Stability and Change in Personality Disorder

ABSTRACT— The standard view of personality disorder is that it is a maladaptive expression of personality traits, which are relatively stable and unchanging. Thus, personality disorder has been considered to have its roots in childhood and adolescence, to persist in adulthood, and to be difficult to change. However, recent research has challenged this view, revealing that personality continues to change, albeit more slowly, well into adulthood, and that the maladaptive manifestations of personality disorder are much less stable than previously believed. These research findings are described, and factors that influence stability and change in personality disorder are discussed. The emerging view of personality disorder has important implications for diagnosis, assessment, and treatment of personality pathology.     

Dimensions of DSM-IV personality disorders and life-success

This study examined associations between dimensional representations of DSM-IV personality disorders and life-success in a community sample of 304 men at age 48. Measures included a standardized social interview and the SCID-II for assessment of personality disorders. The identified indicators of life-success were factor-analyzed resulting in two moderately correlated components representing "status and wealth" and "successful intimate relationships." Avoidant, obsessivecompulsive, and narcissistic dimensional scores were positively associated with "status and wealth." Inverse relationships were found between dependent, schizotypal, schizoid, and adult antisocial personality disorder dimensions and this domain of life-success. Avoidant, schizoid, and borderline personality disorder dimensions were negatively associated with "successful intimate relationships." The findings suggest that although most personality disorders are associated with impaired psychosocial functioning and life-failure, some personality disorder traits (even if considered as pathological) can contribute positively to one important aspect of life-success: status and wealth.     

拒绝敏感性与边缘型人格特征的关联：一项元分析

运用元分析法整合探究拒绝敏感性与边缘型人格特征关联的已有实证研究, 旨在分析两者间的关联, 并同时考察可能影响该关联的其他变量。经过文献检索和筛选, 共纳入符合要求的原始文献50篇, 含84个效应量, 总样本量为7400人。同质性检验结果表明, 纳入研究的异质性较高, 故进一步对各影响因素变量进行了亚样本及元回归分析。结果发现, 在不同研究设计类型、被试所处地、样本类型、边缘型人格特征指标、拒绝敏感性测量类型的亚样本下, 二者之间的关联存在一定差异, 其中在横向设计、其他地区样本、混合被试、整体边缘型人格特征、量表法测量时所得的拒绝敏感性与边缘型人格特征间的关联最强; 年龄与女性被试比例对该关联不存在显著影响。未来研究可通过纵向研究进一步揭示二者间的预测方向, 考察拒绝敏感性不同成分与边缘型人格特征间的关联, 并在国内开展探索二者关联的研究。     

Traumatic Stress Personality Disorder (TrSPD): Intertheoretical Therapy for the PTSD/PD Dissociogenic Organization

This article discusses a new personality disorder entity, traumatic stress personality disorder, conceptualized as a composite organization with transactional properties that mutually structure post-traumatic stress disorder (PTSD) and personality disorders (PDs). The transactional/synergistic view of PTSD/PD comorbidity derives in part from scientific findings that PTSD's enduring biological effects are discernible in the personality of individuals 30 to 50 years or more after the overwhelming event, and from psychodynamic formulations on the development and structuring of personality defenses. An intertheoretical therapy model is also presented, and consists of multiple therapies actively integrated to meet the patient's complex post-trauma needs. This article argues for the development of theoretical, investigatory, and therapeutic measures to address PTSD/PD configurations in traumatized victims. Basically, the position espoused is that PTSD/PD should be measured as one rather than two entities, with neither component being considered as a confounding but integral factor in measurement. The eight components of traumatic stress personality disorder are discussed, along with a case study to demonstrate the model's clinical applications. The integration of cognitive, behavioral, psychodynamic, and existential treatment approaches is geared to assist the victim to developmental progress to survivor status, and then beyond this level of integration to thriver a person whose adaptational learning in therapy created a vital psychological immune system that consistently protects against dissociative regression in response to the daily stresses of life. Transference, countertransference, therapists' self-care and self-monitoring are seen as integral to the treatment of traumatic stress personality disorders.     

Is personality disorder inherited? An overview of the evidence

Genetic factors appear to be of considerable importance in determining normal variation in personality. This is suggested by family, twin, and adoption studies as well as by indirect findings based on animal and psychophysiological studies. In contrast, there is consistent evidence that the contribution of shared family environment is minimal. Despite difficulties in defining personality disorder, it appears that many types of personality disorder, in particular schizotypal personality disorder and antisocial personality disorder/criminality, are also influenced genetically. The genetic transmission of normal personality traits and disorder is most easily explained by the contribution of multiple genes of small effect rather than by single-gene inheritance. Recent advances in molecular genetics have led to the localization of genes of minor effect for some traits. This raises the possibility of detecting a molecular basis of traits and disorders such as personality and personality disorder.Anita Thapar is supported by a Research Training Fellowship from the Medical Research Council.     

