Course and Prognosis for the Personality Disorders

In general, we would not expect a dramatic diminution of personality disorders over time because personality disorders, de facto, are robust and not expected to change greatly. Given recent evidence for their heritability (Coolidge, Thede, et al., 2001; Torgersen et al., 2000) and the DSM-IV-TR definition of personality disorders as enduring patterns of inner experience and external behaviors that are pervasive, inflexible, and stable over time, their chronicity is not surprising. Much more has been written about two specific personality disorders (antisocial and borderline) than the others.

One of the first outcome studies of Antisocial Personality Disorder was performed by Robins (1966). In a 5-year follow-up of 82 adults diagnosed with Antisocial Personality Disorder, she found that 61 % showed no improvement and 5 % had committed suicide. In another study with a 5-year follow-up interval, Maddocks (1970) found that 80% of 59 antisocial men had not improved. Black, Baumgard, Bell, and Kao (1995) further demonstrated the morbidity associated with the Antisocial Personality Disorder diagnosis, as nearly 24% were found to be dead after varying follow-up intervals of 16 to 45 years. Of course, some of these deaths might have been expected over a period as long as 45 years; however, the study also points to the dangers of interpreting course, outcome, or prognosis from cross-sectional studies.

We noted earlier in several cross-sectional studies that the mean level of antisocial behavior is significantly diminished in older groups. As just noted, a contributing factor is selective mortality: The core and associated features of the antisocial personality disorder, including drug abuse, impulsivity, aggressiveness, and novelty-seeking, will over many years lead some to a premature death. Besides selective mortality, an important question is: To what extent does personality change explain the lower rates of criminality in later life? In a classic study using a large sample (Harpur & Hare, 1994), male offenders ranging in age from 16 to 70 years were assessed with the Hare Psychopathy Checklist, which has two factors. The primary findings were that scores on Factor 2 (largely measuring socially deviant behaviors, impulsivity, and sensation-seeking) decreased sharply with age, whereas scores on Factor 1 (largely measuring affective and interpersonal features) remained stable. These findings provide evidence that the core personality traits associated with the antisocial personality (e.g., manipulativeness, callousness, egocentricity, and incapacity to experience empathy, guilt, and remorse) remain constant across the life span although the overt behavioral expressions dramatically decrease with age.

Paris (2003) has similarly noted that a lessening of impulsive and erratic behaviors over the course of a lifetime does not mean that the antisocial individual is cured or has grown out of the diagnosis. The underlying psychopathology is likely to remain present even though some of the behavioral manifestations are likely to change with advancing age. Although Paris noted that in later life people with Antisocial Personality Disorder are less likely to commit violent crimes or be as physically dangerous, they often remain very difficult people. In fact, an emerging crisis facing the prison system is the growing number of older prisoners, some whom have "aged-in-place" in prison and others who have entered (or reentered) the system in later adulthood (Aday, 2003).

A diagnosis of Borderline Personality Disorder also has a generally poor prognostic implication. There have been strong suggestions of a history of childhood trauma as a precipitating event for the development of this disorder (e.g., Millon & Davis, 1996). However, not all borderline patients have a history of trauma and not all individuals with trauma develop the disorder. Also, many personality disordered patients other than Borderline Personality Disorder do have trauma history as well as do adults without a personality disorder. Early traumatic brain injury as a precursor in Borderline Personality Disorder has also been proposed (e.g., van Reekum, 1993). Similar to the finding regarding childhood physical and sexual abuse, some borderline patients have a history of brain injury, but others do not (Coolidge, Segal, Stewart, & Ellett, 2000). Millon and Davis concluded that there are likely many paths to the development of the Borderline Personality Disorder, and for all the personality disorders. One of these factors for the borderline type is genetics. Coolidge, Thede, et al. (2001) found a correlation of .70 for borderline traits in 70 monozygotic twin pairs and a correlation of .39 for these traits in 42 dizygotic twin pairs. The overall heritability of the Borderline Personality Disorder was 76%.

In Perry's (1993) review of the course of personality disorders, Borderline Personality Disorder was the most widely studied. The major findings are summarized as follows. An important caveat, however, is that because most of the reviewed studies focused on younger and middle-aged adults, extrapolations into later life are unknown:

■ An average of 6.1% (range 3% to 9%) of individuals with Borderline Personality Disorder died by suicide in an average of 7.2 years of follow-up. Suicide was less common among the other personality disorders.

■ The greatest risk for suicide was in the immediate 1 to 2 years after initial diagnosis.

■ The natural history is suggestive of some at least some remission. At 10-year and 15-year follow-up, 52% and 33%, respectively, remain with a definite or probable diagnosis of Borderline Personality Disorder. This is not to suggest that the remitted cases are cured, but rather that the patients no longer meet the diagnostic threshold although they are likely to continue experiencing several residual symptoms and can still have significant functional impairment. In fact, the average psychosocial impairment was moderate after a mean of 9.5 years of follow-up.

