Can You Get Ssi for Borderline Personality Disorder

J Pers Disord. Author manuscript; available in PMC 2011 Nov 23.

Published in terminal edited form as:

PMCID: PMC3222934

NIHMSID: NIHMS329895

The ten-Twelvemonth Course of Social Security Disability Income Reported by Patients with Borderline Personality Disorder and Axis Two Comparison Subjects

Abstract

This study had 2 purposes. The beginning purpose was to assess the prevalence also equally the stability of reliance on social security inability income (SSDI) among patients with borderline personality disorder (BPD). The second purpose was to detail the prevalence of aspects of developed competence reported by borderline patients who e'er received disability payments and those who never received such payments. The disability condition and other aspects of psychosocial functioning of 290 borderline inpatients and 72 axis 2 comparison subjects were assessed using a semi-structured interview at baseline and at each of the five subsequent two-twelvemonth follow-upward periods. Deadline patients were 3 times more probable to be receiving SSDI benefits than axis II comparing subjects over fourth dimension, although the prevalence rate for both groups remained relatively stable. Forty percent of borderline patients on such payments at baseline were able to become off disability but 43% of these patients subsequently went back on SSDI. Additionally, 39% of borderline patients who were not on inability at baseline started to receive federal benefits for the commencement time. Even so, borderline patients on SSDI were not without psychosocial strengths. By the fourth dimension of the 10-year follow-up, 55% had worked or gone to schoolhouse at least 50% of the final two years, about 70% had a supportive relationship with at least one friend, and over fifty% a adept relationship with a romantic partner. The results of this study advise that receiving SSDI benefits is both more common and more fluid over time for patients with BPD than previously known.

Clinical feel suggests that it is mutual for patients with borderline personality disorder (BPD) to receive social security inability income (SSDI) – the U.S. federal program to back up those with doc documented medical and/or psychiatric disabilities that forbid them from existence able to back up themselves financially. This link is important because receiving SSDI benefits adds to the cost of BPD as a public wellness trouble. It as well provides an indication of the caste of psychosocial dysfunction associated with BPD.

Despite the public wellness significance of this association, at that place have been a limited number of studies that have explored the relationship between BPD and disability benefits. Offset, at that place were iii studies that looked at BPD in a sample of patients on SSDI disability. As early as 1977, Mikkelsen reported that 12% of individuals receiving psychiatric disability benefits suffered from "deadline personality organization." He found borderline symptoms to be the third most mutual psychiatric diagnosis in disability candidates after "neurotic depression" (26%) and schizophrenia (22%). Later, in a written report of 45 medical outpatients, Sansone, Hruschka, Vasudevan, and Miller (2003) noted that 72% of the participants with a history of medical disability payments versus 26% of the nondisabled participants met borderline criteria on at least one of the two self-report measures. 3 years subsequently with a larger sample, Sansone and colleagues found that the aforementioned self-report measures (of borderline psychopathology and self-harming behaviors) correlated with the length of time on psychiatric inability benefits in particular (as opposed to medical disability benefits) (Sansone, Butler, Dakroub, & Pole, 2006). These results were found to be pregnant for women only, perhaps due to the minor number of male person borderline patients studied.

There have too been 5 studies that have assessed the rates of disability payments in samples of criteria-defined borderline patients. In a cantankerous-sectional study, Skodol et al. (2002) found that borderline patients were significantly more likely than depressed comparing subjects to report being disabled (36% vs. 18%).

The other iv studies were longitudinal in nature. Modestin and Villiger (1989) studied two groups of former inpatients. Information technology was institute that borderline patients (22%) were not significantly more likely than comparison subjects with other personality disorders (12%) to report being on disability later a mean of 4½ years of follow-upward. Sandell et al. (1993) found that 34% of borderline patients initially treated in a day hospital reported being on disability 3–ten years after their index admission.

Links, Heslegrave, and van Reekum (1998) found that 30% of former borderline inpatients were receiving inability pensions seven years after their index admission. These authors likewise found that borderline patients with persistent BPD were more likely to exist receiving such a pension than those with remitted BPD (42.3% vs. 20.0%).

Finally, Zanarini, Frankenburg, Hennen, Reich, and Silk (2005) found that the rates of deadline inpatients and axis II comparison subjects receiving disability payments increased slightly but significantly over six years of prospective follow-up but remained significantly higher among those with BPD (BPD [41% to 47%] vs. axis Ii comparing subjects [8% to fourteen%]). Additionally, 73% of borderline patients who had never experienced a remission supported themselves (at least in part) through disability payments as compared to 38% of borderline patients who had experienced a remission of their BPD.

