Elsevier

Psychiatry Research

Volume 266, August 2018, Pages 309-316
Psychiatry Research

Effects of personality functioning on the global functioning of patients with bipolar disorder I

https://doi.org/10.1016/j.psychres.2018.03.028Get rights and content

Highlights

  • Our findings revealed the impact of the level of personality functioning on global functioning.

  • As it may be expected from a mental disorder that has an early onset and a chronic course, one's mental representations of self and others play key roles in the efficacy of treatment, course of illness, and patient interactions with psychiatric care personnel; however, it may also have a significant effect on functioning.

  • Furthermore, to the best of our knowledge, the effects of the level of personality functioning on psychosocial functioning during the euthymic period of BD have yet to be studied.

  • In the case of BD, the assessment of global functioning during the euthymic period and the identification of predictors of impaired functioning would significantly contribute to the development of follow-up programs as well as the achievement of treatment and psychosocial rehabilitation for patients.

Abstract

Due to the comorbidity of personality traits or disorders and BD, the present study investigated the extent to which the global functioning of patients with BD would be affected by personality functioning. This study included 100 subsequent patients who had been diagnosed with BD-I, and were in the remission phase. Global functioning was assessed with the Bipolar Disorder Functioning Questionnaire (BDFQ) and the Level of Personality Functioning Scale (LPFS) was conducted following psychodynamic-oriented semi-structured interviews to assess the level of personality functioning. Hierarchical linear regression models were conducted. After controlling other variables, the predictability of LPFS components on global functionality was assessed. Global functioning was negatively correlated with subsyndromal depressive symptoms, the presence of a psychiatric comorbidity, alcohol/substance use disorders, the side effects of medication, poor social support, and an impaired level of personality functioning. Finally, a decrease in the level of personality functioning predicted impaired global functioning. The present study demonstrated that the level of personality functioning had a significant impact on global functioning during the euthymic period of BD. Therefore, the assessment of the level of personality functioning in patients with BD will aid in better understanding this population and in the design of long-term treatment plans.

Introduction

Bipolar disorder (BD) leads to serious deficits in global functioning and is considered by the World Health Organisation (WHO) to be a Top 10 cause of disability across the world. Patients who achieve full clinical recovery often experience difficulties maintaining complete functional recovery or return to pre-illness levels of global functioning (Sanchez-Moreno et al., 2009, Keck et al., 1998, Gitlin et al., 1995). Once the clinical symptoms are brought under control following a manic or depressive episode, the patient is generally expected to achieve pre-illness levels of global functioning. However, even patients who have already entered the remission phase may suffer from impairments in social, occupational, and interpersonal global functioning (Depp et al., 2006, MacQueen et al., 2001, Goldberg et al., 1995, Coryell et al., 1993).

A variety of factors influence the level of global functioning in patients with BD. For example, clinical variables, such as age of onset, frequency of cycles, subclinical symptoms, rapid cycling, and the presence of symptoms pertaining to psychotic and mixed cycles have a negative impact on global functioning (Rosa et al., 2009, Suppes et al., 2000, Goldberg and Keck, 1999). Similarly, environmental factors, such as the presence of psychiatric and medical comorbidities (Kupfer, 2005; Feinman and Dunner, 1996), drug side effects (Zarate et al., 2000), substance abuse comorbidity (Lish et al., 1994, McElroy et al., 1992), suicidal behaviour history (Hajek et al., 2005, Kilbourne et al., 2004), compliance with medication (Colom et al., 2003, Colom et al., 2000), life events (Ellicot et al., 1990), and social support (Cohen et al., 2004, Johnson et al., 2003, O'Connell et al., 1985), can affect global functioning. It is also important to note that personality traits can affect global functioning in patients with BD (Hajek et al., 2005, Hecht et al., 2005).

