Article summary by Personality disorder across the life course by Newton-Hoves - 2015

Are personality disorders stable?

Personality develops from birth to adulthood. The persistent effect of personality disorders is often overlooked in clinical practice. Normal and abnormal personality are now known to be continuous across the life course. It is not stable, but it can change during life.

How are personality disorders captured in diagnostic systems?

Personality disorders are seen as categorical constructs in both the ICD-10 and the DSM-5. This approach is criticized for arbitrarily separating normal from abnormal personality. Moreover, there is poor agreement between different diagnostic assessments. The full DSM-5 and ICD-10 systems are not widely used in either clinical practice or research, with their focus being largely restricted to borderline and antisocial personality disorder.

How are personality disorders assessed?

Progress in the understanding of personality and its relation to personality disorder across the lifespan is mainly due to research into personality assessment. Convergent validity between structured questionnaires, clinical interviews,self-reports and questionnaires has been poor. It was also often found during the assessment that there was comorbidity, both between different personality disorders and between personality disorders and other mental state disorders. In summary, there was a problem with the categorical conceptualization of personality disorders, not with the assessments themselves. Personality traits evident in childhood stabilise throughout life beyond age 30 years. These traits are 50% hereditary. It is not known exactly which genes play a role, but research is being done, for example, into the serotonin gene and into epigenetic mechanisms. There is a lot of clinical attention for borderline. It is important to recognize that psychopathological abnormalities also change when the personality changes, which changes the clinical picture. The authors of the article recommend that the medical community adopts a broad, life-course perspective on adaptive and maladaptive personality traits. This allows specific targets for treatment to be identified at different stages of life.

Which normal range personality measures are there?

The study of the normal range of personality has led to a five factor model, known as the Big Five. The factors are Neuroticism, Extraversion, Agreeableness, Conscientiousness and Openness. These factors have strong psychometric properties.

How stable are personality traits?

Personality traits become consistent through exposure to a consistent environment, genetic effects, psychological makeup, the 'goodness of fit' between individuals and their environment and a strong sense of identity. Personality is moderately stable during childhood. This stability increases between adolescence and adult life, and changes more slowly from the age of thirty onwards. Personality further stabilizes until the age of sixty. The causes of these changes are unclear. Personality disorders change from childhood on in the same way as normal personality. There is continuity of personality disorders from adolescence to adulthood, so the disorder does persist. People with a personality disorder often change in the direction of improvement. Acute disruptions that occur in adults often lead to clinical presentations and lead to the mistaken belief that personality disorders only occur in adults. Poor functioning is often a stable characteristic, and can lead to the false belief that personality disorders are stable. Personality disorders have their roots in childhood and adolescence. However, sections of disorders in childhood and adolescence in the DSM or ICD do not mention personality disorder. Risk factors are adverse childhood experiences and maternal reports of anxiety, depressive symptoms and behavioral problems. It often becomes clinically apparent that there is a personality disorder during the transition between childhood and adulthood. This can interfere with achieving adult role functioning. The DSM and ICD indicate that it is highly unusual to diagnose a personality disorder before the age of 18, and also do not offer good diagnostic criteria for doing so.

Which issues surround diagnosis of young people?

The diagnosis in children and adolescents remains taboo, despite scientific evidence for validity. Many clinicians avoid giving the diagnosis on the grounds that they are protecting their clients against the stigma associated with the label. Clinicians, however, should be provided with good information that will help them to make clinically appropriate diagnoses of personality disorders without the fear of stigmatising patients. In section III in the DSM-5, an alternative personality disorder system is described, which removes age-related caveats for diagnosis.

Which issues surround diagnosis in older people?

Hardly any research has been done into age groups above 50 years. This is also due to problems in the criteria, which imply middle-age adult functioning, rather than the roles more common later in life. For example: the ability to keep a job is not really relevant for someone who is retired. People have different environments and roles later in life than when they were younger, which can aggravate or ameliorate maladaptive personality expressions. The stability of personality in older adults is overestimated, and they are more often ascribed a positive profile, with negative attributions related to physical rather than psychological characteristics. Observers also rate maladaptive personality traits less highly in older samples. So there is a bias towards minimizing personality problems later in life, which ignores the effects that traits like neuroticism and negative affectivity have on functioning later in life. Borderline in particular has an association with poor health later in life. Cognitive decline and Alzheimer's are also related to personality changes. More attention should be paid to personality issues in the elderly, as this entails a major health burden that is currently not visible.

