Supplemental Material for Borderline Personality Disorder Does Not Predict Treatment Outcome in a Partial Hospital Program Independent of Internalizing and Harmful Substance Use Dimensions

The association between eating disorders (EDs) and harmful substance use (substance use that causes psychosocial impairment) is well recognized in the literature, and military veterans may be at heightened risk for both issues due to deployment-related stressors. However, little is known about which ED-related symptoms are associated with harmful substance use in veterans, and whether gender plays a differential role in this relationship. Our aims were to: (1) examine gender differences in ED-related symptoms; and (2) examine whether ED-related symptoms differentially predict harmful substance use in US veteran men and women who had recently separated from service. This study was based on a nationally representative four-wave longitudinal sample of post-9/11 veterans (N = 835; 61.2% female). Longitudinal mixed modeling was used to test whether specific ED-related behaviors at baseline predicted harmful substance use at follow-ups. We replicated gendered patterns of ED-related symptoms observed in civilian populations, wherein men had higher weight-and-body-related concerns (including excessive exercise and muscle building) and negative attitude toward obesity, and women had higher bulimic and restricting symptoms. For women, alcohol, drug, and marijuana problems were predicted by higher bulimic symptoms, whereas for men, these problems were predicted by higher restricting symptoms. Gender played a differential role in the relationship between EDs and harmful substance use. Bulimic symptoms were the most robust predictor for harmful substance use among veteran women, whereas restricting was the most robust predictor for harmful substance use among veteran men. The current study found that veteran women had higher bulimic symptoms (characterized by binge eating and purging) and restricting than veteran men. In women, bulimic symptoms predicted future harmful use of alcohol, marijuana, and other drugs. In contrast, veteran men had higher weight-and-body-related concerns (characterized by excessive exercise and muscle building) than veteran women. In men, restricting symptoms predicted future harmful use of alcohol, marijuana, and other drugs.

Borderline personality disorder (BPD) diagnoses reliably predict worse mental health treatment outcomes. It is unknown whether multidimensional models of psychopathology, increasingly viewed as viable alternatives to traditional diagnostic systems, can match BPD's predictive power in clinical settings. In a sample of 2,625 partial hospital patients, we compared BPD with internalizing and harmful substance use dimensions as predictors of treatment success, defined by improvement in symptom severity, functional impairment, and quality of life. On a bivariate level, BPD features were moderately related to posttreatment functional impairment (r = .28) and quality of life (r = -.24), but not self-rated symptom improvement (r = .04). When adjusting for internalizing and harmful substance use, however, BPD features had very little unique predictive power. Instead, the internalizing spectrum was the strongest, most consistent predictor of symptom and functional improvement. This pattern of effects suggests that broad dimensions of psychopathology, particularly internalizing, capture much of BPD's prognostic utility in a partial hospital setting. We advise more attention to how the traditional BPD diagnosis compares to broad psychopathology dimensions in terms of clinical utility. This study's data, analysis code, and materials are posted at https://osf.io/wpy7e. (PsycInfo Database Record (c) 2025 APA, all rights reserved).

Violence, poor mental health, and harmful substance use are commonly experienced by female sex workers (FSWs) in sub-Saharan Africa, all of which are associated with increased HIV susceptibility. We aimed to investigate the associations between violence, poor mental health and harmful alcohol/substance use with hair cortisol concentration (HCC) levels as a potential biological pathway linking the experiences of these stressors and HIV vulnerability. We used the baseline data of the Maisha Fiti study of FSWs in Nairobi, Kenya. Participants reported recent violence, poor mental health, and harmful alcohol/substance use. Hair samples proximal to the scalp were collected to measure cortisol levels determined by ELISA. We analysed the data of 425 HIV-negative respondents who provided at least 2 cm of hair sample. The prevalence of recent violence was 89.3% (physical 54.6%; sexual 49.4%; emotional 77.0% and financial 66.5%), and 29.1% had been arrested due to sex work. 23.7% of participants reported moderate/severe depression, 11.6% moderate/severe anxiety, 13.5% PTSD and 10.8% recent suicidal thoughts and/or attempts. About half of the participants (48.8%) reported recent harmful alcohol and/or other substance use. In multivariable linear regression analyses, both physical and/or sexual violence (adjusted geometric mean ratio (aGMR) = 1.28; 95% CI 1.01–1.62) and harmful alcohol and/or other substance use (aGMR = 1.31; 95% CI 1.03–1.65) were positively and independently associated with increased HCC levels. Findings suggest a role of violence and substance use in elevated HCC levels, which could increase HIV risk due to cortisol-related T cell activation. However, longitudinal and mechanistic studies are needed to confirm this hypothesis.

