Elsevier

Comprehensive Psychiatry

Volume 48, Issue 4, July–August 2007, Pages 329-336
Comprehensive Psychiatry

Psychosocial impairment and treatment utilization by patients with borderline personality disorder, other personality disorders, mood and anxiety disorders, and a healthy comparison group

https://doi.org/10.1016/j.comppsych.2007.02.001Get rights and content

Abstract

This study compared psychosocial functioning and treatment utilization in 130 participants who were diagnosed with a borderline personality disorder (BPD), a non-BPD personality disorder (OPD), a mood and/or anxiety disorder (MAD), or had no current psychiatric diagnosis and served as a healthy comparison group. Diagnostic and Statistical Manual of Mental Disorders (4th Edition) diagnoses, psychosocial functioning, and treatment utilization were determined by using well-established semistructured research interviews conducted by trained doctoral-level clinicians. Analysis of variance revealed the most severe deficits in functioning characterized the BPD group across areas of global functioning with more moderate impairments in functioning occurring in OPD and MAD groups. The BPD group was characterized by significantly greater psychiatric and nonpsychiatric treatment utilization than the other groups. These findings indicate that BPD as well as other personality disorders are a source of considerable psychologic distress and functional impairment equivalent to, and at times exceeding, the distress found in mood and anxiety disorders. The public health impact of BPD diagnosis is highlighted by the high rates of psychiatric and nonpsychiatric treatment utilization.

Introduction

Impairment in psychosocial functioning is a generic requirement for assigning psychiatric diagnoses and is considered an integral aspect of diagnosing personality disorders (PDs). The Diagnostic and Statistical Manual of Mental Disorders (4th Edition) [1] states that symptoms must cause “clinically significant distress or impairment in social, occupational, or other important areas of functioning” to make a psychiatric diagnosis. A few studies have examined psychosocial functioning in PDs relative to other psychiatric disorders, and even fewer have examined whether specific areas of impairment differ between personality disorder groups, particularly between groups with borderline personality disorder (BPD) and other PD diagnoses or healthy controls. In particular, it remains unknown whether there are areas of psychosocial impairment specific to PD or whether impaired functioning is similar to that observed for other psychiatric disorders, relative to psychiatrically healthy controls.

Research suggests that patients with any PD are more functionally impaired than those without a PD [2]. Recent research has documented that individuals with BPD exhibit considerable functional impairment in relation to other diagnoses. A controlled comparison of functional impairment in patients with PDs revealed that individuals with BPD have greater impairment than individuals with other PD diagnoses [3], and substantially greater impairment than patients with major depressive disorder without coexisting PD [4]. Other research suggests that schizoid, antisocial, histrionic, and avoidant along with borderline PDs predict lower functioning even when controlling for axis I disorders [5]. Psychosocial impairment, particularly with social relationships, also seems relatively stable over time [6] Research has also examined the impact that PD diagnoses have on psychiatric and medical treatment utilization. Previous studies on individuals with PD diagnoses demonstrated that BPD individuals differ in usage of outpatient, inpatient, and psychopharmacologic treatments when compared to other PD groups [7], [8] and when compared to major depression groups without PD [9]. Patients with BPD also receive more psychotropic medications when compared to all other non-PD diagnostic groups [10], [11]. Such findings, which require replication, would be further enhanced by comparisons to a broader axis I psychiatric diagnosis group as well as to a nonpsychiatric, healthy group.

Although research has differentiated impairment in BPD patients relative to other PDs and to major depression, research has not examined the clinical significance of dysfunction between these groups when compared to a healthy group. A healthy comparison group is advantageous in providing a context for specific psychosocial impairment while elucidating areas of general psychosocial impairment. A psychiatric comparison group composed of mood and anxiety disorders would extend previous investigations comparing patients with PDs to patients with major depression [4], [9]. The inclusion of a variety of anxiety and mood disorders would accurately reflect the increased rates of comorbidity of these disorders in patients with BPD [12], [13] and would expand upon understanding of the specific psychosocial impairments present in patients with PDs above and beyond patients with a variety of mood or anxiety disorders (MADs). The identification of specific areas of impaired functioning may be useful in providing areas for focused evaluation, intervention, and distinguishing the profile of impairment of PDs distinct from affective or anxiety disorder groups without personality pathology.