Attitudes of clinical psychologists towards clients with personality disorders

Previous studies have found that a variety of mental health professionals hold negative attitudes towards clients diagnosed with a personality disorder. These negative attitudes may lead to clients receiving a lower quality of service. Specialist training has been found to improve attitudes towards personality disorders but no empirical studies in Australia have examined this among clinical psychologists. In this study, the attitudes of 81 clinical psychologists towards clients with personality disorders were examined. We were specifically interested in investigating the relationship between recency of specialist training and clinician's attitudes as well as the influence of percentage of personality disorder clients on the clinician's caseload. Results demonstrated that both recency of specialist training and percentage of clients seen were associated with more positive attitudes; however, a higher caseload of clients with personality disorders was the most important predictor of positive attitudes. The implication is that recent participation in specialist training for personality disorders appears to be valuable in improving clinician's attitudes but that more positive attitudes are associated with seeing a greater number of individuals with personality disorders.     

Current status of the scientific study of the personality disorders: an overview of epidemiological, longitudinal, experimental psychopathology, and neurobehavioral perspectives

Research on the nature and development of personality disorders has grown immensely over the past thirty years. A selective summary overview is given of the current status of the scientific study of the personality disorders from several perspectives, including the epidemiological, longitudinal, experimental psychopathology, and neurobehavioral perspectives. From this research, we now know that approximately 10 percent of the general population suffer from a diagnosable personality disorder. Moreover, contrary to nearly a century of theory and clinical pedagogy, modern longitudinal studies clearly suggest that personality disorders decrease in severity over time. The mechanisms by which this change occurs are not understood at present, though it is not likely that change in underlying normal personality systems drives the change in personality disorder. The methods of the experimental psychopathology laboratory, including neuroimaging approaches, are being brought to bear on the nature of personality disorders in efforts to relate neurobiological and neurocognitive functions to personality disorder symptomatology. A model that links personality disorder feature development to underlying, interacting brain-based neurobehavioral systems is reviewed in brief. Current issues and findings illustrative of these developments are given using borderline personality disorder as an exemplar. Finally, areas of intersection between psychoanalytic treatment approaches and the growing science of personality disorder are highlighted.     

Gender differences in the frequency of personality disorders in depressed outpatients

We examined gender differences in the frequency of DSM-III-R personality disorder diagnoses and symptomatology in a sample of 225 depressed outpatients. This research partially replicates and extends one of the first studies in this area by Golomb et al. (1995). Males were significantly more likely than females to meet diagnoses for schizotypal, paranoid, narcissistic, antisocial, obsessive compulsive, and borderline personality disorder. Compared to females, males were also significantly more likely to have schizoid, schizotypal, narcissistic, antisocial, and obsessive-compulsive personality disorder symptomatology. Females did not predominate in any personality disorder symptomatology or diagnoses. A possible explanation for these findings is discussed. The results of this study challenge traditional assumptions about gender differences in the frequency of personality disorders, and confirm the need for future studies to investigate the relation between gender and personality disorders in specific Axis I samples.     

Cross-cultural clinical judgment bias in personality disorder diagnosis by forensic psychiatrists in the UK: a case-vignette study

Previous research in the UK has suggested that cross-cultural bias in personality disorder diagnosis might partly account for the smaller proportion of Black, relative to White, patients with personality disorder in secure psychiatric hospitals. Using the case-vignette method, we investigated cross-cultural clinical judgment bias in the diagnosis of personality disorder in African Caribbean men by 220 forensic psychiatrists in the UK. In the vignette describing possible DSM-IV antisocial personality disorder, Caucasians were 2.8 times more likely to be given a diagnosis of personality disorder than African Caribbeans. Diagnosis also varied according to the ethnicity of the clinicians. No cross-cultural bias was found in the vignette describing possible DSM-IV borderline personality disorder. These findings are important in relation to recent policies for offenders and others with personality disorder, and to the current focus on delivering race equality in mental health services in the UK. Ongoing debates about the strengths and limitations of the case-vignette method are also discussed.     

