|Year : 2019 | Volume
| Issue : 2 | Page : 114-118
A study of sociodemographic profile, birth risk factors, and social support in personality disorders
Sanjeet Kour, Zaid Ahmad Wani, Shabir Ahmad Dar
Department of Psychiatry, Government Medical College, Srinagar, Jammu and Kashmir, India
|Date of Submission||22-May-2018|
|Date of Decision||01-Jul-2018|
|Date of Acceptance||08-Oct-2018|
|Date of Web Publication||26-Jun-2019|
Dr. Shabir Ahmad Dar
Department of Psychiatry, Government Medical College, Srinagar - 190 003, Jammu and Kashmir
Source of Support: None, Conflict of Interest: None
Background: Personality disorders (PDs) comprise deeply ingrained and enduring behavioral patterns, manifesting themselves as inflexible responses to a broad range of personal and social situations. We aimed to study sociodemographic profile, birth risk factors, and social support in PDs in Kashmir. Materials and Methods: It was an observational study conducted in the Department of Psychiatry, Government Medical College, Srinagar. There were forty one subjects in both the groups-cases and controls. Structured Clinical Interview developed II (SCID II); Oslo 3-item Social Support scale and the Childhood Trauma Questionnaire were used for assessing pattern, social support, and birth risk factors in personality disorders. Results: Mean age of patients and controls was 22.41 ± 4.14 and 22.52 ± 4.15 years, respectively. Majority of the participants were females in both the groups. Most of the cases and controls were single and from nuclear families. Maximum number of patients and healthy controls fitted into the upper-middle socioeconomic class. About 70.73% of cases had good social support while 29.27% of cases had minimal social support. About 99.4% of controls had good and only 1 (0.6%) had minimal social support. Majority of our patients had a borderline PD (35) followed by histrionic PD (3). Other forms of PD seen were avoidant/anxious PD in one patient. Birth complications were seen in 9.76% of cases and none of the controls, therefore, were statistically significant. Conclusion: Most of the cases were borderline, unmarried, from nuclear families belonging to upper-middle socioeconomic class with good social support.
Keywords: Birth risk factors, pattern, personality disorders, social support
|How to cite this article:|
Kour S, Wani ZA, Dar SA. A study of sociodemographic profile, birth risk factors, and social support in personality disorders. Indian J Soc Psychiatry 2019;35:114-8
|How to cite this URL:|
Kour S, Wani ZA, Dar SA. A study of sociodemographic profile, birth risk factors, and social support in personality disorders. Indian J Soc Psychiatry [serial online] 2019 [cited 2020 Apr 9];35:114-8. Available from: http://www.indjsp.org/text.asp?2019/35/2/114/261478
| Introduction|| |
Personality traits are enduring patterns of perceiving, relating to, and thinking about the environment and oneself that are exhibited in a wide range of social and personal contexts. Only when personality traits are inflexible and maladaptive and cause significant functional impairment or subjective distress, they do constitute personality disorders (PDs).
PDs comprise deeply ingrained and enduring behavior patterns, manifesting themselves as inflexible responses to a broad range of personal and social situations; they represent either extreme or significant deviations from the way the average individual in a given culture perceives, thinks, feels, and particularly relates to others. Such behavior patterns tend to be stable and encompass multiple domains of behavior and psychological functioning. They are frequently associated with various degrees of subjective distress and problems in social functioning and performance.
According to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), Text Revision, the PDs are grouped into three clusters based on descriptive similarities. Cluster A includes paranoid, schizoid, and schizotypal PDs. Individuals with these disorders often appear odd or eccentric. Cluster B includes antisocial PD, borderline PD (BPD), histrionic PD (HPD), and narcissistic PD. Individuals with these disorders often appear dramatic, emotional, or erratic. Cluster C includes avoidant, dependent, and obsessive–compulsive PDs. Individuals with these disorders often appear anxious or fearful.
Prevalent estimates for the different clusters suggest 5.7% for disorders in Cluster A, 1.5% for disorders in Cluster B, 6.0% for disorders in Cluster C, and 9.1% for any PD, indicating frequent co-occurrence of disorders from different clusters. Different studies have demonstrated that the history of traumatic events in childhood seems to increase the risk of antisocial behavior, BPD and dependent PD, obsessive–compulsive PD, or psychopathological personality traits such as paranoid, histrionic, narcissistic, or dependent, among others.
Socioeconomic status has been looked at as a potential cause for PDs. There is a strong association with low parental/neighborhood socioeconomic status and PD symptoms. In a recent study, comparing parental socioeconomic status and a child's personality, it was seen that children who were from higher socioeconomic backgrounds were more altruistic, less risk seeking, and had overall higher intelligence quotients. These traits correlate with a low risk of developing PDs later on in life. In a study looking at female children who were detained for disciplinary actions, they found that psychological problems were most negatively associated with socioeconomic problems. Social disorganization was found to be inversely correlated with PD symptoms.
