A Mixed Methods Case Study Proposal for the Treatment of Comorbid?Cluster B and? Cluster C Personality Disorders

The biopsychosocial model of addiction proposes that addiction arises from a culmination of factors including biological, psychological, social, and environmental. In essence, the biopsychosocial model of addiction demonstrates that each of the factors that contribute to the development of addiction also contribute to the development of an individual personality. Personalities arise from the unique and discrete functions of the brain and neurotransmitters interconnected with the individual human experience. The total dynamic individual experience and genetic predisposition of personality create habitual behaviors, explicit psychic reasoning, and intentional and unintentional states of being. A review of disordered personalities reveals that addictive behaviors can arise from tumultuous social and environmental factors, childhood trauma, genetics, and brain structure. The purpose of this paper is to initiate a case study that will examine the relationship between cluster B and C personality disorders and addiction. This paper will also generate an in-depth approach to treating the comorbidity of personality disorders, substance use disorders, and addictive behaviors. The hypothesis predicts that primarily treating the personality disorder will ease and subdue the symptoms of addiction and substance abuse.

Keywords: personality disorders, addictive behaviors, comorbidity, trauma

Research Problem

The DSM – 5th edition divides the 10 types of personality disorders into 3 clusters. Each type of personality disorder arises from abnormalities in the brain structure and genetics interconnected with trauma that occurred during early development. Existing research demonstrates that when an individual is traumatized during the early stages of development, depending on the severity of the trauma, abnormal changes in the physiology of the brain are often a consequence. Later in life, substance use and addiction become the individual’s ill-attempt to stabilize their altered physiological state. One major issue in treating comorbid personality, substance, and addiction disorders is that most individuals are unaware that their personalities are disordered. A positive diagnosis for cluster B and C personality disorder requires that the symptoms have endured for years and have also compromised the individual’s quality of life. Moreover, individuals suffering from the symptoms of cluster B and C personality disorders do not recognize the need for treatment because they lack self-awareness. Most of the individuals in treatment for cluster B and C personality disorders were forced into treatment by law or penalty.

Literature Review

Researchers have conducted many investigations in order to understand the psychopathic traits that co-occur with addiction. The Triarchic model of psychopathy identifies 3 distinct domains of psychopathy: disinhibition, meanness, and boldness. The domain of disinhibition defines an individual’s lack of self-control and self-regulation. Individuals high in disinhibition lack foresight and seek immediate gratification. The psychopathic trait of disinhibition positively correlates to the common traits of cluster B personality disorders (ie. antisocial, borderline, histrionic, and narcissistic). The cluster B personality disorders describe individuals who are emotionally irrational, and unpredictable. These individuals are also highly likely to develop addictive behaviors.

An article published by Frontiers in Psychology demonstrates that sex addiction is significantly correlated to narcissistic personality disorder. The study reveals that the relationship between hypersexuality and narcissism relates to the individual's attempt to stabilize low self-esteem by engaging in excessive sexual behaviors in order to experience the feeling of being desired and to receive attention from various sexual partners. The study by Alavi & Ferdosi, et., al., demonstrated that addiction results from feelings and memories associated with exercising the behavior or using the substance rather than the actual behavior or substance itself. In this case, the feelings of being desired, popular, and in control are what drives the narcissist into hypersexual behavior rather than the sensation of sex.

The study by Irizarry & Gallaher, et., al. makes this notion even more evident. The research theorized that their study would demonstrate that over 50% of individuals exhibiting internet porn addiction would also exhibit co-occurring psychopathic traits associated with cluster B personality disorder. However, the conclusion of the study did not support the hypothesis. As it turns out, cluster B personality traits were inconsistent with internet porn addiction traits. One theory is that solo masturbation and the sensation of sex alone do not satiate their emotionally irrational need for attention and control.

In most cases, trauma, which occurred during the developmental stages of life, altered the normal physiology of the brain in individuals suffering from cluster B and C personality disorders. Researchers theorize that there are executive functioning deficits to a collection of cognitive processes involving self-regulation, memory retention, inhibition, and attention. One study conducted by Albein-Urios & Martinez-Gonzalez, et., al., 2014 hypothesized that individuals with comorbid cocaine dependence and cluster B personality disorders lack inhibition performance, and individuals with comorbid cocaine dependence and cluster C personality disorders present deficits in working memory.

