Personality Disorders Over Time: Precursors, Course, and Outcome

It is not often that one reads a comprehensive text in one or two sittings or over a weekend. As a child, adolescent, and adult psychoanalyst and psychiatrist, I found that reading the very well written distillate of Joel Paris’s long clinical and empirical experience was an invaluable education. It is a book that I will undoubtedly repeatedly refer to for its insights, its elucidation of particular issues, and its highly comprehensive review of the clinical and empirical literature. I recommend this book highly to researchers and clinicians, whether seasoned or novice.

As a psychiatrist for several decades, Joel Paris makes it clear that his education was grounded within a strong psychodynamic educational setting. It is unfortunate that too many younger psychiatrists and psychiatric trainees lack such an education. In my opinion, a strong psychodynamic education allows a psychiatrist to observe and learn about the ongoing impact on a person’s behavior of the interaction among a variety of factors: biology, psychology (including unconscious factors), and the environment. In other words, a person’s thoughts, feelings, and behavior are the result of active conflicting forces within the individual, including unconscious factors. The lack of such a psychodynamic education in many psychiatric residencies has led to the hegemony of the “bio” in the biopsychosocial model. Paris’s theoretical model is exemplary of how psychiatrists should think about their patients.

As Paris concisely tells us, in the current DSM-IV-TR the personality disorders (axis II) are classified as belonging to one of three clusters. These clusters had been previously described as odd (cluster A), dramatic (cluster B), and anxious (cluster C). The disorders in cluster A, such as schizoid personality, are characterized by high levels of introversion and/or unusual cognitions. Cluster B disorders, such as antisocial personality disorder or borderline personality disorder, are associated with high levels of impulsivity and affective instability, and cluster C disorders, such as avoidant personality disorder, are associated with social anxiety or an unusual need for control. Paris stresses that trait profiles are likely to be identified in childhood and that they correspond to the broad dimensions of psychopathology (externalizing traits are related to cluster B, internalizing traits to cluster C, and cognitive traits to cluster A).

Paris is undoubtedly correct when he tells us that, despite the fact that all therapists treat patients with personality disorders (that is, patients with chronic problems in work and relationships), they do so reluctantly because the treatment of these patients can be so very difficult, particularly with the many pharmacological agents that are used for axis I disorders such as depression and anxiety. In fact, many patients are given an axis II diagnosis when usual treatments fail.

Some estimate that the overall community prevalence of personality disorders is as high as 10%. The rate of antisocial personality disorder has been estimated as 2%—twice the rate of schizophrenia or bipolar disorder. Although less common, borderline personality disorder seems more common because people with borderline personality disorder are highly likely to seek treatment. Patients with borderline personality disorder make up 6% of patients in primary care and 25% of patients in psychiatric clinics.

Among the many important contributions of this book are the discussions of long-term outcome studies of adults. Paris describes three important long-term studies—Thomas McGlashan’s at Chestnut Lodge, Michael Stone’s at New York State Psychiatric Institute, and his own with colleagues in Montreal. Three other important studies are noted: at Austen Riggs, at the University of Toronto, and in Oslo, Norway. All of these studies were carried out independent of and without knowledge of each other, but they obtained strikingly similar results. There was a tendency toward naturalistic recovery and little difference in outcome among the groups of patients, whether the patients received short courses of therapy for acute exacerbations to control acute symptoms or long-term therapy.

Paris concludes that the aim of treatment should be to “care” rather than to “cure” and that it may be very worthwhile to hold on to patients in therapy because they will recover over time. Over time, patients with cluster B disorders become less impulsive and may very well learn to modify maladaptive behaviors, learn to avoid stressful situations (such as intense intimate relationships), develop adequate social supports, and attain a comfortable identity. These processes are less likely to occur with patients who have cluster A or C disorders.

In chapter 8, Paris provides an unusually concise yet comprehensive review of the empirical literature on the treatment of patients with personality disorders, particularly those with borderline personality disorder. Although patients with antisocial personality disorder seem to be treatment resistant, patients with borderline personality disorder do respond to psychotherapy, despite the need for more rigorous outcome studies.

Paris’s findings from his own 27-year follow-up study show that patients with borderline personality disorder have an unpredictable course. Most improve functionally, but many continue to show some degree of impairment. Many die prematurely from either natural causes or suicide. Paris stresses that there does not seem to be any relationship between severity of pathology and fatality. In contrast, other personality disorders tend to remain chronic: patients with cluster A personality disorders are often disabled by the negative symptoms that they share with schizophrenia but do not have the positive symptoms of schizophrenia that remit. Patients with cluster C personality disorders have anxiety traits that may very well be self-reinforcing over time (p. 79).

Paris notes,

In the treatment of patients with personality disorders, Paris stresses that one must take individual differences into account. Understandably, the best results are obtained for the highest functioning patients, but therapy can reduce the complications of the disorders of even the more severely ill patients. An example of Paris’s clinical and empirical acumen is his very sophisticated discussion of the problem of how to deal with the suicidality of patients with borderline personality disorder. Hospitalization may be countertherapeutic for suicidal patients with borderline personality disorder in contrast to patients with a clear-cut mood disorder resulting in suicidal wishes. The approach of the hospital milieu is more geared to helping the patient with suicidal mood disorder than the patient with borderline personality disorder.

