- Email: [email protected]
Impact of personality pathology on psychosocial functioning
Accepted Manuscript Title: Impact of Personality Pathology on Psychosocial Functioning Author: Andrew E. Skodol M.D. PII: DOI: Reference:
S2352-250X(17)30195-1 http://dx.doi.org/doi:10.1016/j.copsyc.2017.09.006 COPSYC 571
To appear in: Received date: Revised date: Accepted date:
6-7-2017 4-9-2017 5-9-2017
Please cite this article as: A.E. Skodol, Impact of Personality Pathology on Psychosocial Functioning, COPSYC (2017), http://dx.doi.org/10.1016/j.copsyc.2017.09.006 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ip t
September 4, 2017
a
University of Arizona College of Medicine
Columbia University College of Physicians and Surgeons
Ac ce p
te
d
M
an
b
us
Andrew E. Skodol, M.D.a,b
cr
Impact of Personality Pathology on Psychosocial Functioning
Corresponding Author: Andrew E. Skodol, M.D., 2626 E. Arizona Biltmore Circle, Unit #29, Phoenix, AZ 85016. Phone: (516) 816-1990. Email: [email protected].
1 Page 1 of 16
September 4, 2017
Abstract
us
cr
ip t
Personality disorders impair social, occupational, leisure, and global functioning more than a significant disorder such as major depressive disorder. Impairment is found in clinical and community populations. Impairment is independent of co-occurring other mental disorders. Impairment is more stable over time than are the diagnoses themselves. Personality traits are also impairing and may be more predictive of outcomes over time, but a hybrid of personality disorder features and normal range personality traits may be the most predictive model. A general, “transdiagnostic,” selfother severity factor may be important for understanding the relationship of personality pathology and psychosocial functioning over time. The Alternative DSM-5 Model for Personality Disorders may be useful for the study of psychosocial functioning in individuals with personality pathology.
an
Highlights:
1. Personality disorders impair social, occupational, leisure, and global functioning.
M
2. Impairment is found in clinical and community populations. 3. Impairment independent of co-occurring mental disorders.
d
4. Impairment is more stable than personality disorder diagnoses.
te
5. Personality disorder features and personality traits both predict impairment.
Ac ce p
Conflicts of interest: none
2 Page 2 of 16
September 4, 2017
ip t
Introduction
an
us
cr
Psychosocial functioning refers to a person’s ability to carry out roles and perform activities in daily life, including in social or interpersonal, school or work, recreational or leisure, and basic (i.e., self-care, communication, mobility) functional realms. Impairment in psychosocial functioning, sometimes referred to as “disability,” may be a consequence of having limitations or disruptions in mental capacities (e.g., emotional regulation, self-esteem maintenance, reality testing) that result in the manifestations (i.e., signs, symptoms, traits) of mental disorders, particularly when these limitations or disruptions are severe.
te
d
M
Early studies comparing the psychosocial functioning of patients with PDs to others with no PD or with an Axis I disorder found that patients with PDs were more likely to be separated, divorced, or never married; were more likely to be unemployed, disabled, or having made frequent job changes; and had poorer quality of social and work functioning [1]. In these studies, systematic diagnosis of PDs and assessment of functional impairment were rare, borderline personality disorder (BPD) was most often studied, PDs were rarely compared to one another, and participants were almost exclusively patients as opposed to community dwellers.
Ac ce p
Functional Impairment in Patients with Personality Disorders To address gaps in knowledge, psychosocial functioning assessed by interview and self-report was compared in 668 rigorously diagnosed patients with schizotypal (STPD), borderline (BPD), avoidant (AVPD), or obsessive-compulsive (OCPD) PDs or with major depressive disorder (MDD) and no PD in the Collaborative Longitudinal Personality Disorders Study (CLPS) [2]. There were no differences between the PD and MDD groups on marital status. Patients with STPD and BPD, however, were more than three times as likely to have only a high school education compared to those with MDD and less than one-half as likely to have graduated from college. Patients with STPD and BPD were less frequently employed and had over twice the odds of being on disability. With respect to qualitative impairment, patients with STPD and BPD were found to have significantly more impairment at work, in social relationships, and at leisure than patients with OCPD or MDD; patients with AVPD were intermediate. These differences remained significant after controlling for demographics and co-occurring Axis I psychopathology. Patients with STPD and BPD were between 2.5 and almost 7 times more likely to have severe levels of impairment in employment, relationships with 3 Page 3 of 16
September 4, 2017
parents and siblings, global social adjustment, and GAFS score (<50) than patients with MDD. Psychosocial Functioning in Community Residents with Personality Disorders
d
M
an
us
cr
ip t
The relationship of seven DSM-IV PDs and three emotional disability scores was examined in Wave 1 of the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) [3]. PDs, in general, were associated with being divorced, separated, widowed, or never married and with having low socioeconomic status. AVPD, dependent PD (DPD), schizoid PD (SZPD), paranoid PD (PPD), and antisocial PD (ASPD) were all significant predictors of social functioning impairment, role emotional impairment, and overall impairment due to mental health problems, controlling for age and for DSM-IV Axis I disorders. OCPD was inconsistently related to disability and histrionic personality disorder (HPD) was not associated with disability. In the NESARC Wave 2 survey, BPD was associated with unmarried status, lower income, and lower education and with substantial disability in all three of the above areas, controlling for demographics, Axis I disorders, and other PDs [4]. Narcissistic PD (NPD) was associated with unmarried status and with role emotional impairment and overall impairment in men, but not women [5]. STPD was associated with unmarried status and with disability in all areas in both sexes [6]. Overall annual population reductions in quality of life at Wave 2 was greater for PDs than for myriad common health and mental health conditions other than arthritis and mood disorders [7].
Ac ce p
te
In the Children in the Community Study (CICS), individuals diagnosed with DSM-IV Cluster A, B, or C PDs or PD not otherwise specified (PDNOS) were more likely to have difficulties in interpersonal relationships and poor educational achievement during both adolescence and early adulthood than individuals without PDs, controlling for cooccurring Axis I disorders [8]. Any PD and any Cluster A, B, or C PDs in early adulthood were associated with poorer quality of life at age 33, with Cluster B PDs having the greatest effect [9]. Adolescents with PDs had comparable or greater impairment in educational attainment, occupational status, romantic commitment, partner quality, social support, and GAFS as adolescents with Axis I disorders 20 years later [10]. The National Comorbidity Survey Replication (NCS-R) found associations between Cluster A, ASPD, BPD, Cluster B, Cluster C, and any PD and functioning variables from the World Health Organization Disability Assessment Schedule (WHO-DAS), including basic role functioning (mobility, self-care, and cognition), instrumental role functioning (days out of role, quality of productive role performance), and quality of social role performance, but a number of these findings were not significant when Axis I disorders were controlled [11]. The authors concluded that “the main public health significance of personality disorders lies in their effects on Axis I disorders rather than in their effects on functioning” (p. 553). However, the principal effect of Axis I controls was on the 4 Page 4 of 16
September 4, 2017
WHO-DAS basic role functioning variables. Significant associations remained between any Cluster B and social role functioning impairment and any PD and days out of instrumental role (e.g., as homemaker or worker), impairment in productive role functioning, and impairment in social role functioning.
us
cr
ip t
A recent nationwide register-based study in Denmark confirmed that individuals with BPD had more long-term vocational impairment than individuals with other PDs and most other mental disorders [12]. In another US study, community-based individuals with BPD had significant more impairment in educational/occupational performance and lower quality of relationships with parents, partners, and friends compared to individuals without BPD, but less impairment than patients with BPD [13].
an
Taken together, these clinical and epidemiological studies indicate that most PDs exert a negative impact on psychosocial functioning independent of co-occurring Axis I psychopathology. Certain PDs (e.g., STPD and BPD) appear to be more impairing than others (e.g., OCPD and HPD). That AVPD and DPD are significantly impairing may be surprising.
