you do. You’ve said that you’re [Are you] often grumpy and likely to get into arguments. You’ve said that [Do] you often complain that more than your share of bad things have happened to you. You’ve said that [Do] you often feel that other people don’t understand you or don’t appreciate how much you do. Tell me more about this. Tell me more about that. 30. Tell me more about that. 27. Give me some examples of this. You’ve said that you’ve [Have you] found that most of your ? 1 2 3 ? 1 2 3 ? 1 2 3 bosses. doctors and others who are supposed to know what they are doing really don’t.26. AT LEAST FOUR ITEMS ARE CODED “3” 1 3 ? 1 2 3 PASSIVEAGGRESSIVE 1 . teachers. You’ve said that [Do] you often angrily refuse to do what others want and then later feel bad and apologize. do you feel that bad things are always happening to you? ? 1 2 3 ? 1 2 3 32. 29. 31. Tell me about that. Looking back on your life. You’ve said that if you don’t want to do something you [If you don’t want to do something. do you] often just “forget” to do it. (Do you complain to other people about this?) 28. Tell me when this happens. supervisors. 38. 39. You’ve said that [Do] you often judge other harshly and ? 1 2 3 ? 1 2 3 easily find fault with them. Tell me about that. 33. You’ve said that you [Do you] almost always expect things to turn out badly. You’ve said that [Do] you believe that you are basically an ? 1 2 3 inadequate person and often don’t feel good about yourself. 40. What kinds of things? ? 1 2 3 ? 1 2 3 AT LEAST FIVE ITEMS AR 1 3 3 . ? 1 2 3 Tell me about that. You’ve said that you [Do you] often put yourself down. Tell me about that. You’ve said that you [Do you] think that most people are basically no good. 35. 34. You’ve said that you [Do you] often feel guilty about things you have or haven’t done. Give me some examples of the kinds of things you are critical of.PERSONALITY DISORDER DEPRESSIVE PERSONALITY DISORDER Note: The DSM-IV criterion excludes a diagnosis of Depressive Personality Disorder if the behaviour occurs only during Major Depressive Episodes or is better accounted for by Dysthymic Disorder. (Do you often blame yourself for things that haven’t worked out?) 36. Refer to the User’s Guide for a discussion of options for operationalizng this criterion. Tell me about that. You’ve said that [Do] you keep thinking about bad things that have happened in the past or worry about bad things that might happen in the future. 37. You’ve said that [Do] you usually feel unhappy or ? 1 2 3 that life is no fun. Tell me about that. Tell me about that. 46. 41. 42. 1 ? 1 2 3 ? 1 2 3 . You’ve said that you [Do you] spend a lot of time wondering if you can trust your friend or the people you work with. Describe situations where you’ve gotten that feeling. 45.CODED “3” DEPRESSIVE PERSONALITY DISORDER PARANOID PERSONALITY DISORDER Note: Behaviour should NOT be considered characteristic of Paranoid Personality Disorder if it occurs exclusively during the course of Schizophrenia. When has this happened? Tell me about it. Tell me about that. (Do you feel this way often?) 43. ? 1 2 3 ? 1 2 3 ? 1 2 3 44. Tell me about that. Give me some examples. You’ve said that [Do] you often have to keep an eye out to stop people from using you or hurting you. a Mood Disorder With Psychotic Features. Tell me about that. You’ve said that [Do] you find that it is best not to let other people know much about you because they will use it against you. You’ve said that you’re [Are you] the kind of person who holds grudges or takes a long time to forgive people who have insulted or slighted you. You’ve said that there are [Are there] many people you can’t forgive because they did or said something to you a long time ago. or another Psychotic Disorder or is due to the direct physiological effects of a general medical condition. You’ve said that [Do] you often detect hidden threats or insults in things people say or do. You’ve said that you have [Have you] often suspected that your spouse or partner has been unfaithful. Tell me more about this. do you] often get the feeling that you are being watched or stared at. You’ve said that [Do] you often get angry or lash out when someone criticizes or insults you in some way. tell me about that. 49. You’ve said that when you are out in public and see people talking [When you are out in public and see people talking. a Mood Disorder With Psychotic Features. or a Pervasive Developmental Disorder. 