Improvement of personality functioning among people treated within personality disorder mental health services. A longitudinal, observational study

Elfrida H Kvarstein, Mathias Frøyhaug, Mona S Pettersen, Sara Carlsen, Andreas Ekberg, Jane Fjermestad-Noll, Dag A Ulvestad, Elisabeth L Gikling, Eirik Hjermann, Kenneth Lindberget, Siri Omvik, Ingeborg U-M Eikenæs, Benjamin Hummelen, Katharina T E Morken, Theresa Wilberg, Geir A F Pedersen, Elfrida H Kvarstein, Mathias Frøyhaug, Mona S Pettersen, Sara Carlsen, Andreas Ekberg, Jane Fjermestad-Noll, Dag A Ulvestad, Elisabeth L Gikling, Eirik Hjermann, Kenneth Lindberget, Siri Omvik, Ingeborg U-M Eikenæs, Benjamin Hummelen, Katharina T E Morken, Theresa Wilberg, Geir A F Pedersen

Abstract

Objective: Evidence-based personality disorder (PD) treatments are dominated by interventions targeting Borderline PD, although clinical populations characteristically include different PD features and severity. Personality functioning is a new concept intended to capture common features across PDs. This study aimed to investigate longitudinal improvement of personality functioning in a clinical sample assigned to PD treatment.

Method: An observational, large, longitudinal study of patients in PD treatments on specialist mental health service levels (N = 1,051). DSM-5 PDs were systematically assessed on referral. Personality functioning was repeatedly assessed (LPFS-BF-2.0), supplemented by symptom distress (anxiety: PHQ-GAD-7, depression: PHQ-9), and social/occupational activity (WSAS, work/study activity). Statistics were linear mixed models.

Results: Thirty per cent had personality difficulties below PD threshold. Among PDs, 31% had Borderline (BPD), 39% Avoidant (AvPD), 15% not otherwise specified, 15% other PDs, and 24% > one PD. More severe initial LPFS-BF was associated with younger age, presence of PD and increasing number of total PD criteria. Across PD conditions, LPFS-BF, PHQ-9 and GAD-7 improved significantly (overall effect size 0.9). Mean duration of PD treatment was 15 (SD 9) months. Drop-out rates were low (12%). LPFS-BF improvement-rates were higher for BPD. Younger age was moderately associated with slower PHQ-9 improvement. Work/study activity was initially poor, poorer levels associated with AvPD and younger age, and improvement was non-significant across PD conditions. AvPD was associated with slower WSAS improvement-rates.

Conclusion: Personality functioning improved across PD conditions. The results highlight BPD improvements. The study points to challenges concerning AvPD treatment, poor occupational activity and age-related differences.

Keywords: improvement; longitudinal; personality disorder (MeSH); personality functioning; treatment.

Conflict of interest statement

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Copyright © 2023 Kvarstein, Frøyhaug, Pettersen, Carlsen, Ekberg, Fjermestad-Noll, Ulvestad, Gikling, Hjermann, Lindberget, Omvik, Eikenæs, Hummelen, Morken, Wilberg and Pedersen.

Figures

Figure 1
Figure 1
Longitudinal change during treatment. Figure demonstrates personality functioning (LPFS-BF), symptom distress (PHQ-9), and occupational activity (= > 50% work/study) assessed at different time-points during treatment (N = 1,051). The Y-axes indicate scores of the LPFS-BF, PHQ-9 and number of months in occupational activity. The X-axes indicate the time-points of assessment during treatment. Within subject variation is demonstrated by calculated confidence intervals (CI).
Figure 2
Figure 2
Distribution of scores of LPFS-BF, PHQ-9, and GAF Figure demonstrates the distribution of scores of personality functioning (LPFS-BF), and symptom distress (PHQ-9, GAD7) assessed on referral and in the last phase of treatment. The figure presents LMM predicted values based on the total sample (N = 1,051). Dashed lines to the left indicate clinical-nonclinical levels and to the right scores of considerable severity. Dotted line indicates LPFS-BF norm in a general population study (67).
Figure 3
Figure 3
Demonstrates longitudinal trajectories (LMM predicted values, N = 1,051) for significant predictors of personality functioning (LPFS-BF), symptom distress (PHQ-9), and work and social activity (WSAS). The Y-axes indicate scores of the LPFS-BF, PHQ-9 and WSAS. The X-axes indicate the time-points of assessment during treatment.
Figure 4
Figure 4
Demonstrates LMM 6 month effect sizes (ES) for patients with 0–9 months duration (30%), 18 month effect sizes for patients with 9, 1–18 months duration (37%), and 30 month ES for patients with >18 months duration (33%) 0.

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