Contours of a causal feedback mechanism between adaptive personality and psychosocial function in patients with personality disorders: a secondary analysis from a randomized clinical trial

Ole Klungsøyr, Bjørnar Antonsen, Theresa Wilberg, Ole Klungsøyr, Bjørnar Antonsen, Theresa Wilberg

Abstract

Background: Patients with personality disorders commonly exhibit impairment in psychosocial function that persists over time even with diagnostic remission. Further causal knowledge may help to identify and assess factors with a potential to alleviate this impairment. Psychosocial function is associated with personality functioning which describes personality disorder severity in DSM-5 (section III) and which can reportedly be improved by therapy.

Methods: The reciprocal association between personality functioning and psychosocial function was assessed, in 113 patients with different personality disorders, in a secondary longitudinal analysis of data from a randomized clinical trial, over six years. Personality functioning was represented by three domains of the Severity Indices of Personality Problems: Relational Capacity, Identity Integration, and Self-control. Psychosocial function was measured by Global Assessment of Functioning. The marginal structural model was used for estimation of causal effects of the three personality functioning domains on psychosocial function, and vice versa. The attractiveness of this model lies in the ability to assess an effect of a time - varying exposure on an outcome, while adjusting for time - varying confounding.

Results: Strong causal effects were found. A hypothetical intervention to increase Relational Capacity by one standard deviation, both at one and two time-points prior to assessment of psychosocial function, would increase psychosocial function by 3.5 standard deviations (95% CI: 2.0, 4.96). Significant effects of Identity Integration and Self-control on psychosocial function, and from psychosocial function on all three domains of personality functioning, although weaker, were also found.

Conclusion: This study indicates that persistent impairment in psychosocial function can be addressed through a causal pathway of personality functioning, with interventions of at least 18 months duration.

Trial registration: ClinicalTrials.gov NCT00378248.

Keywords: Marginal structural model; Personality disorders; Personality functioning; Psychosocial function.

Figures

Fig. 1
Fig. 1
Causal graph (DAG [22]) of the study design, to illustrate the effect of exposure (A) on the outcome (Y). Symbols: baseline confounders (V), time – varying confounders including outcome (L) and censoring (C) (loss to follow-up), at baseline and follow-ups 1, 2, 3, in a Norwegian sample of 113 patients with personality disorders. An arrow symbolizes possible direct causal effect, the box around the C-symbol means “conditioned on” to reflect the fact that the analysis is restricted to those “not lost to follow-up”, a potential source of selection bias
Fig. 2
Fig. 2
Psychosocial function (GAF) and three personality functioning domains REL, IDENTITY and SLFC in in a Norwegian sample of 113 patients with personality disorders, over six years of follow – up
Fig. 3
Fig. 3
Boxplot of truncated (99th percentile) exposure weight distribution (SLFC) for each point of time 1 = baseline, …, 5 = 72 months) in a Norwegian sample of 113 patients with personality disorders
Fig. 4
Fig. 4
Non – linear association between IDENTITY at baseline and SLFC at 8 months (spline fit with 95% point-wise confidence interval), in a Norwegian sample of 113 patients with personality disorders

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