51. 52. Tell me about that. you [When you are around people. You’ve said that when you are around people. ? 1 2 3 50. (How did it affect you?) ? 1 2 3 3 . (What clues did you have? What did you do about it? Were you right?) ? 1 2 3 ? 1 2 3 AT LEAST FOUR ITEMS ARE CODED “3” 1 3 PARANOID PERSONALITY DISORDER SCHIZOTYPAL PERSONALITY DISORDER Note: Behaviour should NOT be considered characteristic of Schizotypal Personality Disorder If it occurs exclusively during the course of Schizophrenia. (Do others believe that you often take offense too easily?) 48. You’ve said that you have [Have you ever] felt that you could make things happen just by making a wish or thinking about them.47. You’ve said that you [Do you] often get the feeling that things that have no special meaning to most people are really meant to give you a message. Tell me more about this. another Psychotic Disorder. Tell me more about this. do] you often feel that they are talking about you. Give me some examples. 53. You’ve said that you [Do you] believe that you have a “sixth sense” that allows you to know and predict things that others can’t. vague circumstantial. You’ve said that you [Do you] often see auras or energy fields around people.. over-elaborate or stereotyped) CODE “3” IF ANY OF PARANOID CRITERIA (1). Tell me about that. tell me about that (How did it affect you?) 54. What are you nervous about? (Are you still anxious even after you’ve known them for a while?) ? 1 ? ? 1 2 3 2 2 3 3 1 ? 1 2 3 1 . or peculiar 58. You’ve said that you have [Have you] had the sense that some person or force is around you. (Were you drinking or taking drugs at the time?) 57. even though you cannot see anyone. You’ve said that there are [Are there] very few people that you’re really close to outside of you immediate family. Tell me more about that. (3).g. (were you drinking or taking drugs at the time?) 56. (4). You’ve said that you have [Have you] had a personal experiences with the supernatural. (How does it affect you?) 55. (Were you drinking or taking drugs at the time?) OBSERVED DURING INTERVIEW Odd thinking and speech (e. OR (7) ARE CODED “3” ? 1 2 3 ? 1 2 3 ? 1 2 3 OSERVED DURING INTERVIEW Inappropriate or constricted affect OBSERVED DURING INTERVIEW Behavior or appearance that is odd. Tell me more about that. eccentric. You’ve said that [Do] you often feel nervous when you are with other people. How many close friends do you have? 59. You’ve said that it often seems [Does it often seem] that objects or shadows are really people or animals or noises are actually people’s voices. Metaphorical. (2). (Have you always had little interest in having sex?) 63. 3 ? 1 2 3 ? 1 2 3 ? 1 2 3 ? 1 2 3 ? 1 2 3 . Tell me more about that. You’ve said that it is [Is it] NOT important to you whether you have any close relationships. (Is that true both at work and during your free time?) 62. Tell me more about that. You’ve said that you could [Could you] be content without ever being sexually involved with anyone. You’ve said that you would [Would you] almost always rather do things alone than with other people. or a Pervasive Developmental Disorder or is due to the direct physiological effects of a general medical condition. a Mood Disorder With Psychotic Features. You’ve said that there are [Are there] really very few things that give you pleasure. (What about physical things like eating a good meal or having sex?) ALREADY CODED ON ITEM (8) FOR SCHIZOTYPAL PERSONALITY DISORDER. tell me more about that. (What about you family?) ? 1 2 3 61. another Psychotic Disorder.AT LEAST FIVE ITEMS ARE CODED “3” 1 3 SCHIZOTYPAL PERSONALITY DISORDER SCHIZOID PERSONALITY DISODER Note: Behaviour should NOT be considered characteristic of Schizoid Personality Disorder if it occurs exclusively during the course of Schizophrenia. Lack of close friends other than first-degree relatives 64. 60. You’ve said that it doesn’t [Does it NOT] matter to you what people think of you. (ALSO CONSIDER BEHAVIOUR DURING INTERVIEW) 1 ? 