To our knowledge, the present study is the first comparison of patients with PDs and healthy controls in regard to pattern, social support, and birth risk factors of PDs in Kashmir valley. This will help us a long way in understanding PDs pattern and social support in patients' vis-à-vis healthy controls in Kashmir.
| Materials and Methods|| |
The present study was conducted in the Institute of Mental Health and Neurosciences, Kashmir, which is an associated hospital of Government Medical College, Srinagar. It was an observational, hospital-based, case–control study conducted from March 2016 to August 2017. It was initiated following approval by the Institutional Ethical Committee and Board of Research Studies of Government Medical College, Srinagar. Forty-one patients were recruited through purposive sampling from both outpatient and inpatient department sections of the hospital for this purpose after being diagnosed as PDs by consultant psychiatrist as per DSM-IV criteria. An informed written consent in locally understandable language was taken from each patient, and each was given freedom of choice to accept or refuse participation in the study.
Forty-one age- and sex-matched healthy controls were recruited from the attendants visiting the institute who were related to the patients. Controls screened negative for PDs using DSM-IV criteria for PDs. They were interviewed in the same settings using the same instruments as cases. One age- and sex-matched control was recruited for each case.
All of these cases and controls were further interviewed for sociodemographic variables such as age, gender, employment, educational status, marital status, and socioeconomic level. Socioeconomic class was established by means of revised Kuppuswamy's socioeconomic status scale. SCID II is a version of the Structured Clinical Interview developed for assessing types of DSM-IV PDs. Moreover, the Oslo 3-item Social Support Scale was used for assessing social support. The three items were considered to be the best predictors of mental health, covering different fields of social support, the sum ranging from 3 to 14. A score of 3–8 is poor support, 9–11 is moderate support, and 12–14 is strong support.,
The Childhood Trauma Questionnaire with focus on birth risk factors which included mothers' age >35 years, cesarean section, premature birth or perinatal complications (e.g., asphyxia) was used for assessing birth risk factors.
Data about various parameters were categorized according to age, sex, education, socioeconomic status, clinical phenomenology, etc. The information thus generated was presented in tables. Statistical analysis was carried out with Epi-Info 7.0 version (https://www.cdc.gov/epiinfo). For the analysis of two categorical variables, Chi-square test (Fisher's exact test where applicable) was used, ordinal data were analyzed using Wilcoxon–Mann–Whitney test, and Student's t-test was used to compare continuous variables between two groups. All tests were two-tailed and statistical significance was set at P < 0.05.
| Results|| |
The mean age of our patients was 22.41 ± 4.14 years and that of their healthy controls was 22.52 ± 4.15 years. Majority of the patients were females in our patients as well as their controls with only a few males, most of the cases and controls were unmarried, maximum number of cases and controls belonged to student group, and two-third of cases and controls were from nuclear families. The maximum number of patients and healthy controls fitted into the upper-middle socioeconomic class [Table 1].
Distribution of cases and controls
The majority (35, 85.37%) of our patients had BPD. The less common form was HPD (3, 7.31%). Other forms of PD seen were avoidant/anxious PD in 1 patient (2.44%). One case each (2.44% each) received a dual diagnosis of dependent PD, avoidant PD, BPD, and antisocial PD. A total number of controls recruited were 41 [Table 2].
[Table 3] shows social support in case and control groups where 29.27% of cases had minimal, whereas rest 70.73% had good social support; however, in control group, 99.4% of controls enjoyed good social support and rest 1 (.6%) had minimal social support. P value was statistically significant (P < 0.002).
Birth risk factors
[Table 4] exhibits comparison of birth risk factors for the emergence of PDs and healthy controls. It shows mothers' age to be insignificant. In 2.44% of cases, mothers' age was ≥35 years, and in rest of the cases and all of the controls, it was <35 years. Premature birth was not seen in any of the cases or controls. In 19.51% of cases and 30.06% of controls, lower segment cesarean section (LSCS) was done at the time of their birth, whereas rest were born at full term by normal vaginal delivery. Birth complications were seen in 9.76% of cases and none of the controls. P < 0.001 for birth complications was not statistically significant for mother's age and LSCS.
| Discussion|| |
The PDs are seen in 10%–20% of the general population and in about half of the psychiatric inpatients or outpatients. About one-half of all psychiatric patients have PDs, which is frequently comorbid with other clinical syndromes. PDs and associated traits, such as low self-directedness, are predisposing influences on the full range of other psychiatric disorders (e.g., substance use, suicide, affective disorders, schizophrenia and other psychotic disorders, impulse control disorders, eating disorders, and anxiety disorders). Comorbid PDs interfere with treatment outcomes of patients and increase personal incapacitation, morbidity, and mortality of these patients.
