June 28, 2002 -- The textbooks say people with personality disorders don't change without help. But now it looks as though some problem personalities mellow with age while others get worse.
If you have a personality disorder, you probably don't know it. You know you have trouble forming stable relationships. Your work and personal life suffer. But you probably think it's other people, not you, who are the problem. If you also suffer from depression or anxiety, treatments that help other people likely don't work as well for you.
Without the help of a psychiatrist or psychologist, personality disorders aren't supposed to change much over time. Now a report in the June 29 issue of The Lancet suggests that most personality disorders -- those in the "odd/eccentric" and "anxious/fearful" clusters -- get worse as a person ages. Those in the "flamboyant" cluster, however, get a bit better.
"Flamboyant personality gets better," study leader Peter Tyrer, MD, tells WebMD. "For the others -- and it worries me slightly as we deal with an aging population -- but they are increasing their [suffering]."
Tyrer, head of the department of psychological medicine at Imperial College School of Medicine in London, began the study 12 years ago with 202 patients. All were treated for depression, generalized anxiety disorder, or panic disorder. Tyrer found that more than half of the patients also suffered from underlying personality disorders.
He recently found 178 of the patients and again looked at their symptoms. He found that most of them suffered more from their personality disorders. The findings:
- The odd/eccentric cluster includes people with paranoid, schizoid, and schizotypal personalities. These are the most severe types of personality disorders. Most of these patients became significantly less functional over time.
- The fearful/anxious cluster includes people with avoidant, dependent, and obsessive-compulsive personalities. These patients also experienced significantly more difficulty over time.
- The flamboyant cluster includes people with histrionic, antisocial, borderline, and narcissistic personalities. Except for the borderlines -- considered the most difficult personality disorder to treat -- these patients enjoyed significantly better lives over time.
Tyrer says that most personality disorders get a bit better as a person goes from youth to the prime of life. But as a person with one of these disorders becomes elderly, the problems get worse than ever.
"These are very common disorders in the older population," Tyrer says. "We are going to have some more problems with people whose problems actually are becoming more pronounced. Old grandmother lives with us, she is a cantankerous old woman -- that sort of problem will become larger. We don't know why they get worse. It could be social isolation. Perhaps you can compensate by living in those gregarious communities you have in the U.S. But if left to their own devices they will get more cantankerous, nervous, and irritable."
How do you recognize a personality disorder? Andrew E. Skodol, MD, is professor of clinical psychiatry at New York's Columbia University and is deputy director of the New York State Psychiatric Institute. He leads a large, long-term study that is looking at people with personality disorders.
"Personality disorders are personality gone awry," Skodol tells WebMD. "They are maladaptive and inflexible patterns of looking at the world, relating to others, or viewing oneself. The personality becomes extreme and sort of fixed so that things may be going wrong in a person's life but they can't seem to change their attitudes or styles. I think that people who are experiencing adaptive problems in life, having chronic difficulties in work or relationships -- those kinds of people may very well have personality disorders."
So why do some people seem to get better while some get worse? Jaine Darwin, PsyD, has treated many patients with personality disorders. She is a private-practice psychotherapist, an instructor at Harvard University, and president-elect of the psychoanalysis division of the American Psychological Association.
"The people who have the kind of personality disorder that tends to leave them more isolated and out of contact get worse -- and that's the hallmark of the odd/eccentric and fearful/anxious personalities," Darwin says. "Those whose personality disorders tend to bring them into relationships -- flamboyant personalities -- tend to get better. I think some personality disorders are more amenable to treatment than others."
Darwin says that trouble forming relationships is the main characteristic -- and the main problem -- of people with personality disorders. Wanting to learn to form relationships is the beginning of the way out. Unfortunately, the Catch-22 of personality disorders is that people who have them don't see themselves as being the problem.
"It's not that they don't see anything wrong with themselves, it's that they see the problem as 'out there' and not within them," Darwin says. "People with personality disorders tend to externalize. That is the reason it often makes them hard to treat, because if you don't experience distress as coming from you, there is not much motivation to deal with the conflict that comes up in psychotherapy."
How does treatment work?
"We talk with people about how they think things happen, and what they are trying to find a solution to in their behavior," Darwin says. "We help then look at how there may be other plausible explanations and solutions for their behavior. If you think someone hurts your feelings only out of malice and evil, there are very few responses you can have. But if you help people widen their view of interactions, you help them. That usually won't happen in a regular relationship -- the other person will get fed up. The therapist is able to sit with them and tough out the hard parts."
Darwin says her clinical experience backs Tyrer's finding that untreated personality disorders become worse in elderly people.
"Good mental health is flexibility," Darwin says. "Personality disorder speaks to an inflexibility of reactions. All the stresses of aging rigidify us. As we age we become more of who we are, and if that is something difficult, well, we become a pain in the neck."