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Exploring Social Participation of Peoplewith Cluster B Personality DisordersNadine Larivière a , Johanne Desrosiers b , Michel Tousignant b &Richard Boyer ca School of Rehabilitation , Université de Sherbrooke and Centre derecherche Fernand-Seguin, Hôpital Louis-H. , Lafontaine, Québec,Canadab School of Rehabilitation , Université de Sherbrooke and Centre derecherche sur le vieillissement (Research Centre on Aging) , Québec,Canadac Centre de recherche Fernand-Seguin , Québec, CanadaPublished online: 15 Nov 2010.

To cite this article: Nadine Larivière , Johanne Desrosiers , Michel Tousignant & Richard Boyer (2010)Exploring Social Participation of People with Cluster B Personality Disorders, Occupational Therapy inMental Health, 26:4, 375-386, DOI: 10.1080/0164212X.2010.518307

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Exploring Social Participation of Peoplewith Cluster B Personality Disorders

NADINE LARIVIERESchool of Rehabilitation, Universite de Sherbrooke and Centre de recherche

Fernand-Seguin, Hopital Louis-H. Lafontaine, Quebec, Canada

JOHANNE DESROSIERS and MICHEL TOUSIGNANTSchool of Rehabilitation, Universite de Sherbrooke and Centre de recherche sur le

vieillissement (Research Centre on Aging), Quebec, Canada

RICHARD BOYERCentre de recherche Fernand-Seguin, Quebec, Canada

This study aimed to describe the impact of living with a cluster Bpersonality disorder in an acute phase on social participation.A descriptive cross-sectional design was used. During their firstweek in a day hospital or inpatient admission, 31 participantscompleted the Assessment of Life Habits, examining the quality ofsocial participation in 77 daily activities and social roles (lifehabits). The participants presented significantly more difficultiesand dissatisfaction in realizing social roles than daily activities.Areas of life perceived to be the most problematic to accomplishwere leisure, school, and work. Interpersonal relationships andfitness were the least satisfying. Personal care was the least dis-rupted and most satisfying life habit. Life habits that could beprioritized in psychiatric rehabilitation interventions with peoplewith cluster B personality disorders included leisure activities, workand school, fitness, and interpersonal relationships.

KEYWORDS assessment, cluster B personality disorders, socialparticipation

Address correspondence to Nadine Lariviere, OT (C), Ph.D., Ecole de readaptation,Faculte de medecine et des sciences de la sante, 3001, 12e Avenue Nord, Sherbrooke, QuebecJ1H 5N4, Canada. E-mail: nadine.lariviere@usherbrooke.ca

Occupational Therapy in Mental Health, 26:375–386, 2010Copyright # Taylor & Francis Group, LLCISSN: 0164-212X print=1541-3101 onlineDOI: 10.1080/0164212X.2010.518307

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INTRODUCTION

Personality disorders are estimated to affect about 10–20% of the generalpopulation (Sadock & Sadock, 2007). The fourth revised edition of the Diag-nostic and Statistical Manual (American Psychiatric Association, 2000) definespersonality disorders as enduring subjective experiences and behaviors thatdeviate from cultural standards. These can be manifested in perceptions ofself, others and events, affectivity, interpersonal functioning, and impulsecontrol. They are rigidly pervasive and maladaptive and lead to clinically sig-nificant distress. Personality disorders are grouped into three clusters (A, B,C). Cluster B personality disorders are characterized by dramatic, impulsive,and erratic features. They include antisocial, narcissistic, borderline, and his-trionic personality disorders (Sadock & Sadock, 2007).

Since personality disorders commonly develop in adolescence or earlyadulthood, they occur in a stage of life when a person is usually involvedin productive activities, such as school or work, and developing adultrelationship skills. The use of maladaptive behaviors can thus affect the per-son in several domains of their life (Public Health Agency of Canada, 2002).Although social, occupational, and general functional impairment are anintegral part of the definition of personality disorders (American PsychiatricAssociation, 2000), only a very few studies have examined closely and con-cretely the impact of living with a cluster B personality disorder on one’ssocial participation. In occupational therapy, better understanding the impactof a cluster B personality disorder on these peoples’ social participation isessential to provide more client-centered interventions targeting areas of lifethat are problematic and important for these persons. Enabling social partici-pation can lead to several positive consequences, such as providing a betterquality of life, allowing for the constitution and maintenance of one’s ident-ity, and promoting a sense of belonging (Lariviere, 2008). Being involved inmeaningful activities and contributing to a community is considered to be acentral component of the recovery journey (Davidson, O’Connell, Tondora,Staeheli, & Evans, 2005) and is the core of occupational therapy practice(Crepeau, Cohn, & Schell, 2003).

