Text adapted from: "The adult patient with a personality disorder," in Psychiatry in primary care by Michael Rosenbluth, Matthew Boyle & Lucille Schiffman (CAMH, 2019).
If you confirm that there is longstanding personality pathology, it should not be a reason to avoid robust psychotherapy or pharmacotherapy. Several careful reviews of the literature indicate that personality pathology, despite popular belief, does not worsen the outcome of a major depressive disorder (Kool et al., 2005; Mulder, 2002; Yoshimatsu, 2014). This is very important to keep in mind. The strongest support that personality pathology predicts poor outcome comes from the weakest studies, which did not carefully define personality, who was treated, how the treatment was conducted or how outcome was defined.
Follow-up research has indicated that patients with BPD can improve with treatment. One study found that at six-year follow-up, over half of patients no longer met diagnostic criteria. Interestingly, those patients who no longer met the criteria had a substantial decline in the comorbid Axis I traits described above. Patients who met diagnostic criteria at follow-up did not have a reduction of comorbid Axis I diagnoses (Zanarini et al., 2004).
Most patients with BPD improve with time (Biskin, 2015), but there is debate over whether this indicates that treating the personality disorder decreases rates of co-occurring Axis I disorders or vice versa.
The practical point for primary care practitioners is that all patients with a personality disorder should be screened for comorbid Axis I diagnoses, and that these diagnoses should be treated robustly. Studies with positive outcome findings are very encouraging, showing that with proper diagnosis, treatment and time, a majority of these patients may “outgrow” BPD.