Exercise is increasingly understood as an important resource for people who engage in harmful substance use, including those in prison. Little is known about how inmates adopt various health behaviors during incarceration, without interventions. This cross-sectional study analyzed self-reports from 1464 inmates in Norwegian prisons in 2013–2014, compared them according to harmful substance use pre-incarceration, and explored changes in exercise and nicotine use during incarceration. Results were presented in accordance with the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines. Inmates with harmful substance use reported higher rates of smoking, smokeless tobacco, and physical inactivity pre-incarceration than inmates without harmful use. However, inmates with harmful use also exhibited more behavioral changes: they adopted exercise, ceased smoking, and adopted smokeless tobacco at higher rates during incarceration than the non-harmful group, to the extent that inmates with harmful use exercised during incarceration more. Exercise is being taken up by a significant proportion of inmates, and may in particular be a replacement behavior for substance use. However, unhealthy behaviors also begin or are maintained. If prisons were used as an arena to facilitate healthy behaviors, the public health benefits to a marginalized group such as substance-using inmates could be substantial.

Purpose: How to detect early harmful and hazardous substance use in workplace: a qualitative study. Background: Workers under the influence of psychoactive substances are more likely to commit unsafe acts which damage themselves, others’ lives, and the organization. A question is how to detect substance misuse early in the workplace, without punitive or coercive actions. This study evaluated the implementation of a screening (S) and brief intervention (BI) of substance misuse through (1) the barriers faced and the solutions presented by occupational health professionals when implementing SBI, and (2) the feasibility to use the SBI in this environment for such a preventive procedure. Methods: An action research methodology was used in this study in a City Hall in a southern city of Brazil. First, 26 professionals of the Occupational Health Service were trained in a 20 h course about: psychoactive substances’ effects, how screening (S) using the Alcohol, Smoking and Substance Involvement Screening Test (ASSIST), and how doing BI. After training, they received supervision in doing the task goal of applying SBI in their routine in a random sample of 5% of the employees (the total was 26,129). One year later, two focus group meetings were held with all professionals. Results: The trained professionals were 11 psychologists, 12 social workers, one organizational development analyst, one occupational therapist, and one cultural promoter; 99.2% female; 46 ± 4 years old; 80.6% married. During a one-year period, they detected, in a representative sample of employees (n=1,310), 144 individuals in risky use and 139 dependents on tobacco, alcohol and/or other substances. At three-month follow-up they observed a significant reduction in ASSIST scores. The action research improved the implementation of SBI for substance use in their routine. Professionals agreed that SBI facilitates talking about substances without prejudice or stigma, enabling earlier detection, intervention, and treatment referral. Conclusion: SBI was feasible in this workplace to prevent hazardous/ harmful substance use.

Florez-Salamanca and colleagues’ study1 of transitioning from DSM-IV substance abuse to dependence in this issue of The American Journal of Drug and Alcohol Abuse is important, in part, because the topic represents the juncture of several contemporary unresolved issues that are critical to healthcare. Harmful compulsive substance use, termed substance use disorder (SUD) in Diagnostic and Statistical Manuals (DSM), is among the most prevalent medical conditions. Lifetime DSM-IV SUD prevalence in the U.S. consequent to habitual use of tobacco, alcohol and illegal drugs, respectively, is 24%, 20% and 10%.2–4 Globally, smoking is the 4th leading contributor to disease burden, alcoholism is the 5th leading cause and illegal drug use is the 15th.5In the U.S. alone, harmful substance use costs the nation well over $400 billion annually6 due to consequences such as SUD treatment, crime, traffic accidents, medical and psychiatric disorder, domestic violence, child abuse/neglect, underemployment and job-related injury, suicide, traumatic injuries, and sexually transmitted disease including HIV/AIDS. Thus, research on SUD etiology and developmental transitions has tremendous potential to benefit at-risk individuals, their families and society.

