Stability and Change in Personality Disorder Lee Anna Clark
University of Iowa
ABSTRACT—The standard view of personality disorder is
that it is a maladaptive expression of personality traits,
which are relatively stable and unchanging. Thus, person-
ality disorder has been considered to have its roots in child-
hood and adolescence, to persist in adulthood, and to be
difficult to change. However, recent research has challenged
this view, revealing that personality continues to change,
albeit more slowly, well into adulthood, and that the
maladaptive manifestations of personality disorder are
much less stable than previously believed. These research
findings are described, and factors that influence stability
and change in personality disorder are discussed. The
emerging view of personality disorder has important impli-
cations for diagnosis, assessment, and treatment of person-
KEYWORDS—stability; change; personality disorder
The common view of personality—at least in Western cultures—
is that it is relatively unchanging. For example, meeting friends
at a class reunion with whom we lost touch 10, 20, 30 years ago,
we more typically think, ‘‘She hasn’t changed a bit,’’ than think,
‘‘It feels like I’m talking to a stranger; I can’t believe this is the
same person I knew in high school.’’ This view of personality
stability has long been shared by many personality researchers,
who were apt to cite William James’ (1890/1950) famous state-
ment, ‘‘by the age of 30, the character has set like plaster, and
will never soften again’’ (p. 121). Building on this view, per-
sonality disorder (PD) in the official Diagnostic and Statistical
Manual of Mental Disorders (DSM-IV; American Psychiatric
Association, 2000, p. 689) is defined, in part, as personality
traits that are ‘‘stable and of long duration,’’ as well as ‘‘inflexible
and pervasive.’’ Consequently, PD is characterized by psycho-
social dysfunction, including, for example, having conflict-rid-
den or unstable social and marital relationships, or a notable
absence of such relationships; showing poor judgment and de-
cision making or a marked inability to make decisions; and
having legal problems and employment difficulties.
Although PDs are defined as maladaptive personality traits,
officially they are assessed and diagnosed categorically; that is,
individuals either meet or do not meet criteria for one or more
DSM-IV PDs. Each PD diagnosis represents a pervasive pattern
of one or more maladaptive traits, which are illustrated by seven
to nine specific criteria. For example, ‘‘distrust and suspi-
ciousness’’ are the defining traits of paranoid PD, and ‘‘persis-
tently bears grudges’’ (p. 694) is a specific criterion reflecting
one or both of these traits. For a PD diagnosis, one must manifest
a certain number (typically four or five) of a disorder’s criteria
over time and across situations. (A list of the 10 DSM-IV PDs and
the pervasive patterns defining them is presented in Table 1.)
Measurement and conceptual difficulties with the current
categorical diagnostic system are widely acknowledged (Clark,
2007). Nonetheless, although maladaptive personality traits
have proved to have substantial reliability and validity (Widiger
& Frances, 2002), there is considerable reluctance to replace
the current criterion-based, categorical PD diagnostic system
with one that is based directly on trait dimensions. There are
various reasons for this reluctance, including the fact that in-
formation on the trait set that constitutes personality pathology is
incomplete, that most trait assessments inadequately reflect
extreme psychosocial dysfunction, and that how such a system
would inform treatment remains unclear. Thus, PD researchers
are exploring integrating personality trait and PD research, and
it is in this context that recent research findings have challenged
a simplistic view of personality and PD stability.
NORMAL-RANGE PERSONALITY STABILITY AND
There are multiple ways to consider personality stability and
change (Roberts & Mroczek, 2008). This article focuses on
three: (a) Mean-level/developmental stability/change indexes
the extent to which average trait levels change within a popu-
lation cohort; (b) rank-order stability/change reflects the extent
Address correspondence to Lee Anna Clark, Department of Psy- chology, University of Iowa, E11 SSH, Iowa City, IA 52242-1407; e-mail: email@example.com.
C U R R E N T D I R E C T I O N S I N P S Y C H O L O G I C A L S C I E N C E
Volume 18—Number 1 27Copyright r 2009 Association for Psychological Science
to which individuals maintain their relative trait levels; (c) and
diagnostic stability/change refers to whether or not individuals
meet criteria for the same diagnostic categories across time. If
diagnostic stability/change is assessed dimensionally (e.g., the
number of criteria met), then diagnostic stability/change is the
same as rank-order stability/change.