The current study assesses the grade of social security inability income in a sample of 290 borderline patients and 72 axis II comparison subjects using a semi-structured clinical interview over a period of 10 years. This study extends our prior study, described above, past adding an additional four years of prospective follow-up. It also considers not only prevalence rates but likewise time-to-no longer receiving these payments, time-to-receiving them again, and fourth dimension-to-first receiving them for borderline patients who were self-supporting at baseline. Finally, it assesses the prevalence of three aspects of adult competence among those in ii sub-groups of deadline patients: those who had ever received federal disability payments during the course of the study and those who had never received such payments during this time frame.

Methods

All subjects were initially inpatients at McLean Hospital in Belmont, Massachusetts. Each patient was first screened to determine that he or she: one) was between the ages of xviii–35; ii) had a known or estimated IQ of 71 or higher; 3) had no history or electric current symptoms of schizophrenia, schizoaffective disorder, bipolar I disorder, or an organic condition that could crusade psychiatric symptoms; and iv) was fluent in English.

Afterward the study procedures were explained, written informed consent was obtained. As part of a larger written report (Zanarini, Frankenburg, Hennen, & Silk, 2003), each patient so met with a masters-level interviewer bullheaded to the patient's clinical diagnoses for a thorough diagnostic assessment. Three semi-structured interviews were administered. These diagnostic interviews were: one) the Structured Clinical Interview for DSM-III-R Centrality I Disorders (SCID-I) (Spitzer, Williams, Gibbon, & Starting time, 1992), two) the Revised Diagnostic Interview for Borderlines (DIB-R) (Zanarini, Gunderson, Frankenburg, & Chauncey, 1989), and 3) the Diagnostic Interview for DSM-Iii-R Personality Disorders (DIPD-R) (Zanarini, Frankenburg, Chauncey, & Gunderson, 1987). The inter-rater and test-retest reliability of these measures accept been found to be good-splendid (Zanarini & Frankenburg, 2001; Zanarini, Frankenburg, & Vujanovic, 2002).

Inability status was assessed at baseline using the Background Information Schedule (BIS) (Zanarini, Frankenburg, Hennen, & Silk, 2004; Zanarini, et al., 2005). This semi-structured interview assesses the participant's demographic information, pre-morbid functioning, and history of psychiatric handling. Both the inter-rater and test-retest reliability of this interview have been found to exist good-excellent (Zanarini et al., 2004; Zanarini, et al., 2005).

At each of the written report's five follow-up periods, informed consent was obtained and then disability status was assessed using the Revised Borderline Follow-upwardly Interview (BFI-R), which is the follow-up analog to the BIS used at baseline. Both the follow-up inter-rater reliability (within one generation of raters) and follow-up longitudinal reliability (from one generation of raters to the adjacent) take been constitute to be expert-excellent (Zanarini et al., 2004; Zanarini et al., 2005).

To properly business relationship for the correlation amid repeated measures, generalized estimating equations (GEE), with diagnosis, time, and their interaction equally master effects, were used in longitudinal analyses of prevalence data. These analyses modeled the log prevalence of disability with gender every bit an additional covariate (equally borderline patients were significantly more likely than axis II comparison subjects to be female person), yielding an adapted relative risk ratio (RRR) and 95% confidence interval (95%CI) for diagnosis and time. Similar analyses were conducted for three aspects of adult competence evidenced by deadline patients with and without a history of always receiving SSDI (without gender as a covariate equally the two sub-groups of deadline patients had about the same gender distribution). Alpha was set at 0.05, 2-tailed.

Discrete survival analyses were used to assess time-to-remission, time-to-recurrence, and time-to-new onsets of receiving federal disability benefits. A remission was divers as occurring when a patient was receiving disability payments at baseline but was no longer receiving disability payments at ane of the follow-upwards periods. A recurrence was defined as occurring when a patient was on disability at baseline, stopped receiving inability payments at a follow-up period, and then was dorsum on inability at a later follow-upwardly menstruation. Finally, a new onset was defined as occurring when a patient was not receiving disability payments at baseline but then was receiving SSDI payments at a later menstruum. All analyses were performed using Stata nine.ii software (StataCorp, College Station, Texas, 2007).