M
Longitudinal Course/Stability of Functional Impairment in Personality Disorders
Ac ce p
te
d
A long-standing defining feature of PDs has been “an enduring pattern of inner experience and behavior” that is stable over time [14, p.646], despite numerous followup studies and more recent prospective follow-along studies that show considerable diagnostic instability for PDs [15]. Impairment in psychosocial functioning has been a candidate for a stable aspect of PDs. In the CLPS, the psychosocial functioning of 600 patients was assessed at baseline and three additional times over the next two years [16]. Significant improvement was found in only three of seven domains of functioning—relationships with spouse or mate, recreation, and global social adjustment—and for the latter two was largely the result of improvement in the MDD group. Improvement in relationships with spouse or mate may come as a surprise in a sample of patients most of whom had PDs, but only 20% of the sample had such a relationship, so the finding is limited to a small minority. Patients with BPD who experienced a change in personality pathology showed some improvement in functioning. Impairment in social relationships appeared to be the most stable in patients with PDs, suggesting an enduring component of PD. The stability of functional impairment in patients with BPD, other PDs (AVPD and OCPD), and MDD and no PD was examined again in the CLPS over 10 years [17]. Although 85% of patients with BPD remitted, functional impairment remained severe, with only modest improvement. Only about 20% of patients with BPD achieved a functional remission (GAFS >70), mostly those who met fewer BPD criteria.
5 Page 5 of 16
September 4, 2017
M
an
us
cr
ip t
In the McLean Study of Adult Development (MSAD), psychosocial functioning and personality pathology were assessed every two years over time in 290 hospitalized patients with BPD and 72 with other non-borderline PDs (OPDs). Over 6 years of followup [18], the psychosocial functioning of patients with BPD improved substantially, with the percentage showing good overall functioning increasing from 26% at baseline to 56%. Nevertheless, patients with BPD continued to function more poorly than patients with OPDs. Patients with BPD who experienced a symptomatic remission functioned better both socially and occupationally than those who did not. By the 10-year follow-up [19], results indicated that patients with BPD who did not have good (in both social and vocational areas) psychosocial functioning at baseline had difficulty attaining it. Those who had good functioning had difficulty retaining it and then regaining it. Most of the lasting impairment was vocational, rather than social. Consistent with persisting vocational impairment, patients with BPD were found to be three times more likely to receive Social Security Disability Income over 10 years as the OPD comparisons [20] and less likely to occupy a higher income group [21]. Despite the better social functioning in the patients with BPD, interpersonal problems such as intolerance of aloneness and conflicts over dependency persisted [22].
Ac ce p
te
d
In the CICS [23], individuals were assessed for PD status and functioning at mean ages 14, 16, 22, and 33. Individuals who had persistent PD (PD present at or before age 22 and at age 33) had markedly poorer functioning at age 33 than those who had never been diagnosed with a PD or who had a PD that remitted. Remitted PD was associated with mild long-term impairment. Adult-onset PDs (absent at or before age 22, but present at age 33) were also associated with significant impairment. Analyses controlled for Axis I disorders at age 33. Thus, PD persistence versus improvement is an important determinant of functional impairment over time. Impact of Personality Traits vs. Disorders on Functioning In the CLPS, both categorical and dimensional representations of DSM-IV PDs had stronger relationships to impairment in functioning in areas of employment, social relationships with parents and friends, global social adjustment, and GAFS ratings at baseline than either three-factor (SNAP) or five-factor (NEO-PI-R) models [24]. DSM-IV dimensions predicted functioning best. However, when relationships of five-factor traits and functioning at the 2-year and 5-year follow-ups were examined [25], traits showed relationships with some theoretically consistent specificity (see Table 1). When Morey et al. [26] compared these alternative models of personality pathology to each other over 4 years, they found that although DSM-IV PD dimensions predicted functioning at baseline, this relationship diminished over time, such that by the 4-year follow-up, the PD dimensions had the weakest relationships to functioning. Over time, the SNAP, which combines both pathological and normal traits, performed the best. These results were confirmed over the 6-, 8-, and 10-year follow-ups [27] and suggest that a hybrid 6 Page 6 of 16
September 4, 2017
model combining stable trait and dynamic psychopathological influences might have the most validity over time.
cr
ip t
Ro and Clark [28] examined the relationship of both adaptive- and maladaptive-range personality traits to functioning in both non-clinical and psychiatric outpatient samples. Well-being (personal satisfaction, sense of self, self-control), social/interpersonal functioning (positive relationships, social concordance, empathy), and basic functioning (self-care, mobility, communication) were strongly related to personality traits, especially in patients (See Table 2). DSM-5 Alternative Model and Functioning
te
d
M
an
us
An “Alternative DSM-5 Model for Personality Disorders” (AMPD) was published in Section III of the manual [29]. The central components of this “hybrid” model for the assessment and diagnosis of personality pathology are dimensional ratings of the severity of impairment in personality (self and interpersonal) functioning and 25 pathological personality trait “facets” organized into 5 broad trait “domains.” Impairments in four elements of personality functioning – identity, self-direction, empathy, and intimacy – that were identified in the literature as core aspects of PD that can be reliably assessed [30,31] are measured in combination on a 5-point scale of severity, the Level of Personality Functioning Scale (LPFS). Pathological personality trait domains – negative affectivity, detachment, antagonism, disinhibition, and psychoticism – correspond to the pathological “poles” of the widely validated FiveFactor Model (FFM) of personality [32].
Ac ce p
In a study of 337 clinicians who rated one of their patients on all aspects of the DSM-5 AMPD and all diagnostic criteria for the 10 DSM-IV PDs, the single-item LPFS score was a better predictor of psychosocial functioning than were the 10 DSM-IV PDs combined [33]. In a study by Simms and Calabrese [34] of 628 psychiatric patients, AMPD personality traits, assessed with the Personality Inventory for DSM-5 (PID-5), incremented the prediction of psychosocial functioning over normal-range traits, PD criterion counts, and common psychiatric symptoms. The incremental effects of the latter on functioning were much smaller than for PID-5 traits. Section III traits have also been found to be highly stable, prospectively predictive of psychosocial functioning, and dynamically associated with functioning over time, providing important additional evidence in support of the AMPD [35]. Personality Pathology Severity and Other Transdiagnostic Predictors of Functioning Generalized severity of personality pathology may be the most important single predictor of concurrent and prospective dysfunction. Hopwood et al. [36] found a count of all PD criteria met had the highest coefficient of determination for predicting both 7 Page 7 of 16
September 4, 2017
ip t
current and prospective (at the 5-year follow-up) GAF scores and social, work, and leisure dysfunction variables combining clinician ratings and self-report scores. However, trait-based factors significantly incremented severity in predicting most functioning variables. These results were replicated in the MSAD over 10 years of follow-up: BPD symptoms and FFM personality traits were both strongly related to prospective functioning and incremented each other in prediction [37].
an
us
cr
In the NESARC, four PD severity categories (no, subthreshold, simple, and complex— i.e., co-morbid—PD) were related to mental disability in individuals with Axis I disorders [38]. Significant increases in disability were observed between absent and simple PD and between simple and complex PD for each Axis I disorder except drug dependence. This study supports the utility of a PD severity measure based on number of PDs (or criteria) present. Moran et al. also found that severity of PD was related to educational impairment, receipt of welfare, and absence of long-term relationships in a large population-based prospective longitudinal study of young adults in Australia [39].
Ac ce p
te
d
M
Sharp et al. [40] evaluated a bifactor model of PD pathology in which a general factor and several specific factors accounted for PD criteria covariance in a sample of 966 hospitalized patients. BPD loaded only on the general factor; the other PDs loaded either on the general and a specific factor or largely only on a specific factor. The results suggest that BPD’s self-other pathology may represent something PDs have in common, as is represented by the LPFS in the AMPD. Conway et al. [41] used bifactor modelling to study PDs in a community sample of 700 young adults. They found an “overarching dimension of PD severity” (p. 545) that had symptoms from all PD categories and that strongly predicted multiple functional outcomes, including general functioning, social, family, marital, and work functioning. Specific PD factors uncorrelated with the general factor were much more modestly associated with functioning or not associated at all. Using data from the 10-year follow-along of the CLPS, general and specific factors were identified and patterns of growth of the factors over time were examined by Wright et al. [42]. Concurrent and dynamic associations were established between PD factors and a host of external validators, including psychosocial functioning. Results showed that general PD had much lower absolute stability and was associated most strongly with functioning concurrently and prospectively; specific factors, in this case detachment, dependency, compulsivity, dominance, and disinhibition, had much higher mean stability but more circumscribed associations with functioning. The results are generally supportive of the AMPD’s separation of impairments in personality functioning to determine the severity of personality pathology and pathological personality traits to describe the myriad variations in PD presentations.
