اختلالات شخصیت و کیفیت زندگی: یک مطالعه جمعیت

Abstract The purpose of the study was to investigate the relationship between specific personality disorders (PDs) and specific aspects of quality of life in the common population. The sample consisted of 2053 individuals between 18 and 65 years old. Diagnostic and Statistical Manual of Mental Disorders, Revised Third Edition (DSM-III-R), axis I was studied by means of a structured interview (Composite International Diagnostic Interview) and axis II by means of a Structured Interview for DSM-III-R Personality Disorders; sociodemographic variables were taken into account, and broad aspects of quality of life were included. Personality disorders appeared to be more important statistical predictors of quality of life than sociodemographic variables, somatic health, and axis I disorder. Those with avoidant, schizotypal, paranoid, schizoid, and borderline PDs had the strongest and broadest reduction in quality of life, whereas those with histrionic, obsessive-compulsive, passive-aggressive, and sadistic PDs did not show any reduction. A number of specific relationships occurred. Furthermore, the more PDs that existed and the more personality criteria fulfilled, the poorer the quality of life, pointing to the importance of comorbidity and continuity

. Introduction A number of studies have examined the quality of life of individuals with anxiety disorders [1] and [2], affective disorders [3], and schizophrenia [4]. In contrast, only one Australian population study [5] and one Italian study of individuals contacting community mental health services have included personality disorder (PD) in their study of quality of life and mental disorders [6]. However, their assessment of PDs was based on diagnostic rating and brief screening, and they did not distinguish between different PDs. Subjective report of dysfunction, disability, and impairment are to some extent the reverse of quality of life, because impairment usually encompasses poor qualities in interpersonal relations. Some investigators have studied how PDs are associated with impaired functioning. Andreoli et al [7] found that patients with PDs had poorer work and interpersonal relationships. Levy et al [8] observed that youth in a psychiatric ward with PDs had lower GAF score than other adolescent patients. A number of studies have found that having a PD in addition to a symptom disorder reduces social functioning. Klass et al [9] found a lower GAF among those who had a PD in addition to anxiety disorder. Noyes et al [10] observed that PD in addition to panic disorder reduced work adjustment, social relationships, and family and marriage functioning. Skodol et al [11] found correspondingly that PDs added to drug disorders reduced the Global Assessment of Functioning (GAF) score. Some studies have investigated specific PDs. van Velzen et al [12] found that those with avoidant PD in addition to social phobia had poorer social and occupational adjustment. Most studies have investigated borderline PDs. Pope et al [13] found that those with borderline PD had poorer social and occupational adjustment, compared with patients with bipolar and schizoaffective disorders. Tucker et al [14] observed an improvement in friendship and family relations parallel with an improvement in borderline PD features. Daley et al [15] observed that patients with borderline features experienced