1 2 3 . You’ve said that [Do ] you find that nothing makes you very happy or very sad. Tell me about that. You’ve said that you [Do you] often make a point of being dramatic and colourful. (ALSO CONSIDER BEHAVIOUR DURING INTERVIEW) ? 1 2 3 AT LEAST FOUR ITEMS ARE CODED “3” 1 3 SCHIZOID PERSONALITY DISORDER HISTRIONIC PERSONALITY DISORDER 66. How do you do that? Do you do that all the time? OBSERVED DURING INTERVIEW Has a style that is exceptionally impressionistic and lacking in detail ? 1 ? 1 2 3 70. You’ve said that [Do] you flirt a lot. You’ve said that [Do] you like to be the center of attention. Tell me more about that. Has anyone complained about this? (ALSO CONSIDER BEHAVIOUR DURING INTERVIEW) ? 1 2 2 3 3 ? 1 68. How do you feel when you’re not? 67. You’ve said that you [Do you] try to draw attention to yourself by the way you dress or look. You’ve said that you [Do you] often find yourself “coming on” to people Tell me about it.How do you feel when people praise you or criticize you? 65. (ALSO CONSIDER BEHAVIOUR DURING INTERVIEW) OBSERVED DURING INTERVIEW Displays rapidly shifting and shallow expression of emotion ? 1 2 2 3 3 69. (Do you like to show your emotions – for example. ? 1 2 3 76. How many? Who are they? AT LEAST FIVE ITEMS ARE CODED “3” ? ? 1 2 3 72. Tell me more about that. (Why do you have to see the top person?) 1 ? 1 2 3 74. ? 1 2 3 75. Give me an example You’ve said that people have [Have people] told you that you have too high an opinion of yourself. hugging people even if you don’t know them very well or crying very easily?) 71. fame or recognition that will be yours someday. Give me some examples. (How much time do you spend thinking about this?) You’ve said that when you have a problem [When you have a problem. (How much time do you spend thinking about these things?) You’ve said that [Do] you think a lot about the perfect romance that will be yours someday. 77. do]you almost always insist on seeing the top person. Tell me more about this. You’ve said that you [Do you] often change your mind about things depending on the people you’re with or what you have just read or seen on TV. Tell me more about this. 1 2 3 1 HISTRIONIC PERSONLAITY DISORDER 3 NARCISSISTIC PERSONALITY DISORDER 73. ? 1 2 3 . Give me some examples of this. You’ve said that you [Do you] have lots of friends that you are very close to. You’ve said that [Do] you think a lot about the power. You’ve said that [Do] people often fail to appreciate your very special talents or accomplishments. You’ve said that [Do] you often find it necessary to step on a few toes to get what you want. Tell me more about this. You’ve said that [Do] you often have to put your needs above Other people’s. Give me some examples. You’ve said that [Do] you often expect other people to do what you ask without question because of who you are. You’ve said that you are [Are you] often envious of others. 85. You’ve said that people have [Have people] complained to you that you don’t listen to them or care about their feelings. ? 1 2 3 79. Tell me more about that. ? 1 2 3 83. You’ve said that [Do] you think that its not necessary to follow certain rules or social conventions when they get in your way. Why is that? You’ve said that it is [Is it] very important to you that people pay attention to you or admire you in some way. Tell me some instances of that. give me some examples of when that happens. 82. ? 1 2 3 88. 80. (How often do you feel that way?) You’ve said that [Do] you feel that others are often envious of you. 89. ? 1 2 3 3 . What do they envy about you? You’ve said that you [Do you] find that there are very few people that are worth your time and ? 1 2 3 84. (Does this happen often?) You’ve said that you’re [Are you] NOT really interested in other people’s problems or feelings. Tell me about it. ? 1 2 3 86. Tell me more about this. Why do you feel that way? You’ve said that [Do] you feel that you are the kind of person who deserves special treatment. Tell me more about that. 87. You’ve said that [Do] you feel it is important to spend time with people who are special or influential. (Does that happen often?) ? 1 2 3 81.78. Give me examples of this. ? 