When APA President-elect John Oldham, M.D., speaks to audiences about personality disorders, he will often present a drawing by the legendary cartoonist William Steig depicting an exasperated woman asking her husband, "Why are you the way you are?"
It is a question anyone might ask of acquaintances or loved ones, and it highlights the conundrum presented by scientific inquiry: Is a personality disorder "the way you are" or a disorder you "have"?
"A little bit of both," said Oldham. "Personality types are infinite, and personality pathology is an extreme expression of otherwise normal personality traits."
And the question—Is a personality disorder who you are or what you have?—speaks as well to the ongoing debate about whether disorders should be recast in the emerging DSM-5 as dimensional diagnoses, reflecting a continuum of symptom severity that may wax and wane over time. Oldham said he believes the evidence is "pretty persuasive" that personality is a dimensional construct rather than a categorical one.
In the case of borderline personality disorder, genetic and neurobiological evidence has shown that patients typically possess an inherited predisposition for aggressive impulsivity and emotional dysregulation. In the context of early childhood trauma—neglect, abuse, or massive stress—these traits can result in the phenotype recognized as borderline personality.
But a striking finding from the Collaborative Longitudinal Personality Disorders Study (CLPS), one that would seem to underscore the dimensional nature of personality, is that disorders of personality, as described by DSM-IV-TR, are not stable and enduring over time. Rather, they appear to be a hybrid of stable traits and intermittently expressed symptomatic behaviors that may remit periodically.
(In dozens of publications, CLPS, a multisite, naturalistic follow-up research project, described the outcome over time of hundreds of patients with four personality disorders—schizotypal, avoidant, obsessive-compulsive, and borderline.)
Oldham, who was a co-principal investigator for the Columbia site of CLPS in its early phases, told Psychiatric News that 10-year data from the study showed that when researchers used stringent criteria for remission, a remarkable number of patients got better.
"What the CLPS data show are that the original definition of personality disorders as persistent and enduring is wrong," he said. "Over time a large majority of patients shed some of their symptoms and learn to cope better."
