by Randy A. Sansone, MD, and Lori A. Sansone, MD
Dr. R. Sansone is a professor in the Departments of Psychiatry and Internal Medicine at Wright State University School of Medicine in Dayton, Ohio, and Director of Psychiatry Education at Kettering Medical Center in Kettering, Ohio; Dr. L. Sansone is a family medicine physician (government service) and Medical Director of the Primary Care Clinic at Wright-Patterson Air Force Base. The views and opinions expressed in this column are those of the authors and do not reflect the official policy or the position of the United States Air Force, Department of Defense, or US government.

Psychiatry (Edgemont) 2010;7(3):12–16.

Funding: There was no funding for the development and writing of this article.

Financial Disclosures: The authors have no conflicts of interest relevant to the content of this article.

Key words
Axis II disorders, employment, functionality, personality disorders, work

ABSTRACT

According to the Diagnostic and Statistical Manual of Mental Disorders, personality disorders are characterized by functional impairment, which may unfold in the work environment. A number of empirical studies convincingly suggest that the presence of personality dysfunction has substantial negative and diffuse effects on work functioning. However, not all studies are in agreement. In addition, there may be specific mediating variables that modulate the likelihood that an individual with a personality disorder will experience work difficulties. These include the type of personality disorder, degree of neuroticism and disagreeableness, extent of social dysfunction, and severity of symptoms—all of which appear to be interrelated. Because employment generally promotes an individual’s stability, further research into these variables is essential.

INTRODUCTION

Personality disorders are relatively prevalent in community populations. For example, through a meta-analysis, Lenzenweger[1] found that the median prevalence of any personality disorder in the general populations of three different countries (i.e., an analysis of six major studies) is 10.6 percent. Blanco et al[2] conducted face-to-face psychiatric interviews with college students (n=2,188) and noncollege-attending peers (n=2,904), and found rates for any personality disorder of 17.7 and 21.6 percent, respectively (i.e., 1 out of every 5 young adults). Moran et al[3] examined 1,469 young adults with a mean age of 24 years and encountered Axis II disorders in 18.6 percent. Finally, in a study that examined the causes for involuntary military separation for psychiatric reasons, personality disorders accounted for 11 percent.[4] These data underscore the relatively high prevalence rate of personality disorders in various community samples. In this edition of “The Interface,” we examine the potential effects of personality dysfunction on work functioning.

Personality Disorders and Impaired Functionality

According to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV),[5] an individual with a personality disorder is characterized by some degree of functional impairment, with examples being social and occupational arenas. While work dysfunction is our focus, social dysfunction keenly relates to impaired occupational functioning among those with Axis II disorders. To emphasize this point, Hill et al[6] found that pervasive social dysfunction was associated with a 16-fold increase in the odds of having a personality disorder. Furthermore, while functional impairment is a common defining characteristic for many DSM disorders, Ansell et al[7] note that the degree of impairment experienced by those with personality disorders is often equivalent to, and at times exceeds, that encountered in those with mood and anxiety disorders. However, is there any direct empirical evidence that personality dysfunction impairs employment?

Personality Dysfunction and Work Dysfunction

While available studies are few in number, the majority indicates that having a personality disorder compromises work functionality. Most of these studies began to emerge in the late 1980s. In the first, Patrick[8] examined a sample of workers compensation claimants who were “work ready” (i.e., willing and able to return to work). None demonstrated mean scores on the Minnesota Multiphasic Personality Inventory (MMPI) indicating psychopathology (i.e., scores were in the normal range).

In a study by Gordon et al,[9] investigators compared psychiatric “treatment-seekers” with workmen’s compensation “payment seekers.” Payment-seekers were significantly more likely than treatment seekers to have Axis II disorders.

Eliashof and Streltzer[10] examined the role of “stress” among 26 workers compensation claimants. In this cohort, stress symptoms were most often precipitated by interpersonal issues (56%), with most participants stating that unfair treatment caused their distress (i.e., an inter-relationship between social and occupational dysfunction). In this cohort, 79 percent met the criteria for a personality disorder.

In a study of low-back pain patients (N=324), Gatchel et al[11] examined relationships between initial symptoms and subsequent chronic disability. In analyses designed to predict outcome in six months, the researchers found that the presence of a personality disorder was a significant predictor for not returning to work.

Ekselius et al[12] examined a mixed group of medical patients and found that the presence of a personality disorder within the Cluster B category was associated with an earlier age of longstanding employment disability. Burton et al[13] examined the long-term employment outcome of 70 individuals with work-related upper-extremity chronic pain; borderline personality was a predictor for poor return to work.

Tartaglini et al[14] examined corrections officers (N=1029) who voiced complaints of psychological distress. While V-code diagnoses accounted for most lost workdays, the researchers found that personality disorders, in addition to mood and anxiety disorders, were the most disabling conditions. Among a sample of 45 individuals in an internal medicine clinic, Sansone et al[15] found that, among the employment-disabled, 72 percent met the criteria for borderline personality disorder (BPD).