Many studies show that BD patients have significantly higher prevalence of personality disorder than general population (Barquero et al., 2007, George et al., 2003, Kay et al., 2002). Personality traits are considered to be factors affecting functioning in the BD and bipolar patients with personality psychopathology have poorer response to medications and more virulent course of illness (Fan and Hassel, 2008). Personality profiles in BD have been explored in several studies and some personality dimensions have even been suggested as a phenotype for BP (Savitz and Ramesar, 2006). Cloninger's Temperament and Character Inventory revised (Cloninger, 1999) has frequently been used as a measure of personality. Findings using this measurement confirmed that individuals with BD seem to have a different personality structure than healthy controls, although not all studies support this view (Nery et al., 2008). Vierck and Joyce (2015) assessed personality and cognitive functioning in BD and control participants and they found that the best determinants of good psychosocial functioning were good verbal memory and high self-directedness. The use of self- management techniques were associated with a low level of harm-avoidance.

Skodol et al. (2014) brought forward the personality functioning upon introduction of a novel hybrid personality model presented in the Diagnostic and Statistical Manual (DSM)−5 section III. Personality functioning, like other human tendencies, is the path along which an individual continuously contemplates and understands oneself and interactions with others. Mental representation of self and that of interpersonal relations are in mutual interaction and indivisibly interconnected. The self functioning incorporates identity and self-direction, whereas interpersonal functioning involves empathy and intimacy. The Personality and Personality Disorders Work Group identified the necessity that a new personality functioning measure was to be constructed in view of common psychological processes underlying all personality disorders. In that context, several valid and reliable measures assessing the capacities and psychopathologies of personality were examined, and the self-other dimensional perspective had a considerable employability for both clinical and empirical purposes (Bender et al., 2011). In a recent study (Hopwood et al., 2011) of patients with personality disorders participating in the Collaborative Longitudinal Personality Disorders Study (Gunderson et al., 2000) has claimed that in assessing personality psychopathology, “generalized severity is the most important single predictor of concurrent and prospective dysfunction”. Distorted thinking about self and others is a common factor in personality disorders and it's supported with extensive literature (Livesley and Jang, 2000, Masterson, 1988, Kernberg, 1987, Blatt and Lerner, 1983). Maladaptive patterns of mental representations about self and others have a structural function in conceptualization of general psychopathology of personality. Based on this primary feature of the LPFS, it has been suggested that LPFS will allow clinicians to assess the existence and severity of personality disorders in all subjects. Although personality disorders and personality traits have been studied in previous studies with BD, it has not been observed that level of personality functioning was assessed in these patients.

In the case of BD, the assessment of global functioning during the euthymic period and the identification of predictors of impaired global functioning would significantly contribute to the development of follow-up programs as well as the achievement of treatment and psychosocial rehabilitation for patients. However, few studies have investigated this type of global functioning using BD-specific measures. Furthermore, to the best of our knowledge, the effects of the level of personality functioning on global functioning during the euthymic period of BD have yet to be studied. Personality is an individual's unique constellation of consistent behavioural traits and it is formed and sustained from early ages. Personality disorders and also personality functioning are core structures of an individual. Global functioning in BD are known to be affected by many factors, and we think that these factors will have confounding effects when examining the effect of personality functioning on global functioning. Therefore, in this study, firstly, the variables reported in previous studies, which had an effect on the global functioning in BD during euthymic period were examined to evaluate the effects of personality functioning independently of other factors.

Section snippets

Sample and processing

The present study included subsequent patients who applied to the Psychiatry Polyclinics of Erenkoy Mental Health and Neurology Training and Research Hospital, had been diagnosed with BD-I using the Structured Clinical Interview for DSM-IV Axis I Disorders (SCID-I), were in the remission phase, and confirmed their volunteerism by signing a consent form. The exclusion criteria consisted of being younger than 18 or older than 65 years of age, being illiterate, not being in the remission phase,

Results

The present study included 100 patients with BD. Table 1 reports the distribution of participants across socio-demographic variables, Tables 2a and 2b the results of their clinical features. Psychiatric and medical comorbidities of the patients and medications used by them are shown in Table 3. The average values for global functioning and the level of personality functioning are provided in Table 4.

The correlation analyses assessing the relationships between global functioning and clinical

Discussion

The present study was designed to investigate the level of personality functioning in patients with BD during the euthymic phase and to determine factors that may impair global functioning across several domains and revealed that, even in the euthymic phase, patients with BD suffer from impairments in several domains of global functioning. Most notably, the presence of subclinical symptoms, psychiatric comorbidities, alcohol/substance use disorders, perceived social support and drug side

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