One study documented the subjective well-being and quality of life ofpeople with personality disorders from all clusters (Cramer, Torgensen, &Kringlen, 2006). The dimensions of quality of life assessed included self-realization, contact with friends, support if ill, absence of negative life events,relation to family of origin, and neighbourhood quality. The findings showedthat those with schizotypal, borderline, narcissistic, paranoid, and avoidant per-sonality disorders had the poorest quality of life on all dimensions (Cramer et al.,2006). Some researchers have studied the psychosocial functioning of peoplewith different types of personality disorders. Skodol and colleagues (2002) foundthat thosewith schizotypal and borderline personality disorders had significantly

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more impairment at work, interpersonal relationships, and recreation than thosewith avoidant and obsessive-compulsive personality disorders. Therewas no sig-nificant difference in global satisfaction between people with personality disor-ders and those with a major depression. In addition, overall, people with apersonality disorder did not show a significant impairment in household duties.In their longitudinal investigation of six years, Zanarini, Frankenburg, Hennen,Riech, and Silk (2005) found that people with borderline personality disordersshowed significant impairment in work or school performance and in theircapacity to go to school or work in a sustained way. In addition, they were morelikely to receive disability payments than the individuals in their Axis II compari-son group. There was no significant difference in terms of relationships andmeaningful use of leisure time. Ansell, Sanislow, McGlashan, and Grilo (2007)found that people with borderline personality disorder had significantly moreimpairment in work performance, household duties, recreation, and global sat-isfaction than the other groups which consisted of people with other personalitydisorders (mainly avoidant and obsessive-compulsive), people with moodand anxiety disorders and people without a psychiatric diagnosis. There wasno significant difference between groups regarding student work but therewere few students overall in their sample. Finally, Badey, Bourque, David,Gagnon, and Lariviere (2007) found that in their sample of people with clusterB personality disorders, the participants reported presentingmoderate problemsin their functioning in daily life, social roles, relationship to self, and others aswell as depressive and anxiety symptoms. They stated that they had someproblems with impulsive behaviors and substance abuse.

After examination of the previous studies, important questions concern-ing the social participation of people with cluster B personality disorders stillremain unanswered. Some domains of life that are part of social participationhave not been explored, such as self-care, responsibilities (e.g., meeting finan-cial obligations) and community involvement. As well, some components havebeen assessed in a general way, such as household duties and satisfaction.

In this context, the objective of the present study aims at describing thesocial participation of personswith a cluster B personality disorder. In this study,social participation refers to perceived level of accomplishment and satisfactionin daily activities and social roles (life habits) that results from the interactionbetween personal and environmental factors (Fougeyrollas, Cloutier, Bergeron,Cote, & St-Michel, 1998; Noreau, Fougeyrollas, & Vincent, 2002).

METHODS

Design and Participants

This study used a cross-sectional descriptive design. It is part of a largerprogram of effectiveness evaluation comparing a psychiatric day hospital

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to hospitalization in a psychiatric institution. Ethical approval for this studywas obtained from the site’s Research Ethical Committee.

The sample was a convenient, non-probabilistic accidental sample(Contandriopoulos, Champagne, Potvin, Denis, & Boyle, 1990). To beincluded in the study, candidates were 18 years old and over, fluent inFrench, had a DSM-IV diagnosis, score between 21 and 60 on the GlobalAssessment of Functioning Scale (GAF) (Endicott, Spitzer, Fleiss, & Cohen,1976), indicating that their illness is in an acute phase. Candidates wereexcluded if they were homeless, had a severe loss of physical independence,had a diagnosis of mental retardation, had substance abuse problems as theirsole problem or were involuntarily admitted.