Deconstructing dependency in a five-factor world: a meta-analytic review

Meta-analysis of studies assessing the relation between interpersonal dependency test scores and five-factor model (FFM) domain scores revealed that dependency scores are positively correlated with FFM Neuroticism and Agreeableness scores and negatively correlated with FFM Extraversion, Openness, and Conscientiousness scores. The magnitudes of these correlations were all in the small-to-moderate range, and comparable score intercorrelations were obtained when participants' dependency levels were assessed by means of a trait dependency questionnaire, dependent personality disorder questionnaire, or dependent personality disorder interview. These findings have implications for researchers' efforts to deconstruct dependency into its basic trait elements and for the dimensional approaches to personality disorders being considered for future versions of the Diagnostic and Statistical Manual of Mental Disorders.     

Using DSM axis II information to predict outcome in short-term individual psychotherapy

The present study considered three methods of using DSM Axis II information to examine the effect of personality disorder on outcome in two forms of short-term, individual psychotherapy (interpretive and supportive). The first method involved examining whether the presence of any personality disorder influenced treatment outcome. The second method involved examining the effect of the number of personality disorders on outcome. The third involved examining outcome for specific personality disorders. The study found that a diagnosis of any personality disorder did not influence the outcome of therapy. In contrast, the number of personality disorders was significantly related to outcome at post-therapy and at 12-month follow-up. The findings indicated that a greater number of personality disorders was associated with less favorable outcome across both forms of therapy. This supports the notion that personality pathology is more severe when it involves a greater number of personality disorders. In an exploratory set of analyses, the study also found some evidence of differences in outcome for specific personality disorders.     

Psychoanalytic patients in the U.S., Canada,and Australia: II. A DSM-III-R validation study

A study was conducted to validate our previous work on the DSM-III-R disorders diagnosed in patients in psychoanalysis in the U.S., Canada, and Australia and to determine which specific mood, anxiety, and personality disorders were the most common in these patients. The earlier study consisted of three surveys of psychoanalytic practice that together obtained data on 1,718 patients, through extensive mail surveys to analysts in the three countries. In the validation study, 206 patients were diagnosed using a different technique. Analysts similar in important respects to those who participated in the original surveys rated patients diagnostically before and after DSM-III-R training. After training, no significant changes appeared in the rates for any of the specific mood disorders. For the thirty disorders examined, training effects decreased the identification of the generalized anxiety disorder, and increased the identification of three personality disorders: avoidant, dependent, and personality disorder not otherwise specified. Thus, analysts slightly underdiagnosed the number of personality disorders, and some "anxious" patients appear to have qualified for personality disorders. Some limitations of the DSM-III-R notion of narcissistic personality are discussed, as are the importance and stability of the self-defeating (masochistic) personality disorder. The most common Axis I disorder in psychoanalytic patients was dysthymia, followed by major depression, recurrent. This study reinforces the findings of the original three surveys. Minor corrections were developed to adjust the original three surveys.     

The relationship between comorbid personality disorders and treatment received in patients with anxiety disorders

Few studies have addressed the relationship between the presence of a comorbid personality disorder and the amount of psychiatric treatment received by patients with an Axis I disorder. This issue has not been studied in patients with anxiety disorders. In a prospective, naturalistic, longitudinal study of anxiety disorders, 526 subjects were assessed with the Personality Disorder Examination, and types of treatment received in 1991 and 1996 were identified. In 1991, compared to subjects without a personality disorder, subjects with a personality disorder were as likely to receive medication and they received a greater number of medications. Subjects with borderline personality disorder were more likely to receive heterocyclic antidepressants and interventions characteristic of psychodynamic psychotherapy and cognitive therapy; they also reported receiving a greater number of medications and types of psychosocial treatment than other subjects. In 1996, subjects with borderline personality disorder were more likely to receive psychodynamic interventions. These findings suggest that in patients with an anxiety disorder, the presence of a comorbid personality disorder is associated with receiving a greater number of medications but not with a greater likelihood of receiving pharmacologic or psychosocial treatment. However, the presence of borderline personality disorder is associated with a greater likelihood of receiving, and receiving a greater number of, certain types of somatic and psychosocial treatments.     

Classifying personality disorder according to severity

Current systems for classifying personality disorder according to specific categories are unsatisfactory because they do not take account of wide variations in levels of personality disturbance and associated impairment. We review previous attempts to classify personality disorder according to severity and place these findings in the context of work exploring the severity of other mental disorders. On the basis of these findings, we propose a new system for classifying personality-related problems based on severity defined by the extent of personality disturbance, the level of social dysfunctioning, and the impact of the disorder for individuals and society. We recognize that studies using these definitions will need piloting and testing in field trials, but believe that this simplified approach to classifying personality disorder would encourage greater use by clinicians and assist those involved in planning services for people with personality disorder.     

