Vocational functioning in schizotypal and paranoid personality disorders

Impaired vocational functioning is a hallmark of schizophrenia, but limited research has evaluated the relationships between work and schizophrenia-spectrum personality disorders, including schizotypal (SPD) and paranoid personality disorder (PPD). This study compared employment history and job characteristics of 174 individuals drawn from the community or clinic, based on four personality disorder groups: SPD Only, PPD Only, SPD+PPD, and No SPD or PPD. Symptoms and cognitive functioning were also assessed. Both PPD and/or SPD were associated with lower rates of current employment, and a history of having worked at less cognitively complex jobs than people without these disorders. Participants with PPD were less likely to have a history of competitive work for one year, whereas those with SPD tended to have worked at jobs involving lower levels of social contact, compared with those without these disorders. When the effects of symptoms and cognitive functioning were statistically controlled, PPD remained a significant predictor of work history, and SPD remained a significant predictor of social contact on the job. The findings suggest that impaired vocational functioning is an important characteristic of SPD and PPD.     

The 10‐year course of psychosocial functioning among patients with borderline personality disorder and axis II comparison subjects

Zanarini MC, Frankenburg FR, Bradford Reich D, Fitzmaurice G. The 10‐year course of psychosocial functioning among patients with borderline personality disorder and axis II comparison subjects. Objective: The purpose of this study was to determine the 10‐year course of the psychosocial functioning of patients with borderline personality disorder (BPD). Method: The social and vocational functioning of 290 inpatients meeting both the Revised Diagnostic Interview for Borderlines (DIB‐R) and DSM‐III‐R criteria for BPD and 72 axis II comparison subjects were carefully assessed during their index admission. Psychosocial functioning was reassessed using similar methods at five contiguous 2‐year time periods. Results: Borderline patients without good psychosocial functioning at baseline reported difficulty attaining it for the first time. Those who had such functioning at baseline reported difficulty retaining and then regaining it. In addition, over 90% of their poor psychosocial functioning was due to poor vocational but not social performance. Conclusion: Good psychosocial functioning that involves both social and vocational competence is difficult for borderline patients to achieve and maintain over time. In addition, their vocational functioning is substantially more compromised than their social functioning.     

The impact of bipolar disorder upon work functioning: a qualitative analysis

OBJECTIVES: One important but sometimes poorly-captured area of functioning concerns an individual's ability to work. Several quantitative studies have now indicated that bipolar disorder (BD) can have a severe, and often enduring, negative impact upon occupational functioning. While this data indicates that employment rates are relatively low in this patient population, it throws little light on the specific ways in which this complex psychiatric condition can affect work, or upon how these effects are subjectively interpreted by individuals with BD. In order to further elucidate the relationship between BD and work, we report here on a series of exploratory qualitative interviews undertaken to develop a disease-specific measure of quality of life in BD. METHODS: We conducted 52 interviews with people with BD (n = 35), their caregivers (n = 5) and healthcare professionals (n = 12) identified by both convenience and purposive sampling. The affected sample came from a variety of employment situations, ranging between people with no employment history through to those in highly skilled, stable professional positions. Interviews were tape recorded, transcribed verbatim and analysed thematically. RESULTS: Respondents described the different ways in which the symptoms of depression and hypo/mania presented in the workplace. Five main themes emerged from the data: lack of continuity in work history, loss, illness management strategies in the workplace, stigma and disclosure in the workplace, and interpersonal problems at work. CONCLUSIONS: Patient outcome in BD has traditionally been determined by the assessment of clinical characteristics such as rates of relapse, hospitalization, or degree of symptom reduction. More recently, however, there has been increasing interest in expanding the assessment of outcome to include the measurement of indices such as functioning, a key facet of which relates to an individual's ability to work. The qualitative data obtained here highlights the often complex, varied and intermittent effects of an episodic condition such as BD upon work functioning, and points to the importance of developing more sophisticated and precise measures of occupational functioning for this population.     