more stress and conflicts and were less satisfied than other patients over a 4-year period. However, when they included other PDs in the analyses, they found that histrionic and paranoid features were better predictors of conflicts, and schizotypal and narcissistic traits were almost just as good predictors of “romantic” problems as borderline traits. Shea et al [16] observed that the eccentric and the dramatic, not the fearful, cluster was related to poor social adjustment, but not to poor occupational adjustment. Torgersen [17], however, observed that those with borderline and with schizotypal PD had poorer social as well as occupational adjustment. Two recent studies have investigated a larger number of PDs. Skodol et al [18] found dysfunction in relation to parents, sibs, and friends among patients with schizotypal, borderline, or avoidant PD; occupational dysfunction among those with schizotypal or borderline PD; and dysfunction in relation to more distant family members among those with schizotypal PD. Those with obsessive-compulsive PD were rather well functioning, compared with controls who were depressive patients without PDs. Fossati et al [19] studied aspects of close relationships: confidence, discomfort with closeness, relationships as secondary, need for approval, and preoccupation with relationships among patients with different PDs. Strongest dysfunction was observed among those with avoidant PD, followed by paranoid, depressive, borderline, schizotypal, dependent, and histrionic PDs. In contrast to the few studies of PDs, a number of studies have demonstrated the relationship between personality traits and dimensions, and subjective well-being [20]. Subjective well-being correlated negatively with the so-called Big Five factor neuroticism and positively with the factors extraversion, agreeableness, conscientiousness, and openness to experience in descending magnitude in 2 American studies [21] and [22]. Based on Saulsman and Page [23], metaanalysis of Big Five and PDs, those with avoidant PD will then be expected to have most strongly deficiency in quality of life, followed by borderline, schizotypal, dependent, paranoid, schizoid, and antisocial PD. Those with obsessive-compulsive PD should not have a poor quality of life, and those with histrionic and narcissistic PD a good quality of life. However, subjective well-being is not the only important aspect of quality of life. Also, a number of subjective relational aspects of life are important, as well as broad aspects of the good life [24], [25] and [26]. Consequently, in the present study, we have included in the concept of quality of life also relation to friends, family and neighbors, self-realization, social support, and absence of negative life events. The aim of the present study was to investigate whether PDs are related to broad aspects of quality of life, whether our prediction from the studies of personality dimensions are confirmed, and what specific relationships exist between specific PDs and specific aspects of quality of life. To our knowledge, this is the first study of quality of life and specific PDs.