As a therapist who is very involved in working with and studying the interactions between mothers and babies and toddlers (birth to age 3) (1–3), I was most interested in Paris’s extensive discussions of the nature of severe childhood disturbances, the impact of the environment on the developing child, and the effort to understand the early childhood precursors of adult disturbances. Paris’s conceptual framework stresses the importance of the interactions of a variety of factors. For example, he says,

Paris makes an important contribution by discussing the concept of “traits” to account for the commonalities between the different categories of illness. The major trait distinctions are between externalizing and internalizing symptoms, even though externalizing and internalizing symptoms may and do coexist. The third important trait is the cognitive trait.

The major externalizing disorders are conduct disorder and attention deficit hyperactivity disorder. These disorders have a predisposition to the development of alcoholism and drug abuse (which tend to be comorbid with cluster B personality disorders). In childhood, conduct disorder and attention deficit hyperactivity disorder are usually diagnosed in boys. In contrast, internalizing symptoms may go unrecognized in childhood because moody and nervous children are usually not disruptive in school. People with these disorders seek help later in life as a result of inner suffering. Paris stresses that mood and anxiety disorders overlap to the point that they may be considered a single group.

I fully agree with Paris’s plea that future research must attempt to understand the nature of the precursors and the mechanisms leading to the development of personality disorders. This is a critical area for study because, for example, most children with difficult temperaments and most children who suffer adverse situations do not develop personality disorders (p. 30). Paris summarizes the extant empirical literature concisely. Only a minority of children who attend mental health clinics develop mental disorders in adulthood, in contrast to the substantial risk for adult psychopathology in children who are severely disturbed in childhood. For example, one-third of children with conduct disorder meet criteria for antisocial personality by the age of 18.

The difficulty in understanding the antecedents of adult psychopathology is dramatized in Paris’s excellent and comprehensive discussion of borderline pathology of childhood. He describes two strategies to identify precursors for cluster B personality disorders—the study of children who have been labeled “borderline” and the study of children who have parents with borderline personality disorder. “Borderline children” (or children with “multidimensionally impaired disorder”) are children whose “clinical picture is characterized by a mixture of pathology on several dimensions—externalizing, internalizing, and cognitive. These children are highly impulsive but may also be suicidally depressed and/or have micropsychotic symptoms” (p. 34). Neither children with borderline symptoms nor children with parents who have borderline personality disorder consistently develop borderline personality disorder as adults. Perhaps this is a result of the fact that most children with borderline pathology are male and most adults with borderline personality disorder are female. It may be that girls with internalizing disorders who do not cause disruptions, particularly in school, are not referred to the mental health system.

Throughout the volume Paris discusses the importance of temperamental patterns in children and their interactions with helpful or harmful environments. He stresses that by age 2, these temperamental patterns become stable:

In this model, personality disorders emerge from the interactions between temperamental vulnerability and the cumulative effects of multiple psychosocial adversities. This view allows Paris to understand the individuality of pathology—that each individual has unique predispositions. He also discusses how the gene-environment interactions continue through adulthood, with negative feedback loops between problematic traits and stressful life experiences. For example, children with high levels of aggression and irritability are often in chronic conflict with parents, teachers, and peers. They respond to the conflicts with even more aggression. In contrast, children with behavioral inhibition elicit overprotective responses, which, in turn, increase their inhibition (p. 45).

Clearly, the interaction between infants and toddlers and their mothers is crucial. A great deal occurs between birth and age 2, when the child’s temperamental pattern becomes more or less stable. As Rothbart and colleagues (4) stated, “Temperament arises from our genetic endowment. It influences and is influenced by the experience of each individual, and one of its outcomes is the adult personality” (p. 122). The fact that a child’s temperament does not become stable until age 2 provides us with a crucial window to study the very early interactions as well as to develop early interventions to help mothers and other caretakers approach children in the most effective way, given their inborn temperamental tendencies. In view of how much current research documents the power of the early parent-child relationship, it is remarkable that psychodynamic principles have been so poorly represented by intervention practitioners. A nuanced psychoanalytic/psychodynamic orientation can help us understand and address the nature of these early interactions between mother and baby during the baby’s first 2 years of life in order to help the child navigate and master the normal and abnormal stresses of life.

A psychoanalytic approach to working with parents of babies and toddlers aims at aligning more closely the infant’s developmental and individual needs with the parents’ intrapsychic life, including their conscious and unconscious perceptions of themselves and their children and their resulting caregiving behaviors. Such an approach recognizes that infants are embedded in a relationship that is influenced by their parents’ rich history and their own quickly accumulating “biography.” The subjective experiences of the parents and the child are the links between past and present and are central to understanding motive and meaning of overt behavior.

In a psychoanalytic approach to working with mothers and their babies, for example, the analyst observes (and thus tries to affect) the process whereby the child constructs a representation of the mother during and as a result of the interactions between mother and baby (5). Nachman (6) showed that each mother has a distinctive representational world; thus, children are born into very different self-other environments. In the activities of the daily life of mother and baby, there is a constant repetition of minute mother-child representational patterns. Nachman tells us,

These unique mother-baby patterns are internalized by the child and allow children to master (or not master fully), modulate, and regulate their affective responses.

Paris hopes that one goal of future research will be to gain an understanding of how psychosocial factors interact with biological vulnerability to produce pathology (p. 160). It seems to me that contemporary psychoanalysts can contribute a great deal to the ongoing endeavors of Paris and his colleagues, particularly by studying and addressing the mother-child interaction during those very early years of life and how these interactions lead to normality or pathology.