Psychosocial functioning of transsexuals in Belgium

Male-to-female (M-F) transsexuals differ consistently from female-to-male (F-M) transsexuals in their sociodemographic characteristics, cross-gender and sexual history and the degree to which personality disorder is concomitant to their transsexuality. As a group, female-to-male transsexuals are more homogeneous. Both groups are impaired in their mental functioning, but the male-to-female population is more mentally disordered. In a comparison between Dutch transsexuals and their Belgian counterparts, the latter were shown to have more mental problems.     

Mentalizing in first-episode psychosis: Correlates with symptomatology and traits of borderline personality disorder

Aim

To explore the associations between mentalizing, positive and negative symptoms of psychosis, and traits of borderline personality disorder, in a sample of patients with first-episode psychosis, and in a non-clinical sample.

Methods

A quantitative cross-sectional design was employed. Thirty-two adults with first-episode psychosis and 148 non-clinical participants were assessed using the reflective functioning questionnaire. The questionnaire measures two dimensions of mentalizing, certainty and uncertainty about mental states. Traits of borderline personality disorder and symptoms of psychosis were measured using the self-report version of the Zanarini rating scale, the Community Assessment of Psychotic Experiences, and the Green et al., paranoid thought scale.

Results

Patients with first-episode psychosis reported increased mentalizing impairments, characterized as hypomentalizing tendencies, compared to the non-clinical group. Regression analysis showed significant associations between higher scores on the uncertainty about mental states scale and negative symptoms of psychosis in both groups. No associations were found between mentalizing impairments and traits of borderline personality disorder in the clinical sample, although associations were found in the non-clinical sample.

Conclusions

The present findings suggests that impairments in mentalizing may be associated with negative symptoms of psychosis across both clinical and non-clinical samples. Mentalizing impairments was found to be associated with traits of borderline personality disorder, but this finding was only confirmed in the non-clinical sample. Mentalizing should therefore be considered in the early assessment and treatment of patients experiencing difficulties with negative symptoms of psychosis.     

Stressful life events as predictors of functioning: findings from the collaborative longitudinal personality disorders study

OBJECTIVE: Although much attention has been given to the effects of adverse childhood experiences on the development of personality disorders (PDs), we know far less about how recent life events influence the ongoing course of functioning. We examined the extent to which PD subjects differ in rates of life events and the extent to which life events impact psychosocial functioning. METHOD: A total of 633 subjects were drawn from the Collaborative Longitudinal Personality Disorders Study (CLPS), a multi-site study of four personality disorders--schizotypal (STPD), borderline (BPD), avoidant (AVPD), obsessive-compulsive (OCPD)--and a comparison group of major depressive disorders (MDD) without PD. RESULTS: Borderline personality disorder subjects reported significantly more total negative life events than other PDs or subjects with MDD. Negative events, especially interpersonal events, predicted decreased psychosocial functioning over time. CONCLUSION: Our findings indicate higher rates of negative events in subjects with more severe PDs and suggest that negative life events adversely impact multiple areas of psychosocial functioning.     

Favourable outcome of long-term combined psychotherapy for patients with borderline personality disorder: Six-year follow-up of a randomized study

Objective: This study reports the six-year follow-up data of patients with borderline personality disorder (BPD) who participated in the Ullevål Personality Project (UPP), a randomized clinical study comparing outpatient individual psychotherapy (OIP) with a long-term combination programme (CP) comprising short-term day-hospital treatment followed by outpatient combined group and individual psychotherapy. Methods: For 52 patients, outcomes were evaluated after 8 months, 18 months, 3 years, and 6 years based on a wide range of clinical measures, such as symptom severity, psychosocial functioning, personality functioning, and Axis-I and II diagnoses. Results: At the six-year follow-up, patients in the CP condition reported significantly greater reduction of symptom distress and improvements in the personality functioning domains Identity Integration and Self-control compared with patients allocated to OIP. Patients in the CP also had a more favourable long-term course of psychosocial functioning. There were no differences between treatment conditions in outcomes of interpersonal functioning and self-esteem. Conclusions: Long-term psychotherapy in a combination programme seems favourable for BPD patients. In this study, patients who received combined treatment fared better on crucial parameters than patients who received individual therapy. Of particular importance are the positive effects on fundamental borderline problem areas like Identity Integration and Self-control.     

