Avances en Salud Mental Relacional / Advances in relational mental health
Vol. 7, núm. 1 Marzo 2008
Órgano Oficial de expresión de la Fundación OMIE
Revista Internacional On-Line / An International On-Line Journal
PSYCHOSOCIAL FUNCTIONING IN PATIENTS WITH
PERSONALITY DISORDERS: A REVIEW OF THE
EVIDENCE-BASED RESEARCH STUDIES LITERATURE
Wendy Dávila Wood, Aizpea Boyra and José Guimón
onpguugj@ehu.es
SUMMARY
Evidence based practice is a complex aim to achieve in the area of Psychiatry, and even
more complex, when aspiring to explain personality disorders, theoretical constructs
that in themselves are fully vague, and that have always been a source of confusion and
debate between mental health professionals. This confusion, as much as anything,
justifies the need to empirically back the areas of treatment that can be supported by
evidence, without disregarding the unique elements of clinical practice such as the
professional's own experience, and the patient's preferences and values.
The authors offere a brief revision of the most relevant literature regarding psychosocial
dysfunction on PD´s. Empirically investigations remain scarce, but the existing findings
seem to support that impaired functioning, especially social functioning, is an enduring
component of PD's.
KEY WORDS
psychosocial dysfunction. Borderline Personality disorder
In the last years there has been an increased push for an evidence-based practice, which
started in the area of general medicine, and progressively extended to the area of
Psychiatry. The movement is as much a regulative idea as a research method. It intends
to demonstrate aspects of treatment that can indeed be supported by evidence, and those
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Avances en Salud Mental Relacional / Advances in relational mental health
Vol. 7, núm. 1 Marzo 2008
Órgano Oficial de expresión de la Fundación OMIE
Revista Internacional On-Line / An International On-Line Journal
that must be supported by other valid factors, such as clinical experience, the unique
aspects of clinical situations and patients' preferences and values. This attempt to
become more discriminate, acquires a higher degree of complexity within the area of
mental health, where it is sometimes difficult to find common ground of validity
between the different ethical and theoretical positions inherent in clinical and research
practice.
Proof of this complexity can be found when reviewing the evidence based literature on
the psychosocial functioning in patients with Personality Disorders (PDs). Empirically
based research is scarce, and the need for further well designed clinical studies is
recognized. The present paper seeks to offer a brief review on the current existing
evidence based studies in psychosocial functioning in PDs. To this purpose we will
examine the more prominent variables involved in psychosocial functioning, the
validity of certain measurement tools and the evidence that supports the various results
obtained from the different studies.
1. SOME VARIABLES INVOLVED PSYCHOSOCIAL DYSFUNCTIONING
For some authors, such as Skodol et al. (1), a defining feature of the PD is an enduring
pattern of inner experience and behaviour that is stable over time. However, different
follow-up and follow-along studies have shown a considerable diagnostic instability in
PDs, even over short intervals. Thus, it appears that what remains a constant over time
is the continued pattern of instability. In this way, the authors propose that impairment
in psychosocial functioning is a main stable trait in these patients and a fundamental
aspect in PDs that serves to distinguish it from normal personality. It follows, that the
comparative abilities of competing skills to predict psychosocial impairment, offer a
way to examine their merits.
Currently, different empirical studies have analyzed various variables involved in
psychosocial functioning. There exists abundant literature linking a damaging
psychosocial environment in childhood to an emerging PD in later years. Such is the
case of Jovev et al. (3). These authors have documented poor functioning and higher
rates of negative life events in association with PDs, in particular with borderline
personality disorder (BPD). However, a research from Ullrich (6) qualifies that although
most PDs are associated with impaired psychosocial functioning and life-failure, some
PD traits, (even when considered pathological), can contribute positively to one
important aspect of life-success: status and wealth. Pagano et al. make an important
point (4) on this subject. The authors indicate that although much attention has been
given to the effects of adverse childhood experiences on the development of PDs, we
still know far less about how recent life events influence the ongoing course of
functioning. This would allow to re-evaluate how important early experience is in PDs,
in contrast to later life experiences.
In the clinical presentation of PDs differences in the psychosocial adaptation features
between male and female patients have been observed. Some studies report that men
with BPD are more likely to be diagnosed with substance use disorders, as well as
paranoid, passive-aggressive, narcissistic, sadistic, and antisocial personality disorders.
