Personality Disorders over Time: Precursors, Course, and Outcome
Amada, Gerald, American Journal of Psychotherapy
JOEL PARIS: Personality Disorders over Time: Precursors, Course, and Outcome. American Psychiatric Publishing, Inc., Washington, D.C., 2003, 198 pp., $33.00, ISBN 1-58562-040-8.
Irrespective of theoretical orientation or clinical setting, almost all psychotherapists treat patients with personality disorders. Since, by definition, a personality disorder is ordinarily long-lived and fairly intractable, the course of treatment is often protracted, stormy, and emotionally challenging, making such patients less than popular.
As the author points out at the outset of this book, personality disorders are exemplified by their sheer chronicity. Joel Paris, Professor of Psychiatry at McGill University, reminds us that a proper diagnosis of a personality disorder should prepare us for a treatment that is painstakingly slow, marked by many upheavals (possibly including hospitalizations) and inconsistent recovery, and an outcome that may be less than satisfactory. Paris acknowledges the likelihood of partial successes by wisely pointing out that therapists, who often expect and hope for full recovery in their patients, may be quixotically less satisfied with partial results than their patients. As a safeguard against unrealistic therapeutic expectations, Paris prefers to suggest in this book ways to manage rather than cure patients with personality disorders.
Paris adduces a model that deemphasizes the role of childhood as a causative factor in personality disorders, while underscoring the importance of innate childhood vulnerabilities as they interact with adverse life experiences. He cites research findings that point out that personality pathology can be reliably identified by middle or late adolescence. Although he acknowledges that personality disorders emerge early in life, he avers, based on recent evidence, that they have a significant heritable component.
The author's research has led him to establish two bedrock principles with regard to personality disorders: 1) the earlier the onset of the disorder, the more likely it will be severe and chronic and 2) the earlier the onset of the disorder, the more likely it is that it will have a genetic component. he also finds that the course of these disorders will provide telltale clues about their causes; for example, hard-to-socialize children are likely to have parents who are incompetent and have a paucity of socializing influences in their environment.
Based on longitudinal studies conducted by the author and others, Paris has concluded that many of the disorders-the borderline personality disorder (BPD), the narcissistic personality disorder (NPD) and the antisocial personality disorder (ASPD), for example-will actually recover, "naturalistically," as the author puts it. This knowledge may provide some comfort to those therapists who steadfastly treat patients with these disorders for many years, but given the fact that some deeply entrenched personality defects and behavioral traits are lifelong in nature, perhaps the soundest therapeutic stance, as the author points out, is to regard all the personality disorders as "stably unstable."
Paris bases naturalistic recovery upon biological maturation as changes take place in central serotonergic activity and the rewiring of brain circuitry; social learning that takes place through the process of modeling significant others and, in the case of borderline patients, the avoidance of conflictual intimacy that frees them from the overattachment, tumult, and chaos that ordinarily characterizes their relationships. …