Recent meta-analyses of normal personality (Roberts &
DelVecchio, 2000; Roberts, Walton, & Viechtbauer, 2006) re-
vealed, surprisingly, that there is moderate mean-level change
through most of the life span. However, regarding rank-order
stability, change is modest to moderate throughout childhood
and adolescence, whereas as early as the 20s, trait rank-order
largely stabilizes, and this stability continues to increase slowly
with each successive decade until age 50. From the latter per-
spective, James’ ‘‘set like plaster’’—and our commonsense
feeling that personality is largely stable—appears valid. That is,
although the frame of reference (i.e., mean level) is changing
moderately, within that framework, adult personalities are
fairly—and increasingly—stable, beginning in the early 20s. It
is against this backdrop that I examine PD stability and change.
STABILITY AND CHANGE IN PD
Reports of PD stability vary depending on whether they examine
stability categorically (i.e., whether or not individuals were di-
agnosed with the same PD or PDs across time) or dimensionally
(i.e., rank-order stability measured using either the number of
PD diagnostic criteria met or personality-pathology-scale
scores). Studies examining categories find considerable diagnostic
change regardless of whether the retest interval is short (1 week),
moderate (up to 6 months), or somewhat longer (3 years), whereas
studies examining dimensions yield results similar to those for
normal-range personality: Short-term stability is quite high,
whereas more change is seen over longer intervals (Clark, 2007).
This pattern implicates categorical measurement error; that is, there
being little more diagnostic change in 3 years than in 1 week likely
reflects simply that many patients were diagnosed with (for example)
five criteria on one occasion and four on the next, which would
represent a diagnostic change (from meeting to not meeting criteria
for the disorder). However, when measured dimensionally, this
amount of change (i.e., from five criteria to four) is relatively minor.
More recent longitudinal PD studies provide assurance that these
results are not due simply to interrater unreliability (i.e., scoring
differences between interviewers; Clark, 2007; Grilo et al., 2004).
Further analyses indicate that PD instability is not due simply
to changes across the diagnostic boundary as just described.
Rather, it appears to represent actual decreases in PD mani-
festations. For example, in the Collaborative Longitudinal
Personality Study (CLPS), a large sample of patients diagnosed
with PD met on average 71% of the criteria of their primary PD at
baseline (e.g., 6.4 of 9, or 5.7 of 8 criteria), and the proportion
dropped steadily to 55%, 48%, and 42% at 6-month, 1-year, and
2-year follow-ups, respectively (Grilo et al., 2004). Moreover,
32% of the sample met two or fewer criteria the entire second
year. Similar findings of decreasing PD pathology over time have
been reported in other longitudinal studies, including a 6-year
study of borderline PD patients, a 4-year college-student study,
and a 20-year community epidemiological study, which found a
linear decline in PD manifestations from age 9 to 27 (see Clark,
2005, 2007, for reviews).
Given that age-related decreases in negative traits (e.g.,
neuroticism) also are found in normal personality (Roberts et al.,
2006; Roberts & Mroczeck, 2008) and given overlap between PD
criteria and normal personality traits, the question arises whe-
ther change in PD manifestations represents simply the same
phenomenon as change in normal personality traits or whether
additional processes are involved. If change in personality and
PD are due to the same processes, we might expect the degree
and age-ranges of change to be similar for PD criteria and
personality traits, and that PD criteria would show the same
rank-order stability as personality traits. Regarding the former
expectation, too few data have been published to examine the
The 10 DSM-IV Personality Disorders and the Pervasive Patterns That Define Them (American Psychiatric Association, 2000)
Personality disorder Pervasive patterns
Paranoid Distrust and suspiciousness of others such that their motives are interpreted as malevolent
Schizoid Detachment from social relationships and a restricted range of expression of emotions in interpersonal settings
Schizotypal Social and interpersonal deficits marked by acute discomfort with, and reduced capacity for, close relationships, as
well as by cognitive or perceptual distortions and eccentricities of behavior
Antisocial Disregard for and violation of the rights of others occurring since age 15 years
Borderline Instability of interpersonal relationships, self-image, and affects, and marked impulsivity
Histrionic Excessive emotionality and attention seeking
Narcissistic Grandiosity (in fantasy or behavior), need for admiration, and lack of empathy
Avoidant Social inhibition, feelings of inadequacy, and hypersensitivity to negative evaluation
Dependent Excessive need to be taken care of that leads to submissive and clinging behavior and fears of separation
Obsessive-compulsive Preoccupation with orderliness, perfectionism, and mental and interpersonal control, at the expense of flexibility,
openness, and efficiency
28 Volume 18—Number 1
Stability and Change in Personality Disorder
issue closely (Harpur & Hare, 1994; Johnson et al., 2000), so it is
an important topic for future research.
