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Conduct Disorder and Antisocial Personality in Adult Primary Care Patients

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Conduct Disorder and Antisocial Personality in Adult Primary Care Patients ORIGINAL RESEARCH Conduct Disorder and Antisocial Personality in Adult Primary Care Patients Kristen Lawton Barry, PhD; Michael F. Fleming, MD, MPH; Linda Baier Manwell; and Laurel A. Copeland, MPH Ann Arbor, Michigan, and Madison, Wisconsin BACKGROUND. Conduct disorder has been linked to substance use disorders in clinical populations. This study examined the relationships of conduct disorder and antisocial personality (ASP) disorder to substance use, substance abuse problems, depression, and demographic factors in primary care settings. METHODS. As part of a larger clinical trial, a survey of 1898 patients in the offices of 64 primary care physi­ cians was conducted using a self-administered health habits questionnaire. Childhood conduct disorder and adult antisocial personality disorder were assessed using criteria from the Diagnostic and Statistical Manual of Mental Disorders, Third Edition, Revised. RESULTS. Eight percent of men and 3.1 % of women met criteria for a diagnosis of ASP disorder. The frequen­ cy of a history of childhood conduct disorders was higher, with 13.4% for men and 4% for women. Antisocial personality disorder was predicted by male sex, being unmarried (single, separated, divorced), lifetime history of depression, binge drinking, self-reported history of drug problems, current smoking, and younger age. The pre­ dictors of a history of child conduct disorder were similar to those of ASP. CONCLUSIONS. Primary care physicians treat many patients who have personality disorders and other condi­ tions such as alcohol problems and depression. These patients need to be identified because of the high poten­ tial for comorbidity and the barriers to treatment inherent in these disorders. KEY WORDS. Child behavior disorders; antisocial personality disorder; substance abuse; physicians, family. (J Fam Pract 1997; 54:151-158) hildhood conduct disorder refers to a potential concurrent problems with substance use disorder marked by a variety of behavior disorders. problems at home and in school that The extent of the disorder in the United States begin before the age of 15. If these prob­ has been delineated in two national samples. The lems continue into adulthood in the con­ Epidemiologic Catchment Area (ECA) Study1 inter­ text of a failure to conform to social norms, viewedthe a stratified sample from community and conditionC is likely to become an antisocial person­ institutional populations aged 18 and older ality (ASP) disorder. Persons with the disorder tend (N=20,000) in five US sites in the late 1970s to esti­ to be aggressive and impulsive and often lack nor­ mate rates of a number of mental health disorders. mal capacities for cooperation with authority fig­ This study found that one or more psychiatric dis­ ures.1 These patients are perceived as difficult to orders had been experienced at some time in their treat medically because of compliance issues and lives by 32% of American adults, and 20% had an active disorder. The investigators reported an ASP Submitted, revised, April 17, 1997. From the Veterans Administration, Serious Mental Illness disorder prevalence of 7.3% for men and 1.0% for Treatment Research and Evaluation Center (K.L.B. and women utilizing the Diagnostic Interview Schedule LAC.), and University of Michigan, Department of (DIS) based on the Diagnostic and Statistical Psychiatry, Alcohol Research Center (K.L.B.), Ann Arbor, Michigan; and Center for Addiction Research and Manual of Mental Disorders, Third Edition (DSM- Education, University of Wisconsin-Madison, Madison, III) criteria for ASP disorder. There was striking Wisconsin (M.F.F. and L.B.M.). Requests for reprints should similarity among ethnic groups, but marked differ­ be addressed to Kristen Lawton Barry, PhD, Veterans Administration, SMITREC, PO Box 130170, Ann Arbor, MI ences between the sexes, as had been noted in sev­ 48113-0170. eral previous studies. There was also a significant 6 '"7 Appleton & Lange/ISSN 0094-3509 The Journal of Family Practice, Vol. 45, No. 2 (Aug), 1997 1 51 CONDUCT DISORDER AND ANTISOCIAL PERSONALITY cohort effect, with ASP disorder rates decreasing the question of whether compliance problems and with age. poor treatment outcome can be dealt with in these The National Comorbidity Study (NCS)2 was settings. coordinated by a research team at the University of Patients in primary care settings who meet crite­ Michigan in 1990-91 and was the first study to ria for ASP disorder may present with work, family administer a structured psychiatric interview social, and alcohol or drug-related problems. These (Composite International Diagnostic Interview) to problems can present barriers to treatment in med­ a representative sample of adults aged 18 to 55 ical settings because of substandard compliance years in the United States. The study found the with appointments and treatment regimens as well prevalence of ASP disorder to be 