What are the implications for treatment?

Long-lasting outcomes are more likely to be achieved through changes in personality traits over time, as opposed to treatments solely targeting psychopathological abnormalities. Treatments must therefore focus on personality traits. Almost all references to mental health concern the treatment of mental state disorder. However, half of this also includes a personality disorder. If this is the case, the treatment outcome is often worse than if there is only a mental state disorder. Clinicians often do not recognize personality traits, or see them as persistent symptoms of the mental state disorder. Identifying personality factors in these types of cases can greatly influence the treatment chosen. A major difficulty is that little research has been done into interventions aimed at personality trait domains. 

What are future challenges for research?

The greatest scientific and clinical challenge for a lifespan perspective is the need for a classification system that is clinically useful and scientifically robust. Such a system must show the dimensional nature of the characteristics that underlie adaptive and maladaptive personality. Scientific research must also be translated into clinically useful formats. Recognition of personality disorders in children and adolescents enables prevention, earlier detection, and implementation of evidence-based interventions with the aim of changing the life course of the personality disorder. More attention should also be given to the effect of personality disorders on mental state and physical disorders. A lifespan approach can also lead to less stigma and discrimination.

BulletPoint Summary

• Personality develops from birth to adulthood. Both normal and abnormal personality are known to be continuous across the life course.

• Convergent validity between different measurements determining personality disorder has found to be poor. In addition, comorbidity between different personality disorders and between personality disorders and other mental health disorders is highly prevalent. These issues are mostly ascribed to the categorical conceptualization of personality disorders. Even though both the DSM and ICD use this conceptualization, it is heavily criticized.

• Personality traits evident in childhood stabilize throughout life beyond the age of 30 years. These traits are 50% hereditary. It is not known exactly which genes play a role. It is important to recognize that psychopathological abnormalities also change when the personality changes, which in turn changes the clinical picture. It is therefore suggested by the authors that treatment goals need to be re-evaluated at different stages of life.

• The study of the normal range of personality has led to a five factor model, known as the Big Five. The factors are Neuroticism, Extraversion, Agreeableness, Conscientiousness and Openness. These factors have strong psychometric properties

• Personality traits become consistent through exposure to a consistent environment, genetic effects, psychological makeup, the 'goodness of fit' between individuals and their environment and a strong sense of identity. People with a personality disorder often change in the direction of improvement. Acute disruptions that occur in adults often lead to clinical presentations and often lead to the mistaken belief that personality disorders only occur in adults. Poor functioning is often a stable characteristic, and can lead to the false belief that personality disorders are stable.

• Even though personality disorders have their roots in childhood and adolescence, the DSM and ICD indicate that it is highly unusual to diagnose a personality disorder before the age of 18, and also do not offer good diagnostic criteria for doing so. Many clinicians avoid diagnosing children or adolescents with a personality disorder, because they want to protect them against stigma,

• Little research has been done in age groups above 50 years. This is also due to problems in the criteria, which imply middle-age adult functioning, rather than the roles more common in later life. There is a bias towards minimizing personality problems later in life, which ignores the effects that traits like neuroticism and negative affectivity have on functioning later in life.

• Long-lasting outcomes are more likely to be achieved through changes in personality traits over time, as opposed to treatments solely targeting psychopathological abnormalities. Clinicians often do not recognize personality traits, or see them as persistent symptoms of a mental state disorder. Identifying personality factors in these types of cases can greatly influence the treatment chosen. 

• The greatest scientific and clinical challenge for a lifespan perspective is the need for a classification system that is clinically useful and scientifically robust. Such a system must show the dimensional nature of the characteristics that underlie adaptive and maladaptive personality.