3. Results Table 1 presents the mean standard scores for individuals with different PDs. The means of those with a specific PD (for instance paranoid PD) are compared with the means of those without any PD whatsoever and the means of those with another PD than the specific PD (for instance schizotypal and avoidant PD). Table 1. Mean quality of life scores among individuals with different PDs compared with those without PDs and those with other PDs A PD n Standard score Subjective well-being Self-realization Contact with friends Support if ill Mean SD Mean SD Mean SD Mean SD Paranoid 46 −0.70⁎ 0.98 −0.94⁎⁎ 1.22 −0.65 1.41 −1.10⁎⁎ 2.03 Schizoid 32 −0.76⁎ 1.12 −0.85⁎ 1.11 −1.14⁎⁎ 1.46 −1.48⁎⁎ 2.05 Schizotypal 12 −1.48⁎ 1.02 −0.87⁎ 1.40 −1.22⁎⁎ 1.59 −1.61⁎⁎ 2.19 Antisocial 12 −0.81⁎⁎ 0.98 −0.10 1.68 −0.19 1.36 −1.36⁎⁎ 2.14 Borderline 14 −1.42⁎⁎ 1.13 −0.84⁎ 1.48 −1.18⁎⁎ 1.48 −1.10⁎⁎ 2.16 Histrionic 39 −0.28⁎⁎⁎ 1.02 −0.26⁎⁎⁎ 1.09 −0.03⁎⁎⁎⁎ 1.11 −0.16⁎⁎⁎⁎ 1.29 Narcissistic 17 −1.00⁎ 1.06 −0.51⁎ 1.41 −0.59⁎ 1.56 −0.92⁎ 1.94 Avoidant 102 −0.89⁎⁎ 1.02 −1.12⁎⁎ 1.07 −1.03⁎⁎ 1.43 −0.77⁎⁎ 1.74 Dependent 31 −0.93⁎⁎ 1.31 −0.85⁎ 1.08 −0.56⁎ 1.39 −0.66⁎ 1.54 Obsessive-comp. 39 −0.22⁎⁎⁎ 0.92 −0.32⁎ 1.05 −0.31⁎ 1.04 −0.44⁎ 1.43 Passive-aggressive 32 −0.41⁎ 0.72 −0.13⁎⁎⁎⁎ 1.06 0.05⁎⁎⁎⁎ 0.86 −0.34⁎ 1.16 Self-defeating 17 −1.07⁎⁎ 0.95 −1.04⁎⁎ 1.41 −0.70⁎ 1.65 −0.74⁎ 1.48 Sadistic 4 0.07 0.49 0.28 0.58 0.67⁎⁎⁎⁎ 0.14 −0.34 0.88 Any PD 269 −0.60⁎ 1.02 −0.60⁎ 1.19 −0.44⁎ 1.29 −0.51⁎ 1.51 No PD 1784 0.09 0.96 0.09 0.93 0.07 0.93 0.08 0.87 B PD n Standard score Absence of negative life events Contact with family of origin Neighborhood quality Global quality of life Mean SD Mean SD Mean SD Mean SD Paranoid 46 −0.51⁎ 1.11 −0.65⁎ 1.24 −0.62⁎⁎ 1.06 −1.28⁎⁎ 1.41 Schizoid 32 −0.40⁎ 1.14 −1.00⁎⁎ 1.42 −0.59⁎ 0.98 −1.51⁎⁎ 1.55 Schizotypal 12 −0.87⁎ 1.41 −1.05⁎⁎ 1.21 −0.98⁎⁎ 0.94 −1.97⁎⁎ 1.72 Antisocial 12 −1.77⁎⁎ 2.20 −0.78⁎ 1.50 0.26 1.23 −1.12⁎ 2.01 Borderline 14 −1.41⁎⁎ 1.65 −0.69⁎ 1.33 −0.37 1.46 −1.74⁎⁎ 1.62 Histrionic 39 −0.39⁎ 1.14 −0.43⁎ 1.29 −0.34⁎ 1.07 −0.45⁎⁎⁎ 1.05 Narcissistic 17 −0.99⁎ 1.10 −0.72⁎ 1.33 −0.53⁎ 1.14 −1.34⁎⁎ 1.47 Avoidant 102 −0.26⁎ 1.34 −0.56⁎ 1.30 −0.45⁎ 1.06 −1.27⁎⁎ 1.25 Dependent 31 −0.49⁎ 1.17 −0.32⁎ 1.29 −0.26 1.11 −1.04⁎ 1.40 Obsessive-compulsive 39 0.12⁎⁎⁎⁎ 0.81 −0.34⁎ 0.93 −0.18 0.79 −0.41⁎⁎⁎ 0.90 Passive-aggressive 32 −0.62⁎ 1.14 −0.57⁎ 1.27 −0.23 1.10 −0.51⁎ 0.83 Self-defeating 17 −0.54⁎ 1.35 −0.59⁎ 1.33 −0.31 0.80 −1.27⁎⁎ 1.48 Sadistic 4 −0.62 1.31 0.12 1.63 1.25⁎⁎⁎⁎⁎ 0.71 0.31⁎⁎⁎⁎ 0.85 Any PD 269 −0.34⁎ 1.28 −0.49⁎ 1.27 −0.31⁎ 1.04 −0.81⁎ 1.23 No PD 1784 0.05 0.94 0.08 0.93 0.04 0.99 0.12 0.90 ⁎ Statistical sign P < .05, Duncan test, lower than no PD. ⁎⁎ Statistical sign P < .05, Duncan test, lower than no PD and other PDs. ⁎⁎⁎ Statistical sign P < .05, Duncan test, lower than no PD but higher than other PDs. ⁎⁎⁎⁎ Statistical sign P < .05, Duncan test, higher than other PDs. ⁎⁎⁎⁎⁎ Statistical sign P < .05, Duncan test, higher than no PD and other PDs. Table options Subjective well-being and self-realization is poorer for those with almost all types of specific PDs and also most strongly reduced for those with any PD. Poorer neighborhood quality is typical for fewest of the specific PDs and less deficient among those with any kind of PDs. Those with schizotypal, borderline, schizoid, narcissistic, paranoid, avoidant, and self-defeating PDs have a poorer quality of life on all or almost all indexes, and most marked deficient global quality of life compared to those with no PDs or those with other than the specific PD. On the other hand, those with sadistic PD have more contacts with friends and better global quality of life than those