Participants were screened for eligibility from lists and medical recordsaccessible to the principal investigator at the archives of the hospital, the dayhospital and the inpatient units. If eligible, the principal investigator con-tacted the main treating clinician to inform him=her about the eligibility ofthe client. If the person accepted, the principal investigator met the candidateto explain the study. The consent form was signed in the following days.

Questionnaire

To describe social participation, the Assessment of Life Habits (LIFE-H),version 3.1, Short Form (Fougeyrollas et al., 2002) was used. The LIFE-H isa questionnaire which measures the perceived level of performance inaccomplishment of life habits, the type of assistance needed, which can beassistive devices like medications, adaptation or human assistance, and theresulting level of satisfaction (Noreau et al., 2002). It can be completed bythe participants or through an interview with the person or their carer. Theself-report short form includes 77 life habits grouped into 12 domains of life(Table 1). For each life habit, two scores can be indicated: one for the level ofaccomplishment, which takes into consideration the type of assistancerequired, and one for the level of satisfaction. For the level of accomplish-ment, scores vary from 0 to 9 (0¼not realized, 1¼ accomplished by proxy,2¼with difficulty and all types of assistance, 3¼with difficulty and humanassistance, 4¼no difficulty and all types of assistance, 5¼no difficulty andhuman assistance, 6¼with difficulty and assistive device or adaptation,7¼with difficulty and no assistance, 8¼with no difficulty and assistivedevice or adaptation, 9¼with no difficulty and no assistance). For the levelof satisfaction, scores vary from 0 to 4. The higher the score, the greater thesatisfaction towards how the life habit is currently accomplished. The LIFE-His based on the Disability Creation Process, a conceptual model proposed to‘‘identify and explain the causes and consequences of disease, trauma anddisruptions to the development of a person’’ (Fougeyrollas et al., 2002,p. 4). In this model, the accomplishment of life habits results not onlyfrom personal identity and choices, impairments in organs, abilities and

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disabilities, but also the physical and social characteristics of the livingenvironment which can act as facilitators or obstacles (Fougeyrollas et al.,2002). The LIFE-H shows satisfactory psychometric properties regardinginternal consistency, test-retest reliability and interrater reliability (Noreauet al., 2002; Noreau et al., 2004).

Data Collection Procedure

During the first week after integrating a psychiatric day hospital or being hos-pitalized in a psychiatric hospital, participants completed the LIFE-H ques-tionnaire in the clinical setting in the presence of the principal investigator.Sociodemographic data was collected by the principal investigator throughquestioning of the participants and retrieving information from their medicalrecords. The data collection continued from January 2006 to February 2008.

Statistical Analysis

The data was analyzed with descriptive statistics such as means and stan-dard deviation for the continuous variables and frequencies and percen-tages for the categorical ones. The SPSS software version 15.0 was usedfor the analyses.

Results

Table 2 presents the sociodemographic and clinical profile of the parti-cipants. The sample consisted of 31 respondents, the majority being women.

TABLE 1 Domains of Life Habits Assessed in the LIFE-H

Daily activities Social roles

Nutrition For example, preparingmeals, eating

Responsibilities For example, budget,parental role

Fitness For example, sleep,physical and relaxationactivities

Interpersonalrelationships

For example, spouse,family, friends,neighbours

Personal care For example, hygiene,dressing, using healthcare services

Community life For example, use ofservices and stores

Communication For example, verbal,written, reading, usingcomputer, phone

Education For example,participating in schoolactivities

Housing For example, cleaning,entering=leaving house

Employment For example, seekingwork, holding job,volunteer

Mobility For example, by foot,driving, publictransportation

Recreation=Leisure

E.g. sports, outdoors,artistic, cultural,touristic

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The mean age of the study participants was 35 years (SD¼ 13.9), rangingfrom 18 to 74 years old. Fifty-seven percent of the participants were single.The most frequent education level completed was high school. Concerningemployment, the two most frequent situations were to be on a sick leaveof absence from their current job or unemployed.

