BRIEF REPORTS
Psychosocial Outcome in Bipolar I Patients With a
Personality Disorder
Shay T. Loftus, PhD,* and Judith Jaeger, PhD, MPA*†
Abstract: This study examined whether comorbid personality dis-
orders and other clinical factors were predictive of functional mor-
bidity in bipolar I disorder. Fifty-one participants with a diagnosis of
bipolar I were assessed for personality disorders and administered
measures of symptomatic and functional outcomes approximately 1
year after a psychiatric hospitalization. Forty-five percent of the
sample met criteria for at least one personality disorder, and patients
with a personality disorder reported higher levels of residual symp-
toms at the time of assessment. Two thirds of participants displayed
compromised functional outcomes. The three outcome domains
examined (i.e., occupational, residential, social/leisure) were related
to a range of clinical characteristics, and for all three, either the
presence of a personality disorder diagnosis or maladaptive trait
scores was associated with impaired functioning. These relation-
ships, however, were not independent of mood symptoms according
to multivariate analysis. Residual depression predicted poorer resi-
dential and social/leisure outcomes independent of personality dis-
orders or maladaptive traits.
Key Words: Bipolar disorder, personality disorder, psychosocial
functioning, outcome.
(J Nerv Ment Dis 2006;194: 967–970)
B ipolar I disorder has been associated with enduring impair-
ments in social and occupational functioning (Harrow et al.,
1990; Keck et al., 1998; Tohen et al., 1990). Studies have
suggested that a third to a half of bipolar I patients have difficulty
holding competitive employment (Gitlin et al., 1995; Harrow et
al., 1990) and that many experience distress in family and peer
relationships (Carlson et al., 1974; Coryell et al., 1993). There is
wide variability in social outcomes, however, and the recovery
of role functioning is not always directly related to symptomatic
improvement (Dion et al., 1988).
*Center for Neuropsychiatric Outcome and Rehabilitation Research, Zucker
Hillside Hospital, North Shore Long Island Jewish Health System, Glen
Oaks, New York; and †Albert Einstein College of Medicine, Department
of Psychiatry and Behavioral Sciences, New York, New York.
Supported by NIMH R01MH 60904-01 (J. Jaeger, Principal Investigator)
and the Stanley Medical Research Institute.
Send reprint requests to Shay T. Loftus, PhD, Zucker Hillside Hospital,
Department of Psychiatry Research, 75-59 263rd Street, Glen Oaks, NY
11004. E-mail: sloftus@lij.edu.
Copyright © 2006 by Lippincott Williams & Wilkins
ISSN: 0022-3018/06/19412-0967
DOI: 10.1097/01.nmd.0000243814.35854.10
The Journal of Nervous and Mental Disease • Volume 194, Number 12, December 2006
Relatively few studies have examined functional out-
comes in bipolar I patients with an Axis II personality
disorder (PD). There is a need for greater knowledge in this
area since on average, 40% to 50% of individuals diagnosed
with bipolar I disorder suffer from a co-occurring PD (Bar-
bato and Hafner, 1998; Brieger et al., 2003; Peselow et al.,
1995; Ucok et al., 1998). The negative effects of PDs on the
clinical course of the illness are well established. Axis II
diagnoses have been associated with medication noncompli-
ance (Colom et al., 2000), higher levels of interepisode
symptoms (Barbato and Hafner, 1998; Carpenter et al., 1995;
Dunayevich et al., 2000), more days per year spent hospital-
ized (Barbato and Hafner, 1998), alcohol and substance abuse
disorders (Kay et al., 2002), and suicidality (Ucok et al.,
1998). Mounting empirical evidence suggests similarly det-
rimental effects on social and occupational functioning (Car-
penter et al., 1995; Dunayevich et al., 2000).
The aim of the present study was to examine the impact
of Axis II PDs and other clinical factors on functional morbidity
in a sample of remitted bipolar I patients. We hypothesized
that patients with a PD would demonstrate poorer social and
occupational outcomes than those without a PD.
METHODS
The sample consisted of 51 bipolar I inpatients (N ! 4)
and outpatients (N ! 47) receiving services at a large subur-
ban psychiatric hospital in New York. Participants repre-
sented a subset of a larger group recruited to a 2-year
naturalistic, longitudinal study of the relationship of neuro-
psychological deficits to functional recovery in bipolar dis-
order. Included in the larger cohort were individuals 18 to 59
years old hospitalized for an acute affective episode. Exclu-
sion criteria were mental retardation, neurological disease,
serious medical illness, and lack of fluency in the English
language.
After obtaining written informed consent, patients were
assessed with the Structured Clinical Interview for DSM-IV-
Patient Edition (SCID-I/P; First et al., 2002) by interviewers
previously shown to be reliable with an expert diagnostician.
