Discussion Post
JaniseMCh 8: Course and Outcome
* All content in this PPT comes directly from the book American Psychiatric Publishing, Textbook of Personality Disorders
The concept of stability
DSM 5 criteria specifies that PDs have an “enduring pattern” of problems
Both the DSM and the ICD-10 (which is the classification system used by WHO) acknowledge the stability of these diagnoses
However empirical evidence validating this stability is mixed and debatable
The concept of stability has appeared in every version of the DSM dating back to the first publishing
DSM 3 in fact added the axis II section specifically for PDs as they are a more enduring and stable issue than the typical axis I disorders that the clinician would generally assess for
Literature Review
Early studies dating back to the 70’s reported that BPD and ASPD were highly stable
One study even compared the dysfunction in BPD over 5 years to that of schizophrenia
With the DSM III addition of axis II, more research went into PDs
This research on DSM 3 revealed only moderate stability of PD diagnoses and although they are associated with negative outcomes they can improve over time and can benefit from specific treatment
Two longitudinal studies assessed PD features
Trull study on college students over a two year period found modest stability for BPD
BPD found to have reduced negative affectivity but not personal distress
Also had greater academic and interpersonal difficulties at 2 year follow up
LSPD study compared those meeting criteria for at least 1 pd to those not meeting any criteria
PD group showed more decline in personality traits over time then the non-PD sample
Cluster A had lowest stability and cluster B had the highest
Reliability
In the 80’s standardized assessments were developed for assessing PDs
They were less than perfect though
Although interrater reliability and test-retest reliability are the two most stringent tests for estimating the reliability of an instrument.
Reviews of these instruments puts their reliability measurements for interrater and test-retest pretty similar to instruments used in assessing other disorders
Test-retest reliability is meant to lessen the effects of regression towards the mean
Highly symptomatic people at initial assessment are very likely to have some improvement over time
Shea and Yea found that participants frequently report fewer problems in follow up interviews in order to reduce interview time (in both PD and other diagnoses)
Loranger study using the Personality Diagnostic Examination (PDE) found reduced symptomology in the retest (conducted within 6 months of initial) for all but two of the PD diagnoses
This reflects that the changes observed in such a short period of time were due to regression towards the mean, error in both the test and retest assessments, overreporting of symptoms at intake and underreporting at follow up
Clinicians need to be aware of incentives for over and under reporting
Categorical vs Dimensional Approaches
Longitudinal studies of PDs report moderate levels of stability for most PDs and these stability scores tend to be higher than categorical approaches or diagnostic reliability
Patients that don’t meet full criteria should be viewed as a milder version of the disorder and treated as such
Comorbidity and Comorbidity/Continuity Models
Most studies have participants that technically meet criteria for two or more disorders
Comorbidity is one of the main reasons why there is a push to dump the current classification system
Comorbidities lead us to ask questions such as:
What are the fundamental personality dimensions and disorders of personality?
Think about the discrepancy between section 2 and section 3 of the current DSM
How do the courses affect and how are they affected by the presentation and course of other psychiatric disorders?
Models for the possible relationship between personality disorders and other mental disorders include
The predisposition/vulnerability model, the complication/scar model and various spectrum models
The spectrum model by Siever and Davis poses 4 psychobiological dimensions that account for all psychopathology
Cloninger’s psychobiological model of temperament and character is another approach that examines dimensions of personality and other pathology
Continuity
An issue related to comorbidity and the course of a disorder is continuity
Example: Conduct disorder during adolescence is a prerequisite for an ASPD dx in adulthood
Diverse studies have found that disruptive behavior disorders in adolescence likely predicted several PDs in young adulthood
Children with conduct disorder are at risk for several disorders other than ASPD
Think substance abuse, depression etc.
Also on the contrary, there are several other childhood disorders that can increase the risk of ASPD
So the link between conduct disorder and ASPD is not specific
PD diagnoses in adolescent inpatients (in the Yale Psychiatric Institute Study) predicted future drug use but not functioning
Lewinsohn et al. found that childhood disruptive behavior disorders predicting ASPD in adulthood was mediated by the presence of other disorders
A recent study comparing adults with ASPD vs those who met all criteria for ASPD other than conduct disorder as a child, found very little differences in the two groups over a 3 year period
Age (Early Onset)
PDs need to be conceptualized as having an early onset but validity of PDs in adolescence is still controversial
Some argue that determining early onset of PDs in adolescence is unreliable because this is a time of immense changes in personality and identity
Research shows that personality traits are less stable in childhood and adolescence than in later life
If childhood precursors for PDs do exist they could be included in the criteria in order to create some sort of continuity in the diagnostic system
Several models have positioned temperamental precursors as a central part of understanding the PD
Example: several studies note odd and withdrawn patterns in children who later develop SPD and shyness predicting AVPD
Although personality traits are more stable in adulthood than in childhood or adolescence the transition from adolescence to adulthood is generally characterized by personality stability rather than change
Age and the Aging Process
Research suggests that personality is pretty stable through adulthood and especially stable after age 50
But little is known about older people and PDs
Nottingham Study of Neurotic Disorders had a 12-year follow up on PDs examining changes in trait scores
ASPD and HPD had significant improvements
Cluster A and C appeared to worsen with age though