Clinically, the primary psychiatric diagnosis they presented was a clusterB personality disorder. In the sample, borderline personality disorder was themost frequently observed. In addition, seven participants had a mix of clusterB personality disorders, mainly borderline, narcissistic, and=or histrionic. Aswell, nine respondents presented borderline personality disorder withdependent or avoidant personality traits or disorders. On Axis I, some part-icipants had none or more than one comorbid conditions. The most frequentcondition was a mood or an adjustment disorder, followed by substanceabuse (Table 2). On the GAF scale, participants had a mean score of 48.8(SD¼ 6.8, Range¼ 35–60), indicating that they presented serious symptomsor serious impairment in functioning.

TABLE 2 Sociodemographic and Clinical Characteristics ofStudy Participants (n¼ 31)

Variables

Age (mean, SD, range) 35.0 years(13.9, 18–74)

Gender (n, %)Female 27 (87.1)Male 4 (12.9)

Marital status (n, %)Single 16 (51.6)Married=Common-law 9 (29.0)Separated=Divorced 6 (19.4)

Education (n, %)High school 21 (67.7)College 6 (19.4)University 4 (12.9)

Employment status (n, %)Sick leave 13 (41.9)Unemployed 10 (32.2)Currently working 3 (9.7)Student 2 (6.5)Retired 2 (6.5)Stay-at-home-parent 1 (3.2)

Comorbid conditions on Axis I (n, %)Mood=Adjustment disorders 17 (54.8)Substance abuse 14 (45.2)Anxiety disorders (e.g., Generalized 5 (16.1)Anxiety Disorder)

Psychotic disorder not otherwise 4 (12.9)SpecifiedEating disorder not otherwise specified 2 (6.5)Attention deficit disorder 1 (3.2)

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Global comparisons between perceived level of accomplishment andsatisfaction in daily activities when compared with social roles indicate thatthese participants present more difficulties and dissatisfaction in realizingsocial roles (accomplishment: t(29)¼ 1.00, p< 0.05; satisfaction: t(30),p< 0.05).

Perceived accomplishment in the different life habits is presented inFigure 1. Findings show that the areas of life which appear to be the mostdisrupted are leisure and productive activities, that is, school and work.The least problematic life habit corresponds to personal care. On average,all life habits are perceived as being realized with difficulty and requireassistance.

A closer examination of the mean scores of each life habit (not illu-strated here) reveals that the most problematic life habit to accomplish withineach domain is: holding a paid job (M¼ 1.3, SD¼ 2.9), participating in touristactivities, such as visiting a museum or traveling (M¼ 1.7, SD¼ 2.5), practi-cing physical exercises (M¼ 3.9, SD¼ 3.7), ensuring the education of theirchildren (M¼ 4.1, SD¼ 2.8), maintaining a close relationship with a partner(M¼ 4.4, SD¼ 2.6), doing major household tasks like painting (M¼ 4.7,SD¼ 3.3), communicating with a group (M¼ 4.8, SD¼ 2.6), participating insocial or community groups (M¼ 5.2, SD¼ 2.7), choosing food accordingto need and taste (M¼ 5.6, SD¼ 3.2), meal preparation (M¼ 5.6, SD¼ 2.8),using health care services (M¼ 6.5, SD¼ 2.7) and driving a car (M¼ 7.1,SD¼ 3.6).

Figure 2 illustrates the levels of satisfaction experienced in the variouslife habit domains. Overall, the total mean score of satisfaction is situatedat the more or less satisfied level (M¼ 2.5, SD¼ 0.6). Results show that theleast satisfying life habits in these participants’ current situation areinterpersonal relationships and fitness. Personal care is the most satisfyingarea of life.

FIGURE 1 Level of accomplishment in life habits domains.

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DISCUSSION

This study provides a detailed look at the social participation of people withcluster B personality disorders, a core outcome in psychiatric rehabilitationwhich leads to recovery (King, Lloyd, & Meehan, 2007). From previous stu-dies (Ansell et al., 2007; Skodol et al., 2002; Zanarini et al., 2005) and thisinvestigation, there seems to be a strong trend that employment, relation-ships, and recreation are areas of life that are problematic for people withcluster B personality disorders. The inherent issues related to cluster B per-sonality disorders regarding stability and maintaining positive relationshipssupport the fact that these influence the work, recreation, and relationaldomains. Concerning leisure, it would be interesting to explore further ifother barriers prevent the full and satisfactory realization of that area of life.

