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Personality disorder and impaired functioning from adolescence to adulthood

  • Andrew E. Skodol (a1), Jeffrey G. Johnson (a1), Patricia Cohen (a1), Joel R. Sneed (a1) and Thomas N. Crawford (a1)...
Abstract
Background

Little is currently known about functioning and impairment during adulthood associated with the course of personality disorders.

Aims

To investigate the association of personality disorder stability from adolescence through middle adulthood with measures of global functioning and impairment, using prospective epidemiological data.

Method

A community-based sample of 658 individuals was interviewed at mean ages 14, 16, 22 and 33 years.

Results

Individuals with persistent personality disorder had markedly poorer functioning and greater impairment at mean age 33 years than did those who had never been identified as having such disorder or who had a personality disorder that was in remission, after co-occurring Axis I disorders at age 33 years were taken into account. Remitted disorder was associated with mild long-term impairment. Adult-onset personality disorders, however, were also associated with significant impairment.

Conclusions

Persistent and adult-onset personality disorders are associated with functional impairment among adults in the community. These effects are independent of co-occurring Axis 1 disorders.

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Copyright
Corresponding author
Dr Andrew E. Skodol, Institute for Mental Health Research, 222 W. Thomas Road, Suite 414, Phoenix, AZ 85013, USA. Email: askodol@imhr.org
Footnotes
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Declaration of interest

None. Funding detailed in Acknowledgements.

Footnotes
References
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Personality disorder and impaired functioning from adolescence to adulthood

  • Andrew E. Skodol (a1), Jeffrey G. Johnson (a1), Patricia Cohen (a1), Joel R. Sneed (a1) and Thomas N. Crawford (a1)...
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eLetters

Methodological flaws and confounders in study

Saddichha Sahoo, Resident in Psychiatry
06 June 2007

The study by Andrew et al (2007) on impaired functioning in personality disorders, although interesting in its view, that remission ofpsychopathology is associated with better social functioning, is however limited by inherent methodological flaws. At the outset, we were unable tofind the definition of “adult-onset personality disorders”. Is this a termcoined by the authors, since both DSM-IV (APA, 2000) and ICD-10 (WHO, 1992) describe personality disorders to be an enduring pattern of behaviour that deviates markedly from the individual’s culture, with an onset usually in childhood or adolescence and continues into adulthood. Infact, the closest nosological diagnosis is personality change in ICD 10 (WHO, 1992), which is an entirely different concept and if present, a serious confounder. The calculation of psychosocial impairment also needs clarity, since a range of 0-24 could convey any value from mild to severe impairment.

Further, we believe that the results do not mirror reality since results depict only 64 subjects with persistent PD compared to the 185 with PD, in remission. It is entirely plausible that the majority of patients with persistent PD would have simply dropped out of the study owing to the severity of their psychopathology, thereby skewing the results. Overall, we believe that the investigators have failed to controlfor all these possible confounders in their study.

REFERENCES-1.Skodol, A. E., Johnson, J.G., Cohen, P., et al (2007) Personality disorder and impaired functioning from adolescence to adulthood. British Journal of Psychiatry, 190, 415 – 420.2.World Health Organisation (1992) The ICD-10 Classification of Mental andbehavioural Disorders: Clinical Description and Diagnostic guidelines. WHO, Geneva.3.American Psychiatric Association. (2000). Diagnostic and Statistical manual of Mental Disorders (4th ed.) Text Revision (DSM IV TR). Washington, DC: American Psychiatric Association
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Conflict of interest: None Declared

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Enduring Personality Change

Akeem O. Sule, Consultant Psychiatrist
29 May 2007

We read with keen interest Skodol et al (2007) article on personalitydisorder. However we disagree with the phrase ‘Adult-onset personality disorder’. The author implied that this group of personality disorder individuals’…had any personality disorder at mean age 33 years but not at prior assessment…’ However DSM-IV criteria described personality disorder individuals as having ‘an enduring pattern of inner experience and behaviour that deviates markedly from the individual’s culture’. The criteria also include a statement: ‘the pattern is stable and of long duration and its onset can be traced back at least to adolescent or early adulthood’.A possible explanation for ‘adult onset personality disorder’ is that thisgroup of individuals might be classified under ICD-10, F62 category i.e. ‘enduring personality changes not attributable to brain change or disease’. The ICD-10 states that this group includes ‘disorders of adult personality and behaviour which develops following catastrophic or excessive prolonged stress or following severe psychiatric illness, in people with no previous personality disorder’. We notice that the investigators did not control for all these possible confounders in their study.

American psychiatric Association (2005) Diagnostic and Statistical Manual of Mental Disorders (4th edition) (DSM-IV-TM)

Skodol, A. E., Johnson, J. G., Cohen, p., et al (2007) Personality disorder and impaired functioning from adolescent to adulthood. British Journal of Psychiatry, 190, 415-420.

World Health Organisation (1992) The ICD-10 Classification of Mental and behavioural Disorders: Clinical Description and Diagnostic guidelines.WHO

Declaration of interest: None
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