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Avances en Salud Mental Relacional / Advances in relational mental health
Vol. 7, núm. 1 Marzo 2008
Órgano Oficial de expresión de la Fundación OMIE
Revista Internacional On-Line / An International On-Line Journal
On their side, women with BPD appear to be more likely to report histories of adult
physical and sexual abuse and to meet diagnostic criteria for post-traumatic stress
disorder (PTSD) and eating disorders. However, we must take in consideration the
findings of Johnson et al. (5). These authors outline that a majority of the literature on
BPD focuses on its occurrence in women or does not specifically assess for gender
differences in clinical presentations.
On a more general level, symptom alleviation and improved social functioning have
always been considered to be related. Zanello et al. (2) comment that since the fifties,
social functioning is considered as an important dimension to take into account for
treatment planning and outcome measuring. They contend that, for many years,
symptoms scales have been considered as sufficient outcome measures, and social
functioning improvement has been expected on the basis of symptom alleviation. As
symptoms and social adjustment sometimes appear relatively independent, no accurate
conclusion concerning the patient's social functioning can so be driven on the basis of
his/her clinical symptoms.
2. MEASUREMENT TOOLS
Recently, (Zanello et al. (2)) attention has been directed toward the development of
instruments specifically intended to measure the extent and nature of the social
dysfunction observed in most psychiatric syndromes. Many of these instruments are
designed to be completed by caregivers or remain time consuming and difficult to use
routinely. For this reason, currently in clinical practice, there is a need to rely on simple
and brief instruments that consider the patients' perspective on their social adjustment
over time.
Different authors have used different tools and instruments to measure psychosocial
impairment in PDs. Ullrich et al. (6) used a standardized social interview for the
assessment of the dysfunctional adaptation in personality disorders. The study identified
indicators of life-success by factor-analysis in two moderately correlated components
representing status and wealth and successful intimate relationships. On their part,
Skodol et al. (7) explored the psychosocial impairment through seven domains of
functioning as measured by the Longitudinal Interval Follow-up Evaluation (LIFE) 1,
while in other researches (1, 8) they used the Social Adjustment Scale, a semi-structured
interview assessments and self-report measure.
Psychosocial functioning was also evaluated by Adell et al (9), using well-established
semi structured research interviews conducted by trained doctoral-level clinicians. On
the other hand Chanen et al. (10) chose to assess psychosocial functioning in
adolescents with PDs by means of the Youth Self-Report, the Young Adult SelfReport, the Health of the Nation Outcome Scales for Children and Adolescents, the
Social and Occupational Functioning Assessment Scale, and some socio-demographic
variables.
1
They use some questionnaires assessing three-factor and five-factor dimensional models of personality.
Personality disorder categories, dimensional representations of the categories based on criteria counts,
and three- and five-factor personality dimensions are then compared to patients´ social functioning
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The Questionnaire de Fonctionnement Social, (QFS), developed in Geneva by Zanello
et al. (2) deserves a special mention. This new instrument in French was created initially
in order to assess both, social functioning and psychometric characteristics, in patients
involved in group psychotherapy programs, (within a specialist mental health setting). It
was designed to be completed in less than 10 minutes and the questions are phrased in a
simple and redundant way, in order to limit problems inherent to illiteracy or language
comprehension. The QFS is a 16 items self-report instrument that assesses both the
frequency of, (8 items), and the satisfaction with, (8 items), various social behaviours
adopted during the 2 weeks period preceding the assessment. It yields three separate
indexes of social functioning defined a priori and labelled: "frequency", "satisfaction"
and "global". The higher scores would be an indicator of greater social functioning. (A
Spanish version has been developed in the Department of Psychiatry of the Basque
Country by Guimón et al.)
In their studies, Zanello et al. (2) administered the QFS to 457 subjects, aged between
18 and 65, including 176 outpatients (99 with anxious or depressive disorders, 25 with
personality disorders and 52 with psychotic disorders) and 281 healthy control
subjects2. Internal consistency3 ranged from 0.69 to 0.71 (intraclass correlation
coefficient). The discriminant validity 4 showed to be excellent. In healthy controls, the
convergent validity5 correlation with the SAS-SR was moderate but statistically
significant (rS from - 0.21 to - 0.44, p<0.05). When comparing QFS scores with selfrated symptom severity, lower levels of social functioning were significantly associated
with more severe symptoms according to the Brief Symptom Inventory (BSI: rS from 0.38 to - 0.65, p<0.001). The QFS indexes demonstrated sensitivity to change6. The
factorial validity of the QFS in the first analysis7 considered only Frequency items; 7
out of 8 items had loadings above 0.5 on Factor 1 accounting for 30.7%, (unrotated), of
the variance. The second analysis considered only Satisfaction items; all items had
loadings above 0.6 on Factor 1 explaining 43.4%, (unrotated), of the variance. And
finally, in the third factor analysis, all QFS items were included; 15 out of 16 items had
loadings above 0.4 on Factor 1 accounting for 30%, (unrotated), of the variance.