with other PDs, and report better neighborhood quality than those with no PDs. Those with passive-aggressive PD have also better self-realization and contact with friends than those with other PD. Finally, those with histrionic PD have more contact with friends, and those with obsessive-compulsive PD have less negative life events than those with other PD. Understandably, those with these 4 PDs have no (sadistic) or only a little lower global quality of life than those without PDs (passive-aggressive, histrionic, and obsessive-compulsive). Personality disorder traits are calculated by summing up number of criteria fulfilled for a specific disorder. As the relationship between PD traits and quality of life turned out to be strictly linear for all PDs, Table 2 presents Pearson product-moment correlations and standardized β's based on hierarchical multiple regression analyses for the relationship between PD traits and quality of life indexes and global quality of life. Table 2. Product-moment correlations for the relationship between PD traits and quality of life A PD Subjective well-being Self-realization Contact with friends Support if ill r β r β r β r β Paranoid −0.24 −.04 −0.23 −.08⁎ −0.17 .02 −0.20 −.07⁎ Schizoid −0.20 −.02 −0.26 −.08⁎⁎ −0.26 −.09⁎⁎ −0.26 −.12⁎⁎⁎ Schizotypal −0.26 −.04 −0.26 .00 −0.28 −.12⁎⁎⁎ −0.28 −.09⁎ Antisocial −0.14 −.01 −0.06 .01 −0.04 .03 −0.12 −.05⁎⁎⁎⁎ Borderline −0.31 −.11⁎⁎⁎ −0.20 −.02 −0.18 −.04 −0.17 .00 Histrionic −0.15 .04 −0.09 .05⁎⁎⁎⁎ −0.13 .00 −0.12 −.01 Narcissistic −0.22 −.04 −0.16 .00 −0.19 .04 −0.15 .01 Avoidant −0.28 −.09⁎ −0.34 −.19⁎⁎⁎ −0.31 −.13⁎⁎⁎ −0.23 −.05 Dependent −0.26 −.05⁎⁎⁎⁎ −0.23 −.03 −0.20 −.07⁎⁎⁎⁎ −0.14 .01 Obsessive-compulsive −0.15 .00 −0.18 −.04 −0.19 −.04 −0.12 .03 Passive-aggressive −0.15 −.01 −0.11 .00 −0.09 .03 −0.09 .01 Self-defeating −0.27 −.04 −0.21 −.02 −0.15 .00 −0.23 −.08⁎⁎ Sadistic −0.07 .05⁎⁎⁎⁎ −0.05 .03 −0.05 .03 −0.07 −.01 Variance change Sociodemographic 0.116 0.082 0.015 0.058 Somatic health 0.055 0.032 0.019 0.015 Any axis I 0.034 0.111 0.006 0.079 Total PD traits 0.024 0.027 0.022 0.024 Specific PD traits 0.067 0.090 0.111 0.076 Total variance 0.272 0.215 0.150 0.153 B PD Not negative life events Contact with family of origin Neighborhood quality Global quality of life r β r β r β r β Paranoid −0.17 −.02 −0.19 −.09⁎ −0.14 −.07⁎⁎⁎⁎ −0.33 −.08⁎⁎ Schizoid −0.04 .11⁎⁎⁎ −0.21 −.09⁎⁎ −0.10 −.02 −0.33 −.08⁎⁎ Schizotypal −0.18 −.11⁎⁎⁎ −0.21 −.07⁎⁎⁎⁎ −0.11 .00 −0.39 −.10⁎⁎⁎ Antisocial −0.20 −.09⁎⁎⁎ −0.14 −.07⁎ −0.02 .06⁎ −0.17 −.03 Borderline −0.28 −.12⁎⁎⁎ −0.16 −.04 −0.11 .01 −0.35 −.08⁎⁎⁎ Histrionic −0.15 .00 −0.09 .02 −0.08 .02 −0.20 .03 Narcissistic −0.19 −.04 −0.16 −.03 −0.15 −.08⁎ −0.30 −.05⁎⁎⁎⁎ Avoidant −0.10 .06 −0.18 −.03 −0.15 −.08⁎ −0.40 −.13⁎⁎⁎ Dependent −0.18 −.06⁎⁎⁎⁎ −0.10 −.01 −0.10 −.01 −0.31 −.05⁎⁎⁎⁎ Obsessive-compulsive −0.09 −.01 −0.13 −.01 −0.10 −.04 −0.24 −.03 Passive-aggressive −0.12 .01 −0.08 .04 −0.10 −.01 −0.18 .01 Self-defeating −0.21 −.04 −0.13 −.02 −0.06 .05⁎ −0.32 −.04 Sadistic −0.09 .02 −0.06 .03 −0.05 −.02 −0.10 .05⁎ Variance change Sociodemographic 0.082 0.034 0.069 0.116 Somatic health 0.022 0.008 0.007 0.063 Any axis I 0.013 0.004⁎ 0.001NS 0.026 Total PD traits 0.006⁎⁎ 0.027 0.010 0.054 Specific PD traits 0.061 0.059 0.033 0.154 Total variance 0.178 0.104 0.110 0.360 β's from hierarchical multiple regression with sociodemographic variables, somatic health, and