Double Jeopardy: New Evidence on the Co-Relations of Homelessness and Severe Personality Disorder

Background and Purpose: Compared to the general population, adults diagnosed with personality disorder (PD), especially antisocial PD (ASPD), have greater odds of experiencing homelessness. However, few studies have explored risks of homelessness among persons with PD. This study identifies important behavioral health and socioeconomic correlates of past-year homelessness for persons with the following PDs: ASPD, borderline (BPD), and/or schizotypal (SPD).

Methods: The sample included respondents with ASPD, BPD, and SPD from the third wave of the National Epidemiological Survey on Alcohol and Related Conditions (NESARC-III). The Alcohol Use Disorder and Associated Disabilities Interview Schedule-5 assessed PDs, lifetime suicide attempt, and past-year anxiety, mood, post-traumatic stress, and substance use disorders. Socioeconomic variables included: family income, fired/laid off in the past year from work, debt, health insurance, past-year unemployment, and receipt of welfare benefits. Analyses were adjusted for demographic characteristics, such as age, sex, race/ethnicity, relationship status, and justice-involvement, and weighted to account for the NESARC-III’s sampling design. Descriptive statistics were conducted before testing separate logistic regression models to identify the odds of homelessness for each PD.

Results: For all PDs, higher family income was inversely related to odds of homelessness, whereas overwhelming debt was positively related to homelessness. Being fired/laid off was significant for those with ASPD (OR = 2.33, 95%CI: 1.22, 4.41). Unemployment was associated with higher odds of homelessness for each category except ASPD. Lack of health insurance was associated with higher odds of homelessness for each PD except ASPD and highest for those with SPD (OR = 1.75, 95%CI: 1.13, 2.71). Receipt of welfare was also associated with higher odds of past-year homelessness for each PD, highest for those with ASPD (OR = 3.79, 95%CI: 2.17, 6.62) and lowest for SPD (OR = 2.40, 95%CI: 1.43, 4.03). Past-year psychiatric disorders were uncorrelated with homelessness; however, for those with ASPD, comorbid BPD was positively associated with homelessness (OR = 2.34, 95%CI: 1.23, 4.45) and for those BPD, comorbid ASPD was associated with significantly higher odds of homelessness (OR = 1.70, 95%CI: 1.17, 2.47). Lifetime suicide attempt was associated with homelessness, with odds highest among those with SPD (OR = 2.19, 95%CI: 1.36, 3.53) and lowest for BPD (OR = 1.51, 95%CI: 1.11, 2.06).

Conclusions and Implications: This study explored, using nationally representative data, socioeconomic and behavioral health factors associated with homelessness for persons diagnosed with PD. For those with PD, economic and occupational factors were more frequently and strongly associated with homelessness than behavioral health comorbidities. Actionable strategies exist to promote economic security, stable relationships, engagement in treatment services, and more positive interpersonal functioning. Treatments, such as dialectical behavior therapy, may address difficulties in personality functioning and contribute to improvement in other domains of psychopathology, as personality, although typically understood as stable over time, may respond to clinical intervention.