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While the SURPS has been used extensively with adolescents at risk for substance dependence, its properties with adult substance-dependent populations have been understudied. The aims of the present study were to examine the factor structure of the Bulgarian version of the SURPS, its psychometric properties, and its ability to distinguish individuals with substance dependence from healthy controls. We explored the factor structure of the Bulgarian version of the SURPS with confirmatory factor analyses, examined its reliability and validity, and tested for group differences between substance dependent and non-dependent groups. Significant group differences were found on the Impulsivity and Sensation Seeking subscales, with the three substance dependent groups scoring higher than controls. The Bulgarian version of the SURPS demonstrates adequate to good reliability, concurrent validity, and predictive validity. Its ability to distinguish between groups with and without a history of substance dependence was specific to externalizing traits such as Impulsivity and Sensation Seeking, on which opiate, stimulant, and polysubstance dependent individuals scored higher than non-dependent controls. The latest general population survey in the country, carried out in , indicates that the average lifetime prevalence for illicit drug use was Problem drug use in Bulgaria is related largely to opioid primarily heroin use. Intravenous injection is the primary method of heroin use and heroin and amphetamine use are the leading causes for treatment demand in outpatient and inpatient settings. Licit substance use such as alcohol consumption per capita in liters of pure alcohol for — is Based on data from , Particularly alarming is the high level of substance use among adolescents in Bulgaria. According to the European School Survey Project on Alcohol and Other Drugs ESPAD , the largest cross-national study on adolescent substance use in the world, Bulgarian to year old students report higher than average levels of use for six out of eight substance use variables Kraus and Nociar, Similarly, lifetime use of illicit drugs other than cannabis and lifetime use of new psychoactive substances NPS are almost twice as high for Bulgarian students relative to students in other European countries Kraus and Nociar, Accordingly, not only is licit and illicit substance use and misuse high among Bulgarian adults, but trends among Bulgarian adolescents are also a public health concern. From the multiple etiological risk factors for substance use disorders SUDs , externalizing, and internalizing personality traits have been identified as some of the most salient risk factors. One of the most influential models in this field is the four-factor personality-based developmental model of SUD Castellanos-Ryan and Conrod, , which proposes that four distinct and independent lower-order i. AS has more recently also been associated with cannabis misuse Keough et al. It is comprised of items from a variety of other scales e. Though the four personality traits assessed with the SURPS could be assessed independently with the different scales, the SURPS has the advantage that it incorporates the most predictive items of these scales into a single measurement tool. The four SURPS personality risk factors are successfully targeted by selective personality targeted brief interventions Conrod et al. However, its properties with adult substance-dependent populations have been understudied. In the first of these studies, Schlauch et al. The second study was focused on the predictive validity of the scale with incarcerated male offenders and found that sensation seeking and anxiety sensitivity were associated with institutional drug use Hopley and Brunelle, Notably, no study to date has examined the properties of the SURPS among community samples of substance dependent individuals. To address this gap in the literature and to evaluate the psychometric properties of the Bulgarian version of the scale, we administered the SURPS to a Bulgarian community sample of substance dependent individuals and non-dependent controls. The main goals of the present study were to examine the factor structure of the Bulgarian version of the SURPS, evaluate its reliability and validity, and assess its ability to distinguish individuals with substance dependence from non-dependent controls. Based on previous applications of the SURPS to predominately at-risk adolescent and college student populations, we hypothesized that we will similarly identify four factors in this new sample of Bulgarian substance dependent individuals. Participants were recruited from a larger ongoing study on neurocognitive functioning among substance dependent individuals in Bulgaria, via flyers placed at substance abuse clinics, nightclubs, bars, and cafes, as well as, through the study's web page and Facebook page. Participants were initially screened via telephone or in-person on their medical and substance use histories. All participants were HIV seronegative determined by rapid HIV testing and no participants were on opioid substitution therapy. We screened individuals Of those, individuals participated and individuals did not participate in the study. There were no significant differences in key variables such as age and sex between individuals who participated in the study and those who were only screened. The sample also included 64 control individuals with no history of substance abuse or dependence, as well as, 43 unaffected siblings of heroin users and 29 unaffected siblings of amphetamine users who were treated as controls. At the time of testing, the majority of substance dependent participants were in protracted abstinence i. All participants were ethnic Bulgarians. Please see Table 1 for participant characteristics by group. All subjects gave written informed consent in accordance with the Declaration of Helsinki. Participants who met the inclusion criteria were contacted via telephone and invited to participate in the study. Briefly, after signing an informed consent form participants underwent urine drug screens and a Breathalyzer test for alcohol. The first session included assessment of substance use disorders, externalizing psychopathology e. The second session included neurocognitive tasks of impulsivity and decision-making and