1 2 3 93. Tell me more about that. You’ve said that [DO] your relationship with people you really care about have lots of extreme ups and downs. and so on. Give me some example of this. Tell me about them (Were there times when you thought they were everything you wanted and other times when you thought they were terrible? How many relationships were like this?) You’ve said that you have [Have you] all of a sudden changed your sense of who you are and where you are headed.(ALSO CONSIDER BEHAVIOUR DURING INTERVIEW) AT LEAST FIVE ITEMS ARE 1 3 CODED “3” NARCISSISTIC PERSONALITY DISORDER BORDERLINE PERSONALITY DISORDER 90. regions beliefs. You’ve said that you’ve [have you] often done things impulsively. 94. What kind of things? 1 ? 1 2 3 . Tell me more about that. 96. You’ve said that you are [Are you] different with different people or in different situation so that you sometimes don’t know who you really are. You’ve said that you have [Have you] often become frantic when you thought that someone you really cared about was going to leave you. [Do you feel this way a lot?] 95. You’ve said that your sense of who you are often changes [does your sense of who you are often change ]dramatically. What have you done? (Have you threatened or pleaded with him/her?) ? 1 2 3 91. You’ve said that there have been [ Have there been ] lots of sudden changes in your goals. career plans. ? 1 2 3 92. . 98. or unsafe sex? ……Drinking too much or taking drugs?…. ? 1 ? 1 2 2 3 3 102. Does this happen often? 103.Having sex with people you hardly know. (How long do your “bad” moods last? How often do these mood changes happen? How suddenly do your moods change?) ? 1 2 3 Tell ? 1 2 3 99. 101. you [When you are under a lot of stress. 100.Driving recklessly? ……. burned. You have said that [Do] you hit people or throw things when you get angry. Tell me about this.uncontrollable eating?) 97. You’ve said that [Do] even little things get you very angry? when does this happen? (Does this happen often?) 104. You’ve said that you have [Have you] tried to hurt or kill yourself or threatened to do so. You’ve said that [Do] you have a lot of sudden mood changes. You’ve said that when you are under stress. You’ve said that [Do] you often feel empty inside? Tell me about this.. You’ve said that you have [Have] you ever] cut. or scratched yourself on purpose.(How about……. Tell me about that. Tell me about that AT LEAST FIVE ITEMS ARE 1 3 CODED “3” BORDERLINE PERSONALITY DISORDER ? 1 2 3 1 .. You’ve said that [Do] you often have temper outbursts or get so angry that you lose control. do you] get suspicious of other people or feel especially spaced out.buying things you really couldn’t afford? ……. Tell me about this. me about that.. [Before you were 15. broken bottle. You’ve said that before you were 15. Tell me about it.knife. You’ve said that before you were 15 would you [before you were 15.you robbed. like a bat. or ? 1 2 3 ? 1 2 3 to have sex with you. How often? 107. brick. Tell me about that.[ before you were 15 did you hurt or threaten someone]with a weapon.did you torture or hurt animals on purpose?] What did you do? forcibly take] something from someone by threatening him or her. you would[before you were 15 would you] start fights. You’ve said that before you were 15 you [Before you were 15.did you force someone] ? 1 ? 1 2 2 3 3 ? 1 2 3 109. or to touch you. 112. Tell me about it. to get undresses in front of you. 111. You’ve said that before you were 15.ANTISOCIAL PERSONALITY DISORDER Note: Behaviour should NOT be considered characteristics of Antisocial Personality disorder if it occurs exclusively during the course of schizophrenia or a manic Episode. You’ve said that before you were 15. B. You’ve said that before you were 15. or gun.you deliberately tortured someone or caused someone physical pain and suffering. There is evidence of conduct disorder with onset before 15 years [as evidenced by at least two of the following] 105.would you] bully or threaten other kids. 3 . You’ve said that before you were15. [Before you were 15. ? 1 2 3 110. The individual is at least 18 years.did you deliberately torture someone or caused someone physical pain and suffering?] What did you do? You’ve said before you were 15 you tortured or hurt animals on purpose. mugged. ? 1 2 3 did you ]set fires. 108. or to touch you sexually. C. Tell me about that ? 1 2 3 ? 1 2 3 106. you sometimes stole or ? 