Epidemiological literature suggests that urbanization is potentially linked to a number of stressors that could be associated with harmful substance use and mental disorders. This may vary by country. This review gives attention to emergent literature examining the pathways between urbanization and harmful substance use. Studies examining the links between urbanization, mental health and substance use suggest complex pathways between urbanization and substance use as well as a range of modifying variables that could contribute to these associations. Such variables include increased supply of illicit and licit substances brought about by economic development, globalization and technology as well as an increased demand for particular substances. Rural areas may also have unique factors associated with harmful substance use but these are beyond the scope of this review. We have presented evidence to suggest potential associations between urbanization and harmful substance use. We acknowledge that data are limited because of a paucity of longitudinal studies elucidating these relationships.

IntroductionClimate change is increasing the frequency and intensity of severe heatwaves, storms, floods, droughts, and wildfires. These events cause widespread economic and social disruption and are undermining population health worldwide. Despite a growing literature on how climate change threatens mental health, its influence on harmful substance use has not been systematically addressed.ObjectivesWe propose an explanatory framework explicating the plausible links between climate change-related stressors and an increase in harmful substance use.MethodsWe critically review and synthesise literature documenting the pathways, processes and mechanisms linking climate change to increased substance use vulnerability.ResultsSeveral plausible pathways link climate change to increased risk of harmful substance use worldwide. These include: (1) anxiety about the impacts of unchecked climate change, (2) destabilisation of psychosocial and economic support systems, (3) increasing rates of mental disorders, and (4) increased physical health burden. Children may face disproportionate risk due to their vulnerability to both mental disorders and substance use, particularly during adolescence. We argue that a developmental life-course perspective situated within a broader ‘systems thinking’ approach provides a coherent framework for understanding how climate change is aggravating the multiple, persistent, interacting risks that influence harmful substance use pathways.ConclusionsClimate change is already undermining health and wellbeing of global populations. By inference, it is also aggravating pathway to harmful substance use. This is a critical psychosocial problem for individuals and communities alike. Conceptual and methodological work is urgently needed so that effective adaptive and preventive action can be taken.DisclosureNo significant relationships.

Harmful substance use is prevalent among bisexual emerging adults, due in part to their unique minority stressors. The goals of this study were (a) to classify cisgender bisexual emerging adults, ages 18–29 years, based on their substance (i.e., alcohol and other drug) use and (b) to identify modifiable psychosocial variables associated with substance use group membership. Bisexual women (N = 249, M age=23.35) and men (N = 201, M age=23.31) were recruited on the Internet via the CloudResearch platform. Participants answered a 20-minute survey assessing substance use, lifetime traumas, romantic relationships, sexual-minority related stressors, and structural influences on interpersonal violence exposure. Self-reported substance use was used to classify participants using Ward’s method cluster analysis. Among bisexual women, self-esteem was the only variable that differed significantly between the low and high substance use clusters. Among bisexual men, significant differences in mean scores were documented for sexual identity disclosure, felt sexual stigma, everyday discrimination, internalized sexual stigma, and self-esteem across three substance use clusters. Our findings provide important information for tailoring selected prevention initiatives among bisexual men and emphasize the importance of screening bisexual emerging adults for both harmful substance use and sexual minority stressors.

The Module ”Self-Control and Avoiding Harmful Substance Use” highlights key aspects of parental education, where the educator will explain to parents why discussing harmful substance use is essential. It emphasizes that an informed and attentive parent is far more likely to prevent their child from using harmful substances than a parent who dismisses the topic with statements like, "This can't happen to me" or "My child would never do that." In the first part of the module, the parental educator will introduce participants to the concept of harmful substance use, what harmful substances are and their various types, through practical activities, participants will explore why teenagers may turn to harmful substances. The module will include case studies and examples, providing a basis for group discussions. In the second part, topics will focus on: identifying signs of substance use among teenagers, understanding different types of users practical advice for parents on prevention and steps to take in case of emergencies, including where to seek help. The module includes brainstorming exercises and hands-on activities to enhance understanding and practical application. This module is part of the materials dedicated to the training of parental educators.