Information gathered from the patient and available collater-
als, and the medical record was compiled by the interviewer
into a detailed case summary. This case summary was pre-
sented to a committee of at least three senior investigators
who then rendered a consensus SCID diagnosis. Symptom
status was measured using the Hamilton Rating Scale for
Depression (Hamilton, 1960) and the Clinician-Administered
Rating Scale for Mania (Altman et al., 1994).
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Loftus and Jaeger The Journal of Nervous and Mental Disease • Volume 194, Number 12, December 2006
Axis II diagnoses were assessed with the Structured
Clinical Interview for DSM-IV PDs (SCID-II; First et al.,
1997) in participants whose symptoms were in the mild range
(defined as !17 on the first 17 items of the Hamilton
Rating Scale for Depression and !15 on the first 10 items
of the Clinician-Administered Rating Scale for Mania) at
approximately 1 year posthospital discharge (M ! 11.88
months, SD ! 5.31). Good interrater reliability for the pres-
ence or absence of an Axis II diagnosis was demonstrated in
joint ratings of 11 interviews (" index ! .744).
In addition to deriving categorical PD classifications, a
dimensional PD trait score was calculated by summing the
number of items on the SCID-II that were endorsed as present
(scored 3) across each of the 12 DSM-IV PDs. Childhood
conduct disordered traits (criterion C of antisocial PD) were
summed in place of antisocial PD traits in calculating the total
PD trait score.
Occupational and residential role recovery was evalu-
ated using the Multidimensional Scale for Independent Func-
tioning (MSIF; Jaeger et al., 2003). The MSIF is a 7-point
rating scale designed to capture role functioning in psychiat-
ric patients in three domains: work environment (including
caring for dependent children or disabled family members),
educational/vocational training environment, and residential
environment. Role functioning in turn is rated in three di-
mensions: role position (responsibility inherent in the role),
level of support (assistance provided by others to maintain the
role), and level of performance (success with which role
activities are fulfilled). Global ratings for each of the three
role domains are made after adjusting for levels of support
and performance. The MSIF has been shown to have good
criterion, discriminant, interrater, and construct validity in
both schizophrenic (Jaeger et al., 2003) and bipolar (Berns
et al., In press) patient populations. Interpersonal role func-
tioning was measured using the social and leisure activity
subscale of the Social Adjustment Scale-II (SAS-II; Schooler
et al., 1979).
Interviewers were experienced master’s and doctoral
level research assistants who were required to demonstrate
interrater reliability against a gold standard as part of their
training on all symptom and social functioning measures
(intraclass correlation coefficients ".80).
Nonparametric (#2 with Fisher exact test) and para-
metric methods (Student t test) were used to compare
variables as appropriate. Multiple linear and logistic re-
gression analyses were conducted to examine the effects of
PDs/traits and other clinical variables on work, residential,
and social/leisure outcomes.
RESULTS
Approximately half of the sample was male (43%), two
thirds were Caucasian (60.8%), and 86.3% were single or
divorced. The mean age of participants was 35.47 years (SD !
11.39), and the mean number of years of schooling was 13.88
(SD ! 2.44); 78.5% of participants were high school graduates,
while 33.3% had completed college. The cohort, overall, was
representative of a chronically ill population presenting with an
968
average of 7.12 hospitalizations (SD ! 5.32). The average age
of first hospitalization was 24.00 years (SD ! 9.05).
With regard to psychiatric comorbidities, 30 partici-
pants (58.8%) met criteria for at least one comorbid Axis I
disorder; 18 (35.3%) carried an alcohol abuse or dependence
diagnosis; 21 (41.2%) carried a drug abuse or dependence
diagnosis; and six (11.8%) carried an anxiety disorder diag-
nosis. Twenty-three participants (45.1%) met criteria for at
least one Axis II PD; and three (5.9%) received more than
one diagnosis (one borderline and depressive, one antisocial
and narcissistic, one avoidant and borderline). The most
frequently diagnosed PD was borderline PD (N ! 10, 20%),
followed by avoidant PD (N ! 3, 6.0%), antisocial PD (N !
2, 4.0%), obsessive-compulsive PD (N ! 2, 4.0%), narcis-
sistic PD (N ! 2, 4.0%), depressive PD (N ! 2, 4.0%), and
passive-aggressive PD (N ! 1, 2.0%). Five patients (10.0%)
were diagnosed with PD NOS. The mean dimensional trait
score was 6.80 (SD ! 5.50).
Participants with and without a PD did not differ on any
of the demographic or clinical characteristics with the excep-
tion of residual symptoms. Those with a PD were distin-
guished by a greater number of both manic (5.95 #4.62$ vs.