1 2 3 shoplifted things or forged someone’s signature. How often? 119.did you] often stay out very late. CONTINUE ON NEXT PAGE 1 . You’ve said that before you were 15. You’ve said than before you were 15. long after the time you were supposed to be home.you often skipped ? 1 2 3 [Before you were 13. What did you do? 114. You’ve said that before you were 15.. “some” evidence of conduct disorder) 1 3 CRITERION C OF ANTISOCIAL PERSONALITY DISORDER MET. did you deliberately destroy] things that weren’t yours. How often? AT LEAST TWO ITEMS ARE CODED “3”(i. ? 1 2 3 other building. 117.did you lie a lot or “con”]other people.Tell me about it 113. 115.you lied a lot or “conned” ? 1 2 3 [before you were 15.you would [Before you ? 1 2 3 were 13. You’ve said that before you were 13.[before you were 15. You’ve said that before you were 15. or cars. You’ve said that before you were 15 .did you break]into houses. Tell ma about that. What would you lie about? 116. You’ve said that before you were 13.did you sometimes steal or shoplift things or forge someone’s signature?] Tell me about it. you deliberately destroyed ? 1 2 3 [Before you were 15. you ran away from home ? 1 2 3 and stay]away overnight Was it more than once? (With whom were you living with at the time?) 118.e.did you often skip] school. (How often?) 124. Since you were 15 have you been in any fights? ? 1 2 3 ? 1 2 3 ? 1 2 3 How often? Have you ever hit or thrown things at your spouse or partner? How often? Have you ever hit a child. Do you always use protection if you have sex with someone you don’t know well? (Has anyone ever said that you allowed a child that you were taking care of to be in a dangerous situation?) 126. since you were 15…. writing bad checks. did you miss a lot of work? IF YES: WHY? 3 .. yours or someone else’s – so hard that he or she had bruises or had to stay in bed or see a doctor? Tell me about that.GO TO PERSONALITY DISORDER NOT OTHERWISE SPECIFIED 120. Now. How much of the time in the last 5 years were you not working? IF FOR A PROLONGED PERIOD: Why (Was there work available?) When you were working. Do you often find that you have to lie to get what you want? (Have you ever used an alias or pretended you were someone else?) (Have you often” conned “ others to get what you want?) 122. Have you done things that are against the law (even if you weren’t caught) like stealing. Do you often do things on the spur of the moment without thinking about how it will affect you or other people? What kind of things Was there a time when you had no regular place to live? (For how long) 123. Did you ever drive a car when you were drunk or high? ? 1 2 3 How many speeding tickets have you gotten or car accident have you been in? 125. using or selling drugs. or having sex for money? IF NO: Have you ever been arrested for anything? ? 1 2 3 121. Have you physically threatened or hurt anyone else? Tell me about that. Did you ever walk off a job without having another one to go to? IF YES: How many times did this happen? 127. An example is the presence of features of more than one personality disorder that do not meet the criteria of any one personality disorder (“mixed personality”) but together cause clinically significant distress or impairment in one or more important areas of functioning (e..g. B. self defeating personality disorder) is appropriate. social or occupational). 1 PERSONALITY DISORDER NOT OTHERWISE SPECIFIED ..g. Have you ever owed people money and not paid them back? (HOW OFTEN?) What about not paying child support. IF THERE IS EVIDENCE OF ANTISOCIAL ACTS AND ? 1 2 3 IT IS UNCLEAR WHETHER THERE IS ANY REMORSE: How do you feel about [LIST ANTISOCIAL ACTS]? (Do you think what you did was wrong in any way?) AT LEAST THREE ITEMS ARE CODED “3” 1 3 CRITERION A OF ANTISOCIAL PERSONALITY DISORDER MET CRITERIA A. AND C ARE CODED “3 “ 1 3 ANTISOCIAL PERSONALITY DISORDER PERSONALITY DISORDER NOT OTHERWISE SPECIFIED This category is for disorders of personality functioning that 1 3 do not meet criteria for specific personality disorder. or not giving money to children or someone else who depended on you? 128. This category can also be used when the clinician judges that a specific personality disorder is not included in the classification (e. 1 .