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Antecedents of Personality Disorders in Young Adults

by Joseph M. Rey, M.D.

Psychiatric Times February 1996 Vol. XIII Issue 2

Personality disorders are characterized by the presence of inflexible and maladaptive patterns of perceiving ones
and relating to the environment that result in psychosocial impairment or subjective distress. The enduring natur
the behaviors, their impact on social functioning, the lack of clear boundaries between normality and illness, and
patient's perception of the symptoms as not being foreign make this group of conditions more difficult to
conceptualize than the more typical, episodic mental disorders.

Personality disorders are both frequent and difficult to treat. Individuals with these problems consume substantia
resources and seriously burden society. A survey of the work of Australian psychiatrists showed that although
patients with personality disorders amounted to only 6 percent of the people in treatment, they exhausted 13 perc
of the psychiatrists' treatment time (Andrews and Hadzi-Pavlovic).

The term personality disorders includes diverse conditions that originated in very different clinical, theoretical a
research settings, as Rutter pointed out. Some conditions, such as the concept of borderline personality disorder,
mainly the result of psychodynamic thinking. Others, such as schizotypal personality disorder, have their origin
predominantly in genetics. Irrespective of the history of each construct, most experts agree that personality
disorders emanate from childhood.

Despite this, little empirical evidence is available on the developmental pathways that underpin these disorders,
with the exception of antisocial personality disorder (Robins; Zoccolillo and others). This evidentiary lack may b
the consequence of ambiguities surrounding the concepts of temperament, character and personality (Rutter) or t
result of child and adolescent psychiatrists being reluctant to make a diagnosis of personality disorder. The recen
surge of research reports dealing with personality disorders in adolescent groups suggests that this reluctance ma
be waning.

Because personality is shaped by experiences during childhood and adolescence, it is likely that mental disorder
occurring during these years may have an influence on personality development. Childhood mental disorders ma
increase the risk of affected children developing a personality disorder when they grow up. This can happen in a
variety of ways. The disorder itself, for example, depression, may directly influence personality development.
Alternatively, symptoms of the condition (e.g., disruptive disorder) may elicit environmental responses (e.g.,
increased control or likelihood of abuse by caregivers) that in turn may alter personality development. It may be
the disorder observed in childhood is an earlier manifestation of the same underlying pathology that results in th
development of personality disorder in adulthood. Consequently, the study of the continuities between child or
adolescent disorders and adult personality disorders is likely to be a fertile ground that will facilitate our
understanding of these conditions.

Referred Adolescents

Seeking to clarify some of these issues, my colleagues and I followed up a group of adolescents who had been
referred for assessment to an adolescent unit in Sydney, Australia (Rey and others). Follow-up consisted of a
lengthy interview during which a variety of diagnostic instruments and questionnaires was administered. These
included the Personality Disorders Examination (Loranger). At the time of initial assessment, the average age wa
14 years, while at follow-up it was 20 years. Of the 205 subjects who were located, 145 were fully interviewed.
About half of these (44 percent) were female.

During the ensuing six years, four of the subjects had died. One female, initially diagnosed as having attention-
deficit disorder with hyperactivity, died of a heroin overdose following a period of severe disturbance during wh
she probably met criteria for conduct disorder. Two males suffered from conduct disorder. One committed suicid