Examination of the findings in the present study suggests that toimprove the social participation of people with cluster B personality disor-ders, the life habits that could be prioritized in psychiatric rehabilitation inter-ventions include leisure activities, work and school, fitness (sleeping,physical, and unwinding activities), as well as interpersonal relationships(particularly with the partner and children). A review of treatmentapproaches for people with personality disorders indicates that their aimsusually revolve around changing problematic specific behaviors, such asself-destructive impulsive behaviors, tolerating and integrating affect, becom-ing more consciously aware of self, understanding the origins of the person-ality disorder and changing personality structure (Piper & Joyce, 2001). Thus,the life habit usually addressed in treatment appears to be intrapersonal andinterpersonal relationships. Also, modalities that have been studied includeindividual and group psychotherapy oriented by psychodynamic orcognitive-behavioral frames of reference (Piper & Joyce, 2001; Oldhamet al., 2006). Outcomes assessed have mainly focused on social dysfunction,

FIGURE 2 Level of satisfaction of life habits domains.

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social performance, symptomatology, treatment dropout (Bateman &Fonagy, 1999, 2001; Munroe-Blum & Marziali, 1995; Linehan, Heard, &Armstrong, 1993; Linehan, Tutek, Heard, & Armstrong, 1994; Perris, 1994;Piper, Rosie, Azim, & Joyce, 1993); parasuicidal behaviors, inpatient admis-sions (Linehan et al., 1993; Linehan et al., 1994; Perris, 1994); satisfaction,well-being (Linehan et al., 1993; Linehan et al., 1994; Piper et al., 1993)and work performance (Linehan et al., 1993; Linehan et al., 1994).

Thus, there seem to be very few programs for personality disorders pro-posed in the literature that clearly describe interventions facilitating partici-pation in activities of daily living and leisure. Karterud and Urnes (2004)and Gunderson (2001) have noted that therapeutic groups targeting lifehabits such as physical activities, cooking, and outings have been used inclinical practice for people with personality disorders but there is currentlyno evidence of their effectiveness with this population. Gunderson (2001)suggests that rehabilitative approaches should be part of all outpatientphases of treatment for people with personality disorders. For example, inthe partial hospital care=residential care phase (such as halfway houses),the proposed target goals include teaching or stabilizing daily living skills,(such as eating, sleeping, hygiene), initiating vocational rehabilitation andidentifying and modifying maladaptive behavioral and interpersonal traitsthat act as barriers for personal achievement (for example, impulse control,affect recognition, and tolerance). He mentions that vocational rehabilitationis most likely to be overlooked because patients tend not to introduce it orwelcome it and young or inexperienced staff may have little consciousnessabout its value and importance.

CONCLUSION

Although the sample size in this study is small, the findings confirm the use-fulness in exploring in more depth how living with a cluster B personalitydisorder in its acute phase can affect several domains of social participationand many life habits, both in terms of the level of accomplishment and thesatisfaction. The information provided can offer a deeper understandingof this population and consequently better guide occupational therapistsand their colleagues in other disciplines in planning their interventions withthese clients to enable them to reengage in meaningful life habits. Tocontinue to provide knowledge in this important area, studies couldexplore the personal and environmental barriers and facilitators for optimalsocial participation of people with cluster B personality disorders. It wouldalso be interesting to expand investigations to examine the social partici-pation of individuals with cluster A and cluster C personality disorders.Finally, there is a clear need to incorporate and examine more closely theeffectiveness of psychiatric rehabilitative approaches with those who live

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with a personality disorder, where clinical and research occupational thera-pists can be at the forefront.

ACKNOWLEDGEMENTS

The authors wish to sincerely thank the Canadian Institutes of HealthResearch, the Association des hopitaux de jour en psychiatrie du Quebec,the Reseau Quebecois de Recherche sur le Vieillissement, the FormationInterdisciplinaire en Sante et Vieillissement and the Canadian OccupationalTherapy Foundation for their financial support. The authors also send theirwarmest regards to the study participants.

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