8 Page 8 of 16
September 4, 2017
Summary and Conclusions
us
cr
ip t
PDs impair psychosocial functioning more than a significant Axis I disorder such as MDD. Impairment is found in both clinical and community populations. Impairment is independent of co-occurring other mental disorders. Impairment is more stable over time than are PD diagnoses themselves. Personality traits are also impairing and may be more predictive over time, but a hybrid of PD features and normal range personality traits may perform the best. A general, “transdiagnostic” self-other severity factor may be important for understanding the relationship of personality pathology and psychosocial functioning over time.
M
an
Impairing personality pathology is often neglected in clinical assessment, treatment, and research. Longitudinal descriptive and neurobiological studies are needed to better understand the mechanisms determining impairment in PDs. The DSM-5 AMPD may provide a useful assessment model for the study of psychosocial functioning and personality pathology. References
te
d
[1] Skodol AE, Bender DS, Gunderson JG, Oldham JM: Personality disorders. In American Psychiatric Publishing Textbook of Psychiatry, 6th Edition. Edited by Hales RE, Yudofsky SC, Roberts L. American Psychiatric Publishing; 2014: 851-894.
Ac ce p
[2] Skodol AE, Gunderson JG, McGlashan TH, Dyck IR, Stout RL, Bender DS, Grilo CM, Shea MT, Zanarini MC, Morey LC, et al: Functional impairment in patients with schizotypal, borderline, avoidant, or obsessive-compulsive personality disorder. Am J Psychiatry 2002, 159:276-283. [3] Grant BF, Hasin DS, Stinson FS, Dawson DA, Chou SP, Ruan WJ, Pickering RP: Prevalence, correlates, and disability of personality disorders in the United States: results from the National Epidemiologic Survey on Alcohol and Related Conditions. J Clin Psychiatry 2004, 65:948-958. [4] Grant BF, Chou SP, Goldstein RB, Huang B, Stinson FS, Saha TD, Smith SM, Dawson DA, Pulay AJ, Pickering RP, Ruan WJ: Prevalence, correlates, disability, and comorbidity of DSM-IV borderline personality disorder: results from the wave 2 National Epidemiologic Survey on Alcohol and Related Conditions. J Clin Psychiatry 2008, 69:533-545. [5] Stinson FS, Dawson DA, Goldstein RB, Chou SP, Huang B, Smith SM, Ruan WJ, Pulay AJ, Saha TD, Pickering RP, Grant BF: Prevalence, correlates, disability, and comorbidity of DSM-IV narcissistic personality disorder: results from the wave 2 9 Page 9 of 16
September 4, 2017
National Epidemiologic Survey on Alcohol and Related Conditions. J Clin Psychiatry 2008, 69:1033-1045.
ip t
[6] Pulay AJ, Stinson FS, Dawson DA, Goldstein RB, Chou SP, Huang B, Saha TD, Smith SM, Pickering RP, Ruan WJ, et al: Prevalence, correlates, disability, and comorbidity of DSM-IV schizotypal personality disorder: results from the wave 2 National Epidemiologic Survey on Alcohol and Related Conditions. Primary Care Companion J Clin Psychiatry 2009, 11:53-67.
us
cr
[7*] Penner-Goeke K, Henriksen CA, Chateau D, Latimer E, Sareen J, Katz LY: Reductions in quality of life associated with common mental disorders: results from a nationally representative sample. J Clin Psychiatry 2015, 76:1506-1512.
te
d
M
an
The NESARC Wave 2 sample is very large, enabling examination of the impact of many variables on QoL simultaneously. All 10 DSM-IV PDs were assessed, as well as a wide range of other mental and physical disorders, and impact on QoL was examined at both individual and population levels. The authors found that mood disorders were associated with the greatest decreases in health related QoL, followed by psychotic disorders, stroke, and arthritis. Due to the relative prevalence of the various disorders, however, the greatest annual QoL losses were caused by arthritis, mood disorders, and PDs at a population level. These “burden of disease” findings demonstrate the importance of personality pathology in the general population, among individuals unselected for seeking treatment. Treatment-seeking can be assumed to be associated with distress or functional impairment, so the impact of PDs on QoL in community samples strengthens conclusions that can be drawn about the associations, but also underscores the need for PD assessment in clinical populations.
Ac ce p
[8] Johnson JG, First MB, Cohen P, Skodol AE, Kasen S, Brook JS: Adverse outcomes associated with personality disorders not otherwise specified in a community sample. Am J Psychiatry 2005, 162:1926-1932. [9] Chen H, Cohen P, Crawford TN, Kasen S, Johnson JG, Berensen K: Relative impact of young adult personality disorders on subsequent quality of life: findings of a community-based longitudinal study. J Pers Disord 2006, 20:510-523. [10] Crawford TN, Cohen P, First MB, Skodol AE, Johnson JG, Kasen S: Comorbid Axis I and Axis II disorders in early adolescence: outcomes 20 years later. Arch Gen Psychiatry 2008, 65:641-648. [11] Lenzenweger MF, Lane MC, Loranger AW, Kessler RC: DSM-IV personality disorders in the National Comorbidity Survey Replication. Br J Psychiatry 2007, 62:533-564.
10 Page 10 of 16
September 4, 2017
[12] Hastrup LH, Kongerslev M, Simonsen E: Lower vocational outcome in borderline personality disorder: a Danish nationwide 9-year register-based study. J Pers Disord in press.
ip t
[13] Javaras KN, Zanarini MC, Hudson JI, Greenfield SF, Gunderson JG: Functional outcomes in community-based adults with borderline personality disorder. J Psychiatr Res 2017, 89:105-114.
cr
[14] American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. American Psychiatric Association; 2013.
an
us
[15] Grilo CM, McGlashan TH, Skodol AE: Course and outcome of personality disorders. In American Psychiatric Publishing Textbook of Personality Disorders, 2nd Edition. Edited by Oldham JM, Skodol AE, Bender DS. American Psychiatric Publishing; 2014:165-186.
M
[16] Skodol AE, Pagano ME, Bender DS, Shea MT, Gunderson JG, Yen S, Stout RL, Morey LC, Sanislow CA, Grilo CM, et al: Stability of functional impairment in patients with schizotypal, borderline, avoidant, or obsessive-compulsive personality disorder over two years. Psychol Med 2005, 35:433-451.
te
d
[17] Gunderson JG, Stout RL, McGlashan TH, Shea MT, Morey LC, Grilo CM, Zanarini MC, Yen S, Markowitz JC, Sanislow C, et al: Ten-year course of borderline personality disorder: psychopathology and function from the Collaborative Longitudinal Personality Disorders Study. Arch Gen Psychiatry 2011, 68:827-837.
Ac ce p
[18] Zanarini MC, Frankenburg FR, Hennen J, Reich DB, Silk KR: Psychosocial functioning of borderline patients and axis II comparison subjects followed prospectively for six years. J Pers Disord 2005, 19:19-29. [19] Zanarini MC, Frankenburg FR, Reich DB, Fitzmaurice G: The 10-year course of psychosocial functioning among patients with borderline personality disorder and axis II comparison subjects. Acta Psychiatrica Scand 2010, 122:103-109. [20] Zanarini MC, Jacoby RJ, Frankenburg FR, Reich DB, Fitzmaurice G: The 10-year course of social security disability income reported by patients with borderline personality disorder and axis II comparison subjects. J Pers Disord 2009, 23:346356. [21] Niesten IJ, Karan E, Frankenburg FR, Fitzmaurice GM, Zanarini MC: Description and prediction of income status of borderline patients over 10 years of prospective follow-up. Personal Ment Health 2016, 10:285-292.