axis I last year first entered into the analysis. NS indicates not significant. ⁎ Statistical sign P < .05, Duncan test, lower than no PD but higher than other PDs. ⁎⁎ Statistical sign P < .05, Duncan test, lower than no PD. ⁎⁎⁎ Statistical sign P < .05, Duncan test, lower than no PD and other PDs. ⁎⁎⁎⁎ Statistical sign P < .05, Duncan test, higher than other PDs. Table options We observe that, more or less, all PD traits are statistically significantly negatively correlated with, more or less, all quality of life subindexes. That means that the higher the score on the PD score, the worse the quality of life. However, PDs are strongly intercorrelated, so we have, in addition to the univariate correlations, applied hierarchical multiple regression analysis. Table 2 show the variance explained by sociodemographic variables: sex (females have better quality of life), age (not related to global quality of life), education, income, civil status (married is beneficial), cohabitat (gives better quality of life), population density (less density implies better quality of life), by somatic health subjectively experienced (the better health, the better quality of life), by axis I disorder last year (disorder decreases quality of life), and finally, the variance explained by the specific PD traits and by the total number of PD traits. Self-realization and contact with family of origin is most strongly explained by total PD traits, whereas contact with friends and self-realization is most strongly explained by the specific PDs. The higher the number of PD traits, the worse the quality of life. Relatively speaking, contact with friends and contact with family of origin are most strongly explained by the specific PD traits. For these subindexes and for neighborhood quality, PD traits are much more important predictors than axis I disorder. The specific PDs traits are also the most important predictor of global quality of life. Avoidant, schizotypal, schizoid, paranoid, and borderline PD traits are the strongest predictors, followed by dependent and narcissistic PDs. Self-defeating and antisocial PD traits have a specific negative relationship to quality of life subindexes, obsessive-compulsive and passive-aggressive do not, whereas histrionic PD traits has a positive relationship to one subindex, and sadistic PD a positive relationship to one subindex and to global quality of life. There exist a number of interesting relationships between specific quality of life subindexes and specific PD traits. Subjective well-being is especially negatively related to borderline PD and self-realization and contact with friends to avoidant PD traits. Support if ill is most strongly negatively related to schizoid PD traits. The higher the borderline PD trait score, the more the negative life events. Paranoid and schizoid PD traits are negatively related to contact with family of origin. The higher the narcissistic and avoidant PD trait score, the worse is the neighborhood quality. Interestingly, when all other predictors are taken into account, the higher the schizoid PD trait score, the fewer the negative life events; the higher the histrionic PD score, the stronger the self-realization; the higher the self-defeating PD score, the better the neighborhood quality; and finally, the higher the sadistic PD trait score, the better the subjective well-being. However, the standardized β's are small.