Concerning the factorial validity of the instrument, these results suggest that all QFS
items belong to the same underlying dimension.
2
No significant difference was found between patients and controls according to age or gender
distribution. Acceptance rate was high (>95%). Moreover, the QFS was generally acceptable to the
clinicians who used it.
3
calculated for each index ranged from 0.65 to 0.83 (Cronbach alpha). Test-retest reliability, calculated
within a 15 days time interval on a sample of 49 healthy controls,
4
It was calculated on healthy controls and patients divided into sub-groups according to their diagnosis,
showing significantly higher scores in control subjects than in psychiatric patients and significant
differences across diagnostic categories (Kruskal-Wallis ANOVA with post-hoc tests, all p<0.05).
5
The QFS was compared with other measures of social functioning was calculated, using the Social
Adaptation Self-Evaluation Scale (SASS) and the Social Adjustment Scale Self-Report (SAS-SR). With
the SASS, the convergent validity was higher among patients (Spearman rS 0.71 to 0.92, p<0.01) than
controls (rS from 0.49 to 0.66, p<0.001)
6
The Wilcoxon showed all p<0.05 on a sample of 27 out-patients suffering from anxious-depressive
disorders questioned before and after 4 months of cognitive behavioural group therapy running on a
weekly basis during 16 sessions of 2 hours each.
7
It was measured through 3 separate factor analysis conducted using the data of 457 subjects.
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Zanello et al. provide provisional norms for the QFS for healthy controls, in order to
characterize individual patients or patient subgroups. The authors contend that the need
for assessment in clinical routine, in order to estimate different aspects of the patients'
conditions, as well as the quality of the treatment provided, has contributed to the
development of a large variety of instruments measuring several domains. Concerning
the level of social functioning, many instruments fail to meet chief criterion of
feasibility, remaining often too complex or time consuming. Moreover, only few of
them are available in French. Zanello et al. conclude that the QFS is a brief, simple and
easy to administer self-rating scale that displays satisfactory psychometric properties. It
seems to be a valuable instrument for the monitoring of social functioning in psychiatric
patients which, from a therapeutic point of view, may have a clear impact. This
instrument sets up an expectation for change and allows both, to reality test patients and
therapists beliefs about the presence of progress (or not), and to identify if therapy is
working in this specific outcome domain. Nonetheless, to date, the administration of the
QFS to other populations and treatment modalities requires further investigation.
3. RESULTS
Related to the different psychosocial variables and to the different implemented
measurement tools described previously, the various authors mentioned above have
reached a series of empirical conclusions which we will proceed to describe briefly.
Ullrich et al (6) found that the avoidant, obsessive compulsive and narcissistic
dimensional scores of their patients were associated with status and wealth. Inverse
relationships were found between dependent, schizotypal, schizoid, and adult antisocial
personality disorder dimensions and this domain of life-success. In addition, avoidant,
schizoid, and BPD dimensions were negatively associated with successful intimate
relationships.
Skodol et al (7, 8)8 find that patients with schizotypal personality disorder and BPD
have significantly more impairment at work, in their social relationships and at leisure
than patients with obsessive-compulsive personality disorder or major depressive
disorder; patients with avoidant personality disorder were intermediate. These
differences were found across assessment modalities and remained significant after covarying for demographic differences and comorbid axis I psychopathology. The three
and five factor models were compared to three-dimensional representations of DSM-IV
PDs and standard categories regarding their associations with psychosocial functioning.
Both the categorical and dimensional representations of DSM-IV personality disorders
showed stronger relationships to impairment in functioning in the domains of
employment, social relationships with parents and friends, global social adjustment and
DSM-IV axis V ratings than the three- and five-factor models. The DSM-IV dimensions
8
They studied six hundred sixty-eight patients with semistructured interview diagnoses of schizotypal,
borderline, avoidant, or obsessive-compulsive personality disorders or with major depressive disorder and
no personality disorder.
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were the ones that best predicted functional impairment of the four approaches. And,
although the Five-Factor personality traits captured variance in functional impairment
not predicted by DSM-IV PD dimensions, the DSM-IV dimensions accounted for
significantly more variance than the measures of personality. They concluded that
scores on dimensions of general personality functioning do not appear to be as strongly
associated with functional impairment as the psychopathology of DSM personality
disorder. PDs are a significant source of psychiatric morbidity, accounting for more
impairment in functioning than major depressive disorder alone. These conclusions
suggest that that personality disorders may not represent distinct diagnostic entities and
that their categorical classification is not optimal.