11 Page 11 of 16
September 4, 2017
[22] Choi-Kain LW, Zanarini MC, Frankenburg FR, Fitzmaurice GM, Reich DB: A longitudinal study of the 10-year course of interpersonal features in borderline personality disorder. J Pers Disord 2010, 24:365-376.
ip t
[23] Skodol AE, Johnson JG, Cohen P, Sneed JR, Crawford TN: Personality disorder and impaired functioning from adolescence to adulthood. Br J Psychiatry 2007, 190:415-420.
us
cr
[24] Skodol AE, Oldham JM, Bender DS, Dyck IR, Stout RL, Morey LC, Shea MT, Zanarini MC, Sanislow CA, Grilo CM, et al: Dimensional representations of DSM-IV personality disorders: relationships to functional impairment. Am J Psychiatry 2005, 162:1919-1925.
an
[25] Hopwood CJ, Morey LC, Ansell EB, Grilo CM, Sanislow CA, McGlashan TH, Markowitz JC, Gunderson JG, Yen S, Shea MT, Skodol AE: The convergent and discriminant validity of five-factor traits: current and prospective social, work, and recreational dysfunction. J Pers Disord 2009, 23:466-476.
M
[26] Morey LC, Hopwood CJ, Gunderson JG, Skodol AE, Shea MT, Yen S, Stout RL, Zanarini MC, Grilo CM, Sanislow CA, McGlashan TH: Comparison of alternative models for personality disorders. Psychol Med 2007, 37:983-994.
Ac ce p
te
d
[27] Morey LC, Hopwood CJ, Markowitz JC, Gunderson JG, Grilo CM, McGlashan TH, Shea MT, Yen S, Sanislow CA, Ansell EB, Skodol AE: Comparison of alternative models for personality disorders, II: 6-, 8-, and 10-year follow-up. Psychol Med 2012, 42:1705-1713. [28] Ro E, Clark LA: Correlations between psychosocial functioning and adaptiveand maladaptive-range personality traits. J Abnorm Psychol 2013, 122:822-835. [29] Skodol AE, Morey LC, Bender DS, Oldham JM: The Alternative DSM-5 Model for Personality Disorders: a clinical application. Am J Psychiatry 2015, 172:606-613. [30] Bender DS, Morey LC, Skodol AE: Toward a model for assessing level of personality functioning in DSM-5, part I: a review of theory and methods. J Pers Assess 2011, 93:322-346. [31] Morey LC, Berghuis H, Bender DS, Verheul R, Krueger RF, Skodol AE: Toward a model for assessing level of personality functioning in DSM-5, part II: empirical articulation of a core dimension of personality pathology. J Pers Assess 2011, 93:347-353.
12 Page 12 of 16
September 4, 2017
[32] Krueger RF, Derringer J, Markon KE, Watson D, Skodol AE: Initial construction of a maladaptive personality trait model and inventory for DSM-5. Psychol Med 2012, 42:1879-1890.
ip t
[33] Morey LC, Bender DS, Skodol AE: Validating the proposed Diagnostic and Statistical Manual of Mental Disorders, 5th Edition, severity indicator for personality disorder. J Nerv Ment Dis 2013, 201:729-735.
cr
[34**] Simms LJ, Calabrese WR: Incremental validity of the DSM-5 Section III personality disorder traits with respect to psychosocial impairment. J Pers Disord 2016, 30:95-111.
an
us
The results of this large clinical study demonstrate the incremental validity of DSM-5 Alternative Model personality traits. Section III traits predicted psychosocial impairment over and above what was predicted by normal range five-factor model personality traits, PD criteria counts derived from SCID-II interviews, and common psychiatric symptoms also elicited by semistructure interview. Incremental effects for normal-range personality traits, PD criteria counts, and psychiatric symptoms over Section III traits were substantially smaller.
d
M
[35] Wright AG, Calabrese WR, Rudick MM, Yam WH, Zelazny K, Williams TF, Rotterman JH, Simms LJ: Stability of Section III pathological personality traits and their longitudinal associations with psychosocial functioning in personality disordered individuals. J Abnorm Psychol 2015, 124:199-207.
Ac ce p
te
[36] Hopwood CJ, Malone JC, Ansell EB, Sanislow CA, Grilo CM, McGlashan TH, Pinto A, Markowitz JC, Shea MT, Skodol AE, et al: Personality assessment in DSM-5: empirical support for rating severity, style, and traits. J Pers Disord 2011, 25:305320. [37] Hopwood CJ, Zanarini MC: Borderline personality traits and disorder: predicting prospective patient functioning. J Consult Clin Psychol 2010, 78:585-589. [38] Pulay AJ, Dawson DA, Ruan WJ, Pickering RP, Huang B, Chou SP, Grant BF: The relationship of impairment to personality disorder severity among individuals with specific axis I disorders: results from the National Epidemiologic Survey on Alcohol and Related Conditions. J Pers Disord 2008, 22:405-417. [39*] Moran P, Romaniuk H, Coffey C, Chanen A, Degenhardt L, Borschmann R, Patton GC: The influence of personality disorder on future mental health and social adjustment: a population-based cohort study. Lancet Psychiatry 2016, 3:636-645. In a unique longitudinal cohort study using a structured clinical assessment of personality pathology in a large community population, the authors found that young adults with personality disorder are at risk for continuing psychosocial problems and for anxiety disorders and major depressive disorder 11 years later. Importantly, severity of personality disorder, including 13 Page 13 of 16
September 4, 2017 subthreshold personality difficulties, was a strong predictor of future problems, controlling for comorbid mental disorders and impairment in functioning at baseline. These results provide support for including personality disorder in global studies of the community burden of mental disorders.
ip t
[40] Sharp C, Wright AG, Fowler JC, Frueh BC, Allen JG, Oldham J, Clark LA: The structure of personality pathology: both general (‘g’) and specific (‘s’) factors? J Abnorm Psychol 2015, 124:387-398.
us
cr
[41] Conway CC, Hammen C, Brennan PA: Optimizing prediction of psychosocial and clinical outcomes with a transdiagnostic model of personality disorder. J Pers Disord 2016, 30:545-566.
an
[42**] Wright AG, Hopwood CJ, Skodol AE, Morey LC: Longitudinal validation of general and specific structural features of personality pathology. J Abnorm Psychol 2016, 125:1120-1134.
Ac ce p
te
d
M
Using data from the prospective 10-year follow-along Collaborative Longitudinal Personality Disorders Study (CLPS), the authors separated general from specific PD features and then studied the longitudinal course of these features and their association to broad markers of psychosocial functioning. General features, shared by all PDs, showed lower absolute stability and were most strongly predictive of impairment in functioning concurrently and longitudinally, whereas specific features, describing PD types, had much higher mean stability but more circumscribed relationships with functioning. These results support the hybrid Alternative DSM5 Model for Personality Disorders which measures both the severity of impairments in personality functioning (a general factor) and descriptive pathological personality traits.
14 Page 14 of 16
September 4, 2017
Psychosocial Functioning Domain Occupational Recreational + + -
-
us
Neuroticism Extraversion Openness Agreeableness Conscientiousness
Social + -
cr
Trait
ip t
Table 1. Associations Between Five-Factor Personality Traits and Impairment in Psychosocial Functioning Domains at 2- and 5-year Follow-up [25].
-
an
+ Positive relationship between personality trait and impairment in psychosocial functioning domain.
Ac ce p
te
d
M
- Negative relationship between personality trait and impairment in psychosocial functioning domain.
15 Page 15 of 16
September 4, 2017
Table 2. Associations Between FFM and SNAP Personality Traits and Impairment in Psychosocial Functioning Domains in Patients and Non-patients [28].
ip t
+
cr
Neuroticism/Negative Affectivity Extraversion/Positive Affectivity Agreeableness Disinhibition
Psychosocial Functioning Domain Well-Being Social/Interpersonal Basic +
us
Trait
+
an
+ Positive relationship between personality trait and impairment in psychosocial functioning domain.