Albein-Urios and her colleagues investigated 107 participants for the study; of which, 22 participants were cocaine users with cluster B disorders, 15 participants were cocaine users with cluster C disorders, 36 participants were cocaine users alone, and there were also 34 control participants. The study utilized psychological evaluation testing to assess the working memory, attention, inhibition, and shifting of each participant of the study. The results of the study concluded that cocaine-dependent individuals with cluster B and C personality disorders possess distinct executive functioning deficits.

Participants in the cluster B group showed significantly reduced attention, regulation, and inhibition in comparison to cluster C and the controls. Participants in the cluster C group showed significantly reduced memory functioning in comparison to the control group and cluster B group. Overall, the important implications of this research highlight the notion that executive dysfunctions in addicts provide an explanation for why they lack the ability to control themselves toward goal-directed behavior. While the sample size of this study is too small to make generalization assumptions about the entire population, the information shared in the study demonstrates why rehabilitation is extremely challenging for individuals suffering from comorbid addiction and personality disorders.

One study designed to examine the relationship between personality traits and self-control identified key symptoms of low self-control. This descriptive correlational study analyzed the reactions of 384 men incarcerated in Kerman, Iran addicted to nicotine. The results demonstrated that personality had the strongest impact on self-control and whether or not an individual could be rehabilitated. According to the General Theory of Crime, individuals with low levels of self-control are prone to social deviance and risky behaviors because they are untrained in the skills needed to control themselves.

The concept of perceived health competence was discussed in an article published in the Scientific Reports journal. The article defined perceived health competence as the individual’s confidence in their ability to manage and maintain their health. A questionnaire was administered to 320 university students and the results demonstrated that in both men and women self-control was influenced by their awareness of impulsivity. Health competence was therefore related to conscientiousness where perceived health was an act of effortful control.

Importance of Implications to Biological Psychology

Due to the emotional, economic, and health impact that these disorders have on individuals globally, there is an incentive to assist these individuals in accepting their true reality and addressing their issues. Individuals with comorbid Cluster B and Cluster C personality disorders may require medications to dampen the intensity of their emotional state. Individuals with Cluster B and Cluster C personality disorders tend to cover up their issues as a defense mechanism. Therefore getting them to accept their true reality and address their issues is necessary to see progress and retention in addiction treatment. Approximately $94 million dollars of United States taxpayer dollars is awarded to healthcare and rehabilitation centers nationwide to assist with the addiction crisis.

Biological theories on addiction influence the policies and expansion of nearly 8% of rehabilitation and addiction treatments. The biopsychosocial theory of addiction proposes that treatment programs are enhanced when they develop a single framework to address genetic, psychological, and sociocultural factors contributing to an individual’s addiction. Fully understanding how comorbidity and personality influence substance use and addiction progression can set the stage for clinicians to administer more effective addiction treatments and medications to their patients.

Research Methodology: Case Study

Conducting a case study will enable the researcher to develop an in-depth understanding of the intricacies of treating comorbid Cluster B and Cluster C personality disorders. Using the cluster procedure will permit the study of a large population sample and provide generalizations about comorbid Cluster B and Cluster C Personality Disorders that can allow the study to make a broad inference about the total population as a whole from the results of the exploratory case study. Using the clustering procedure will also study participants across a wide geographical location.

Recruits for the sample population will be composed of men and women seeking treatment in various rehabilitation clinics globally. The demographics for the study will include all volunteer participants, both men and women, enrolled in addiction treatment facilities included in the program from ages 18-65. The DSM-5th edition will be used to conduct psychological evaluation testing for personality disorders. Weekly toxicology screening will be used to test for substance use, and biweekly semi-structured interviews will be used to measure addiction stabilization.

Procedures

Due to the complexity of the issue, a mixed methods procedure will be used for the study. Using this design method will provide the research with the information and data necessary to gain more insight into the symptoms of comorbid personality disorders. The participants will be clustered into 3 groups: individuals with comorbid Cluster B personality disorders (Cluster B), individuals with comorbid Cluster C personality disorders (Cluster C), and individuals without comorbidities. The participants will complete a demographic questionnaire to report information on their specific addiction development, characteristics, and symptoms.

