Growing out of personality disorder

The pessimism which was once associated with personality disorder and its intractability, is no longer fully justified. There is a growing body of research – particularly with the most commonly encountered personality disorder diagnoses, antisocial and borderline – that suggests positive change over time. When followed up for long periods of time, the majority of personality disordered individuals show fewer symptoms and experience less distress over the course of a decade or so, many of them no longer meeting the diagnostic criteria at follow up.

Why might this be?

• First, it is likely that the diagnosis is rather unreliable under the age of 25; certainly many offenders between the ages of 17 and 25 are likely to present with antisocial and borderline traits associated with repeat offending. Many will mature over time, testosterone levels will drop and so, therefore, will levels of aggression and impulsivity. Personality disorder is, broadly speaking, an exhausting state of being, and individuals lose the capacity to take drugs, engage in fights, experience such extremes of emotion, and so on.
• Unfortunately, personality disorder is also a relatively risky diagnosis, and a significant minority (perhaps as many as 10-15%) of such individuals will have died prematurely. Death may be as a result of self-harm, but also due to accidental overdoses, and as a consequence of other reckless behaviours and as victims of other personality disordered offenders.
• However, many personality disordered individuals are likely to be responsive, at least in part, to a range of interventions. These are detailed in chapter 3, but in summary, perhaps 10% of such individuals will improve with intervention.

It is important to consider quite what it is that changes over time. Current thinking suggests that dysfunctional personality should be divided broadly into two types of trait:

1. Core characteristics, often genetic, or at least apparent at a very early age
2. Secondary characteristics, usually the behavioural expression of the core traits.

The research suggests that there is very little change in core characteristics, but improvements do occur in the secondary characteristics. So, for example, antisocial and psychopathic individuals show little change in empathy deficits or callousness, but do show improvements in behavioural controls, taking increasing responsibility, reduced impulsivity, and setting more realistic life goals. Borderline individuals remain emotionally sensitive, but are less prone to being overwhelmed by intense emotional states, or engaging in repetitive self harming behaviour. Narcissistic individuals remain aloof, arrogant and contemptuous, but are less prone to erupt into a rage when challenged, less driven to demonstrate their superiority by engaging in self-destructive behaviours. (See chapter four for more information on traits). That is, we would suggest that although there are minimal shifts in core beliefs about the self, the world and other people, there can be more significant improvements in the expressive acts and interpersonal strategies.