Natural History And Longterm Outcome In Personality Disorder

Data on the natural history of personality disorders are skewed towards the most severe cases and most of these have been identified in psychiatric hospitals and forensic settings. Furthermore, most of the follow-up studies in this area are not really accounts of the natural history of these disorders, but are reports of long-term outcome after variable degrees of widely divergent interventions. Borderline and antisocial personality disorders have attracted particular attention because the impulsive and destructive behaviour of these individuals causes such concern among both carers and society in general. As noted above, borderline patients often make heavy demands on the health service. In contrast, individuals with antisocial personality disorder are unlikely to seek treatment voluntarily and are more likely to be seen by psychiatrists in prison than in hospital. Meanwhile, personality disordered individuals who are functioning reasonably well may never seek treatment; if they do, it may be for an Axis I disorder and the personality disorder may never be identified.

Stone (2001) reviews the available data on the natural history and long-term outcome of personality disorders, noting that individuals within the 'antisocial realm' historically constituted a diverse group incorporating those meeting criteria for DSM antisocial personality disorder; psychopaths, as defined by Hare et al. (1990); and individuals with sadistic personality disorder (Appendix, DSM-III). The Hare Psychopathy Checklist-Revised (PCL-R) (Hare et al., 1990) allows for the differentiation of psychopaths from individuals who are antisocial without scoring high on psychopathy. Recent studies suggest that the prognosis is considerably better for those in the latter group than it is for the former, who score high on the extreme narcissistic traits subsumed in Hare's Factor-I. While Dinwiddie & Daw (1998) found that antisocial personality disorder was largely stable over an eight-year follow-up, other studies have shown a tendency for criminality to decrease over time (Arboleda-Florez & Holley, 1991; Robins, Tipp & Przybeck, 1991; Stone, 1990). Sadistic personality is common among serial killers and there is no evidence that it burns out over time (Stone, 2001).

Large studies during the 1980s followed up individuals diagnosed with BPD over an average of 15 years - the 'Chestnut Lodge' study (McGlashan, 1985, 1986a, 1986b; Paris, Brown & Nowlis, 1987; Plakun, Burckhardt & Muller, 1985) and the 'PI-500' study (Stone, 1990; Stone, Hurt & Stone, 1987). All these subjects had previously been hospitalised. At trace time two-thirds were functioning within the GAS (Global Assessment Scale) (Endicott et al., 1976) range 61-70, or above: they were therefore functioning within the normal range. Among the third who fared less well, some had died from suicide (3 % in McGlashan's study and 9 % in the studies of Paris and Stone). Age was a significant risk factor for suicide: the late 20s were a high-risk period for this group. Both the Chestnut Lodge and PI-500 studies showed that these cohorts typically experienced their greatest difficulties during their twenties and were likely to improve thereafter if they survived, although individuals who remained chronically angry often encountered renewed difficulties when they reached middle age because they had alienated carers and companions. Factors associated with poor outcome for BPD are a history of sexual abuse (particularly incest occurring pre-puberty and involving penile penetration - Paris, 1994; Van der Kolk, 1996); parental brutality; antisocial traits and chaotic impulsivity. Stone (2001) cautions that available data on prognosis for BPD may well be overly optimistic because individuals with BPD who have also experienced significant socioeconomic disadvantages are under-represented in existing studies. However, Fonagy & Bateman (2006) suggest that the natural course of BPD may be more benign than previously thought. Citing recent prospective studies (Shea et al., 2004; Zanarini et al., 2003) they note remission in 75 % of patients diagnosed with BPD over a 6-year period.

There are fewer data on natural history and long-term outcome in other personality disorders. Existing findings suggest that the prognosis for schizotypal personality disorder may be limited (Aarkrog, 1981,1993; McGlashan, 1986a; Stone, 1993). McGlashan found that these patients fared only slightly better than those with schizophrenia and a Scandinavian study providing a 20-year follow-up of 50 schizotypal individuals showed poor social and occupational functioning (Aarkrog, 1993). Schizoid personality disorder, infrequently seen in psychiatric settings in the absence of comorbidity, also appears stable over time (Wolff &

Chick, 1981). Long-term outcome for narcissistic personality disorder was similar to that of BPD in both the Chestnut Lodge and PI-500 studies.

Break Free From Passive Aggression

Break Free From Passive Aggression

This guide is meant to be of use for anyone who is keen on developing a better understanding of PAB, to help/support concerned people to discover various methods for helping others, also, to serve passive aggressive people as a tool for self-help.

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