This study compared psychosocial functioning and treatment utilization in 4 groups: individuals diagnosed with BPD, individuals diagnosed with 1 or more non-BPD personality disorder diagnosis (OPD), individuals diagnosed with a current MAD with no PD diagnosis, and a group of healthy individuals with no PD diagnoses and no current or recent MAD (healthy control).

Section snippets

Methods

Participants were respondents to broad media advertisements posted in newspapers, online, and on public notice boards for men and women between the age of 18 and 50 to participate in studies on personality, emotion, and mood being conducted at a medical school in an urban setting. Participants were excluded from participation if there were psychiatric contraindications (eg, acute psychosis or a schizophrenia spectrum diagnosis indicative of thought disorder) or mental status issues (eg,

Demography

Table 1 summarizes the differences in demographic characteristics of the study groups. Logistic regression analyses were used to test the likelihood that groups differed in marital status, educational attainment, and employment status. Odds ratios with 99% CIs were calculated comparing each of the study groups to the healthy comparison group. As summarized in Table 1, logistic regression analyses revealed no significant differences between groups in these demographic features.

Psychosocial functioning

Table 2 summarizes

Discussion

This study examined psychosocial functioning and treatment utilization in 4 groups: individuals diagnosed with BPD, individuals diagnosed with 1 or more OPD, individuals diagnosed with a current MAD with no PD diagnosis, and a group of healthy individuals with no current psychiatric diagnoses. Although several studies have documented functional impairment in patients with PDs compared to patients with axis I disorders, none have documented the clinical impairment of these groups in relation to

Acknowledgment

This work was supported by the Borderline Personality Disorder Research Foundation (McGlashan, Grilo, Sanislow) and NIH grants MH50850 (McGlashan, Grilo, Sanislow, Ansell), MH073708 (Sanislow), and MH01654 (McGlashan).

References (24)

  • M.C. Zanarini et al.

    Treatment histories of borderline inpatients

    Compr Psychiatry

    (2001)
  • R.A. Sansone et al.

    Borderline personality and psychotropic medication prescription in an outpatient psychiatry clinic

    Compr Psychiatry

    (2003)
  • American Psychiatric Association

    Diagnostic and statistical manual of mental disorders (DSM-IV)

    (1994)
  • K. Nakao et al.

    Functional impairment in personality disorders

    J Personal Disord

    (1992)
  • M.C. Zanarini et al.

    Psychosocial functioning of borderline patients and axis II comparison subjects followed prospectively for six years

    J Personal Disord

    (2005)
  • A.E. Skodol et al.

    Functional impairment in patients with schizotypal, borderline, avoidant, or obsessive-compulsive personality disorder

    Am J Psychiatry

    (2002)
  • J.P. Hong et al.

    The longitudinal relationship between personality disorder dimensions and global functioning in a community-residing population

    Psychol Med

    (2005)
  • A.E. Skodol et al.

    Stability of functional impairment in patients with schizotypal, borderline, avoidant, or obsessive-compulsive personality disorder over two years

    Psychol Med

    (2005)
  • M.C. Zanarini et al.

    Mental health service utilization of borderline patients and axis II comparison subjects followed prospectively for six years

    J Clin Psychiatry

    (2004)
  • D.S. Bender et al.

    Treatment utilization by patients with personality disorders

    Am J Psychiatry

    (2001)
  • E.H. Makela et al.

    Medication utilization patterns and methods of suicidality in borderline personality disorder

    Ann Pharmacother

    (2006)
  • T.H. McGlashan et al.

    The Collaborative Longitudinal Personality Disorders Study: baseline axis I/II and II/II diagnostic co-occurrence

    Acta Psychiatr Scand

    (2000)
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