3.54 #3.38$, t ! 2.14, p ! 0.038) and depressive (6.23 #3.77$
vs. 4.36 #2.78$, t ! 2.02, p ! 0.049) symptoms at the time of
the SCID-II interview. Dimensional PD trait scores were also
significantly related to manic (r ! .35, p ! 0.014) and
depressive (r ! .35, p ! 0.014) symptoms.
The highest global role score selected from between the
work and educational/vocational training domains was used
to describe occupational role recovery in this study. Due to
the bimodal distribution of scores, global work role scores
were dichotomized to create good (ratings of 1–3; part-time
to full-time competitive employment or college enrollment)
and poor (ratings of 4 –7; supported employment/nonmain-
stream vocational training to unemployment) functioning
groups. Of the 21 patients (41.2%) classified as having a good
outcome, 15 (29.4%) were engaged in full-time competitive
employment, four (7.8%) were full-time college students, and
two (3.9%) were caregivers of dependent family members. Of
the 30 patients (58.8%) who were classified as functioning
poorly, four (7.8%) had been rehospitalized, 10 (19.6%) were
attending a psychosocial or prevocational day program, three
(5.9%) were sporadically employed, and 13 (25.5%) were not
currently engaged in a work-related or rehabilitative activity.
Participants with a greater number of maladaptive traits
relative to those with fewer traits were more likely to be
classified in the poor work functioning group (t ! 2.50, p !
0.016). Further, participants with poorer work functioning
had a significantly greater number of prior hospitalizations
(t ! 2.07, p ! 0.044), a higher level of residual manic
symptoms (t ! 2.18, p ! 0.034), and a trend toward a history
of alcohol abuse or dependence (#2 ! 4.13, p ! 0.073).
When the four univariate variables were entered into a logis-
tic regression, the overall model correctly predicted occupa-
tional role recovery in 72% of the sample (#2 ! 12.51, df !
4, p ! 0.014). Among the individual variables, only PD traits
were a significant independent contributor at the trend level
(Wald #2 ! 2.73, p ! 0.098).
© 2006 Lippincott Williams & Wilkins
The Journal of Nervous and Mental Disease • Volume 194, Number 12, December 2006 Psychosocial Outcome in Bipolar I Patients
With regard to place of residence at 1 year follow-up,
13 participants (17.6%) were living alone or with a roommate
in a mainstream setting, eight (15.7%) were residing with
their spouses and/or dependent children, 19 (37.3%) were
residing with parents, 11 (21.6%) were living in housing
subsidized by the mental health system, and four (7.8%) had
been readmitted to the hospital. Residential role recovery
(MSIF global residential role score M ! 3.88, SD ! 1.81)
was negatively correlated with patients’ age (r ! –.40, p !
0.004) and educational level (r ! –.38, p ! 0.006), and
positively correlated with number of manic (r ! .39, p !
0.005) and depressive (r ! .30, p ! 0.035) symptoms. Thus,
older and more highly educated participants and those with
fewer residual symptoms were more likely to be functioning
independently. The number of PD traits affirmed showed a
near significant association with impaired residential func-
tioning (r ! .26, p ! 0.066). In a multiple linear regression
analysis with MSIF residential global role score as the de-
pendent variable and age, education, personality disordered
traits, and manic and depressive symptoms as the predictor
variables, the overall model was found to explain 43% of the
variance (F ! 6.58 #5, 44$, p % 0.001). Age (t ! 3.18, p !
0.003) and depressive symptoms (t ! 2.58, p ! 0.013) were
significant independent contributors after controlling for the
other variables.
Patients (N ! 44) were rated on the SAS-II as experi-
encing moderate social maladjustment (M ! 3.41, SD !
1.56). Subjects with a categorical Axis II disorder relative to
those without were more likely to show impaired interper-
sonal functioning (M ! 4.10 #1.83$ vs. 2.83 #1.01$, t ! 2.91,
p ! 0.006). Residual manic (r ! .31, p ! 0.041) and
depressive (r ! .51, p ! 0.001) symptoms were also signif-
icantly related to poor functioning. When SAS-II scores were
regressed on manic and depressive symptoms and the pres-
ence of an Axis II diagnosis, the overall model explained
31% of the variance (F ! 5.82 #3, 39$, p ! 0.002). Only
depressive symptoms were an independent contributor to
poor social and leisure outcomes (t ! 2.91, p ! 0.006).