An additional questionnaire and interview will be administered to develop a personal history log of before and after addiction and or substance use developed. The participants will be informed of the results of their psychological evaluations prior to treatment. Lastly, participants will report substance use, addictive behaviors, and cravings once a week on Friday either via interview or toxicology screen.

Ethical Criteria

All participants will be volunteers. The study will be approved by the Institutional Review Board and Protection of Human Subjects in Clinical Trials. All volunteer participants will be read the informed consent and required to sign before the commencement of the study. Each participant will be allowed to withdraw from the study at any time. All personal health information of the participants will be held on an encrypted hardware device in a safe on the facility site. Each healthcare personnel will sign a confidentiality disclosure agreement for the study.

Hypothesis Verification

The hypothesis predicts that primarily treating the personality disorder will ease and subdue the symptoms of addiction and substance abuse. The null hypothesis states that aggressive treatment of the personality disorder will not ease or subdue the symptoms of addiction or substance abuse. Support for the hypothesis will be verified using descriptive analysis statistics calculated in SPSS. These statistics will demonstrate the percentage of individuals with comorbid addiction and Cluster B and Cluster C Personality Disorders who were able to successfully ease and subdue the symptoms of addiction and/or substance abuse following aggressive treatment for Cluster B and Cluster C Personality Disorders. The hypothesis will provide an answer to the research question which ponders whether substance use and addiction are in fact the individual’s ill attempt to stabilize their altered physiological state.

One major question for the initiation of the research asks what are the current treatments for comorbid addiction and Cluster B and Cluster C Personality Disorders, and what are the effective rates? The hypothesis also works to assist with future treatments for comorbid addiction and Cluster B and Cluster C Personality Disorders by generating a case study to review the current treatments. This study will demonstrate the treatments that are working for this population and specifically why they are working for this population. It is important for people with comorbid addiction and Cluster B and Cluster C personality disorders to understand their diagnosis and the impact that it has on their rehabilitation. This study will contribute to furthering treatment options for people with comorbid addiction and Cluster B and Cluster C personality disorders and provide educators and healthcare personnel with valuable information to share with their students and clients.

Validity

The validity of the research will be ensured by cluster sampling a large population across a large geographical location. Using cluster sampling from the entire global population will allow the research to obtain and report the most accurate measure of validity due to the population size. The validity of the study will be maintained by using a reliable and professional unbiased third party to conduct documentation, interpolation, and extrapolation of statistical data. The unbiased third party will implement a systematic approach to conducting interviews, case studies observations, and collecting data in order to strengthen the validity of the study. Since correlation does not equal causation there may be some limits to the reliability of relationships discussed in the study.

Summary

Treatments of comorbid Cluster B and Cluster C personality disorders are complex in and of themselves. Patients may require cognitive and dialectical behavioral therapy to reduce the symptoms of these disorders. Additionally, comorbid Cluster B and Cluster C personality disorders can overlap with addiction, depression, and anxiety, and depending on comorbidity, clinicians may treat Axis 1 disorders ( ie. anxiety, affective, and psychotic disorders, etc.) with medication in order to reduce the symptoms of the maladaptive behaviors associated with these disorders. Moreover, the symptoms of Cluster B and Cluster C personality disorders are disruptive to treatment and result in stigmas attached to patients seeking treatment for addiction.

Individuals with Cluster B and Cluster C personality disorders lack confidence and self-control as a consequence of their disorder and this symptom of their disorder could be misconstrued as low motivation to change. It is important to diagnose and identify any personality disorders prior to treatment in order to reduce stigmatization and support these individuals in the unique way that they need to be supported. The purpose of this research is to provide the field of psychology and biopsychology with more information about comorbid Cluster B and Cluster C personality disorders in order to optimize care, and treatments and develop new rehabilitation techniques. The case study plan was designed to provide a modern approach to understanding how comorbid Cluster B and Cluster C personality disorders impact individuals across various cultures, societies, and generations.

References

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