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The personality profile of euthymic bipolar affective disorder patients at a tertiary care centre

Maldar Aftab Ahmed^*, Safeekh A. T.^#

 

Abstract               Objective: The purpose of this study was to study the prevalence of personality disorders (PD) in euthymic bipolar affective disorder (BPAD) patients. We also aimed to study the distribution of individual personality disorders in such prevalence. Methods: We assessed 30 bipolar affective disorder outpatients in euthymia, using the International Personality Disorder Examination (IPDE). For those personality disorder patients who had troublesome symptoms but did not meet any specific pattern of a PD, a DCR-10 diagnosis of Mixed Personality Disorders was used. The euthymicity was confirmed by administering the Young Mania Rating Scale (YMRS) and Hamilton Rating Scale for Depression. Results: Sixteen patients (53.3%) met criteria for personality disorders. The most common was Mixed Personality Disorders (43.3%). This was followed by Dissocial Personality Disorder (6.7%) and Borderline Personality Disorder (3.3%).Younger age patients were found to be more likely to have comorbid personality disorders. The patients with comorbid personality disorder were more likely to have legal issues. Conclusion: More than half of patients in this study had comorbid personality disorder. Although no significant effect on course was found, personality disorders were found more in the younger patients and associated with more legal issues.

                                        Keywords: Bipolar, personality, legal, comorbidity.

 

INTRODUCTION

The comorbidity of personality disorders (PD) with bipolar affective disorder (BPAD) is found not uncommonly. A study by George et al³ found the prevalence as 28.8%. Other studies have found a varied range from 9-89%.^2,7,8,9 The comorbid personality disorders affect the outcome of bipolar disorder in many ways. These patients were less likely to be compliant with medications and had poor response to treatment. There was also more substance use a disorder in such patients.¹² Theintermorbid recovery was also affected with some persistent mood symptoms. They were found to spend more time in hospital stay.¹² Suicidal ideation¹² and poor socio-occupational functioning were more in them. This study was designed primarily to assess the prevalence of personality disorders in euthymic bipolar affective disorder patients. We also aimed to study the distribution of prevalence of individual personality disorders in such patients.

 

METHODS

Participants

All patients presenting at the psychiatry outpatient department of Father Muller Medical College, Mangalore (South India) between December 2013 to January 2014, were considered for the inclusion criteria. The following were the inclusion criteria used: (i) All patients diagnosed with BPAD according to DCR-10 criteria. (ii)aged between 18-64 years (iii) being clinically in remission (iv)patients who gave written informed consent. The exclusion criteria were: (i) patients with BPAD not in remission (ii) patients diagnosed with other psychiatric disorders as per DCR-10 except alcohol/ nicotine dependence. (iii) Patients not giving consent for the study. Ethical clearance was taken from the institution’s ethical clearance committee before commencing the study. At the outset, the patients who had been diagnosed with bipolar affective disorder during previous admissions were screened. The diagnosis was reconfirmed by using the DCR-10 criteria for BPAD. A written informed consent was taken from all. After the confirmation and consent, the patients were assessed for remission by using the Hamilton Rating Scale for Depression and the Young Mania Rating Scale. Remission was clinically defines as a score of less than 7 on Hamilton Rating Scale for Depression and a score of less than 5 on Young Mania Rating Scale. Thirty consecutive patients meeting the above criteria with Bipolar affective disorder in remission were selected as participants for the study.

Tools

1. Sociodemographic data and clinical variables such as number of episodes, number of past admissions, family history, history of drug abuse, legal issues and other medical comorbidity history were all obtained by interviewing the patient. When available, the data was corroborated with a relative.
2. The International Personality Disorder Examination was used to assess for the presence of personality disorders. All patients were interviewed by the first author. Those individuals, who had troublesome symptoms but did not meet any specific pattern of personality disorders, were diagnosed with a DCR-10 diagnosis of Mixed Personality Disorders.
3. Hamilton Rating Scale for Depression is a rating scale used to assess depression. It has 17 items.⁴It was used to assess depressive symptoms.
4. Young Mania Rating Scale was used to assess mania. It has 11 items.¹⁵

Statistics

Chi-squared test and Fisher’s exact test were used to examine the statistical differences between bipolar patients with a comorbid personality disorder and those without on demographic and clinical variables.

 

 

RESULTS

Out of the thirty participants in this study, sixteen were diagnosed to have personality disorder. Of these, thirteen were diagnosed to have Mixed personality disorders. Two participants met criteria for Dissocial personality disorder and one met criteria for Borderline personality disorder. Fourteen participants did not meet any criteria for personality disorders.

 

Table 1: The comorbidity of personality disorders in the sample

 

Table 2: Shows the comparison of participants based on clinical variables

 

The study showed two findings which were of statistical significance. First, patients who had a comorbid personality disorder were more likely to have a legal issue. (p=0.002). Figure 1 explains the relation between comorbid PD and legal issues. Secondly these patients with comorbid PD were found to be having less comorbid medical conditions. (p=0.004). Figures 2 and 3 highlight this finding, with relation to age distribution of participants.

This study failed to find any significant impact of comorbid PD on the other clinical variables like number of previous episodes or admissions.

 

DISCUSSION

This was a study which examined the prevalence of comorbid personality disorders in patients with bipolar affective disorder in euthymia. It examined also the relation between clinical correlates and comorbid personality disorder. In this study, about 53% of participants had a comorbid personality disorder. Earlier studies had shown a range from 9-89%.^2,7,8,9 The wide variance could have been due to the differences in the scales and population assessed in the prior studies. The majority of the participants with comorbid personality disorder had Mixed personality disorders. However earlier studies had found that Cluster C personality disorders were more commonly found.^13,14 This study failed to find any significant relation between the comorbid personality disorder and number of previous episodesor number of previous admissions. However earlier studies have shown that the course of bipolar disorder is affected by comorbid personality disorders.^6,11 The current investigators found that bipolar patients with comorbid personality disorder were more likely to have legal issues. This study also showed that the bipolar patients with comorbid personality disorder were less likely to have comorbid medical conditions. This finding could have been due to the older age group of patients without comorbid personality disorder, in this study. Our study had a small sample size, which was a limitation. As our sampling was not randomized but consecutive participants were chosen, the findings cannot be generalized. The finding that medical comorbidities occur less in bipolar patients with comorbid personality disorder, could well be confounded by the age of participants. This area will need to be investigated with a much larger and homogenous sample.

 

CONCLUSION

Personality disorders as comorbidity are prevalent in more than half of patients with bipolar affective disorder patients. These lead to legal issues in patients which in turn could affect the disease outcome. Future prospective controlled trials with larger samples will be needed to assess the impact of comorbid personality disorders on bipolar affective disorder patients.

 

REFERENCES

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Young, R., Biggs, J., Ziegler, V. and Meyer, D. (1978). A rating scale for mania: reliability, validity and sensitivity. The British Journal of Psychiatry, 133(5).429-435.

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