Jackson and Burgess[16] examined data from the Australian National Mental Health and Well-Being Survey (N=10,641) and found that having specific types of personality disorders, especially BPD, was strongly associated with lost days of role functioning. In comparing women with (n=214) versus without (n=1004) antisocial personality disorder features, Pajer et al[17] found that participants with these Axis II features were more likely to be unemployed. In another Australian sample, Jovev and Jackson[18] compared those with BPD to those with another or no personality disorder. Those with BPD reported the poorest levels of interpersonal functioning and found employment stressful and difficult from a coping standpoint. Finally, in an Australian study examining the vocational rehabilitation of injured workers, Wall et al[19] found that personality factors (affecting about one third of this cohort) were associated with poorer outcome.

What does this sampling of studies from the literature summarily suggest? Personality pathology may be relatively common in those who seek compensation for work-related injuries, do not successfully rehabilitate, do not return to work, and/or are unemployed. In addition, workers with personality pathology may experience greater interpersonal difficulties at work, perceived job stress, impairment in role functioning, and disability. Succinctly, these data indicate that the presence of a personality disorder has pervasive influences on work functionality.

Studies Refuting a Relationship

Not all studies affirm an association between personality dysfunction and work dysfunction. For example, Owen[20] examined personality pathology in 125 chronic low-back pain patients and concluded that personality pathology was not related to return-to-work status at one-year follow-up. In a Spanish study, Sans et al[21] examined employee time off for psychiatric reasons. Depression and anxiety were the most frequent reasons, at 48 and 38 percent, respectively, whereas personality disorders accounted for only one percent of individuals (i.e., this percentage is unexpectedly low, given the anticipated frequency of personality disorders in the general population). Ericsson et al[22] examined 184 Swedish pain patients with the Karolinska Scales of Personality; neither baseline personality traits nor the diagnosis of a personality disorder were predictors of subsequent disability status. Finally, in a United States study, Gatchel et al[23] examined the successful return-to-work of 152 employees following their rehabilitation for low back pain. In this sample, more than 50 percent had an Axis II diagnosis based upon structured clinical interview, but personality pathology was not a predictive factor for returning to work at the one-year evaluation point.

These preceding studies suggest that there must be tempering variables in the relationship between personality dysfunction and work dysfunction. However, these variables have yet to be fully elucidated.

Tempering Factors Between Personality Dysfunction and Work Dysfunction

Given that the majority of available studies indicate that personality dysfunction has a potentially detrimental effect on various aspects of employment, what underlying factors are presently known that might mediate this relationship?

Personality volatility. Personality disorders vary greatly in terms of their emotional stylings. In comparing the three personality disorder clusters, Cluster B disorders are characterized by emotional, dramatic, and erratic features, as opposed to the odd/eccentric features in Cluster A disorders and the fearful/anxious features in Cluster C disorders. Given our previous discussion about the relevance of social functioning in the successful negotiation of the work environment, Cluster B disorders might predictably be the most imperiling. According to Lang and Helweg,[24] Cluster B disorders, in particular, are associated with an earlier age of work disability and failure to return to work.

Neuroticism and disagreeableness. Given the ongoing discussion around the categorical versus dimensional diagnosis of personality disorders, the five-factor model of personality is particularly relevant to our discussion because of its potential role in Axis II dimensional assessment. According to this model, the most prominent and consistent personality dimensions underlying a large number of personality disorders are neuroticism (i.e., a tendency to experience unpleasant emotions easily, such as anger, anxiety, depression, or vulnerability) and low agreeableness (i.e., disagreeableness).[25] In this regard, in a Dutch study, Michon et al[26] found that higher levels of neuroticism are significantly associated with subsequent impairment in work functioning, independent of psychiatric diagnosis. These data suggest that neuroticism, an underlying temperamental feature of most of the personality disorders, is an important factor in work impairment.

Social dysfunction. Like all psychiatric disorders, personality disorders vary from individual to individual in terms of their severity. In a United Kingdom study, Newton-Howes et al[27] surveyed 2,528 workers and randomly interviewed 282 to assess social dysfunction. In this study, social dysfunction and personality dysfunction were inter-related—and to a greater extent than other types of psychopathology.

Symptom severity. Like other psychiatric disorders, symptom severity in personality disorders is likely to contribute to functional impairment. In a multisite study comprising five psychiatric hospitals, investigators examined the effects of various types of psychiatric disorders on social disability.[28] In this study, the severity of symptoms was the most significant factor in determining the level of social dysfunction, which is secondarily related to occupational functioning. Figure 1 summarizes these various tempering variables.

Conclusion

From our review of the empirical literature, there appears to be reasonably strong evidence that personality dysfunction tends to exert a detrimental effect on employment functioning. Importantly, this association is not invariable and there may be a number of tempering factors that mediate this relationship, such as the type of personality disorder, the degree of neuroticism and disagreeableness, the extent of social dysfunction, and symptom severity. Clearly, these relationships warrant further investigation, particularly because employment may be a valuable tool for structuring a patient’s environment and promoting stability. Can interventions be developed for those with personality disorders to alleviate key areas that challenge employment? Clearly, the relationship between personality dysfunction and work dysfunction is highly relevant for both psychiatric and primary care clinicians.

