Personality Disorders over Time: Precursors, Course, and Outcome

219 Pages·2003·3.04 MB·English

by  Joel Paris

Personality Disorders
Over Time
Precursors, Course, and
Outcome
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Personality Disorders
Over Time
Precursors, Course, and
Outcome
Joel Paris, M.D.
Professor of Psychiatry
McGill University
Montreal, Quebec, Canada
Washington, DC
London, England
Note: The authors have worked to ensure that all information in this book is ac-
curate at the time of publication and consistent with general psychiatric and medi-
cal standards, and that information concerning drug dosages, schedules, and routes
of administration is accurate at the time of publication and consistent with stan-
dards set by the U.S. Food and Drug Administration and the general medical com-
munity. As medical research and practice continue to advance, however, therapeutic
standards may change. Moreover, specific situations may require a specific thera-
peutic response not included in this book. For these reasons and because human and
mechanical errors sometimes occur, we recommend that readers follow the advice
of physicians directly involved in their care or the care of a member of their family.
Books published by American Psychiatric Publishing, Inc., represent the views and
opinions of the individual authors and do not necessarily represent the policies and
opinions of APPI or the American Psychiatric Association.
Copyright © 2003 American Psychiatric Publishing, Inc.
ALL RIGHTS RESERVED
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Library of Congress Cataloging-in-Publication Data
Paris, Joel, 1940–
Personality disorders over time : precursors, course, and outcome / Joel Paris.
p. cm.
Includes bibliographical references and index.
ISBN 1-58562-040-8 (alk.paper)
1. Personality disorders--Longitudinal studies. 2. Personality disorders--
Treatment. I. Title.
RC554.P369 2003
616.85¢8--dc21
2002043871
British Library Cataloguing in Publication Data
A CIP record is available from the British Library.
This book is dedicated to my daughters, Leslie and Nancy, who give
me continuity over time.
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Contents
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ix
1
Time and Illness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1
2
Precursors of Personality Disorders . . . . . . . . . . . . . 19
3
Borderline Pathology of Childhood . . . . . . . . . . . . . 33
4
Personality Disorders in Adulthood. . . . . . . . . . . . . 41
5
Long-Term Outcome of Personality Disorders . . . . 61
6
Patients With Borderline Personality
Disorder After 27 Years. . . . . . . . . . . . . . . . . . . . . . . 81
7
Mechanisms of Recovery . . . . . . . . . . . . . . . . . . . . . 103
8
Course, Prevention, and Management . . . . . . . . . 111
9
Suicide and Borderline Personality Disorder . . . . 133
10
Working With Traits. . . . . . . . . . . . . . . . . . . . . . . . . 145
Epilogue: A Program for Future Research . . . . . . . 159
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 163
Index. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 189
Introduction
Why Personality Disorders Are Important
All therapists treat patients with personality disorders. Some do so by
choice, others by chance. Personality change has long been the central goal
of extended courses of treatment. Clinicians whose practices center on
long-term psychotherapy are interested in patients with personality disor-
ders. These therapists are not satisfied with only relieving immediate dis-
tress but aim for more, seeking to modify personality.
Patients with personality disorders are difficult. Many clinicians at-
tempt, whenever possible, to avoid treating them (Lewis and Appleby
1988). Yet even practitioners with no special interest in personality dis-
orders are forced to grapple with the problem. In practice, most therapy
focuses on managing symptoms. We administer courses of therapy that are
effective for most patients, yet we find ourselves spending more time on the
significant minority that fails to respond. Many of these “treatment-
resistant” patients meet diagnostic criteria for personality disorders, and as
I show in this book, approaches that are effective for Axis I disorders can
sometimes be counterproductive for Axis II pathology.
Clinicians sometimes acknowledge this problem by describing difficult
patients as having “Axis II comorbidity.” This way of thinking implies that
Axis I symptoms such as depression or anxiety are the main issue, albeit
complicated by Axis II pathology. Yet in many cases, it would make more
sense to make a primary diagnosis of personality disorder and then to speak
of “Axis I comorbidity.”
Patients with personality disorders have chronic problems in many areas
of their lives, making them less than popular with clinicians. This book is
about chronicity. To understand disorders with a chronic course, we must
know how they evolve over time. The precursors, the onset, and the out-
come of personality disorders constitute a meaningful sequence shedding
ix