5.8% (SE=0.6) for as greater complexity of care associated with possi­ men and 1.2% (SE=0.3) for women, with an overall ble comorbid conditions. Both the potential rate of 3.5% (SE=0.3). These results were similar to increased cost of dealing with these patients in pri­ those of the ECA study. Higher rates of ASP disor­ mary care settings and the need to effectively work der were found for male subjects, younger adults, with patients who may be less compliant and may and those at lower income levels. There were no have multiple social and medical problems mean differences in ASP disorder rate by race or ethnici­ that primary care physicians need to understand the ty. In addition, across diagnoses, 79% of subjects in correlates and predictors of this disorder to be bet­ this study had more than one psychiatric diagnosis, ter prepared to understand, work with, and refer indicating the importance of addressing comorbidi­ patients who have personality disorders. ty in any population experiencing mental health Because no studies have addressed the issues of problems. conduct disorder and ASP disorder in primary care Most of the studies examining correlates of ASP settings, this study is the first step in delineating the disorder and conduct disorder have focused on prevalence and correlates of these personality disor­ either psychiatric or alcoholism treatment sam­ ders. Factors of interest in this study as potential ples. Rates of psychiatric comorbidity, and partic­ correlates of personality disorders include sex, age, ularly ASP disorder, have been as high as 70% in race, education, marital status, drug use, alcohol use, patients being treated for alcoholism.3 In a study of at-risk drinking, binge drinking, depression, other male veterans entering alcohol treatment, Shuckit health habits, and family history of mental and addic­ (1985)4 found that patients with a primary diagno­ tive disorders. This is the first time all these variables sis of ASP disorder were less educated, younger, have been reported within the same study for a pri­ and more likely to have secondary affective mary care population from a diverse sample of urban episodes, suicide attempts, and psychiatric hospi­ and rural areas. This study provides the groundwork talizations than were patients with a primary diag­ for further research on associated medical prob­ nosis of alcoholism. Depression, suicidal ideation, lems, costs of primary care treatment, and treatment and suicidal attempts have been linked with ASP compliance over tune in this at-risk population. disorder in clinical samples.5,6 A number of studies have found poor clinical out­ METHODS comes for substance abuse patients who have a comorbid diagnosis of conduct disorder or ASP dis­ The research sites were the practices of 64 primary order.78 Other studies have found, however, that ASP care physicians located in 10 counties in southern disorder does not predict short-term treatment Wisconsin. All the physicians were in community- response.9,10 In a study of medically ill alcoholics, based practice. Data were collected between April Willenbring et al11 found that medical inpatients with 1992 and April 1993. A self-administered health alcoholism who refused transfer to an alcohol treat­ screening survey (HSS) was offered to all adult ment program were more likely to have antisocial patients (aged 18 to 65 years) presenting to one of characteristics and low compliance with medical the primary care physicians’ offices participating in appointments in general. These studies provide Project TrEAT (Trial for Early Alcohol Treatment). background on the disorder in clinical populations The methodology and results of this trial are dis­ but do not address the extent of conduct disorder or cussed elsewhere.12 ASP disorder in primary medical care settings and The HSS is a masked screening instrument 152 The Journal of Family Practice, Vol. 45, No. 2 (Aug), 1997 CONDUCT DISORDER AND ANTISOCIAL PERSONALITY designed to assess smoking, exercise, weight con­ a major affective disorder in the DIS-R, ie, persons cerns, and alcohol use during the previous 3 who responded positively to both the probe question months. The instrument was developed by Wallace and four or more of the seven symptom groups were and Haines (1988)13 and modified by Fleming and defined as “ever depressed in their lifetime.” A more Barry (1991)14 for use in brief alcohol intervention complete discussion of depression in primary care trials to minimize the intervention effect of the from Project TrEAT can be found in Rowe et al.15 alcohol use questions. A random sample of 10% of Alcohol use was assessed by first asking patients the respondents (n=1944) were also asked to com­ whether they had consumed alcohol during the past plete an extended form (HSS-B), which asked addi­ 3 months. Those who responded yes were then tional questions regarding depression, conduct dis­ asked more detailed questions about consumption: orders, drug use and problems, and family history quantity and frequency of beer, wine, or liquor con­ of other mental health or substance use problems.
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