Screening for personality disorder: a comparison of personality disorder assessment by patient and informants

The Structured Clinical Interview for DSM-IV Personality Disorders (SCID-II Version 2.0) is becoming the most favoured instrument to measure personality disorder but takes up to an hour to complete. The Standardized Assessment of Personality (SAP), an informant-based measure, takes 10 to 15 minutes to complete. Both instruments have been validated independently. This study aimed to determine whether the SAP is a suitable screening instrument for personality disorder as measured by the SCID-II. Fifty-seven psychiatric patients were assessed for personality disorder using both the SAP and the SCID-II. The SAP assessments were conducted blind to the results of the SCID-II assessments. Agreement between the two instruments in this population was low (kappa = 0.3). The level of agreement differed between personality disorder categories, ranging from kappa = 0.4 (antisocial) to 0.1 (narcissistic). In this population of patients, the SAP proved to be a poor screen for the SCID-II. The study highlights the discrepancy between informant and self-report assessments for personality disorder.     

Axis II comorbidity of borderline personality disorder: description of 6-year course and prediction to time-to-remission

OBJECTIVE: The purpose of this study was to compare the axis II comorbidity of 202 patients whose borderline personality disorder (BPD) remitted over 6 years of prospective follow-up to that of 88 whose BPD never remitted. METHOD: The axis II comorbidity of 290 patients meeting both DIB-R and DSM-III-R criteria for BPD was assessed at baseline using a semistructured interview of demonstrated reliability. Over 96% of surviving patients were reinterviewed about their co-occurring axis II disorders blind to all previously collected information at three distinct follow-up waves: 2-, 4-, and 6-year follow-up. RESULTS: Both remitted and non-remitted borderline patients experienced declining rates of most types of axis II disorders over time. However, the rates of avoidant, dependent, and self-defeating personality disorders remained high among non-remitted borderline patients. Additionally, the absence of these three disorders was found to be significantly correlated with a borderline patient's likelihood-of-remission and time-to-remission; self-defeating personality disorder by a factor of 4, dependent personality disorder by a factor of 3 1/2, and avoidant personality disorder by a factor of almost 2. CONCLUSION: The results of this study suggest that axis II disorders co-occur less commonly with BPD over time, particularly for remitted borderline patients. They also suggest that anxious cluster disorders are the axis II disorders which most impede symptomatic remission from BPD.     

Feasibility and effectiveness of cognitive remediation in the treatment of borderline personality disorder

Several studies have demonstrated that borderline personality disorder (BPD) is associated with neuropsychological deficits and there is evidence that the neurocognitive profile of patients with BPD may be related to the outcome of this disorder. The aim of this study was to investigate the feasibility and the effectiveness of a cognitive remediation intervention in patients with BPD. Thirty patients with a DSM-IV-TR diagnosis of BPD were assessed on clinical, neuropsychological and functional outcome measures at baseline and after 16 weeks of a computer-assisted cognitive remediation (CACR) intervention or treatment as usual (TAU). Patients who received CACR showed a greater improvement in working memory and psychosocial functioning measures than patients treated with TAU. Symptom severity was not significantly affected by CACR treatment. The findings of this pilot study suggest the feasibility and potential effectiveness on specific cognitive domains, but modest clinical usefulness of a computerised modality of cognitive remediation in the treatment of BPD.     