Ac ce p
te
d
M
- Negative relationship between personality trait and impairment in psychosocial functioning domain.
16 Page 16 of 16
S2352-250X(17)30195-1 http://dx.doi.org/doi:10.1016/j.copsyc.2017.09.006 COPSYC 571
To appear in: Received date: Revised date: Accepted date:
6-7-2017 4-9-2017 5-9-2017
Please cite this article as: A.E. Skodol, Impact of Personality Pathology on Psychosocial Functioning, COPSYC (2017), http://dx.doi.org/10.1016/j.copsyc.2017.09.006 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ip t
September 4, 2017
a
University of Arizona College of Medicine
Columbia University College of Physicians and Surgeons
Ac ce p
te
d
M
an
b
us
Andrew E. Skodol, M.D.a,b
cr
Impact of Personality Pathology on Psychosocial Functioning
Corresponding Author: Andrew E. Skodol, M.D., 2626 E. Arizona Biltmore Circle, Unit #29, Phoenix, AZ 85016. Phone: (516) 816-1990. Email: [email protected].
1 Page 1 of 16
September 4, 2017
Abstract
us
cr
ip t
Personality disorders impair social, occupational, leisure, and global functioning more than a significant disorder such as major depressive disorder. Impairment is found in clinical and community populations. Impairment is independent of co-occurring other mental disorders. Impairment is more stable over time than are the diagnoses themselves. Personality traits are also impairing and may be more predictive of outcomes over time, but a hybrid of personality disorder features and normal range personality traits may be the most predictive model. A general, “transdiagnostic,” selfother severity factor may be important for understanding the relationship of personality pathology and psychosocial functioning over time. The Alternative DSM-5 Model for Personality Disorders may be useful for the study of psychosocial functioning in individuals with personality pathology.
an
Highlights:
1. Personality disorders impair social, occupational, leisure, and global functioning.
M
2. Impairment is found in clinical and community populations. 3. Impairment independent of co-occurring mental disorders.
d
4. Impairment is more stable than personality disorder diagnoses.
te
5. Personality disorder features and personality traits both predict impairment.
Ac ce p
Conflicts of interest: none
2 Page 2 of 16
September 4, 2017
ip t
Introduction
an
us
cr
Psychosocial functioning refers to a person’s ability to carry out roles and perform activities in daily life, including in social or interpersonal, school or work, recreational or leisure, and basic (i.e., self-care, communication, mobility) functional realms. Impairment in psychosocial functioning, sometimes referred to as “disability,” may be a consequence of having limitations or disruptions in mental capacities (e.g., emotional regulation, self-esteem maintenance, reality testing) that result in the manifestations (i.e., signs, symptoms, traits) of mental disorders, particularly when these limitations or disruptions are severe.
te
d
M
Early studies comparing the psychosocial functioning of patients with PDs to others with no PD or with an Axis I disorder found that patients with PDs were more likely to be separated, divorced, or never married; were more likely to be unemployed, disabled, or having made frequent job changes; and had poorer quality of social and work functioning [1]. In these studies, systematic diagnosis of PDs and assessment of functional impairment were rare, borderline personality disorder (BPD) was most often studied, PDs were rarely compared to one another, and participants were almost exclusively patients as opposed to community dwellers.
Ac ce p
Functional Impairment in Patients with Personality Disorders To address gaps in knowledge, psychosocial functioning assessed by interview and self-report was compared in 668 rigorously diagnosed patients with schizotypal (STPD), borderline (BPD), avoidant (AVPD), or obsessive-compulsive (OCPD) PDs or with major depressive disorder (MDD) and no PD in the Collaborative Longitudinal Personality Disorders Study (CLPS) [2]. There were no differences between the PD and MDD groups on marital status. Patients with STPD and BPD, however, were more than three times as likely to have only a high school education compared to those with MDD and less than one-half as likely to have graduated from college. Patients with STPD and BPD were less frequently employed and had over twice the odds of being on disability. With respect to qualitative impairment, patients with STPD and BPD were found to have significantly more impairment at work, in social relationships, and at leisure than patients with OCPD or MDD; patients with AVPD were intermediate. These differences remained significant after controlling for demographics and co-occurring Axis I psychopathology. Patients with STPD and BPD were between 2.5 and almost 7 times more likely to have severe levels of impairment in employment, relationships with 3 Page 3 of 16
September 4, 2017
parents and siblings, global social adjustment, and GAFS score (<50) than patients with MDD. Psychosocial Functioning in Community Residents with Personality Disorders
d
M
an
us
cr
ip t
The relationship of seven DSM-IV PDs and three emotional disability scores was examined in Wave 1 of the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) [3]. PDs, in general, were associated with being divorced, separated, widowed, or never married and with having low socioeconomic status. AVPD, dependent PD (DPD), schizoid PD (SZPD), paranoid PD (PPD), and antisocial PD (ASPD) were all significant predictors of social functioning impairment, role emotional impairment, and overall impairment due to mental health problems, controlling for age and for DSM-IV Axis I disorders. OCPD was inconsistently related to disability and histrionic personality disorder (HPD) was not associated with disability. In the NESARC Wave 2 survey, BPD was associated with unmarried status, lower income, and lower education and with substantial disability in all three of the above areas, controlling for demographics, Axis I disorders, and other PDs [4]. Narcissistic PD (NPD) was associated with unmarried status and with role emotional impairment and overall impairment in men, but not women [5]. STPD was associated with unmarried status and with disability in all areas in both sexes [6]. Overall annual population reductions in quality of life at Wave 2 was greater for PDs than for myriad common health and mental health conditions other than arthritis and mood disorders [7].
Ac ce p
te
In the Children in the Community Study (CICS), individuals diagnosed with DSM-IV Cluster A, B, or C PDs or PD not otherwise specified (PDNOS) were more likely to have difficulties in interpersonal relationships and poor educational achievement during both adolescence and early adulthood than individuals without PDs, controlling for cooccurring Axis I disorders [8]. Any PD and any Cluster A, B, or C PDs in early adulthood were associated with poorer quality of life at age 33, with Cluster B PDs having the greatest effect [9]. Adolescents with PDs had comparable or greater impairment in educational attainment, occupational status, romantic commitment, partner quality, social support, and GAFS as adolescents with Axis I disorders 20 years later [10]. The National Comorbidity Survey Replication (NCS-R) found associations between Cluster A, ASPD, BPD, Cluster B, Cluster C, and any PD and functioning variables from the World Health Organization Disability Assessment Schedule (WHO-DAS), including basic role functioning (mobility, self-care, and cognition), instrumental role functioning (days out of role, quality of productive role performance), and quality of social role performance, but a number of these findings were not significant when Axis I disorders were controlled [11]. The authors concluded that “the main public health significance of personality disorders lies in their effects on Axis I disorders rather than in their effects on functioning” (p. 553). However, the principal effect of Axis I controls was on the 4 Page 4 of 16
September 4, 2017
WHO-DAS basic role functioning variables. Significant associations remained between any Cluster B and social role functioning impairment and any PD and days out of instrumental role (e.g., as homemaker or worker), impairment in productive role functioning, and impairment in social role functioning.
us
cr
ip t
A recent nationwide register-based study in Denmark confirmed that individuals with BPD had more long-term vocational impairment than individuals with other PDs and most other mental disorders [12]. In another US study, community-based individuals with BPD had significant more impairment in educational/occupational performance and lower quality of relationships with parents, partners, and friends compared to individuals without BPD, but less impairment than patients with BPD [13].
an
Taken together, these clinical and epidemiological studies indicate that most PDs exert a negative impact on psychosocial functioning independent of co-occurring Axis I psychopathology. Certain PDs (e.g., STPD and BPD) appear to be more impairing than others (e.g., OCPD and HPD). That AVPD and DPD are significantly impairing may be surprising.
