Discussion Wk 11Amblerchick
Personality Disorders Over Time: Implications for Psychotherapy
JOEL PARIS, M.D.
Personality disorders have an early onset, and are associated with dysfunction over the course of adult life. Antisocial and borderline personality disorders tend to remit with age, hut other categories do not usually show improve- ment. The chronicity of personality disorders is hoth a challenge and a frame for treatment planning. Psychotherapy for these patients can focus on rehabilitation and the development of social niches that match their person- ality profiles.
THE NATURE OF PERSONALITY DISORDERS
Patients with personality disorders are common in clinical practice (51). But this population presents a number of difficulties for effective treatment (17,29). These conditions are associated with strikingly low levels of functioning (23,44). Moreover, by definition, personality disor- ders begin early in development and go on to have a chronic course (1).
This degree of chronicity and dysfunction requires an explanation. It has long been assumed that "deep-seated" problems must originate in early childhood, and that problems present for years require years of therapy. This point of view has led to therapeutic approaches designed to discover and repair conflicts arising in early development.
However, recent evidence suggests that these etiological assumptions are, at least in part, mistaken. In medicine, diseases that begin early in life and go on to chronicity tend to be associated with higher genetic vulner- ability (7), and similar principles apply to most mental disorders (25). Behavioral genetic studies show that about half the variance affecting personality traits (12), as well as personality disorders themselves (46), is accounted for by genetic factors. There is strong evidence that personality disorders are rooted in heritable traits that reflect temperament (40,43,29).
However, these findings do not mean that personality disorders are
Professor of Psychiatry, McGill University. Mailing address: Institute of Community and Family, Psychiatry, 4333 chemin de la cote Ste. Catherine, Montreal, Quebec, H3T 1E4, Canada, e-mail: [email protected]
AMERICAN JOURNAL OF PSYCHOTHERAPY, Vol. 58, No. 4, 2004
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purely genetic, or that their causes lie only in "chemical imbalances." Environmental factors, most particularly childhood adversities, are also important (13). These risk factors have been most consistently identified in research on antisocial personality (38) and on borderline personality (50).
The real issue is that the impact of adverse events can only be understood in interaction with temperament. This principle is supported by research showing that in most cases, childhood trauma does not lead to pathological sequelae (41). In general, life events have greater effects on those who are vulnerable (25). The development of a diagnosable person- ality disorder depends on a complex combination of genetic and environ- mental factors, which are best formulated in a stress-diathesis model (22,25).
PRECURSORS, COURSE AND OUTCOME OF PERSONALITY DISORDERS
Personality disorders do not arise in adulthood de novo. These condi- tions have a continuous relationship with normal personality traits (17), and differences are only a matter of degree. These trait profiles also reflect patterns of vulnerability that can be identified prior to the onset of a diagnosable disorder.
Although personality disorders may only be present clinically at ado- lescence, they usually have childhood precursors. The best documented example concerns antisocial personality, for which conduct disorder is an established precursor (38). Patients who later develop borderline person- ality may also have had difficulties during childhood, probably a combi- nation of externalizing and internalizing symptoms (27). Patients who develop avoidant personality disorder in adulthood may have been unusu- ally shy ("behaviorally inhibited") as children (14,25). Finally, patients who develop schizoid or schizotypal personality disorders may show similar symptoms during childhood (48).
Childhood precursors reflect temperamental variations that shape trait profiles, and temperament also explains why personality is highly stable over the life course (18). But traits do not, by themselves, lead to psychopathology. Disorders require an amplification of traits to dysfunc- tional proportions, a process strongly affected by environmental factors. For this reason, one can conceive of reversing the process in therapy, bringing patients back from personality pathology to temperamental bed- rock.
By adolescence, one sees fairly typical cases of personality disorder (15). While specific categories tend to be unstable, diagnostic shifts usually fall
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within the Axis II clusters, and patients remain symptomatic in young adulthood (5). Over the course of adulthood, personality disorders are chronic but not necessarily continuous. They often show a waxing and waning pattern marked by improvements and exacerbations (8). In pro- spective studies of borderline personality, some patients even seem to "remit," in the sense that they no longer meet criteria for a category; however most still have low levels of functioning (44) and continue to merit an overall diagnosis of personality disorder.
The long-term outcome of personality disorders varies by category. The diagnoses in Cluster B of Axis II show the most improvement. For example, many patients with antisocial personality disorder (ASPD) no longer meet criteria by middle age. But they continue to have problems in interpersonal relationships, consistent with an overall diagnosis of person- ality disorder (6). Thus, while antisocial patients are less likely to commit crimes in later life, they continue to be poor spouses, inadequate parents, and unsteady workers. A quarter of them will die prematurely. These findings support the caution of most clinicians about treating these patients.
