An Empirical Examination Of The Concept of "Stress-Induced" Personality Disorders

Personality is considered to be stable or, at the very least, something that changes slowly over time. However, each person responds differently to stress. A person's reaction under stress represents varying degrees of modification of his or her normal personality style and sometimes exposes personality vulnerabilities that cause more radical changes in personality style.

Personality disorders have been conceptualized in a variety of ways. A review of all of the conceptualizations of personality disorder is beyond the scope of this article, but two of the current major definitions are mentioned. The current DSM-IV diagnosis of personality disorder is "An enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual's culture. . . "¹ The pattern is manifested in two or more of the following areas: cognition, affectivity, interpersonal functioning, and impulse control. The pattern is inflexible and pervasive across a broad range of situations, has an early onset, is stable, and leads to significant distress or impairment. According to the ICD-10 diagnostic guidelines, personality disorders ". . . comprise deeply ingrained and enduring behaviour patterns, manifesting themselves as inflexible responses to a broad range of personal and social situations. They represent either extreme or significant deviations from the way the average individual in a given culture perceives, thinks, feels, and, particularly, relates to others. Such behaviour patterns tend to be stable and to encompass multiple domains of behaviour and psychological functioning. They are frequently, but not always, associated with various degrees of subjective distress and problems in social functioning and performance."²

The DSM-IV does not allow for the possibility of a stress-induced personality disorder. The ICD- 10 allows for a personality disorder to be created by stress. An enduring personality change is defined as ". . . a disorder of adult personality and behaviour that has developed following catastrophic or excessive prolonged stress, or following a severe psychiatric illness, in an individual with no previous personality disorder. There is a definite and enduring change in the individual's pattern of perceiving, relating to, or thinking about the environment and the self. The personality change is associated with inflexible and maladaptive behaviour that was not present before the pathogenic experience and is not a manifestation of another mental disorder or a residual symptom of any antecedent mental disorder."^2,3 The ICD-10 definition does not allow for a stressinduced personality disorder to reverse itself.

These two definitions of personality emphasize the stability of personality functioning over time. However, there is no question that measurements of personality characteristics can be elevated if taken when a patient is acutely ill with an Axis I disorder. These measurements return to baseline after resolution of the Axis I disorder.^4-10 One must consider the possibility that this is a measurement artifact. If this were the case, traits distorted by the presence of an Axis I disorder would have no clinical value (ie, they would just be "noise" confusing the clinical picture). Taking this approach, some developers of tests for DSM personality disorder have worked to reduce this effect in their instruments. For example, Loranger et al.¹¹ have taken that approach and have eliminated much of this noise from their test results.

However, personality measurements taken during an acute Axis I illness predict the outcome of treatment of that illness.^12,13 If a phenomenon predicts an important variable, such as outcome, we may be dealing with an important phenomenon in its own right and not an artifact. This would indicate that it is an area worthy of further study. Other researchers have speculated about the possibility of stress-induced personality disorders. After a review of the literature on personality and the anxiety and depressive disorders, Bronisch and Klerman¹⁴ concluded that a stress-induced personality disorder was a reasonable concept. They referred to it as "personality change."

This article examines the problem of stressinduced personality disorders empirically. Three different groups—state personality disorder, stress-induced personality disorder, and no personality disorder—are compared on clinical symptoms, functioning, and family history. If stress-induced personality disorders are a measurement artifact, the stress-induced personality disorder group will resemble the no personality disorder group. If the stress-induced personality disorder group forms a distinctive clinical and family history pattern, it may represent a clinical syndrome worthy of further study.

METHODS

Population

Subjects for this study were drawn from a freestanding Veterans' Administration outpatient clinic in a city in the northeastern United States with a population of approximately 300,000. The population was 100% male. Subjects were a random sample of nonpsychotic psychiatric outpatients.

Instruments

The information used in this article was gathered by direct interview. The interview consisted of an established measure of Axis I disorders, the Structured Clinical Interview for DSM-III-R Diagnoses (SCID1)¹⁵; and an established measure of DSM-lll-R personality disorders, the Personality Disorder Examination, version 2 (PDE).^16,17 The PDE has been designed to be resistant to the effects of state.¹¹ The Personality Diagnostic Questionnaire-Revised (PDQ-R), a 152-item self-report by patient or informant(s) using DSM-III-R criteria, was the second personality instrument administered.^18,19 This is a personality instrument that appears to be affected by state effects.^6-9

The interview also included a measure of socioeconomic status by Hollingshead's method and the Global Assessment Scale (GAS).^20,21 The Brief Symptom Inventory (BSI)²² was also administered. The BSI is a 50-item self-report measure of acute symptomatology. A dimensional selfreport of family-home functioning was also used.

Two standardized, validated instruments were used to measure family history. The first was the Family History-Research Diagnostic Criteria (FH-RDC),^23,24 which measures the psychotic and affective disorders. The second was the Family History for the DSM-III Anxiety and Personality Disorders (FHPD),^25,26 which measures the DSM-III anxiety disorders and personality disorder clusters. In this study, patients were asked about first-degree relatives only.

Procedures

Patients in the psychiatric clinic were approached, either by mail or in person at the time of their visit, to take part in the study. Approximately 65% of those eligible to be in the study completed the interviews. No demographic or diagnostic differences were found between responders and nonresponders.

The interviews were performed by research assistants who had undergone extensive training on all of the instruments involved. This training included reading, watching videotapes, attending didactic sessions, and participating in supervised practice interviews. The interviews were performed in person, not over the telephone. The...

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James H. Reich, MD, MPH, is a board-certified Forensic Psychiatrist with extensive civil psychiatry experience who has done hundreds of evaluations. His services are available for civil and some criminal law cases. Clients are assured of his personal dedication to each case. He does high quality research, expert evaluations, writes a solid report, and will testify well. Dr. Reich has been deposed over 50 times..

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