M
Longitudinal Course/Stability of Functional Impairment in Personality Disorders
Ac ce p
te
d
A long-standing defining feature of PDs has been “an enduring pattern of inner experience and behavior” that is stable over time [14, p.646], despite numerous followup studies and more recent prospective follow-along studies that show considerable diagnostic instability for PDs [15]. Impairment in psychosocial functioning has been a candidate for a stable aspect of PDs. In the CLPS, the psychosocial functioning of 600 patients was assessed at baseline and three additional times over the next two years [16]. Significant improvement was found in only three of seven domains of functioning—relationships with spouse or mate, recreation, and global social adjustment—and for the latter two was largely the result of improvement in the MDD group. Improvement in relationships with spouse or mate may come as a surprise in a sample of patients most of whom had PDs, but only 20% of the sample had such a relationship, so the finding is limited to a small minority. Patients with BPD who experienced a change in personality pathology showed some improvement in functioning. Impairment in social relationships appeared to be the most stable in patients with PDs, suggesting an enduring component of PD. The stability of functional impairment in patients with BPD, other PDs (AVPD and OCPD), and MDD and no PD was examined again in the CLPS over 10 years [17]. Although 85% of patients with BPD remitted, functional impairment remained severe, with only modest improvement. Only about 20% of patients with BPD achieved a functional remission (GAFS >70), mostly those who met fewer BPD criteria.
5 Page 5 of 16
September 4, 2017
M
an
us
cr
ip t
In the McLean Study of Adult Development (MSAD), psychosocial functioning and personality pathology were assessed every two years over time in 290 hospitalized patients with BPD and 72 with other non-borderline PDs (OPDs). Over 6 years of followup [18], the psychosocial functioning of patients with BPD improved substantially, with the percentage showing good overall functioning increasing from 26% at baseline to 56%. Nevertheless, patients with BPD continued to function more poorly than patients with OPDs. Patients with BPD who experienced a symptomatic remission functioned better both socially and occupationally than those who did not. By the 10-year follow-up [19], results indicated that patients with BPD who did not have good (in both social and vocational areas) psychosocial functioning at baseline had difficulty attaining it. Those who had good functioning had difficulty retaining it and then regaining it. Most of the lasting impairment was vocational, rather than social. Consistent with persisting vocational impairment, patients with BPD were found to be three times more likely to receive Social Security Disability Income over 10 years as the OPD comparisons [20] and less likely to occupy a higher income group [21]. Despite the better social functioning in the patients with BPD, interpersonal problems such as intolerance of aloneness and conflicts over dependency persisted [22].
Ac ce p
te
d
In the CICS [23], individuals were assessed for PD status and functioning at mean ages 14, 16, 22, and 33. Individuals who had persistent PD (PD present at or before age 22 and at age 33) had markedly poorer functioning at age 33 than those who had never been diagnosed with a PD or who had a PD that remitted. Remitted PD was associated with mild long-term impairment. Adult-onset PDs (absent at or before age 22, but present at age 33) were also associated with significant impairment. Analyses controlled for Axis I disorders at age 33. Thus, PD persistence versus improvement is an important determinant of functional impairment over time. Impact of Personality Traits vs. Disorders on Functioning In the CLPS, both categorical and dimensional representations of DSM-IV PDs had stronger relationships to impairment in functioning in areas of employment, social relationships with parents and friends, global social adjustment, and GAFS ratings at baseline than either three-factor (SNAP) or five-factor (NEO-PI-R) models [24]. DSM-IV dimensions predicted functioning best. However, when relationships of five-factor traits and functioning at the 2-year and 5-year follow-ups were examined [25], traits showed relationships with some theoretically consistent specificity (see Table 1). When Morey et al. [26] compared these alternative models of personality pathology to each other over 4 years, they found that although DSM-IV PD dimensions predicted functioning at baseline, this relationship diminished over time, such that by the 4-year follow-up, the PD dimensions had the weakest relationships to functioning. Over time, the SNAP, which combines both pathological and normal traits, performed the best. These results were confirmed over the 6-, 8-, and 10-year follow-ups [27] and suggest that a hybrid 6 Page 6 of 16
September 4, 2017
model combining stable trait and dynamic psychopathological influences might have the most validity over time.
cr
ip t
Ro and Clark [28] examined the relationship of both adaptive- and maladaptive-range personality traits to functioning in both non-clinical and psychiatric outpatient samples. Well-being (personal satisfaction, sense of self, self-control), social/interpersonal functioning (positive relationships, social concordance, empathy), and basic functioning (self-care, mobility, communication) were strongly related to personality traits, especially in patients (See Table 2). DSM-5 Alternative Model and Functioning
te
d
M
an
us
An “Alternative DSM-5 Model for Personality Disorders” (AMPD) was published in Section III of the manual [29]. The central components of this “hybrid” model for the assessment and diagnosis of personality pathology are dimensional ratings of the severity of impairment in personality (self and interpersonal) functioning and 25 pathological personality trait “facets” organized into 5 broad trait “domains.” Impairments in four elements of personality functioning – identity, self-direction, empathy, and intimacy – that were identified in the literature as core aspects of PD that can be reliably assessed [30,31] are measured in combination on a 5-point scale of severity, the Level of Personality Functioning Scale (LPFS). Pathological personality trait domains – negative affectivity, detachment, antagonism, disinhibition, and psychoticism – correspond to the pathological “poles” of the widely validated FiveFactor Model (FFM) of personality [32].
Ac ce p
In a study of 337 clinicians who rated one of their patients on all aspects of the DSM-5 AMPD and all diagnostic criteria for the 10 DSM-IV PDs, the single-item LPFS score was a better predictor of psychosocial functioning than were the 10 DSM-IV PDs combined [33]. In a study by Simms and Calabrese [34] of 628 psychiatric patients, AMPD personality traits, assessed with the Personality Inventory for DSM-5 (PID-5), incremented the prediction of psychosocial functioning over normal-range traits, PD criterion counts, and common psychiatric symptoms. The incremental effects of the latter on functioning were much smaller than for PID-5 traits. Section III traits have also been found to be highly stable, prospectively predictive of psychosocial functioning, and dynamically associated with functioning over time, providing important additional evidence in support of the AMPD [35]. Personality Pathology Severity and Other Transdiagnostic Predictors of Functioning Generalized severity of personality pathology may be the most important single predictor of concurrent and prospective dysfunction. Hopwood et al. [36] found a count of all PD criteria met had the highest coefficient of determination for predicting both 7 Page 7 of 16
September 4, 2017
ip t
current and prospective (at the 5-year follow-up) GAF scores and social, work, and leisure dysfunction variables combining clinician ratings and self-report scores. However, trait-based factors significantly incremented severity in predicting most functioning variables. These results were replicated in the MSAD over 10 years of follow-up: BPD symptoms and FFM personality traits were both strongly related to prospective functioning and incremented each other in prediction [37].
an
us
cr
In the NESARC, four PD severity categories (no, subthreshold, simple, and complex— i.e., co-morbid—PD) were related to mental disability in individuals with Axis I disorders [38]. Significant increases in disability were observed between absent and simple PD and between simple and complex PD for each Axis I disorder except drug dependence. This study supports the utility of a PD severity measure based on number of PDs (or criteria) present. Moran et al. also found that severity of PD was related to educational impairment, receipt of welfare, and absence of long-term relationships in a large population-based prospective longitudinal study of young adults in Australia [39].
Ac ce p
te
d
M
Sharp et al. [40] evaluated a bifactor model of PD pathology in which a general factor and several specific factors accounted for PD criteria covariance in a sample of 966 hospitalized patients. BPD loaded only on the general factor; the other PDs loaded either on the general and a specific factor or largely only on a specific factor. The results suggest that BPD’s self-other pathology may represent something PDs have in common, as is represented by the LPFS in the AMPD. Conway et al. [41] used bifactor modelling to study PDs in a community sample of 700 young adults. They found an “overarching dimension of PD severity” (p. 545) that had symptoms from all PD categories and that strongly predicted multiple functional outcomes, including general functioning, social, family, marital, and work functioning. Specific PD factors uncorrelated with the general factor were much more modestly associated with functioning or not associated at all. Using data from the 10-year follow-along of the CLPS, general and specific factors were identified and patterns of growth of the factors over time were examined by Wright et al. [42]. Concurrent and dynamic associations were established between PD factors and a host of external validators, including psychosocial functioning. Results showed that general PD had much lower absolute stability and was associated most strongly with functioning concurrently and prospectively; specific factors, in this case detachment, dependency, compulsivity, dominance, and disinhibition, had much higher mean stability but more circumscribed associations with functioning. The results are generally supportive of the AMPD’s separation of impairments in personality functioning to determine the severity of personality pathology and pathological personality traits to describe the myriad variations in PD presentations.
