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Internalizing-Externalizing Psychopathology and Personality

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Internalizing-Externalizing Psychopathology and Personality INTERNALIZING-EXTERNALIZING PSYCHOPATHOLOGY AND PERSONALITY PATHOLOGY AS PREDICTORS OF TREATMENT REJECTION IN SUBSTANCE USERS Jonathan James Lewis Thesis Prepared for the Degree of MASTER OF SCIENCE UNIVERSITY OF NORTH TEXAS August 2013 APPROVED: Craig Neumann, Major Professor Jennifer Callahan, Committee Member Thomas Parsons, Committee Member Vicki Campbell, Chair of the Department of Psychology Mark Wardell, Dean of the Toulouse Graduate School Lewis, Jonathan James. Internalizing-externalizing psychopathology and personality pathology as predictors of treatment rejection in substance users. Master of Science (Psychology), August 2013, 108 pp., 18 tables, 10 illustrations, references, 166 titles. Substance use disorders (SUDs) are often comorbid with other psychopathology such as mood disorders, anxiety disorders, and personality disorders. While some research suggests individuals with comorbid psychopathology are more likely to seek substance use treatment than those with independent disorders, other studies have also shown many individuals with dual diagnoses still never seek treatment. Moreover, few studies have tried to elucidate the underlying structure of SUD treatment rejection, and instead examined it in more simplistic terms. In addition, studies have tended to examine the impact of individual disorders on treatment rejection, but have not incorporated an empirically supported approach to conceptualizing psychopathology in terms of comorbidity between broad latent dimensions referred to as internalizing (e.g., depression, anxiety) and externalizing (e.g., antisocial personality disorder, polysubstance use) psychopathology. Modeling psychopathology in terms of internalizing and externalizing psychopathology is becoming a prominent approach to understanding mental disorders, yet little research to date has investigated the effects these broad dimensions have on SUD treatment rejection. The current study utilized latent variable modeling techniques to (1) determine the latent structure of SUD treatment rejection in a large U.S. sample, and investigate whether treatment rejection is a multidimensional construct; and (2), to explore the ability of internalizing psychopathology, externalizing psychopathology, and personality pathology to predict the SUD treatment rejection factor(s). The current study relied on use of a general population sample of 43,093 individuals from the first wave of National Institute on Alcohol Abuse and Alcoholism’s National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) study. Support was found for the hypothesis that SUD treatment rejection would be a multidimensional construct. Exploratory structural equation modeling indicated a three-factor model best fit the data. Operational definitions and clinical implications of these three treatment rejection factors (“Objective barriers,” “Psychological barriers,” and “Self-focused barriers”) are discussed. Among internalizing psychopathology, externalizing psychopathology, and personality pathology, structural equation modeling identified internalizing psychopathology as the most robust predictor of these three factors for alcohol treatment rejection (n = 1063), indicating endorsement of treatment barriers increased as levels of internalizing psychopathology increased. This pattern also held true for externalizing psychopathology, while personality pathology only negatively predicted objective treatment barriers. For drug treatment rejection (n = 562), only internalizing psychopathology significantly predicted the treatment rejection factors, indicating treatment endorsement of drug treatment barriers increased as levels of internalizing psychopathology increased. Implications of these findings and directions for future research are discussed. Copyright 2013 by Jonathan James Lewis ii TABLE OF CONTENTS Page LIST OF TABLES ......................................................................................................................... vi LIST OF ILLUSTRATIONS ....................................................................................................... viii CHAPTER 1. INTRODUCTION .................................................................................................. 1 Substance Use Disorders..................................................................................................... 3 Prevalence, Consequences, and Comorbidity of SUDs .......................................... 5 Internalizing Psychopathology and SUDs .......................................................................... 7 Comorbidity ............................................................................................................ 7 Treatment Rejection ................................................................................................ 8 Externalizing Psychopathology and SUDs ......................................................................... 9 Comorbidity ............................................................................................................ 9 Treatment Rejection .............................................................................................. 10 SUDs and Personality Disorders ....................................................................................... 11 Comorbidity .......................................................................................................... 11 Treatment Rejection .............................................................................................. 12 Addiction Theories............................................................................................................ 13 The Self-Medication Hypothesis .......................................................................... 13 Heritability Theories of SUDs .............................................................................. 14 SUD Treatment Rejection ................................................................................................. 15 Motivation and Attitudes toward Treatment ......................................................... 17 Conclusion ........................................................................................................................ 19 CHAPTER 2. METHODS ........................................................................................................... 20 Participants ........................................................................................................................ 20 Materials ........................................................................................................................... 20 Data Analysis .................................................................................................................... 22 Descriptive Statistics ............................................................................................. 22 Primary Data Analysis .......................................................................................... 22 Research Questions and Hypotheses ................................................................................ 24 Research Question and Hypothesis 1: Which Aspects of Psychopathology are more Prevalent in Those Who Do Not Seek SUD Treatment? ............................. 24 iii Research Question and Hypothesis 2: Are Certain Disorders More Prevalent in Treatment Neglecters than Treatment Utilizers? .................................................. 24 Research Question and Hypothesis 3: How Strong is the Relationship between Treatment Rejection and Broad/Specific Composites among Individuals with a Specific SUD Diagnosis? ...................................................................................... 25 Research Question and Hypothesis 4: Can Treatment Rejection be Understood in Terms of Underlying Dimensions? ....................................................................... 25 Research Question and Hypothesis 5: After Determining the Factor Structure of Treatment Rejection, What Variables Predict Specific Treatment Rejection Factors? ................................................................................................................. 26 CHAPTER 3. RESULTS ............................................................................................................. 27 Demographics ................................................................................................................... 27 Descriptive Statistics ......................................................................................................... 27 Internalizing Psychopathology.............................................................................. 27 Externalizing Psychopathology ............................................................................ 28 PD Pathology ........................................................................................................ 28 Treatment Utilization and Rejection ..................................................................... 29 Prevalence of Psychopathology in Treatment Neglecters and Treatment Utilizers ......... 30 Prevalence of DSM-IV Disorders in Treatment Neglecters and Utilizers ........................ 30 The Relationship between Treatment Neglect and Psychopathology ............................... 32 The Factor Structure of Substance Use Disorder Treatment Rejection ............................ 33 The Prediction of Substance Use Disorder Treatment Rejection ..................................... 35 Model Specification .............................................................................................
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