Results

2 hundred and 90 patients met both DIB-R and DSM-Iii-R criteria for BPD and 72 met DSM-Three-R criteria for at to the lowest degree i nonborderline centrality Two disorder (and neither criteria ready for BPD). Of these 72 comparing subjects, 4% met DSM-III-R criteria for an odd cluster personality disorder, 33% met DSM-III-R criteria for an anxious cluster personality disorder, 18% met DSM-Iii-R criteria for a non-borderline dramatic cluster personality disorder, and 53% met DSM-Three-R criteria for personality disorder not otherwise specified (which was operationally defined in the DIPD-R as meeting all only one of the required number of criteria for at least two of the 13 axis II disorders described in DSM-Three-R).

Baseline demographic data have been reported before (Zanarini et al., 2003). Briefly, 77.one% (N=279) of the subjects were female and 87% (N=315) were white. The average age of the subjects was 27 years (SD=6.3), the mean socioeconomic status was 3.3 (SD=1.5), where 1=highest and 5=lowest (Hollingshead, 1957), and their mean GAF score was 39.viii (SD=7.viii) indicating major impairment in several areas, such as work or school, family unit relations, judgment, thinking, or mood.

In terms of continuing participation, xc.1% (N=309) of surviving patients were re-interviewed at all 5 follow-upwards waves. More specifically, 91.5% of surviving borderline patients (249/272) and 84.5% of surviving axis II comparing subjects (sixty/71) were evaluated six times (baseline and 5 follow-up periods).

Table i details the prevalence of disability payments reported by borderline patients and axis II comparison subjects over ten years of prospective follow-up. Every bit can exist seen, a significantly higher per centum of borderline patients than axis Ii comparison subjects reported receiving disability payments. When all subjects were considered together, the rate of disability payments did not modify significantly over time.

Tabular array 1

Prevalence of Social Security Disability Reliance among Borderline Patients and Centrality 2 Comparison Subjects over Ten Years of Prospective Follow-up

	Deadline Patients (%/Due north)						Centrality 2 Comparing Subjects (%/N)
	BL (Northward=290)	two Year FU (N=275)	4 Yr FU (N=269)	half-dozen Yr FU (N=264)	viii Yr FU (N=255)	10 Twelvemonth FU (N=249)	BL (N=72)	2 Yr FU (North=67)	4 Yr FU (N=64)	6 Yr FU (N=63)	8 Yr FU (Due north=61)	ten Yr FU (Due north=60)	RRR Diagnosisa Timeb Interactionc	95% CI Diagnosis Time Interaction
SSDI Disability	40.7 (N=118)	fifty.2 (N=138)	51.7 (North=139)	46.6 (N=123)	44.7 (N=114)	44.2 (N=110)	8.iii (Due north=vi)	16.4 (North=11)	18.eight (North=12)	14.three (N=9)	13.ane (N=8)	xviii.3 (Northward=eleven)	3.26 0.99 ---	ii.00, 5.31 0.88, ane.13 ---

The relative risk ratios (RRRs) for diagnosis and time in the table comprise more than fine-grained information. As can be seen, 41% of borderline patients (North=118) (and 8% of centrality II comparison subjects [Northward=vi]) were receiving SSDI at the time of their index admission. Past the time of their 10-year follow-up, these prevalence rates increased to about 44% (N=110) and 18% (Due north=eleven) respectively. The RRR of three.26 (95%CI 2.00, 5.31) indicates that deadline patients were nearly 3 times more likely to be receiving SSDI than axis Two comparison subjects. The RRR of 0.99 (95%CI 0.88, one.13) indicates that the risk of receiving SSDI over the class of the study for all subjects considered together remained relatively constant over time ([ane−0.99] × 100=1% decline).

Effigy ane displays time-to-remission, recurrence, and new onsets of disability amid borderline patients over 10-years of prospective follow-upward. (As a issue of the low number of centrality II comparison subjects reporting being on inability, Effigy one considers only deadline patients.)

Fourth dimension to Remission, Recurrence, and New Onsets of Disability among Borderline Patients over Ten Years of Prospective Follow-up

Notation: Since a recurrence can only occur after a remission, there is no possibility of a recurrence occurring at the ii-year follow upwards. Even though recurrences are displayed in this effigy at the 4, half-dozen, 8, and 10-twelvemonth follow-up periods, these recurrences are actually occurring ii, 4, 6, and 8 years after the remission.

Every bit can be seen, the percentage of borderline patients who had a remission of being on disability past the time of the x-yr follow-upwardly was about forty%. Of these borderline patients, 43% experienced a recurrence and once again were receiving payments. Of those borderline patients who had not reported being on disability at baseline, 39% experienced a new onset during the 10 years of follow-upwards.