8 Page 8 of 16
September 4, 2017
Summary and Conclusions
us
cr
ip t
PDs impair psychosocial functioning more than a significant Axis I disorder such as MDD. Impairment is found in both clinical and community populations. Impairment is independent of co-occurring other mental disorders. Impairment is more stable over time than are PD diagnoses themselves. Personality traits are also impairing and may be more predictive over time, but a hybrid of PD features and normal range personality traits may perform the best. A general, “transdiagnostic” self-other severity factor may be important for understanding the relationship of personality pathology and psychosocial functioning over time.
M
an
Impairing personality pathology is often neglected in clinical assessment, treatment, and research. Longitudinal descriptive and neurobiological studies are needed to better understand the mechanisms determining impairment in PDs. The DSM-5 AMPD may provide a useful assessment model for the study of psychosocial functioning and personality pathology. References
te
d
[1] Skodol AE, Bender DS, Gunderson JG, Oldham JM: Personality disorders. In American Psychiatric Publishing Textbook of Psychiatry, 6th Edition. Edited by Hales RE, Yudofsky SC, Roberts L. American Psychiatric Publishing; 2014: 851-894.
Ac ce p
[2] Skodol AE, Gunderson JG, McGlashan TH, Dyck IR, Stout RL, Bender DS, Grilo CM, Shea MT, Zanarini MC, Morey LC, et al: Functional impairment in patients with schizotypal, borderline, avoidant, or obsessive-compulsive personality disorder. Am J Psychiatry 2002, 159:276-283. [3] Grant BF, Hasin DS, Stinson FS, Dawson DA, Chou SP, Ruan WJ, Pickering RP: Prevalence, correlates, and disability of personality disorders in the United States: results from the National Epidemiologic Survey on Alcohol and Related Conditions. J Clin Psychiatry 2004, 65:948-958. [4] Grant BF, Chou SP, Goldstein RB, Huang B, Stinson FS, Saha TD, Smith SM, Dawson DA, Pulay AJ, Pickering RP, Ruan WJ: Prevalence, correlates, disability, and comorbidity of DSM-IV borderline personality disorder: results from the wave 2 National Epidemiologic Survey on Alcohol and Related Conditions. J Clin Psychiatry 2008, 69:533-545. [5] Stinson FS, Dawson DA, Goldstein RB, Chou SP, Huang B, Smith SM, Ruan WJ, Pulay AJ, Saha TD, Pickering RP, Grant BF: Prevalence, correlates, disability, and comorbidity of DSM-IV narcissistic personality disorder: results from the wave 2 9 Page 9 of 16
September 4, 2017
National Epidemiologic Survey on Alcohol and Related Conditions. J Clin Psychiatry 2008, 69:1033-1045.
ip t
[6] Pulay AJ, Stinson FS, Dawson DA, Goldstein RB, Chou SP, Huang B, Saha TD, Smith SM, Pickering RP, Ruan WJ, et al: Prevalence, correlates, disability, and comorbidity of DSM-IV schizotypal personality disorder: results from the wave 2 National Epidemiologic Survey on Alcohol and Related Conditions. Primary Care Companion J Clin Psychiatry 2009, 11:53-67.
us
cr
[7*] Penner-Goeke K, Henriksen CA, Chateau D, Latimer E, Sareen J, Katz LY: Reductions in quality of life associated with common mental disorders: results from a nationally representative sample. J Clin Psychiatry 2015, 76:1506-1512.
te
d
M
an
The NESARC Wave 2 sample is very large, enabling examination of the impact of many variables on QoL simultaneously. All 10 DSM-IV PDs were assessed, as well as a wide range of other mental and physical disorders, and impact on QoL was examined at both individual and population levels. The authors found that mood disorders were associated with the greatest decreases in health related QoL, followed by psychotic disorders, stroke, and arthritis. Due to the relative prevalence of the various disorders, however, the greatest annual QoL losses were caused by arthritis, mood disorders, and PDs at a population level. These “burden of disease” findings demonstrate the importance of personality pathology in the general population, among individuals unselected for seeking treatment. Treatment-seeking can be assumed to be associated with distress or functional impairment, so the impact of PDs on QoL in community samples strengthens conclusions that can be drawn about the associations, but also underscores the need for PD assessment in clinical populations.
Ac ce p
[8] Johnson JG, First MB, Cohen P, Skodol AE, Kasen S, Brook JS: Adverse outcomes associated with personality disorders not otherwise specified in a community sample. Am J Psychiatry 2005, 162:1926-1932. [9] Chen H, Cohen P, Crawford TN, Kasen S, Johnson JG, Berensen K: Relative impact of young adult personality disorders on subsequent quality of life: findings of a community-based longitudinal study. J Pers Disord 2006, 20:510-523. [10] Crawford TN, Cohen P, First MB, Skodol AE, Johnson JG, Kasen S: Comorbid Axis I and Axis II disorders in early adolescence: outcomes 20 years later. Arch Gen Psychiatry 2008, 65:641-648. [11] Lenzenweger MF, Lane MC, Loranger AW, Kessler RC: DSM-IV personality disorders in the National Comorbidity Survey Replication. Br J Psychiatry 2007, 62:533-564.
10 Page 10 of 16
September 4, 2017
[12] Hastrup LH, Kongerslev M, Simonsen E: Lower vocational outcome in borderline personality disorder: a Danish nationwide 9-year register-based study. J Pers Disord in press.
ip t
[13] Javaras KN, Zanarini MC, Hudson JI, Greenfield SF, Gunderson JG: Functional outcomes in community-based adults with borderline personality disorder. J Psychiatr Res 2017, 89:105-114.
cr
[14] American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. American Psychiatric Association; 2013.
an
us
[15] Grilo CM, McGlashan TH, Skodol AE: Course and outcome of personality disorders. In American Psychiatric Publishing Textbook of Personality Disorders, 2nd Edition. Edited by Oldham JM, Skodol AE, Bender DS. American Psychiatric Publishing; 2014:165-186.
M
[16] Skodol AE, Pagano ME, Bender DS, Shea MT, Gunderson JG, Yen S, Stout RL, Morey LC, Sanislow CA, Grilo CM, et al: Stability of functional impairment in patients with schizotypal, borderline, avoidant, or obsessive-compulsive personality disorder over two years. Psychol Med 2005, 35:433-451.
te
d
[17] Gunderson JG, Stout RL, McGlashan TH, Shea MT, Morey LC, Grilo CM, Zanarini MC, Yen S, Markowitz JC, Sanislow C, et al: Ten-year course of borderline personality disorder: psychopathology and function from the Collaborative Longitudinal Personality Disorders Study. Arch Gen Psychiatry 2011, 68:827-837.
Ac ce p
[18] Zanarini MC, Frankenburg FR, Hennen J, Reich DB, Silk KR: Psychosocial functioning of borderline patients and axis II comparison subjects followed prospectively for six years. J Pers Disord 2005, 19:19-29. [19] Zanarini MC, Frankenburg FR, Reich DB, Fitzmaurice G: The 10-year course of psychosocial functioning among patients with borderline personality disorder and axis II comparison subjects. Acta Psychiatrica Scand 2010, 122:103-109. [20] Zanarini MC, Jacoby RJ, Frankenburg FR, Reich DB, Fitzmaurice G: The 10-year course of social security disability income reported by patients with borderline personality disorder and axis II comparison subjects. J Pers Disord 2009, 23:346356. [21] Niesten IJ, Karan E, Frankenburg FR, Fitzmaurice GM, Zanarini MC: Description and prediction of income status of borderline patients over 10 years of prospective follow-up. Personal Ment Health 2016, 10:285-292.