Patterns of personality pathology in patients with generalized anxiety disorder, panic disorder with and without agoraphobia, and social phobia

The relationship between co-occurring personality disorders and anxiety disorders (panic disorder with or without agoraphobia, social phobia, and generalized anxiety disorder) was examined, taking into account the effect of major depression. This article describes findings for 622 participants in the Harvard/Brown Anxiety Research Project, a longitudinal follow-up study of DSM-III-R-defined anxiety disorders. A total of 24% of participants had at least one personality disorder, with avoidant, obsessive compulsive, dependent, and borderline most common. Generalized anxiety disorder, social phobia, and major depression were positively associated with the occurrence of one or more personality disorders, whereas panic disorder with agoraphobia was not associated. Major depression was associated in particular with dependent, borderline, histrionic, and obsessive compulsive personality disorders and social phobia was associated with avoidant personality disorder. Whereas some of our findings confirm results from earlier studies, others are somewhat inconsistent with previous results and indicate the need for further investigation.     

Commonality and specificity of personality disorder profiles in subjects with trauma histories.

Recently, attention has been drawn to a range of disturbances in personality functioning that commonly characterize individuals with a history of severe or prolonged trauma. Many of these features overlap with criteria for some of the Axis II personality disorders. The current study investigated the similarity of personality disorder features in different samples of patients with trauma histories, and specificity of such features compared to other psychiatric samples. Profiles of Axis II features, based on relative frequencies of individual disorder "diagnoses" derived from a common measure (Personality Diagnostic Questionnaire-Revised), were compared in three trauma samples: male Vietnam combat veterans with PTSD, female inpatients with a history of childhood sexual abuse, and female outpatients with a history of childhood sexual abuse. The PDQ-R derived profiles in each of the three trauma samples were then compared with similar PDQ-R derived profiles in published reports of psychiatric samples selected for other diagnoses. Each of the three Spearman rank correlations among the three trauma samples were significant, ranging from .72 to .94. There was a clear pattern of higher correlations within the trauma samples (average correlation of .81) than between the trauma and nontrauma samples (average correlations of .11, .36, and .25 between the nontrauma samples and the combat sample, inpatient sexual abuse sample, and outpatient sexual abuse sample, respectively). The findings suggest that a pattern of personality disorder features may be distinctly associated with individuals with trauma histories, at least of the type examined here. Future studies using more clinically valid measures of personality features and including other types of trauma samples are needed to determine the generalizability of the current findings. Also needed are studies with longitudinal designs to address questions of causal pathways that may underlie such associations.     

PERSONALITY MEASURES AS PREDICTORS OF JOB PERFORMANCE: A META-ANALYTIC REVIEW

The purpose of this study was to investigate conflicting findings in previous research on personality and job performance. Meta-analysis was used to (a) assess the overall validity of personality measures as predictors of job performance, (b) investigate the moderating effects of several study characteristics on personality scale validity, and (c) appraise the predictability of job performance as a function of eight distinct categories of personality content, including the "Big Five" personality factors. Based on review of 494 studies, usable results were identified for 97 independent samples (total N = 13,521). Consistent with predictions, studies using confirmatory research strategies produced a corrected mean personality scale validity (.29) that was more than twice as high as that based on studies adopting exploratory strategies (.12). An even higher mean validity (.38) was obtained based on studies using job analysis explicitly in the selection of personality measures. Validities were also found to be higher in longer tenured samples and in published articles versus dissertations. Corrected mean validities for the "Big Five" factors ranged from .16 for Extroversion to .33 for Agreeableness. Weaknesses in the reporting of validation study characteristics are noted, and recommendations for future research in this area are provided. Contrary to conclusions of certain past reviews, the present findings provide some grounds for optimism concerning the use of personality measures in employee selection.     

Personality disorder cognitions in the eating disorders

The eating disorders are frequently found to be comorbid with Axis II cluster B and C personality disorders. It is important to identify the personality-level cognitions that typify these disorders. This study of a clinical group examines the personality disorder cognitions in the eating disorders. The cognitions that were most relevant to the eating disorder pathology were those relating to avoidant and obsessive-compulsive personality disorder. Other personality disorder cognitions were associated with comorbid psychopathology in largely clinically meaningful ways. These findings extend our understanding of the comorbidity of eating disorders and personality pathology, suggesting that some cases need to be assessed and formulated with such cognitions in mind. Treatment strategies are required that address both the eating and the personality pathology, while considering the impact of these cognitions on the therapeutic relationship.