Borderline personality disorder traits and their relationship with dimensions of normative personality: a web-based cohort and twin study

Kendler KS, Myers J, Reichborn‐Kjennerud T. Borderline personality disorder traits and their relationship with dimensions of normative personality: a web‐based cohort and twin study. Objective: To describe the structure of genetic and environmental risk factors for four dimensions of borderline personality disorder (BPD) and to understand the source of resemblance of these dimensions and normal personality. Method: A web‐based sample (n = 44,112 including 542 twin pairs) completed items from 4 scales of the Dimensional Assessment of Personality Pathology Basic Questionnaire and the Big Five Inventory. Results: A one‐factor common pathway model best fits the 4 BPD scales producing a highly heritable latent liability (heritability = 60%) and strong loadings on all 4 dimensions. Affective instability had the lowest trait‐specific genetic loading, suggesting that it was a core feature of BPD. A complex pattern of genetic and environmental associations was found between the big five personality traits and BPD dimensions. The strongest genetic correlations with the BPD traits were generally seen for neuroticism (positive), followed by conscientiousness and agreeableness, both negative. Conclusion: In the general population, these four BPD dimensions reflect one underlying highly heritable factor. The association between normative personality and dimensions of BPD is complex with high degrees of genetic correlation.     

Ego functioning predicts first-year status in adults with anorexia nervosa and bulimia nervosa

Severe personality disturbance is a feature that possibly explains chronicity in eating disorders, a largely inexplicable development in terms of previously investigated factors. We tested this hypothesis in a group of 41 anorectics and bulimics with ratings of 13 ego functions and of status at 1-year follow-up. Patients who still were preoccupied with weight or shape and had a DSM-III-R eating disorder at follow-up had more severe ego disturbance at initial presentation than those who were free from symptoms. The relevance of demographics, syndromal diagnosis and clinical factors other than ego functioning was limited. The importance of ego functioning for prognosis in eating disorders thus appears to overshadow that of several factors that have been extensively cited in the literature.     

Schizophrenic disorder and social functioning

Abstract Social functioning is assessed according to 84 questioned subjects with schizophrenic disorder and their 84 key figures. Schizophrenic subjects showed significant dysfunction in all reviewed areas of behaviour and social roles. Key figures of all schizophrenic subjects most often showed a positive attitude in regard to the future of the schizophrenic members of their family. In relation to social functioning of the schizophrenic subject and the attitude of family key figures there is a statistically significant difference as well as a relationship. Results of assessment confirmed the impact of family life on social functioning of the schizophrenic patient and stresses the importance of active family support in rehabilitation programs.     

Exploration of personality factors and their predictive impact on therapy utilization: The externalizing mode of functioning

Abstract

The aim of this study was to identify personality factors predicting psychotherapy utilization on the basis of personality pathology, affect regulation and interpersonal functioning. The authors assessed affectivity (using the Affect Experience and Affect Regulation Q-Sort), interpersonal context (using the Quality of Object Relations Scale), and character pathology (using the Shedler–Westen Assessment Procedure-200). Combination of instruments showed one stable factor predictive for nonengagement in psychotherapy, revealing an externalizing personality dimension, dominated by externalizing defenses, acting out, deficient superego functions, and impairment in reflective functioning and in relating to others. Stability of the predictive power of this personality factor for therapy engagement could be shown, and replication in two other samples confirmed the findings. The results highlight the importance of measuring affect-regulatory mechanisms, and clinical implications for intervention techniques are discussed.     

Nidotherapy: a new approach to the treatment of personality disorder

OBJECTIVE: To develop a treatment, nidotherapy, or nest therapy, so named because it aims to alter the sufferer's personal environment rather than symptoms or behaviour, in the management of personality disorders. METHOD: Case studies, in which analysis of the environmental circumstances associated with the problems of personality disorder is followed by planned adjustment to that environment so that it makes a more appropriate fit for the personality. RESULT: Sustained improvement was found in two individuals with personality disorder after nidotherapy. Those with persistent and predictable personality attributes are easier in principle to treat than those with episodic or variable problems. CONCLUSION: Nidotherapy deserves further consideration in the management of personality disorders.     