The prognosis of borderline personality (BPD) is much better (28). If one defines recovery as attaining close-to-normal functional status and no longer meeting diagnostic criteria for the disorder, then we can say that most patients achieve that recovery. While in naturalistic studies (36), little improvement is seen at five-year follow-up. However, striking degrees of recovery have been documented at 15-year follow-up (19,45,29,35): by age 40, most patients are doing reasonably well, i.e., attaining scores over 60 on global assessment of functioning, and with only 2 5 % still meeting BPD criteria. After 27 years (at a mean age of 50), only 8% still meet BPD criteria) and mean global functioning scores are still over 60 (31). Thus, therapists can be reasonably optimistic, at least in the long-term, when taking on these patients.
A recent report from Zanarini et al. (50) documented a more rapid improvement (although not full recovery) in BPD patients followed over six years. An ongoing NIMH longitudinal study (9) followed patients in four categories (borderline, schizotypal, avoidant, and compulsive) and reported similar results. The findings showed remission from Axis II disorder (8), although most continued to have functional impairment (44).
These findings seem to suggest that patients with personality disorders can improve naturalistically, independent of treatment. However, thera- pists tend to focus their efforts on more severely dysfunctional sub- populations, and these patients are less likely to get better with time (52).
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Moreover, more rapid improvement may occur in research subjects who accept regular follow-up evaluation and who stay in long-term treatment. Given the natural sifting process of clinical practice, in which many patients drop out, those who stay in therapy may do somewhat better than those who do not.
But these patterns of improvement have a "down side." About 2 5 % of recovered patients with BPD still suffer from chronic mood symptoms (31). Improvement in Cluster B disorders seems to be mainly related to decreases in levels of impulsivity, while affective symptoms are more likely to continue (29). Also, the overall rate of completed suicide in naturalis- tically followed BPD samples is close to 10% (45,29), and there is also an unusually high rate (8%) of death from natural causes (31). Nonetheless, most patients with BPD recover, even after long periods of chronic suicidality.
The age at which suicide occurs is clinically important. The mean age at completion is 30 at 15-year follow-up (45), and 37 at 27-year follow-up (31). Thus, suicide completions in BPD usually take place relatively late in the course of the illness, not in the early 2O's when patients show the highest rates of suicidal threats and attempts (30). While most patients do not commit suicide, this outcome is most likely to occur when patients despair after years of unsuccessful treatment.
There is only a small amount of data on the outcome of other personality disorders. In Cluster A disorders, such as schizotypal person- ality, one rarely sees remission (20). Patients with Cluster C personality disorders also tend to remain dysfunctional over time (42,37). While some studies point to improvement in narcissistic personality (34,39), the data are derived from patients hospitalized for depression, a sample that is not representative of clinical practice. For most narcissistic patients, the prognosis must be guarded (14a).
A REHABILITATIVE STRATEGY EOR TRAIT MODIFICATION IN PATIENTS WITH PERSONALITY DISORDERS
In chronic disorders, therapy needs to have realistic goals. In person- ality disorders, the goal of treatment can be rehabilitation rather than "cure".
While there is overall evidence for the efficacy of psychotherapy in patients with personality disorders (32), results vary by category. Several studies (11,47,45a) have shown that patients with Cluster C disorders can respond to either dynamic or cognitive therapy. However, most research has focused on BPD. Many borderline patients receive pharmacotherapy,
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but the results can best be described as ameliorative (24). On the other hand, the evidence for the efficacy of psychotherapy is strong (29).
Several approaches to the psychotherapy of BPD have been tested empirically. The most extensive research is on dialectical behavior therapy (DBT), which has been shown to be effective for parasuicidal behaviors over a year of treatment (16), although we do not know whether DBT changes long-term course. Psychodynamic therapy, specifically "mental- ization based treatment" (3), has also been shown to be effective in BPD, at least within the context of day treatment (2) and other types of dynamic therapy also have proven effectiveness in this context (33). Schema therapy (49), a mixture of cognitive and dynamic therapy, is currently being exposed to clinical trials.
The question is whether these methods can be applied to the ordinary practice of psychotherapy. These approaches have been tested in special- ized treatment programs that are expensive and not always available. Therapists require a set of methods that they can apply in their offices. For this reason, several authors have recommended practical approaches to the therapy of personality disorders that are at least consistent with existing empirical data (10,17,26,29).
The method suggested here can best be described as rehabilitative. It stands on three general principles. First, since personality traits are stable over time, therapists need not attempt to achieve radical change; it is sufficient to help patients to reach a better level of functioning. Second, the chronic course of personality disorders means therapists should set real- istic goals, with scaled down expectations, seeing small gains as significant victories. Third, patients need to focus less on their past, and more on the way they feel, think and behave in the present. When patients can reflect and identify current problems, they are more likely to modify emotions, thoughts and behaviors when faced with new stressors.
While it is illusory to expect therapy to change personality, traits can be modified to modify their behavioral expression. Moreover, patients can learn to make more judicious and selective use of existing traits, and put them to better use. The same characteristics that are maladaptive in some contexts can be adaptive in other contexts (4). Therefore, patients can capitalize on their strong points by selecting environments in which traits are most likely to be useful. They can also minimize weak points by avoiding environments in which their traits are not useful. This process might be described as finding a suitable social niche.