Majority of the participants were females in patient as well as the control group, most of the cases and controls were single, maximum number of cases and controls belonged to student group, and two-thirds of cases and controls were from nuclear families. Major proportion of the participants belonged to upper-middle socio-economic status.
BPD is more prevalent in younger age groups (19–34 years), females and whites, associated with poor work history and single marital status and is more common in urban areas.
The reason of young participants in our study seems to be emerging difficulties and unhelpful behaviors, for example, self-harm, drug and alcohol use, binge eating, social withdrawal, aggressive, and risky sexual behavior due to which these patients are bought to psychiatric emergencies by their caregivers. Female predominance in the study can be explained by BPD patients, unequivocally more common in women than men.
PDs lead to a disturbance in functioning as great as that in most major mental disorders. They are associated with high rates of separation and divorce, unemployment and inefficiency, and poor quality of life for the individual and his/her family. The current study results are in unison with the study done by Whisman et al. where it was found that PDs are associated with a significant increase in the likelihood of marital termination. PD patients tend to have chronic impairments in their ability to love and tend to have more marital difficulties. These disorders have chronic impairments in their ability to work and tend to be less educated and unemployed. Patients with BPD expect and perceive social rejection stronger than the general population;,, besides in PDs, there seem to be the significant interpersonal conflicts and the volatile relationships.
Among cases, BPD (85.37%) was the most common PD followed by HPD (7.31%) and anxious PD. About 2.44% each received a dual diagnosis of dependent and anxious/avoidant PDs, BPD, and antisocial PD. This is in line with the study by Lana et al. in which BPD was the most prevalent PD among those persons seen in the state public mental health network followed by HPD. However, in another study carried out by Maanasa et al., the prevalence of PD was 21.55% (95% confidence interval: 14.07–29.03) among the psychiatric in patients. The most common type of PD in this study was avoidant PD (7.7%), antisocial PD (5.17%), and BPD (3.45%). In a study by Gawda and Czubak, approximately 9% of the sample had at least one PD (the overall rate was 8.9%), and rates on sex differences in PDs were similar to other European and North American countries. In this study, the most prevalent PDs were obsessive–compulsive (9.6%), narcissistic (7%), and BPDs (7%). Results showed the considerable comorbidity of PD which meant that about 9% of the adult population has at least one PD and infract them display features of many specific PDs.
In PDs, early developmental phase (involving immature defense mechanisms and a fragmentary self-concept) pathologically persists in later periods. Etiologically, this pathological persistence of immaturity is postulated to reflect either constitutional factors (e.g., poor anxiety tolerance, high aggressivity, and genetic vulnerability to certain effects) or environmental traumatic factors (e.g., early separation, loss of a parent, physical or mental abuse, and neglect). Because of such traumatic etiological factors, aggressively charged, negative representations of the self and external objects are predominantly incorporated into the internal world.
In this study, the overall support of the family was much better in control group than in the patient group, and the difference was statistically significant. The mothers' unemployment was seen significantly more in patient group than control group which was also found to be statistically significant. This is in line with the study by Bandelow et al. in which 42.4% of cases had unemployed mothers and only 16.5% of controls had unemployed mothers with statistically significant difference. On the other hand, it cannot be excluded that borderline patients may confabulate histories or exaggerate certain events. Splitting may make a borderline patient more likely to see the family as all good or bad. In addition, social support has been linked with more use of active coping strategies and less use of avoidant and self-destructive coping strategies. In turn, low levels of social support have been linked to grief and suicidal ideation in bereaved samples.
According to a study by Chang, in which associations between parental rearing patterns and social support PD were studied in prisoners, positive significant correlations were found between PDs, and punishment of parental, rejection and denial of parental, overprotection of father, and preference of mother and significant inverse correlations were found between PD and warmth of feeling and understanding of parents. Furthermore, there were correlations between PD and subjective support and the usage of support.
Birth complications were seen to be more significant in patient group (9.76%) than control group (0). No significant difference was seen in both the groups regarding other birth risk factors such as mothers' age of >35 years, low birth weight, and cesarean section. In contrast to our finding, the study by Bandelow et al. revealed significant difference in premature birth in BPD cases (21.5%) than controls (9.2%) and no significant difference in other birth risk factors; there was only a trend toward statistical significance. According to Fazel et al., perinatal complications such as prematurity, asphyxia, and complicated delivery were associated with PD in the population-based study. The difference in this study can be because the information about prenatal, perinatal, and postnatal periods was not obtained from parents directly but was taken from the patients only.
| Conclusion|| |
We conclude that the most common PD to present at the tertiary care psychiatric hospital in Kashmir is BPDs followed by HPDs. Our study has few limitations in the form sample size of patients in our study was small. Being only a case–control study, only relative risk could be calculated and absolute risk could not be found. This study has applied retrospective design to cross-sectional samples, that is, most of the data were drawn from interviews of adult patients about their memories of childhood experiences, which can never establish causality. To determine causality, prospective methodology is needed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4]