In studies of schizoid adolescents and young adults, Wolff (1995) found that a strong majority are still diagnosed schizoid and/or schizotypal in follow-up periods of up to a decade after initial diagnosis. However, she used a broad definition of schizoid behavior that often included aberrant thinking and intense focus on single ideas or subjects. The latter two symptoms are more suggestive of Schizotypal Personality Disorder and Asperger's syndrome, respectively. Nonetheless, Wolff's studies seem to confirm the suspicion that Schizoid Personality Disorder (and/or Schizotypal Personality Disorder) tend to be chronic and unremitting from late adolescence at least into early adulthood.

Studies of the long-term outcome and course of other personality disorders such as histrionic, narcissistic, obsessive-compulsive, avoidant, and dependent are sparse. Paris (2003) is one of the few researchers to address the outcomes of these other personality disorders even if he relied primarily on clinical studies and cross-sectional data. Paris postulated that older histrionic patients are likely to draw attention to themselves through somatic and hypochondriacal complaints rather than with their customary sexual seductiveness and physical charms. In some cases, they may become overreliant on cosmetic surgery as a consequence of their overestimation of physical attractiveness and their quest for youthfulness. It also seems likely that the superficiality of their emotional and social attachments is likely to become more distressing and ego-dystonic as they find themselves less capable of managing others and obtaining attention through physical attractiveness and seductiveness, especially from those people who are much younger than they are.

Paris (2003) and Kernberg (1976) also speculated about the course of Narcissistic Personality Disorder, suggesting that some narcissists may become more interested in therapy as they age. Their charming, bold, manipulative, and self-assured style may become less rewarded with advancing age. As their professional and familial powers over others diminish with retirement and other aspects of advanced aging (e.g., sensory losses), and as their physical prowess declines, it seems likely that they will seek attention, power, and reinforcement through relationships with their therapist and other professionals who fill their need for attention. It may also be predicted that as their disappointments with their customary search for accolades and valuation of their worth by others diminishes with age, individuals with Narcissistic Personality Disorder might become significantly depressed and anxious, and like aging individuals with Histrionic Personality Disorder, they may exhibit somatic and hypochon-driacal complaints.

In the few studies of the course of Cluster C personality disorders (avoidant, obsessive-compulsive, dependent), Seivewright, Tyrer, and Johnson (2002) and Tyrer and Seivewright (2000) over a 12-year follow-up found that most of these patients did not improve with age. In fact, they found that their tendency toward anxiety and strong need for control tended to increase over time. The data from Reich et al. (1988) are also suggestive of a slight increase in anxious personality disorder traits in later life. Finally, as noted later in this chapter, patients with Cluster C personality disorders are prone to experience a diverse array of comorbid Axis I disorders, with anxiety, mood, and somatoform disorders particularly common.

In summary, it is relatively common for clinicians to offer somewhat bleak prognoses for the personality disorders, but the picture does not necessarily have to be this grim. First, many inroads are being made into the psychopharmacological treatment of personality disorders (Soloff, 1998), particularly targeting the cognitive/perceptual, emotional, and impulse dyscontrol symptoms associated with the disorders. There are also many partially successful medications for the anxious, depressive, and obsessive manifestations of personality disorder symptomatology. These medications do not in any sense cure the underlying personality disorder or character structure. They can, however, remove barriers to psychotherapy so that standard psychothera-peutic techniques (e.g., cognitive-behavioral, psychodynamic approaches) may be more likely to succeed. Second, new and innovative psychotherapies are continually being developed in psychology, some specifically targeting personality disorders (Linehan, 1993; Millon, 1999). Although it still seems unlikely that the higher-order factors (e.g., temperaments) that help shape personality disorders will be dramatically or radically changed, the expressions of these temperaments can sometimes be reformed, massaged, sublimated, or reexpressed in ways that are less troubling for the patients and their families, including those in later life. Traits can also be redirected to more adaptive contexts, a concept demonstrated in several of our case examples presented in earlier chapters. And, although groups of people with personality disorders may on average show little change over time, the potential for individuals to change, adapt, and grow over time is much greater.

As for the stability of personality traits over time, individuals differ in the degree to which their attributes and behaviors are enduring and pervasive. Millon and Grossman (2006) note: "[E]ach individual displays this durability and pervasiveness only in certain of his or her characteristics; that is, each of us possesses a limited number of attributes that are resistant to changing times and situational influences, whereas other of our attributes are more readily modified" (p. 16). Furthermore, traits, whether adaptive or maladaptive, only have a probabilistic influence on behavior. People who possess any trait are not unfailingly consistent in expressing it (Costa & McCrae, 2006). Applying this concept to individuals with personality disorders, Pincus (2005) states, "Clearly, these patients do not walk around like robots emitting the same behaviors over and over again regardless of the situation (or interpersonal situation)" (p. 133). The fluctuation of personality disorder symptomology can inform psychotherapeutic intervention—strategies can take advantage of stable periods and work to reestablish adaptive functioning during particular times of deterioration or crisis (Pincus, 2005).

Break Free From Passive Aggression

Break Free From Passive Aggression

This guide is meant to be of use for anyone who is keen on developing a better understanding of PAB, to help/support concerned people to discover various methods for helping others, also, to serve passive aggressive people as a tool for self-help.

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