In another article, Skodol et al (1)9 discuss the stability of impairment in psychosocial
functioning in patients with four different PDs. They find that a significant
improvement in psychosocial functioning occurred in only three of seven domains of
functioning and was largely due to improvements in the MDD and no PD group.
Patients with BPD or OCPD showed no improvement in their overall functioning, but
patients with BPD who experienced change in personality psychopathology did show
some improvement in functioning. (The impairment in social relationships appeared
most stable in patients with PDs). They conclude that impaired functioning, especially
social functioning, may be an enduring component PDs.
Ansell et al. (9) compared psychosocial functioning and treatment utilization in 130
participants who were diagnosed with BPD, non-BPD personality disorder (OPD),
mood and/or anxiety disorder (MAD), or those with no current psychiatric diagnosis
that served as a healthy comparison group. The analysis of variance revealed that the
most severe deficits in functioning lay within 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
non-psychiatric treatment utilization than the other groups. These findings indicate that
BPD, as well as other personality disorders, is a source of considerable psychological
distress and functional impairment equivalent to, and at times exceeding, the distress
found in mood and anxiety disorders.
Chanen et al.(10) examined adaptive functioning and psychopathology in adolescents
with DSM-IV BPD10. The borderline personality disorder group (N = 46) had the most
severe psychiatric symptoms and functional impairment across a broad range of
domains, followed by other personality disorders (N = 88) and no personality disorder
group (N = 43), respectively. BPD was a significant predictor, over and above Axis I
disorders and other PD diagnoses for psychopathology, general functioning, peer
relationships, self-care, and family and relationship functioning. The authors conclude
that the borderline personality disorder diagnosis should not be ignored or substituted
by Axis I diagnoses in adolescent clinical practice, and early intervention strategies
need to be developed for this disorder.
9
They compared the findings with those of patients with major depressive disorder (MDD) and no PD,
prospectively over a 2-year period. Skodolm e al RESULTS:
10
The study included 177 psychiatric outpatients (derived from 2 samples collected between March 1998
and July 1999 and between November 2000 and September 2002) aged 15 to 18 years
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Jovev et al. (3) investigated the impact of recent life events, daily hassles and uplifts on
psychosocial functioning in patients with PDs, while extending previous research by
examining the role of perceived coping effectiveness and perceived stress of recent life
events11. Results indicated that the BPD group reported the poorest levels of
functioning, especially in what related to interpersonal functioning. The BPD group also
reported more negative life events, particularly in the interpersonal relationships,
personal health, crime, and financial domains. This group also reported to experience
less uplifts, more hassles and found employment circumstances particularly stressful
and difficult to cope with. Intensity of hassles was a predictor of functioning
independent of a BPD diagnosis. A greater frequency of life events was closely
associated with a non-BPD diagnosis in predicting a decrease in psychosocial
functioning.
Pagano et al.(4) examined the extent to which PD subjects differ in rates of life events
and the extent to which life events impact psychosocial functioning12. Borderline
personality disorder subjects reported significantly more total negative life events than
other PDs or subjects with Major Depressive Disorder. Negative events, especially
interpersonal events, predicted decreased psychosocial functioning over time. The
authors conclude that higher rates of negative events in subjects with more severe PDs
and suggest that negative life events adversely impact multiple areas of psychosocial
functioning.
And lastly, as mentioned initially when describing some psychosocial variables,
Johnson et al. (5) examined gender differences in BPD13. Men with BPD were more
likely to present with substance use disorders, and with schizotypal, narcissistic, and
antisocial PDs, while women with BPD were more likely to present with PTSD, eating
disorders, and the BPD criterion of identity disturbance. Generally speaking, women
and men with BPD displayed more similarities than differences in clinical presentations.
The differences that did emerge are consistent with those found in epidemiological
studies of psychopathology and therefore do not appear unique to BPD. Additionally,
many gender differences traditionally found in epidemiological samples did not emerge
in BPD subjects. For example, no difference was found in rates of major depressive
disorder, a condition that is more prevalent in females.
11
There were ninety-seven participants (Axis I group, N = 30; BPD group, N = 23; Other PD group, N =
44
12
They studied 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.
13
They used baseline data from the Collaborative Longitudinal Personality Disorders Study (CLPS), men
and women who met criteria for BPD were compared on current axis I and II disorders, BPD diagnostic
criteria, childhood trauma histories, psychosocial functioning, temperament, and personality traits
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BIBLIOGRAPHY
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