To achieve these goals, it is useful to think of psychotherapy as a form of education, with a curriculum focusing on better and more adaptive use
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of traits. The classroom teaching takes place in the therapist's office, the laboratory is the patient's life, and the homework consists of applying new behaviors to old situations.
In managing personality disorders, therapists can also keep in mind that most patients improve without treatment. Naturalistic recovery prob- ably occurs as a result of modulating problematical behaviors and finding more adaptive solutions to problems. The goal of therapy is to speed up this process.
A general model of treatment for personality disorders might be divided into four steps:
1) Identifying when traits or behavioral patterns are maladaptive. 2) Observing the emotional states that lead to problematic behaviors. 3) Experimenting with more effective alternatives to see how they
work. 4) Practicing new strategies. To illustrate how the model can be applied in practice, I will present a
clinical example of the treatment of a patient with BPD.
Claudia was a 19-year-old student who complained of depression and therefore was referred by her supervisor to a psychiatrist. When he immediately prescribed an antidepressant, Claudia felt misunderstood, and angrily swallowed the whole bottle, precipitating a hospital admission.
Claudia had also felt misunderstood by her parents. Claudia's father, a military man, had moved around the country, leaving Claudia's mother feeling neglected and unhappy. But these family problems have to be understood in interaction with Claudia's volatile temperament, apparent even during her childhood. Claudia was one of four children, and the only one to have significant psychological symptoms.
Claudia spent two months in the hospital, and there were complications concerning her discharge. Facing separation from the protected milieu, she had a micropsychotic episode, marked by disorientation and auditory hallucinations. Claudia was prescribed a low-dose neuroleptic for the next few months, and was then followed in outpatient psychotherapy over a period of three years.
Identifying: A primary goal was to help Claudia identify her inner reactions to life
events, as opposed to blaming others for bringing feelings on. Most of this work focused on increasing Claudia's tolerance for the defects of her parents. Claudia also had to undergo a slow and painful separation from
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a fellow student with BPD. This student was admitted to the ward at the same time, and encouraged her to think about suicide rather than about coping.
Claudia had to learn to observe episodes of emotional dysregulation in order to manage them better. Many therapy sessions focused on her disappointments and separations. Claudia also needed to identify her tendency to devalue people when they disappointed her. She learned to tolerate the fact that the therapist would not always understand her, and that she needed to wait when he went on vacation.
Experim en ting: Claudia began a series of relationships with men, but her initial choices
were unsuitable. She learned from these experiences about the strength of her needs and how to modulate them. Aware of these sensitivities, Claudia was less likely to have her emotions spin out of control. Once Claudia completed her education, she developed professional competence that became an important protective element from emotional storms. She also established better friendships, finding confidantes who supported health rather than pathology.
During the course of her therapy, Claudia developed her career and entered a serious relationship, marrying a man who appeared to be a stabilizing factor in her life. She now no longer fell into uncontrolled emotional states and gave up her impulsive behavioral patterns. Termina- tion was mutually agreed on, and did not lead to the complications that had occurred when she was discharged from the hospital.
Claudia was interviewed 15 years after her initial presentation. At age 34, she had no symptoms, and was rising in the hierarchy of her company. But Claudia's marriage was not a success, and she had begun a long-term affair with a married man. They would meet briefly in town, or for longer periods during conferences. Claudia may have found it easier to have a relationship with a man who she did not have to live with. The excitement of a secret romance trumped the disillusionment of intimacy.
When Claudia was interviewed at age 49, again, she had no symptoms. Claudia had risen in her company, and now held an executive position. But she had left her husband, and had borne a child by her lover. This man had never been willing to leave his wife, and while he and Claudia were no
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longer physically involved, they still saw each other. The son, now eight years old, was the center of Claudia's life. She expressed concern that at some point she would have to tell her son the identity of his father.
Claudia had found a niche in life that was unconventional, but may have been more suitable for her than ordinary family life. She also found that raising a child avoided the difficulties associated with depending on other people. At this point, Claudia did not seem to be recreating previous interpersonal conflicts with her son, although one wondered how she would deal with his adolescence.
The case presented here is fairly representative of the therapy of patients with personality disorders. Its long-term outcome, with steady employment but somewhat restricted intimate relationships, is typical for the larger sample described in our research (31). A good outcome need not consist of an untroubled life, but a way around troubles.
In patients with personality disorders, difficulties can sometimes con- tinue for some years following termination, consistent with the chronic and slowly remitting patterns observed in long-term follow-up studies.
Thus, further courses of psychotherapy are not uncommon in this population. Researchers on the long-term outcome in BPD (21,29) have recommended that the therapist's door should always be kept open. Once a patient's problems are well known, "retreads" can often be brief. Thus, intermittent rather than continuous therapy may be the most appropriate and cost-effective prescription for patients with personality disorders.
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