Personality Disorders —“Why Bother? They Never Get Better…” Or Do They?
By Lynn K. Jones, DSW
Social Work Today
Vol. 5, No. 1, Page 32

Every social worker has encountered an intractable client diagnosed with a personality disorder, and we’ve all heard the rationales used to shuffle this client aside: “You can only handle one borderline in a caseload.” “Personality disordered clients are the prime reason therapists burn out.” “Why bother? They never get better.”

According to conservative estimates, approximately 10% of the population is affected with a personality disorder. A recent national study (Grant, Hasin, Stinson, et al., 2004) suggests that the figure is closer to 13%. That represents millions of “hopeless” cases.

In 1890, William James suggested that the personality is “set in plaster” by the age of 30. With this as a premise, it follows that a “disorder of the personality” is no more amenable to change than personality. In fact, it is this model that seems to underlie everything currently understood about personality disorders and remains a cardinal assumption in psychiatry and psychology today. The Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) cautions that the symptoms of clients diagnosed with personality disorders are “stable, enduring, and persistent across the life span.”

Just as the characteristics of personality disorders are believed to be firmly set, so also are the defenses of an individual with a personality disorder. In an article titled “The Beginning of Wisdom is Never Calling a Patient Borderline” that appeared in the Journal of Psychotherapy Practice and Research (1992), George E. Vaillant, MD, says, “The defenses of patients with personality disorders have become part of the warp and woof of their life histories and of their personal identities.”

Mark F. Lenzenweger, PhD, a professor of psychology at Binghamton University, began studying people with personality disorders in the 1980s in an effort to develop an assessment tool, referred to as the International Personality Disorder Examination. During that work, he discovered that there were no empirical data to support the conventional wisdom that individuals with personality disorders can’t change. To test this supposition, in 1990 he launched a longitudinal study of young adults diagnosed with personality disorders. It was the first study examining personality disorders over time using modern methods and design features.

To understand personality, it is necessary to consider temperament. Thought to be more biologically based, temperament is in evidence at birth. It is the foundation upon which personality develops. Psychologists often think of personality as being the interaction of temperament and environment, along with other influences. “Temperament is the basic material, the building block of what will be your personality,” Lenzenweger suggests.

Normal personality is subject to substantial genetic influences, and it is increasingly believed that there is a genetic component to personality disorders also. Just as personality seems to be a composite of genetics, neurobiology, environment, and experience, so too are personality disorders. In some personality disorders, there seems to be a greater correlation with one of these factors. For example, 70% of people diagnosed with a borderline personality disorder (BPD) have experienced severe childhood sexual abuse.

Lenzenweger’s study, funded in part by the National Institute of Mental Health, has for the last 14 years been following 250 young adults. Approximately one-half of the individuals were deemed to be at increased risk for a personality disorder and the other half were deemed to be at low risk. Lenzenweger hoped to understand what happened to the personality disorder features of these young adults over time. In this “naturalistic study,” the participants were able to seek treatment on their own. The study did not dictate what type of treatment the clients participated in, but the majority of them sought either conventional psychotherapy or counseling.

The participants were initially selected based on their responses to a well-developed screening questionnaire that revealed either a likely personality disorder or a low risk for one. All were first examined when they were 18, again at 19, and then again at 21. Lenzenweger was interested in this age group based on the DSM-IV’s determination that personality disorders develop during late adolescence and are clearly evident by early adulthood. Each participant was intensively assessed through two psychiatric interviews with a skilled diagnostician, a PhD-level psychologist, or a social worker experienced with this age group. A professional never assessed the same individual twice as Lenzenweger wanted to avoid the possibility that an assessor would remember responses from a previous interview, which might taint their findings.

Each participant was carefully characterized in terms of personality disorder features. Two assessment methods were used on each participant to avoid technique bias. In addition, the participants’ normal personality features, their temperament features, and their sexual conformity features, among others, were also assessed. They were also evaluated using normal measures of mental disturbance for conditions such as depression, bipolar disorder, or schizophrenia.

Lenzenweger, along with his colleagues Matthew Johnson, PhD (State University of New York, Binghamton), and John B. Willet, PhD (Harvard), analyzed the findings using a technique called growth curve analysis. This technique looks at a trajectory for each person over time to develop a picture of how he or she is changing, and it also allows the researchers to estimate a rate of change. They found that the rate of change for the sample as a whole was “very substantial.” The research indicated that, on average, people in the study were dropping approximately 1.4 personality features per year. “For something that is not supposed to be changing at all, that was a rather large amount of change,” says Lenzenweger.

They looked to see if they could explain the change in other ways. They found that one sex was not changing more than the other and that there was no another condition, such as major depression or another Axis I disorder, driving the change. They also found that whatever treatment the individual had sought during the study was unrelated to the change.

The striking finding was that every personality disorder underwent some statistically reliable degree of change, although the paranoid personality disorder changed a little less than the others. The researchers concluded that all the personality disorders declined in features over time. This stunning conclusion overturns the mind-set that has dominated the very definition of personality disorder for more than a century. Not only can people with personality disorders change, but they do.

Robert L. Trestman, PhD, MD, director of the Personality Disorders Foundation, has been studying the neuropsychology and neuropsychiatry of severe personality disorders since the early 1990s and believes that the study’s findings “make a good deal of sense.” Trestman’s view is that this study needs to be understood in the context of evolving diagnostic criteria for personality disorders. He explains, “Thirty to 40 years ago, people with personality disorders were all diagnosed in a more ambiguous way, without clear criteria sets and more dimensionally—ie, by the severity of different characteristics, behaviors, and coping styles. Since the development of the DSM-IV, diagnostic criteria were more carefully articulated.” The upside of these improved diagnostic criteria is that they point the way for more research, such as Lenzenweger’s study. The downside is that diagnosis became more categorical—someone either has a personality disorder or he doesn’t.