By adding the number of borderline patients who were on disability at baseline (Due north= 118) to the number of borderline patients who experienced a new onset of receiving inability payments (N = 57), we establish that 60.iii% (118 + 57=175/290) of borderlines were always on inability over the 10-twelvemonth period.

Tabular array ii details the prevalence of 3 aspects of adult competence among borderline patients who were on inability at some point in the study (baseline and/or 1 of the study's five follow-upwards periods) and borderline patients who were never on inability during the course of the written report. As can be seen, the deadline patients who were ever on disability were significantly less likely than the borderline patients who were never on disability to accept worked or gone to schoolhouse at least 50% of the time, to accept a good relationship with friends, and to have a good human relationship with a romantic partner. As tin also be seen, the percentage of both groups of borderline patients reporting each of these three aspects of adult psychosocial functioning increased significantly over time.

Table 2

Prevalence of Aspects of Adult Competence among Borderline Patients Receiving and Not Receiving Disability Benefits over Course of Written report

	Borderline Patients E'er on Disability (%/North)						Deadline Patients Never on Disability (%/North)
	BL (Northward=175)	2 Yr FU (N=170)	four Yr FU (Due north=167)	6 Twelvemonth FU (N=165)	8 Yr FU (North=160)	10 Yr FU (Northward=156)	BL (N=115)	2 Yr FU (North=105)	4 Twelvemonth FU (Due north=102)	6 Twelvemonth FU (Northward=99)	8 Yr FU (N=95)	10 Yr FU (Due north=93)	RRR Disabilitya Timeb Interactionc	95% CI Disability Time Interaction
Sustained Work/School History (l% or More of Time Period)	51.4 (N=90)	37.1 (N=63)	56.iii (Northward=94)	58.2 (N=96)	58.i (Northward=93)	55.i (N=86)	96.v (N=111)	95.2 (Due north=100)	97.1 (North=99)	95.0 (N=94)	94.seven (N=90)	89.iii (N=83)	0.49 0.94 ane.34	0.43, 0.55 0.89, 0.99 1.thirteen, 1.59
Good Relationship with Friend(south)	48.0 (N=84)	59.4 (Due north=101)	68.3 (Due north=114)	66.one (Due north=109)	72.5 (N=116)	70.5 (N=110)	61.7 (Northward=71)	69.5 (N=73)	80.4 (Due north=82)	83.viii (N=83)	86.three (N=82)	87.1 (N=81)	0.82 1.36 ---	0.75, 0.90 1.25, 1.48 ---
Good Relationship with Partner	29.1 (N=51)	36.five (Northward=62)	37.i (N=62)	50.nine (North=84)	51.3 (Due north=82)	50.6 (N=79)	twoscore.0 (N=46)	fifty.5 (N=53)	58.8 (N=60)	seventy.7 (N=lxx)	68.4 (N=65	67.seven (North=63)	0.75 one.63 ---	0.64, 0.87 i.43, 1.87 ---

But i of these three aspects of adult functioning was constitute to have a pregnant interaction between diagnosis and time. The relative chance ratio of 0.49 (95%CI 0.43, 0.55) indicates that borderline patients who were ever on disability were just one-half as probable as borderline patients who were never on disability to study having worked or gone to school for at least half of the two-year time menstruation prior to baseline. The RRR of 0.94 (95%CI 0.89, 0.99) for fourth dimension indicates that the relative change in these reports from baseline to x-year follow-up resulted in an approximately six% decline among borderline patients who were never on disability (1.0−0.94×100=6%). In dissimilarity, the meaning interaction between diagnosis and time of 1.34 (95%CI 1.xiii, 1.59) indicates a relative increase in these reports of about 26% for borderline patients who were ever on disability ([0.94×1.34 − 1.0]×100=26%).

Word

This report has four primary findings. The first finding is that a significantly higher percentage of borderline patients than centrality II comparison subjects were receiving SSDI benefits. In fact, borderline patients were more than four times every bit probable equally axis Two comparison subjects to be on SSDI disability at baseline and more than two times as likely to be receiving inability payments at the 10-yr follow-up mark. The baseline and follow-up prevalence rates plant in this study are consistent with those establish in earlier studies (Skodol et al., 2002; Modestin et al., 1989; Sandell et al., 1993; Links et al., 1998; Zanarini et al., 2005). However, it is a new finding that about lx% of borderline patients received SSDI payments at some signal in time during the study.

