Functional impairment in patients with Schizotypal, Borderline, Avoidant, and Obsessive-Compulsive Personality Disorder

Objective: The purpose of this study was to compare psychosocial functioning in patients with schizotypal, borderline, avoidant, or obsessive-compulsive personality disorder and patients with major depressive disorder and no personality disorder. Method: Patients (N=668) were recruited by the four clinical sites of the Collabora-tive Longitudinal Personality Disorders Study. The carefully diagnosed study groups were compared on an array of domains of psychosocial functioning, as measured by the Longitudinal Interval Follow-Up Evaluation—Baseline Version and the Social Adjustment Scale. Results: Patients with schizotypal personality disorder and borderline personality disorder were found to have significantly more impairment at work, in 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. Conclusions: Personality disorders are a significant source of psychiatric morbidity, accounting for more impairment in functioning than major depressive disorder alone. Impai rment in psychosocial functioning is integral to the concept of a personality disorder. Only when personality traits are sufficiently inflexible and maladaptive to cause significant functional impairment (or subjective distress) is normal personality style distinguished from a pathological personality disorder. DSM-IV codified a requirement for impairment in its criterion C of the general diagnostic criteria for a personality disorder, which states that " the enduring pattern [of inner experience and behavior , i.e., personality] leads to clinically significant distress or impairment in social, occupational, or other important areas of functioning " (p. 633). Since 1980, when attention was focused on personality disorders by placing them on a separate diagnostic axis (axis II) of DSM-III's multiaxial system, a number of studies have documented functional impairment in patients with personality disorders compared with patients with no personality disorder or with other axis I disorders. Most of these studies inferred functional impairment from various sociodemographic statuses believed to reflect psychosocial functioning, such as educational attainment , marital status, or employment. A majority of these studies found that patients with personality disorders were more likely than those without or with other disorders to be separated, divorced, or never married (1– 11) and to have had more unemployment, frequent job changes, or periods of disability (4, 5, 7, 9, 12, 13). Only rarely were they found to be less educated (1, 12). Fewer studies have examined quality of functioning, but in those that …