Purpose – Prevalence of HIV/AIDS infection in the South African construction industry exceeds that of most other economic sectors. Voluntary counselling and testing is pivotal in combatting the spread of the disease. Little is known about the attitudinal fear of testing among construction workers, and the determinants thereof. The purpose of this paper is to address these shortcomings. Design/methodology/approach – A conceptual integrated model of fear of testing is proposed. Demographic characteristics and behavioural and cognitive factors are posited to explain attitudinal fear of testing. Regression analysis and structural equation modelling are used to test the model, using data gathered from 512 site-based participants in a questionnaire survey. Findings – Prejudice and lifestyle risk are the terminal predictors of fear of testing. Prejudice is determined by education level and HIV/AIDS transmission knowledge. Knowledge is predicted by education level and ethnicity. Lifestyle risk is determined by age, gender, harmful substance use, and knowledge. Harmful substance use is determined by age, gender, ethnicity, and employment type. The inter-relationship between knowledge about HIV/AIDS, prejudice towards HIV+ persons, and fear of testing is complex and nuanced. Practical implications – Intervention strategies by firms should positively address attitudinal fear of testing. Employers should ensure that effective communication is established with workers. Interventions relating to harmful substance use by employees need particular attention. Awareness campaigns should be sensitive to ethnic and cultural values, and to inter-generational differences. Originality/value – Harmful substance use and knowledge about HIV/AIDS transmission are indirect predictors of fear of testing. Education and ethnicity are critical dimensions of knowledge. The complex inter-relationship between knowledge, prejudice, lifestyle risk, and fear of testing is highlighted, providing guidelines for intervention management.

This chapter summarizes the molar behavioral economic approach to studying harmful substance use and substance use disorder, a prevalent addictive behavior. General features of behavioral economics as a scientific framework for understanding behavior in context are described, followed by consideration of measurement issues involved in translating basic behavioral economic research findings to human behavior. Human studies are then summarized that have established the utility of molar behavioral economics to understand key features of harmful substance use, including initiation and prevention, maintenance, and cessation of harmful use. This body of translational work is robust across multiple levels of analysis and application and offers a compelling framework for understanding and changing harmful substance use. The perspective is compared and contrasted with the reductive brain disease model of addiction.

Adverse childhood experiences and their accumulation over childhood have negative outcomes to children, yet earlier findings on the independent effect of parental substance abuse seem inconsistent. Our aims were to examine: (i) whether parental substance abuse is associated with children's mental disorders in mid-childhood (7-12 years) and mental disorders and own substance use in adolescence (13-17 years); and (ii) whether children are affected differently by a mother or father's substance abuse. A register-based longitudinal data on a complete birth cohort of children born in Finland in 1991 (n = 65 117) and their biological parents. The children were followed until their 18th birthday. Data were derived from the Finnish administrative registries. Bivariate and multivariate logistic regression models were used in the analysis. Maternal, paternal and both parents' substance abuse were significant predictors of mental disorders and harmful substance use in children aged 13-17 years, even after controlling for other adverse childhood experiences, parental education and child's gender. Parental substance abuse predicted mental disorders in children aged 7-12 years in bivariate model but in multivariate model the association disappeared. Maternal substance abuse had stronger effect on harmful substance use in adolescent children than paternal. There were no significant interactions between substance abusing parents' gender and the child's gender. Early identification, prevention and treatment of substance abuse in families with children in primary health care, child welfare and other services are crucial in preventing intergenerational transmission of the problems associated with parental substance abuse. [Jääskeläinen M, Holmila M, Notkola I-L, Raitasalo K. Mental disorders and harmful substance use in children of substance abusing parents: A longitudinal register-based study on a complete birth cohort born in 1991. Drug Alcohol Rev 2016;35:728-740].

Utility of substance-free alternatives in treating and preventing harmful substance use: A narrative review of the translational research spectrum

The Module ”Self-Control and Avoiding Harmful Substance Use” highlights key aspects of parental education, where the educator will explain to parents why discussing harmful substance use is essential. It emphasizes that an informed and attentive parent is far more likely to prevent their child from using harmful substances than a parent who dismisses the topic with statements like, "This can't happen to me" or "My child would never do that." In the first part of the module, the parental educator will introduce participants to the concept of harmful substance use, what harmful substances are and their various types, through practical activities, participants will explore why teenagers may turn to harmful substances. The module will include case studies and examples, providing a basis for group discussions. In the second part, topics will focus on: identifying signs of substance use among teenagers, understanding different types of users practical advice for parents on prevention and steps to take in case of emergencies, including where to seek help. The module includes brainstorming exercises and hands-on activities to enhance understanding and practical application. This module is part of the materials dedicated to the training of parental educators.