11 Page 11 of 16
September 4, 2017
[22] Choi-Kain LW, Zanarini MC, Frankenburg FR, Fitzmaurice GM, Reich DB: A longitudinal study of the 10-year course of interpersonal features in borderline personality disorder. J Pers Disord 2010, 24:365-376.
ip t
[23] Skodol AE, Johnson JG, Cohen P, Sneed JR, Crawford TN: Personality disorder and impaired functioning from adolescence to adulthood. Br J Psychiatry 2007, 190:415-420.
us
cr
[24] Skodol AE, Oldham JM, Bender DS, Dyck IR, Stout RL, Morey LC, Shea MT, Zanarini MC, Sanislow CA, Grilo CM, et al: Dimensional representations of DSM-IV personality disorders: relationships to functional impairment. Am J Psychiatry 2005, 162:1919-1925.
an
[25] Hopwood CJ, Morey LC, Ansell EB, Grilo CM, Sanislow CA, McGlashan TH, Markowitz JC, Gunderson JG, Yen S, Shea MT, Skodol AE: The convergent and discriminant validity of five-factor traits: current and prospective social, work, and recreational dysfunction. J Pers Disord 2009, 23:466-476.
M
[26] Morey LC, Hopwood CJ, Gunderson JG, Skodol AE, Shea MT, Yen S, Stout RL, Zanarini MC, Grilo CM, Sanislow CA, McGlashan TH: Comparison of alternative models for personality disorders. Psychol Med 2007, 37:983-994.
Ac ce p
te
d
[27] Morey LC, Hopwood CJ, Markowitz JC, Gunderson JG, Grilo CM, McGlashan TH, Shea MT, Yen S, Sanislow CA, Ansell EB, Skodol AE: Comparison of alternative models for personality disorders, II: 6-, 8-, and 10-year follow-up. Psychol Med 2012, 42:1705-1713. [28] Ro E, Clark LA: Correlations between psychosocial functioning and adaptiveand maladaptive-range personality traits. J Abnorm Psychol 2013, 122:822-835. [29] Skodol AE, Morey LC, Bender DS, Oldham JM: The Alternative DSM-5 Model for Personality Disorders: a clinical application. Am J Psychiatry 2015, 172:606-613. [30] Bender DS, Morey LC, Skodol AE: Toward a model for assessing level of personality functioning in DSM-5, part I: a review of theory and methods. J Pers Assess 2011, 93:322-346. [31] Morey LC, Berghuis H, Bender DS, Verheul R, Krueger RF, Skodol AE: Toward a model for assessing level of personality functioning in DSM-5, part II: empirical articulation of a core dimension of personality pathology. J Pers Assess 2011, 93:347-353.
12 Page 12 of 16
September 4, 2017
[32] Krueger RF, Derringer J, Markon KE, Watson D, Skodol AE: Initial construction of a maladaptive personality trait model and inventory for DSM-5. Psychol Med 2012, 42:1879-1890.
ip t
[33] Morey LC, Bender DS, Skodol AE: Validating the proposed Diagnostic and Statistical Manual of Mental Disorders, 5th Edition, severity indicator for personality disorder. J Nerv Ment Dis 2013, 201:729-735.
cr
[34**] Simms LJ, Calabrese WR: Incremental validity of the DSM-5 Section III personality disorder traits with respect to psychosocial impairment. J Pers Disord 2016, 30:95-111.
an
us
The results of this large clinical study demonstrate the incremental validity of DSM-5 Alternative Model personality traits. Section III traits predicted psychosocial impairment over and above what was predicted by normal range five-factor model personality traits, PD criteria counts derived from SCID-II interviews, and common psychiatric symptoms also elicited by semistructure interview. Incremental effects for normal-range personality traits, PD criteria counts, and psychiatric symptoms over Section III traits were substantially smaller.
d
M
[35] Wright AG, Calabrese WR, Rudick MM, Yam WH, Zelazny K, Williams TF, Rotterman JH, Simms LJ: Stability of Section III pathological personality traits and their longitudinal associations with psychosocial functioning in personality disordered individuals. J Abnorm Psychol 2015, 124:199-207.
Ac ce p
te
[36] Hopwood CJ, Malone JC, Ansell EB, Sanislow CA, Grilo CM, McGlashan TH, Pinto A, Markowitz JC, Shea MT, Skodol AE, et al: Personality assessment in DSM-5: empirical support for rating severity, style, and traits. J Pers Disord 2011, 25:305320. [37] Hopwood CJ, Zanarini MC: Borderline personality traits and disorder: predicting prospective patient functioning. J Consult Clin Psychol 2010, 78:585-589. [38] Pulay AJ, Dawson DA, Ruan WJ, Pickering RP, Huang B, Chou SP, Grant BF: The relationship of impairment to personality disorder severity among individuals with specific axis I disorders: results from the National Epidemiologic Survey on Alcohol and Related Conditions. J Pers Disord 2008, 22:405-417. [39*] Moran P, Romaniuk H, Coffey C, Chanen A, Degenhardt L, Borschmann R, Patton GC: The influence of personality disorder on future mental health and social adjustment: a population-based cohort study. Lancet Psychiatry 2016, 3:636-645. In a unique longitudinal cohort study using a structured clinical assessment of personality pathology in a large community population, the authors found that young adults with personality disorder are at risk for continuing psychosocial problems and for anxiety disorders and major depressive disorder 11 years later. Importantly, severity of personality disorder, including 13 Page 13 of 16
September 4, 2017 subthreshold personality difficulties, was a strong predictor of future problems, controlling for comorbid mental disorders and impairment in functioning at baseline. These results provide support for including personality disorder in global studies of the community burden of mental disorders.
ip t
[40] Sharp C, Wright AG, Fowler JC, Frueh BC, Allen JG, Oldham J, Clark LA: The structure of personality pathology: both general (‘g’) and specific (‘s’) factors? J Abnorm Psychol 2015, 124:387-398.
us
cr
[41] Conway CC, Hammen C, Brennan PA: Optimizing prediction of psychosocial and clinical outcomes with a transdiagnostic model of personality disorder. J Pers Disord 2016, 30:545-566.
an
[42**] Wright AG, Hopwood CJ, Skodol AE, Morey LC: Longitudinal validation of general and specific structural features of personality pathology. J Abnorm Psychol 2016, 125:1120-1134.
Ac ce p
te
d
M
Using data from the prospective 10-year follow-along Collaborative Longitudinal Personality Disorders Study (CLPS), the authors separated general from specific PD features and then studied the longitudinal course of these features and their association to broad markers of psychosocial functioning. General features, shared by all PDs, showed lower absolute stability and were most strongly predictive of impairment in functioning concurrently and longitudinally, whereas specific features, describing PD types, had much higher mean stability but more circumscribed relationships with functioning. These results support the hybrid Alternative DSM5 Model for Personality Disorders which measures both the severity of impairments in personality functioning (a general factor) and descriptive pathological personality traits.
14 Page 14 of 16
September 4, 2017
Psychosocial Functioning Domain Occupational Recreational + + -
-
us
Neuroticism Extraversion Openness Agreeableness Conscientiousness
Social + -
cr
Trait
ip t
Table 1. Associations Between Five-Factor Personality Traits and Impairment in Psychosocial Functioning Domains at 2- and 5-year Follow-up [25].
-
an
+ Positive relationship between personality trait and impairment in psychosocial functioning domain.
Ac ce p
te
d
M
- Negative relationship between personality trait and impairment in psychosocial functioning domain.
15 Page 15 of 16
September 4, 2017
Table 2. Associations Between FFM and SNAP Personality Traits and Impairment in Psychosocial Functioning Domains in Patients and Non-patients [28].
ip t
+
cr
Neuroticism/Negative Affectivity Extraversion/Positive Affectivity Agreeableness Disinhibition
Psychosocial Functioning Domain Well-Being Social/Interpersonal Basic +
us
Trait
+
an
+ Positive relationship between personality trait and impairment in psychosocial functioning domain.
Ac ce p
te
d
M
- Negative relationship between personality trait and impairment in psychosocial functioning domain.
16 Page 16 of 16