Because there are many gradations in a personality disorder, the categorical determination of a diagnosis is particularly problematic when considering change, according to Trestman. For example, if someone originally met nine out of nine of the criteria for BPD and improved on three, they still meet criteria for a diagnosis of BPD. He or she still carries the diagnosis even though the severity of illness may be dramatically reduced and the residual symptoms diminished. Similarly, if a person originally had five of the criteria and only three after one year, then they no longer meet criteria for a BPD diagnosis, even though the two remaining criteria may be problematic for them.

Lenzenweger and his colleagues were able to circumvent this limitation of the current DSM-based categorical method by approaching each of the personality disorders as a dimension, which is a more sensitive way to study change and stability.

Do the findings of Lenzenweger’s study change the current DSM-IV definition that personality disorders are “stable, enduring, and persistent across the life span”? Trestman believes this description still applies. He sees personality disorders as a spectrum of disorders. While they have the capacity to change, they are nonetheless chronic—more like hypertension or diabetes, which cannot be cured but can be controlled and managed. Just as the severity waxes and wanes over time, so too, he believes, do personality disorders.

Trestman is most excited about this research because of its potential to change the way we think about the personality disorder diagnosis. He hopes that it will help clinicians understand that “a diagnosis is not the reality but a way to recognize that people with particular signs, symptoms, and problems have tended to have similar risks and to respond to similar kinds of treatments.” He also hopes that it will begin to destigmatize the illness. In this new model, personality disorders are understood to be chronic illnesses for which the severity of the symptoms can be reduced and the individuals’ functional status improved. Personality disorder is not a hopeless diagnosis but one that carries the potential for improvement and building meaningful lives.

In fact, there are two specialized treatment modalities that show promise, especially for BPDs. Otto F. Kernberg, MD, FAPA, of the Weill College of Medicine of Cornell University, has developed one treatment approach that has been getting good outcomes. His transference-based psychotherapy is a modification of the more traditional psychoanalytic therapy. Marsha M. Linehan, PhD, of the University of Washington, has developed a form of treatment called dialectical behavior therapy that is successful in reducing self-harming and self-mutilating behaviors and also attempts to incorporate more proactive approaches into the therapy to deal with stormy emotional moments in the life of someone with BPD. Linehan has found that approximately 30% of the symptoms in BPD will reduce after one year of treatment with dialectical behavior therapy. With medication, the symptoms may be even further reduced.

For people diagnosed with personality disorders, there is a new ray of hope. Clinicians, patients, and family members can reframe their idea of personality disorders as fixed and hopeless to chronic and treatable. They can feel encouraged to not give up. Clearly, we now know that many people with personality disorders do get better, even though we can’t easily predict who they are at this time. Hopefully, more research will yield further insights. In the meantime, we also know that clinical programs to support people with personality disorders produce worthwhile results.

“Why bother? They never get better” is no longer a sound perspective.

— Lynn K. Jones, DSW, is a freelance writer and an executive coach and organizational consultant in Santa Barbara, CA. As a specialist in organizational culture, she supports leaders and organizations in developing mission-driven cultures.

References
Grant, B. F., Hasin, D. S., Stinson, F. S., et al. (2004). Prevalence, correlates, and disability of personality disorders in the United States: Results from the national epidemiologic survey on alcohol and related conditions. J Clin Psychiatry, 65, 948-958. Retrieved from http://www.psychiatrist.com/privatepdf/2004/v65n07/v65n0711.pdf.
Vaillant, G. E. (1992). The beginning of wisdom is never calling a patient a borderline. J Psychotherapy Practice and Research, 1, 117-134.

Resources
Treatment and Research Advancements National Association for Personality Disorder (BPD)
A nonprofit organization whose mission is to foster education and research in the field of personality disorders, specifically (but not exclusively) borderline personality disorder.
www.tara4bpd.org

Personality Disorders Foundation
An informational Web site about personality disorders, how they are diagnosed, the impact on individuals and loved ones, educational resources, and clinical services.
http://pdf.uchc.edu

National Education Alliance for Borderline Personality Disorder
The National Education Alliance for BPD seeks to raise public awareness, provide education, promote research on BPD, and enhance the quality of life of those affected by this serious mental illness.
www.borderlinepersonalitydisorder.com

Borderline Personality Disorder Research Foundation
A nonprofit organization that supports international research on the underlying causes, characteristics, and treatment of BPD.
www.borderlineresearch.org

International Society for the Study of Personality Disorders
Regional and national organizations that encourage the initiative of education and research on personality disorders, as well as collaborative efforts across countries and regions.
www.isspd.com

Behavioral Research & Therapy Clinics
Directed by Marsha M. Linehan, PhD, the Behavioral Research & Therapy Clinics is a research facility that specializes in developing and evaluating new treatments for difficult-to-treat disorders and training therapists in the use of effective behavioral treatments for complex, multisystemic disorders.
www.brtc.psych.washington.edu

Borderline Personality Disorder Resource Center
New York-Presbyterian, The University Hospital of Columbia and Cornell
Directed by Otto F. Kernberg, MD, FAPA, this program is set up specifically to help those affected by BPD find the most accurate information on the nature of BPD and sources of available treatment.
www.bpdresourcecenter.org