DISCUSSION
Our results concur with the findings of a number of
investigators documenting persistent disability among recov-
ered bipolar I patients (Coryell et al., 1993; Harrow et al.,
1990; Tohen et al., 1990). Nearly 60% of participants in the
present sample were unable to return to a full time occupa-
tional or educational role 1 year after being hospitalized for
an acute affective episode. Forty percent were residing with
parents, while 20% were residing in nonmainstream, super-
vised housing. Quality of peer relationships and frequency of
social and leisure activities were also compromised. Either
PD trait scores or categorical PDs were associated with poor
functioning in each of the outcome domains. However, con-
trary to our hypothesis, the relationships were not robust after
concurrent mood symptoms and other clinical variables were
accounted for.
The three outcome domains were differentially related
to a range of clinical characteristics. Work functioning was
associated with hospitalization history, a lifetime alcohol
© 2006 Lippincott Williams & Wilkins
abuse or dependence diagnosis, concurrent manic symptoms,
and PD trait scores, although none of the variables emerged
as a significant independent factor in the logistic regression.
Previous studies have reported similar associations between
poor functional outcomes and number of past hospitalizations
or episodes (Harrow et al., 1990; Tohen et al., 1990), interepi-
sode symptoms (Gitlin et al., 1995), and history of alcohol
use (Tohen et al., 1990).
Existing studies examining the impact of categorical
PDs on functional outcomes in bipolar patients using such
measures as the LIFE (Dunayevich et al., 2000) and the
SAS-SR (Carpenter et al,. 1995) have also demonstrated
significant relationships in univariate but not multivariate
analyses. In contrast, Hammen et al. (2000) found that di-
mensional PD trait scores and the quality of marital/close
relationships predicted level of work role adjustment in bi-
polar patients over a 2-year follow up. Differences between
the findings of Hammen et al. (2000) and our findings may be
due to sample differences (i.e., demographics, illness chro-
nicity of participants, definitions of remission applied), length
of the follow-up interval, and use of an alternate work role
functioning measure. Our small sample size may have limited
the power to detect predictive relationships, especially in the
case of PD traits, which showed a trend toward an indepen-
dent relationship to work role recovery.
Recovery of independent living was correlated with
older age, greater educational attainment, fewer manic and
depressive symptoms, and PD traits. Only older age and
residual depression contributed to residential functioning af-
ter controlling for the effects of the other variables. Finally,
quality of social and leisure pursuits were associated with
residual mania and depression, and categorical PDs, but again
only residual depression was a significant factor in the mul-
tivariate analysis. The latter two results support the debilitat-
ing effect of subsyndromal depression in line with a recent
report from the Collaborative Depression group (Judd et al.,
2005), which described a linear association between depres-
sive symptoms and levels of disability in bipolar disorder.
Thus, interventions targeting subsyndromal depression may
be fundamental to improving psychosocial outcomes.
The 45% prevalence rate for PDs observed in our
sample is consistent with other investigations using standard-
ized interviews. The most frequently diagnosed disorders
were in cluster B (28%), particularly borderline PD (20%).
This result is congruent with at least one study (Peselow et
al., 1995), but not others (Barbato and Hafner; 1998; Brieger
et al., 2003; Ucok et al., 1998) that have reported equally high
rates of cluster C disorders with a preponderance of obses-
sive-compulsive and avoidant diagnoses. Differences may be
due to patients’ clinical state at the time of assessment since
PD trait scores have been associated with mania and depres-
sion (Brieger et al., 2003) and appear to vary with symptom
levels (Peselow et al., 1995).
Diagnosing an Axis II disorder in the presence of an
Axis I illness, even when acute symptoms have remitted,
remains a theoretical and methodological challenge to re-
searchers. In light of the correlation between dimensional PD
trait scores and residual symptoms in our study, the incidence
969
Loftus and Jaeger The Journal of Nervous and Mental Disease • Volume 194, Number 12, December 2006
of PDs may reflect a state trait artifact or, alternately, identify
a subset of individuals with a more severe symptom course.
Several limitations should be considered. The sample
was comprised of recently recovered, chronically ill patients;
thus, our results may not generalize to a less ill population.
Although participants were assessed when mildly symptom-
atic, subsyndromal symptoms may have biased the reporting
of both social outcomes and personality disordered traits.
Finally, our cross-sectional design did not allow us to exam-
ine causal relationships between symptoms, clinical and per-
sonality characteristics, and functional outcomes. Notwith-
standing these limitations, we have shown that depressive
symptoms predict poorer social/leisure adjustment and ability
to live independently over a short-term follow-up period.
Secondly, there is some evidence to suggest that maladaptive
traits may hinder occupational role recovery, although this
finding merits further exploration.
ACKNOWLEDGMENTS
The authors thank Dr. Stefanie Berns, Dr. Rebecca
Ianuzzo, Sherif Abdelmessih, Pamela DeRosse, Giovanna
Musso, Cristina Gonzalez, Priya Matneja, and Joanne Mc-
Cormack for their contributions to the data collection and
management of this project.
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