570 CHAPTER 13
typically should date back at least to early adulthood and should not primarily
arise from a substance-related or medical disorder or another psychological disor-
der (American Psychiatric Association, 2000). We can now answer the question of
whether Reiland’s diffi culties were more than those of an overwhelmed mother of
young children. Specifi cally, her problems—in all four areas of functioning listed
in Criterion A (cognition, affectivity, interpersonal functioning, and impulse con-
trol) as well as those listed in Criteria B through F—indicate that she has a per-
sonality disorder.Although personality disorders are generally considered to be stable, at
least from adolescence into adulthood, research suggests that (as shown in
Figure 13.1) these disorders are not as enduring as previously thought (Clark,
2009; Durbin & Klein, 2006; Lenzenweger, Johnson, & Willett, 2004; Zanarini
et al., 2005); rather symptoms can improve over time for some people (Grilo
et al., 2004; Johnson et al., 2000; Lenzenweger, 1999). Nevertheless, these dis-
orders are typically among the most resistant to treatment.
As a group, people with personality disorders obtain less education
(Torgersen, Kringlen, & Cramer, 2001) and are more likely never to have mar-
ried or to be separated or divorced (Torgersen, 2005) than people who don’t
have such disorders. Personality disorders are associated with suicide: Among
people who die by suicide, about 30% are thought to have had a personality
disorder; among people who attempt suicide, about 40% are thought to have
a personality disorder (American Psychiatric Association Work Group on Sui-
cidal Behaviors, 2003).Why Are Personality Disorders on Axis II Instead of Axis I?
When the fi ve-axis diagnostic system of DSM was instituted, mental retardation
and personality disorders were placed on Axis II because both involved persistent
conditions that began in childhood and were believed to be stable—in contrast to
the fl uctuations observed with most Axis I disorders (Oldham, 2005). However,
subsequent research indicates that personality disorders and Axis I disorders don’t
differ signifi cantly on these two variables (Livesley, 2001). As discussed in previous
chapters, many Axis I disorders involve symptoms that emerge in adolescence or
young adulthood, or even in childhood (such as depression and eating disorders).CASE 13.1 • FROM THE OUTSIDE: Personality Disorder
Sarah, a 39-year-old single female, originally requested therapy at... an outpatient clinic, to
help her deal with chronic depression and inability to maintain employment. She had been
unemployed for over a year and had been surviving on her rapidly dwindling savings. She
was becoming increasingly despondent and apprehensive about her future. She acknowl-
edged during the intake interview that her attitude toward work was negative and that she
had easily become bored and resentful in all of her previous jobs. She believed that she might
somehow be conveying her negative work attitudes to prospective employers and that this
was preventing them from hiring her. She also volunteered that she detested dealing with
people in general....
Sarah had a checkered employment history. She had been a journalist, a computer techni-
cian, a night watch person, and a receptionist. In all of these jobs she had experienced her
supervisors as being overly critical and demanding, which she felt caused her to become
resentful and ineffi cient. The end result was always her dismissal or her departure in anger.
Sarah generally perceived her co-workers as being hostile, unfair, and rejecting. However, she
would herself actively avoid them, complaining that they were being unreasonable and coer-
cive when they tried to persuade her to join them for activities outside of work. For example,
she would believe that she was being asked to go for drinks purely because her co-workers
wanted her to get drunk and act foolishly. Sarah would eventually begin to take “mental
health” days off from work simply to avoid her supervisors and colleagues.
(Thomas, 1994, p. 211)Figure 13.113.1 • Stability of Personality
Disorders Within 2 years of being
diagnosed with a personality disorder,
around one quarter to one third of the
people in one study no longer met the
diagnostic criteria for 12 consecutive
months (Grilo et al., 2004). This fi nding
indicates that personality disorders are
not as stable as once thought.
Source: Grilo et al., 2004. For more information
see the Permissions section.g30 604020608010012
Time from initial evaluation (months)Percentage with diagnosablepersonality disorder18 24Schizotypal personality disorder
Borderline personality disorder
Avoidant personality disorder
Obsessive-compulsive personality
disorder