self-report measurements of personality e. Some of the self-report instruments e. The rest of the measures were translated into Bulgarian by the senior author JV , a clinical neuropsychologist and a native Bulgarian speaker. The measures were then back-translated into English by Bulgarian psychiatrists and psychologists, including co-authors GV and KB. The scale consists of 4 subscales: Impulsivity 5 items , Sensation seeking 6 items , Hopelessness 7 items , and Anxiety sensitivity 5 items. The instrument was administered in paper-and-pencil format. Respondents were asked to mark the level to which they agreed with each item on a 4-point Likert Scale ranging from 1 strongly disagree to 4 strongly agree. All but one of the items in the Hopelessness subscale were reverse scored. The composite score ranges from 0 to 1, with higher score indicating greater problem severity. The Sensation Seeking Scale-V SSS-V; Zuckerman, is a item forced choice measure comprised of four subscales related to sensation-seeking behaviors: thrill and adventure seeking, experience seeking, disinhibition, and boredom susceptibility. We used the existing unpublished Bulgarian version of the scale. We used the existing Bulgarian adaption of the scale Shtetinski and Paspalanov, The Bulgarian version of the instrument Wilson et al. Interviews and psychopathy ratings were conducted by an experienced team of research assistants and psychologists who were initially trained for reliability and supervised closely by JV, the author of the Bulgarian version of the Psychopathy Checklist-Revised PCL-R with its publisher Multi Health Systems. In line with our earlier findings Wilson et al. Respondents were asked to retrospectively evaluate the presence and severity of childhood symptoms of ADHD. We used the recently validated item Bulgarian version of the scale Nedelchev et al. The scale consists of three factors: Factor 1, comprised of items assessing the capacity to identify feelings and to distinguish between feelings and bodily sensations of emotional arousal; Factor 2, comprised of items reflecting the inability to communicate feelings to other people; and Factor 3, comprised of items assessing externally oriented thinking. We also tabulated years of heroin and amphetamine use and length of abstinence, indexed as number of days converted to years since last met DSM-IV heroin or amphetamine dependence criteria. The factor structure was assessed by confirmatory factor analysis CFA in the OpenMx software package version 2. Internal consistency was assessed using Cronbach's alpha. Because we included siblings, the nested structure of the data was accounted for by using the statsBy function in the psych package Revelle, This simple function provides basic descriptive statistics for two level models, where we were simultaneously able to control for the sibling data and sex. The observed correlations are decomposed into the within group and between group correlations. GEE models are an extension of generalized linear models to the analysis of longitudinal data or data that otherwise violates the assumption of independence Liang and Zeger, In these models, the assumption of normal distributions is also relaxed. We included age, sex, and global psychiatric status assessed by the ASI Psychiatric Composite as covariates in all models. Finally, the ability of the SURPS subscales to distinguish among the four groups control, heroin, amphetamine, and polysubstance users was determined using the anova function Fox, in the car package Fox and Weisberg, by providing the function with fitted geeglm models. For generalized linear models such as these, the anova function calculates the Wald chi-square. Tukey's post-hoc comparisons were then conducted using the pairs procedure in the emmeans package Emmeans Package, In such cases, the absolute fit index RMSEA is generally more reliable and we therefore relied more heavily on this index than on the others Fan et al. Factor loadings ranged between 0. The alpha coefficients for each subscale were as follows: IMP: 0. All coefficients were above the recommended value of 0. The Pearson correlation matrix between each SURPS subscale and other measures purported to assess the same construct are shown in Table 2. Taken together, these results demonstrate good convergent validity. Overall, the magnitude of the correlations were highest between the SURPS subscales and measures purported to measure similar constructs i. The results of the GEE generalized linear models are shown in Table 3. The majority of the theoretically related measures were significantly associated with their specific subscales as expected. The SURPS-AS was also significantly associated with nicotine dependence, number of symptoms of cannabis abuse, amphetamine dependence, antisocial personality disorder, and years of heroin use. However, somewhat surprisingly, none of the SURPS subscales were significantly associated with heroin abuse, heroin dependence, and years since last met DSM-IV criteria for heroin and amphetamine dependence. Table 3. Predictive validity: Generalized estimating equation GEE generalized linear model results. The results of the ANOVAs and Tukey's post-hoc comparisons are shown in Table 4 , along with the N for each group, the group means, and standard errors. Table 4. The aims of the present study were to examine the factor structure and psychometric properties of the Bulgarian version of the SURPS and its ability to distinguish between substance dependent groups and non-dependent controls. In line with our theoretical predictions, the four-factor solution provided a very good fit to the Bulgarian data, indicating that the SURPS performs well in this translated measure. Factor loadings from the CFA were all above 0. Conceptually, this item appears more closely related to psychopathy than to impulsivity per se. The SURPS also correlated well with theoretically related measures and was a very good predictor of associated outcomes, such as SUDs, indicating that the Bulgarian version of the scale has good concurrent and predictive validity. Though the SURPS has demonstrated good psychometric properties with non-substance dependent adolescent and college student samples, its validity and clinical utility with substance dependent community samples remained unexplored. To our knowledge, this was the first study investigating