Personality Disorders Can Be More Disabling Than Depression

Which mental illnesses are most severe? A new study may surprise some people with its finding that certain personality disorders are even more impairing than major depression.

The study was conducted by Andrew Skodol, M.D., a psychiatrist-researcher at the New York State Psychiatric Institute, and colleagues and was reported in the February American Journal of Psychiatry.

More than 600 subjects with borderline personality disorder, schizotypal personality disorder, avoidant personality disorder, obsessive-compulsive personality disorder, or major depressive disorder were included in the investigation. They were recruited from sites of the long-term Collaborative Longitudinal Personality Disorders Study, which is being conducted with the participation of investigators from Brown University, Columbia University, Harvard University, Texas A&M University, and Yale University.

The psychological and sociological functioning of these subjects was then assessed with the Longitudinal Interval Follow-Up Evaluation. It included questions to evaluate functioning in employment, household duties, student work, and recreation; interpersonal relationships with parents, siblings, partners, and friends; and global functioning. Subjects also rated their own functioning using the Social Adjustment Scale. The researchers then tallied the results of these assessments for each of the five groups and compared results.

Results from the Longitudinal Interval Follow-Up Evaluation indicated that persons with borderline personality disorder or schizotypal personality disorder were most impaired functionally; that individuals with avoidant-personality disorder were next; and that persons with obsessive-compulsive disorder or major depressive disorder were least so.

The subjects’ own functional ratings using the Social Adjustment Scale gave similar results. Persons with schizotypal personality disorder or borderline personality disorder rated themselves as significantly more impaired in all individual domains of functioning and overall than did persons with obsessive-compulsive personality disorder or major depressive disorder. Individuals with avoidant personality disorder remained intermediate.

In fact, persons with schizotypal personality disorder and borderline personality disorder had greater impairment on virtually every measure of impairment than did persons with obsessive-compulsive disorder or major depressive disorder regardless of whether the evaluation was interview based or by patient self-report.

What’s more, these results remained statistically significant even when the investigators took into consideration possibly confounding factors such as age, gender, or minority status.

“Our findings are especially noteworthy,” Skodol and his team wrote in their study report, “given the growing appreciation for the degree and persistence of limitations in functioning of patients with major depressive disorder. Impairment due to major depressive disorder has been found to be comparable with that of patients with chronic medical illnesses such as diabetes and arthritis.”

In other words, although major depressive disorder is quite debilitating, borderline personality disorder, schizotypal personality disorder, and avoidant personality disorder appear to be all the more so.

Paul Links, M.D., is a professor of psychiatry at the University of Toronto in Canada. Since he is especially interested in personality disorders, Psychiatric News asked him whether he would comment on the study by Skodol and his team.

The study, Links said, provides “an unparalleled opportunity to compare the functioning across subjects with severe, less-severe, and no personality disorders. As our clinical experience would suggest, patients with severe personality disorders—schizotypal and borderline—have greater impairments in all areas measured compared with subjects with no or less-severe personality disorders.”

This report, however, “is just the first step,” he continued. “We need to have better methods of assessing functioning, including observational data. We need to understand the relationship between personality psychopathology and functioning. Finally, we need to examine how interventions affect functioning.”

The investigation was financed by grants from the National Institute of Mental Health and from the Borderline Personality Disorder Research Foundation.

The study report, “Functional Impairment in Patients With Schizotypal, Borderline, Avoidant, or Obsessive-Compulsive Personality Disorder,” is posted on the Web at http://ajp.psychiatryonline.org under the February issue. ▪