Age-related change in personality disorder trait levels between early adolescence and adulthood: a community-based longitudinal investigation

OBJECTIVE: To investigate change in personality disorder (PD) traits between early adolescence and early adulthood among individuals in the community. METHOD: PD traits were assessed in 1983 (mean age = 14), 1985-86 (mean age = 16) and 1992 (mean age = 22) in a representative community sample of 816 youths. RESULTS: Overall, PD traits declined 28% during both adolescence and early adulthood. PD traits were moderately stable during the first 2-year interval, and were as stable as they have been reported to be among adults over similar intervals. PD trait stability declined slightly as the inter-assessment interval increased. Adolescents with PDs tended to have elevated PD traits during early adulthood. CONCLUSION: PD traits tend to decline steadily in prevalence during adolescence and early adulthood. However, adolescents with PDs often have elevated PD traits as young adults, and the stability of PD traits appears to be similar during adolescence and early adulthood.     

Acute and transient psychotic disorder: comorbidity with personality disorder

A study sample of 51 patients with acute and transient psychotic disorder (ATPD) (ICD-10) is presented. The findings suggest that, in hospital settings, ATPD is a non-frequent condition with onset in early adult life and most often associated with female sex, good premorbid social functioning and no or minor/moderate psychosocial stressors. The DSM-IV criteria distribute the patients into three diagnostic categories: schizophreniform disorder (41%), brief psychotic disorder (33%) and psychotic disorder not otherwise classified (25%). A high prevalence (63%) of personality disorders (PD) is revealed after recovery from the psychotic episode. The ATPD is not related to any specific PD, and in a substantial minority (37%) of cases no PD is found. The unspecified category is by far the most frequent PD in patients with ATPD. The sample will be followed up and reassessed.     

Personality disorders and relationship to personality dimensions measured by the Temperament and Character Inventory in patients with obsessive-compulsive disorder

The occurrence of personality disorders was investigated in 36 patients with obsessive-compulsive disorder by means of the SCID Screen questionnaire. In addition, the personality dimensions were explored by means of the Temperament and Character Inventory (TCI). In total, 75% of the patients fulfilled the criteria for a personality disorder according to the SCID Screen questionnaire, mostly (55%) within cluster C. Several significant correlations were found between the separate personality disorders (PD) and subscales of the TCI, the most pronounced being between avoidant and obsessive-compulsive PD and novelty-seeking and self-directedness. Strong correlations were also found between self-directedness and paranoid and borderline PD. In multiple regressions where the presence of PD in clusters A, B and C, respectively, were used as dependent variables and where the separate subscales of the TCI were used as independent variables, the multiple R reached 0.68, 0.76 and 0.80 in clusters A, B and C, respectively. Thus 46–64% of the variance in the personality disorder clusters could be explained by the TCI subscales.     

Associations between self-induced vomiting and personality disorder in patients with a history of anorexia nervosa.

Fifty-five patients of an eating disorders service with a history of anorexia nervosa (AN), defined by a history of refusal to maintain body weight above a level of 15% below that expected, completed a modified version of the revised Personality Diagnostic Questionnaire (PDQ-R) based on DSM-III-R personality disorders (PD). The subjects were divided into 2 groups based on AN subtypes: vomiters, defined by a history of self-induced vomiting, and non-vomiters, who had maintained low weight mainly or only by diet +/- excessive exercise. Vomiters showed significantly higher scores on self-report measures of borderline and antisocial PD criteria. Discriminant analysis based on PD scores for all 13 DSM-III-R PD categories correctly predicted AN subtype membership based on vomiting history in 85.5% of patients. The implications of PD comorbidity for the development and management of eating disorders are discussed.     

A self-psychology approach to narcissistic personality disorder: a nursing reflection

TOPIC: The use of Heinz Kohut's self-psychology perspective in understanding and providing care for patients with narcissistic personality disorder (NPD). PURPOSE: To describe how nurses can apply the self-psychology perspective as a way to understand the development of self for individuals with NPD and to enhance the therapeutic relationship between the nurse and patient with NPD. SOURCES: Theoretical literature; the author's clinical experience. CONCLUSIONS: Self-psychology provides nurses with a theoretical perspective that can enhance the interpersonal relationship between the nurse and patient with NPD.