the properties of the SURPS with non-treatment seeking community drug users with a history of substance dependence. In regard to the ability of the SURPS to distinguish between groups, we found significant group differences on the two externalizing SURPS factors Impulsivity and Sensation Seeking , where the three substance dependent groups scored higher than controls. Contrary to expectations, we found no group differences on internalizing traits such as Hopelessness and Anxiety Sensitivity, which raises questions about the utility of these traits with substance dependent samples. The lack of association with internalizing traits may also be related to the protracted abstinence stage of the addiction cycle, which characterized the majority of our substance dependent participants. These symptoms may be more prominent soon after discontinuation of drug use and may partially recover with longer periods of abstinence. In general, the protracted abstinence stage of the addiction cycle is relatively understudied and not well-understood. There is a need for systematic studies examining recovery of function with increasing length of abstinence in users of different classes of drugs. One surprising finding was that all SURPS subscales except for the SURPS-SS were significantly associated with alexithymia, a personality trait characterized by difficulty identifying, differentiating, and expressing emotions, which is highly prevalent among substance dependent individuals Morie et al. Alexithymia is proposed to be a coping strategy for dealing with negative emotions Bilotta et al. Consistent with our findings, alexithymia has previously been associated with impulsivity Shishido et al. Of particular relevance to our findings is the recently proposed heuristic framework for Addictions Neuroclinical Assessment Kwako et al. Alexithymia may become potentially more important than anxiety sensitivity or hopelessness during the protracted abstinence phase of the addiction cycle. During the earlier stages of addiction, the cycling between active drug use and abstinence may sensitize substance users to the physiological symptoms of anxiety i. The ability to remain abstinent may reduce hopelessness and anxiety sensitivity during the protracted abstinence stage of addiction. However, these negative affective states may be replaced by other dimensions of negative emotionality such as alexithymia and anhedonia, characterized by inability to express feelings or to experience positive emotions. Given that protracted abstinence is one of the least well-understood stages of the addiction cycle, this question needs more detailed investigation. Even more surprising was the lack of associations between any of the SURPS subscales with heroin abuse or dependence. Given that the SURPS has been validated mainly with adolescents who primarily use alcohol, cannabis, and stimulants, the sensitivity of the scale in relation to heroin dependence needs more research. Heroin addiction has some unique characteristics that distinguish it from addictions to other classes of drugs, such as having the largest amount of drug-specific genetic variance and the least amount of shared genetic variance among illicit drugs Tsuang et al. It is also associated with specific genetic susceptibility to opioid use vs. Further, our heroin dependent participants were characterized by longer duration of abstinence relative to amphetamine and polysubstance users. Therefore, the lack of associations between heroin dependence and the SURPS subscales could also be due to neuroplasticity and recovery of function in brain circuits affected by drugs of abuse. Consistent with our findings, there is evidence that disruptive behavioral disorders and mood disorders are often comorbid with SUDs Roberts et al. Research shows that the covariance between SUDs and different dimensions of antisocial behavior could be modeled by a single underlying externalizing factor that is influenced by genetic risk Kendler et al. However, the externalizing spectrum is highly correlated with the internalizing spectrum, which has been shown to be due to common genetic and environmental risk factors Cosgrove et al. The observed moderate correlation of AS with trait anxiety is in line with previous research demonstrating that AS and trait anxiety are distinct constructs McNally, AS is currently viewed as being both an independent construct and a lower-order factor of trait anxiety McWilliams and Cox, There are some limitations of our study that need to be noted. Second, our small sample size precluded investigations of potential sex differences in SURPS risk profiles and their relations to addiction to different classes of drugs. The use of DSM-5 might show slightly different results, since some of the criteria have changed. Fourth, some of the instruments were self-report measures including some reverse-keyed items , which may lead to significant variations due to subjective and cultural factors. The Bulgarian version of the SURPS replicated the original factor structure of the scale and demonstrated acceptable to good reliability and validity. Accordingly, it is a useful tool for conducting research in SUDs and substance related disorders in Bulgaria. It also appears to be useful for assessing personality risk for SUD, which could be targeted by tailored personality-based interventions. EL performed the statistical analyses, drafted the analysis and results sections, and led the revisions. SM drafted the introduction and discussion sections and assisted with the revisions. NG consulted on the statistical analyses. JV supervised the findings of this work, drafted portions of the manuscript, and oversaw the revisions. All authors discussed the results and contributed to the final manuscript. GV has ownership interests in the Bulgarian Addictions Institute, where data collection took place. The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. Ali, A. 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Materials and Methods Participants Participants were recruited from a larger ongoing study on neurocognitive functioning among substance dependent individuals in Bulgaria, via flyers placed at substance abuse clinics, nightclubs, bars, and cafes, as well as, through the study's web page and Facebook page. Table 1. Figure 1. Table 2. Convergent and discriminant validity: Pearson correlations.