The second finding is that the prevalence of disability payments was relatively stable among deadline patients over the form of the study, with about xl% of borderline patients receiving such payments at baseline and at each of the 5 two-year follow-up periods—a charge per unit that is 10 times the 4% of adults in Massachusetts anile 18–64 on SSDI for concrete and/or psychiatric reasons (Social Security Assistants, 2007). This new finding also suggests that almost threescore% of the borderline patients in the study were able to support themselves financially at each of the study'southward six fourth dimension periods.

The tertiary finding is that a substantial percentage of borderline patients were not chronically receiving disability benefits. More specifically, about forty% of borderline patients receiving inability payments at baseline no longer needed such payments (i.e., experienced a remission). However, about 40% of those borderline patients experiencing this type of inability "remission" later went dorsum on disability (i.due east., experienced a recurrence). Further, virtually xl% of borderline patients who were not on disability at baseline afterwards started to receive such payments (i.e., experienced a new onset). Taken together, these findings suggest that the human relationship between BPD and disability payments is more fluid than previously known, with patients ending and commencement to receive such payments over time.

The fourth finding is that borderline patients on disability were not necessarily unable to role in most areas of their lives. Rather after ten years of follow-up, about 55% were able to work or go to school 50% of the time or more, most 70% have a good human relationship with at least one friend, and about l% have a adept relationship with a romantic partner. These findings advise that about half of borderline patients receiving federal disability benefits accept some capacity to function vocationally. They also suggest that the social functioning of deadline patients on disability is better than their vocational functioning. Even so, it seems that intimate relationships with partners are harder to develop and maintain than relationships with friends.

It should besides exist noted that borderline patients who were never on inability benefits functioned substantially better in all areas. About 85% had a sustained vocational operation and a skilful relationship with at least one friend by the time of the ix-tenth years of follow-up. In addition, almost seventy% had an emotionally sustaining relationship with a romantic partner during the fifth follow-upwards period.

The clinical implications of this study are complicated. In terms of vocational functioning, information technology may be that some borderline patients are and then dysfunctional that helping them observe a source of income is a reasonable thing to practice for those treating them. It may also be that some borderline patients requite up working, reduce their hours, or piece of work under the table in order to receive the associated wellness insurance benefits (Medicare and Medicaid) that they demand to proceed their psychiatric (and medical) intendance.

In the former case, vocational counseling may exist a useful form of adjunctive treatment and/or the focus of a primary therapy. In the latter case, a national health insurance organisation that separates vocational operation from access to health care might well be a better model for borderline patients who can work just are discouraged from doing so under our current system.

In terms of social functioning, near a third of deadline patients who received SSDI during the course of the report did not take a expert relationship with at least one friend during the fifth follow-up period and about half did not have a adept relationship with a spouse or partner during this period. Looked at another style, almost a 3rd had either no friends or a conflicted relationship with i or more friends. In a like vein, about one-half either did not have a partner or had a contentious relationship with 1. Taken together, these results propose that a focus in therapy on the interpersonal functioning of borderline patients receiving disability benefits would be useful. While this seems obvious, none of the four chief forms of therapy for BPD have been shown to be effective in improving interpersonal functioning—either in terms of forming new relationships or developing less contentious ones (Gunderson & Links, 2008).

This written report has a number of limitations. The first is that all subjects were initially inpatients. It may exist that borderline patients who have never been hospitalized are less likely to rely on SSDI. The second is that the subjects provided all of the data pertaining to SSDI. Whether they were accurate historians, were exaggerating their histories, or minimizing them is unknown. The tertiary is that the majority of the sample was in treatment prior to their index admission and over time and thus, the results may non generalize to untreated subjects. More specifically, almost 90% of those in both patient groups were in private therapy and taking psychotropic medications at baseline and almost 70% were participating in each of these outpatient modalities during each follow-upwardly catamenia (Zanarini et al., 2004).

In addition, we have no data as to the diagnosis that was used on the disability application forms. It could take been BPD, PTSD, major depression, etc. We too accept no fashion of knowing if the inability payments were sought to requite a patient a monthly income considering information technology was believed that he or she could non work or if the payments were sought every bit a kickoff-step in the procedure of obtaining Medicare insurance for treatment. Of form, the motivation might have been both to give someone a small-scale but sustaining income (as well as access to low income housing and nutrient stamps) and to obtain health insurance for connected psychiatric treatment.

Acknowledgments

Supported by NIMH grants MH47588 and MH62169.

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