Similarly, the Chestnut Lodge follow up studies found decreases in impulsivity and interpersonal instability but increases in avoidance over the years
Galione and Oltmanns found significant association between BPD and major depression (MDD) in older adults
History of MDD is associated with stable BPD features related to distress
PDs are common and associated with various forms of medical and psychiatric disability in older adults
The Collaborative Longitudinal Personality Disorders Study/CLPS
The CLPS is a longitudinal repeated measures study designed to examine the course and outcome of PDs with a primary focus on STPD, BPD, AVPD or OCPD
The study includes a comparison group of people with MDD but no PD
This group is chosen because of the nature of MDD: its discontinuous course and because it is easily studied
It also includes the concepts of remission and relapse
Remission- 12 consecutive months meeting two or less criteria
Relapse- return to full criteria for at least 2 consecutive months
The CLPS reported on different concepts of categorical and dimensional stability of the 4 PDs over 12 months, 24 months and 10 years using data obtained from 668 patients recruited from 4 universities
CLPS findings
Greater proportion of patients in the PD group (any of the 4) remained at a higher diagnostic threshold throughout the first 12 months of follow up than did those in the MDD group
24 month follow up revealed remission rates ranging from 50-61% for PDs
Compared to the PD group, the MDD group had shorter times to and higher rates of remission
Thus PDs do have more stability over time than other mental disorders but substantial improvement in psychopathology of PDs is not uncommon
Another examination of CLPS, particularly BPD remission compared to AVPD and OCPD (called OPD together) vs BPD remission compared to MDD
By 10 years 85-91% of BPD patients achieved remission (depending on whether 2 month or 12 month criteria for remission was used)
Remission of BPD was significantly slower than remission of MDD or of OPD
Only 12% of BPD patients relapsed
This was a lower rate and a slower to relapse time than those with OPD or MDD
Social functioning continued to show severe impairments with only modest improvements overtime
BPD remained more socially impaired than MDD or OPD
The course of BPD is characterized by high rates of diagnostic remission and low rates of relapse but severe and enduring social impairments
CLPS findings continued
Grilo et al. concluded that individual differences in PD features are stable although there may be fluctuation in severity or number of criteria met over time
Within PDs the more fixed and stable criteria were trait like whereas the behavioral criteria fluctuated more
Hopwood et al found that normal and abnormal traits were more stable than PD symptoms
This probably reflects the episodic/unstable pathology of PDs in comparison to more normal traits that are stable
In contrast to symptomatic improvement, patients with PDs showed less improvement in their functioning particularly in social relationships
Because personality pathology usually develops in adolescence the potential for developmental delays is great and if symptoms improve it would take considerable time to “Catch up” in this department
The course of BPD was associated with the course of MDD and PTSD and the course of AVPD was associated with Social phobia and OCD
Changes in BPD severity occurred before improvements in MDD
Other PDs did not have longitudinal associations
PDs predicted a significantly worse course for MDD and some anxiety disorders but not for eating disorders
McLean Study of Adult Development (MSAD)
MSAD is an ongoing longitudinal study that retests every 2 years with reported outcomes at 6, 10 and 16 years
Reported remission rates for BPD were 35%, 49% and 74% (by years 2, 4, and 6)
“Symptomatic improvement is both common and stable even among the most disturbed borderline patients and that the symptomatic prognosis for most, but not all, severely ill borderline patients is better than previously recognized”- Zanarini et al
Other psychiatric disorders found to be less common over time in ppl with BPD
Also found psychosocial impairment but unlike the CLPS this impairment was vocational not social
After 16 years remission rates for BPD ranged from 78-99% and for other PDs 97-99%
Lower recovery rates for BPD than the other PDs
Relapses occurred at a higher rate and much faster for BPD patients compared to other PDs
Remission is more common than recovery for BPD as per Zanarini and the MSAD studies
Children in the Community Study (CICS)
CICS is a prospective study of about 1,000 families (with kids ages 1-10) following these families over the years from 1975
This study produced 20 year outcomes that were able to provide some great info on longitudinal comorbidities and continuity
Important findings include:
Documentation of the validity of certain forms of dramatic-erratic PDs in adolescence
Age related changes in PD symptoms including their moderate levels of stability throughout adolescence and early adulthood
The association between PD psychopathology in adolescents and educational achievement and interpersonal issues
Indications that early forms of behavioral issues predict PDs in adolescence and that PDs in adolescence predict other mental disorders, PDs, suicidality and criminal behavior in adulthood
Continuity of PD related impairment continuing through young and middle adulthood
Many children with PD pathology will improve but the most severe will likely continue to have issues into adulthood
Chapter Conclusions
The PDs defined in section II of the DSM 5 have only moderate stability
They can improve over time and many of those improvements will last
PDs indicate a negative prognosis for many other types of psychiatric disorders and are associated with long standing social impairments
The studies reviewed here relate to the alternative model of PDs proposed in the DSM 5 section III
Section III revised the definition calling PDs “relatively stable”
PDs in section III are redefined by impairment in core personality functioning shared by all PDs and also by certain pathological personality traits derived from the Big five model
Personality functioning and personality traits are dimensional in nature
These dimensional qualities are more stable than the typically categorical diagnosis approach
Personality functioning and personality traits will work to increase each other and predict clinical outcomes over time
By representing PDs in a hierarchical trait structure (as done in section III) comorbidities and continuities with other psychiatric disorders becomes more clear as certain susceptibilities are easier to perceive