References
1. Lenzenweger MF. Epidemiology of personality disorders. Psychiatr Clin North Am. 2008;31:395–403.
2. Blanco C, Okuda M, Wright C, et al. Mental health of college students and their non-college-attending peers. Arch Gen Psychiatry. 2008;65:1429–1437.
3. Moran P, Coffey C, Mann A, et al. Dimensional characteristics of DSM-IV personality disorders in a large epidemiological sample. Acta Psychiatr Scand. 2006;113:233–236.
4. Hoge CW, Toboni HE, Messer SC, et al. The occupational burden of mental disorders in the U.S. military: psychiatric hospitalizations, involuntary separations, and disability. Am J Psychiatry. 2005;162:585–591.
5. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 4th Edition. Washington, DC: 1994.
6. Hill J, Pilkonis P, Morse J, et al. Social domain dysfunction and disorganization in borderline personality disorder. Psychol Med. 2008;38:135–146.
7. Ansell EB, Sanislow CA, McGlashan TH, Grilo CM. Psychosocial impairment and treatment utilization by patients with borderline personality disorder, other personality disorders, mood and anxiety disorders, and a healthy comparison group. Compr Psychiatry. 2007;48:329–336.
8. Patrick J. Personality characteristics of work-ready workers’ compensation clients. J Clin Psychol. 1988;44:1009–1012.
9. Gordon RE, Eisler RL, Gutman EM, Gordon KK. Predicting prognosis by means of the DSM-III multiaxial diagnoses. Can J Psychiatry. 1991;36:218–221.
10. Eliashof BA, Streltzer J. The role of “stress” in workers’ compensation stress claims. J Occup Med. 1992;34:297–303.
11. Gatchel RJ, Polatin PB, Kinney RK. Predicting outcome of chronic back pain using clinical predictors of psychopathology: a prospective analysis. Health Psychol. 1995;14:415-420.
12. Ekselius L, Eriksson M, von Knorring L, Linder J. Personality disorders and major depression in patients with somatoform pain disorders and medical illnesses in relation to age at onset of work disability. Eur J Psychiatry. 1996;10:35–43.
13. Burton K, Polatin PB, Gatchel RJ. Psychosocial factors and the rehabilitation of patients with chronic work-related upper extremity disorders. J Occup Rehabil. 1997;7:139–153.
14. Tartaglini AJ, Safran DA. A topography of psychiatric disorders among correction officers. J Occup Environ Med. 1997;39:569–573.
15. Sansone RA, Hruschka J, Vasudevan A, Miller SN. Disability and borderline personality symptoms. Psychosomatics. 2003;44:442.
16. Jackson HJ, Burgess PM. Personality disorders in the community: results from the Australian National Survey of Mental Health and Well-Being Part III: relationships between specific type of personality disorder, Axis I mental disorders and physical conditions with disability and health consultations. Soc Psychiatry Psychiatr Epidemiol. 2004;39:765–776.
17. Pajer K, Stouthamer-Loeber M, Gardner W, Loeber R. Women with antisocial behaviour: long-term health disability and help-seeking for emotional problems. Crim Behav Ment Health. 2006;16:29–42.
18. Jovev M, Jackson HJ. The relationship of borderline personality disorder, life events and functioning in an Australian psychiatric sample. J Pers Disord. 2006;20:205–217.
19. Wall CL, Ogloff JR, Morrissey SA. The psychology of injured workers: health and cost of vocational rehabilitation. J Occup Rehabil. 2006;16:513–528.
20. Owen EM. Personality pathology in patients with chronic low back disability: assessment and treatment effects. Dissert Abst Int. 1995;55:5082B.
21. Sans M, Batalla C, Villagrasa D, Ezpeleta A, Escorza S, Comin E. Temporal disability caused by psychiatric pathology at a health center. Aten Primaria. 2000;25:412–416.
22. Ericsson M, Poston WS, Linder J, et al. Depression predicts disability in long-term chronic pain patients. Disabil Rehabil. 2002;24:334–340.
23. Gatchel RJ, Polatin PB, Mayer TG, Garcy PD. Psychopathology and the rehabilitation of patients with chronic low back pain disability. Arch Phys Med Rehabil. 1994;75:666–670.
24. Lang UE, Hellweg R. Prevalence and role of psychiatric disorders in disability. Versicherungsmedizin. 2006;58:164–169.
25. Saulsman LM, Page AC. The five-factor model and personality disorder empirical literature: a meta-analytic view. Clin Psychol Rev. 2004;23:1055–1085.
26. Michon HW, ten Have M, Kroon H, et al. Mental disorders and personality traits as determinants of impaired work functioning. Psychol Med. 2008;38:1627–1637.
27. Newton-Howes G, Tyrer P, Weaver T. Social functioning of patients with personality disorder in secondary care. Psychiatr Serv. 2008;59:1033–1037.
28. Rymaszewska J, Jarosz-Nowak J, Kiejna A, et al. Social disability in different mental disorders. Eur Psychiatry. 2007;22:160–166.