Clinical importance of personality difficulties: diagnostically sub-threshold personality disorders

Abstract

BackgroundCurrent categorical classification of personality disorders has been criticized for overlooking the dimensional nature of personality and that it may miss some sub-threshold personality disturbances of clinical significance. We aimed to evaluate the clinical importance of these conditions. For this, we used a simple four-level dimensional categorization based on the severity of personality disturbance.MethodsThe sample consisted of 352 patients admitted to mental health services. All underwent diagnostic assessments (SCID-I and SCID-II) and filled in questionnaires concerning their social situation and childhood adversities, and other validated tools, including the Beck Depression Inventory (BDI), Alcohol Use Disorders Identification Test (AUDIT), health-related quality of life (15D), and the five-item Mental Health Index (MHI-5). The patients were categorized into four groups according to the level of personality disturbance: 0 = No personality disturbance, 1 = Personality difficulty (one criterion less than threshold for one or more personality disorders), 2 = Simple personality disorder (one personality disorder), and 3 = Complex/Severe personality disorder (two or more personality disorders or any borderline and antisocial personality disorder).ResultsThe proportions of the groups were as follows: no personality disturbance 38.4% (n = 135), personality difficulty 14.5% (n = 51), simple personality disorder 19.9% (n = 70), and complex/severe personality disorder 24.4% (n = 86). Patients with no personality disturbance were significantly differentiated (p < 0.05) from the other groups regarding the BDI, 15D, and MHI-5 scores as well as the number of Axis I diagnoses. Patients with complex/severe personality disorders stood out as being worst off. Social dysfunction was related to the severity of the personality disturbance. Patients with a personality difficulty or a simple personality disorder had prominent symptoms and difficulties, but the differences between these groups were mostly non-significant.ConclusionsAn elevated severity level of personality disturbance is associated with an increase in psychiatric morbidity and social dysfunction. Diagnostically sub-threshold personality difficulties are of clinical significance and the degree of impairment corresponds to actual personality disorders. Since these two groups did not significantly differ from each other, our findings also highlight the complexity related to the use of diagnostic thresholds for separate personality disorders.

The relationship between executive functions and emotion regulation in females attending therapeutic community treatment for substance use disorder

“…This is particularly important given that substance-related changes in cognition are influenced by sex (Becker et al, 2017), and gender differences potentially lead to diversity in SUD treatment response (Becker et al, 2016). Additionally, the current study utilised a screening measure of personality disorder and, although evidence suggests that this is an appropriate brief and cost-effective measure for SUD populations (Gonzalez, 2014;Hesse and Moran, 2010;Hesse et al, 2008), future studies may wish to examine the relationship between basic EFs and emotion regulation using full diagnostic assessments and/or other dimensional measures (Karukivi et al, 2017) of personality disorder. With regards to Axis I diagnoses, a high prevalence and significant heterogeneity was observed in the current study.…”

“…Additionally, the SAPAS demonstrated modest internal consistency and test-retest correlation, and was shown to correlate with clinician-report of externalising and global assessment of functioning (Hesse et al, 2008). The current study utilised SAPAS scores as a dimensional indicator of personality disorder, in light of research suggesting that personality disorder may be more accurately characterised as a dimensional, rather than categorical, construct (Karukivi et al, 2017). Higher scores indicated greater likelihood and severity of personality disorder.…”

Subthreshold personality disorder: how feasible is treatment in primary care?

“…Initial findings suggest that individuals with as little as one BPD trait still experience a degree of disability and distress that rivals the impairment of full-syndrome BPD (Bos et al, 2011;Kaess et al, 2017;Lu et al, 2017;Zimmerman et al, 2013). Furthermore, individuals experiencing subthreshold BPD traits possess higher rates of co-morbidity, in particular depression and anxiety, posing poorly for treatment outcomes and full-syndromes alike (French et al, 2017;Gorwood et al, 2010;Hepgul et al, 2016;Hill et al, 2016;Karukivi et al, 2017;Newton-Howes et al, 2006).…”

Threading a pathway through the forest of mood and personality disorders

“…All the existing categories of personality disorder have been discarded from the 11th revision, as, despite their popularity in lay circles, they have no scientific standing (Livesley 2013). Most people have some personality disturbance, and although it is at the lower end of the spectrum, the subsyndromal condition of personality difficulty is still associated with significant pathology and dysfunction (Karukivi 2017). Severe personality disorder is diagnosed only when there is a high risk of harm to self or others (although this is not ‘automatic’ as Luty states).…”