Regarding rank-order stability, however, some preliminary
data do exist. Specifically, Grilo et al. (2004) reported that rank-
order stability over 2 years for the dimensional measure ‘‘number
of criteria met,’’ averaged across four PDs, was moderately high,
whereas by 4 years it had dropped notably. In the community
study (Johnson et al., 2000), the average retest correlation for 11
specific types of PD manifestation from age 14 to 16 was quite
similar to that found in normal-range traits for ages 12 to 18.
However, from age 16 to 22, the average stability coefficient
dropped rather than increased as normal personality traits do.
Thus, in both samples, dimensionally assessed PD manifesta-
tions clearly showed greater change compared to normal-range
personality traits, raising the question of whether this is because
personality is more unstable in individuals with PD than in those
without or because PD manifestations are more unstable than
personality traits per se.
Morey et al. (2007) provide an initial answer to this question:
The stability of personality traits in the same patient sample
examined by Grilo et al. (2004), over the same 2 years, was high
regardless of whether the measures were designed to assess per-
sonality pathology or normal-range personality. Further, trait
stability remained at the same high level in the 4-year data, so it
appears that PD manifestations are less stable than personality
traits in both patient and community samples, and not that indi-
viduals with PD have less stable personalities than those without.
This, in turn, raises questions regarding the factors involved in
personality and PD stability and change, particularly in the
differential stability of personality traits versus PD manifesta-
tions. My focus being on stability and change in PD, readers
interested in the stability and change of normal personality are
referred elsewhere (Caspi, Roberts, & Shiner, 2005; Fraley &
Roberts, 2005; Roberts, Wood, & Caspi, 2008).
FACTORS INFLUENCING PD STABILITY AND CHANGE
Personality disorder is notoriously difficult to treat (Critchfield &
Benjamin, 2006), therapy dropout rates are high (e.g., McFar-
land & Klein, 2005), and typical response to pharmacotherapy
is modest and limited in scope (Morana & Camara, 2006).
Although extended, newly developed psychotherapies have
documented efficacy (Gabbard, 2000), little change is found
with outpatient ‘‘treatment as usual’’ (e.g., Bohus et al., 2004),
the context of most PD-stability studies. Thus, in contrast to the
relatively sharp picture that has emerged for normal personality,
our understanding of PD change is still fuzzy.
Relations With Other Disorders
Stability and change in PD manifestations must be considered in
the context of co-occurring mental disorders. Multiple studies
document that a PD diagnosis typically co-occurs with one or
more other PD diagnoses, as well as with a wide array of de-
pressive, anxiety, eating, and disruptive disorders (Clark, 2007),
so PD stability might be reduced by changes in these other
disorders. However, research into interrelations between the
course of PD and that of other disorders has found that im-
provement in PD generally is more likely to lead to improvement
in other disorders than vice versa (Clark, 2005) and that the co-
occurrence of another disorder tends to increase PD stability. For
example, in the community study cited earlier, when adolescent
personality pathology co-occurred with another mental/behavioral
disorder, the likelihood of the personality pathology continuing or
worsening in young adulthood increased by up to 19 times.
Stability of Functioning
Several recent studies have found that PD-based dysfunction is
quite stable, clearly more so than diagnostic criteria are (e.g.,
Clark, 2007; Skodol et al., 2005). Moreover, although baseline
PD manifestations (scored dimensionally) and personality trait
scores related roughly equally to functioning at both baseline
and over 2 years, over 4 years personality traits predicted
functioning more strongly than did PD manifestations (Morey et
al., 2007). Thus, the stability of dysfunction appears linked more
closely to personality traits than to PD manifestations, which are
somewhat less stable. This may be in part because adaptive
functioning takes time to develop. That is, a decrease in indi-
viduals’ PD manifestations does not translate immediately into
adaptive outcomes, such as getting and holding a job or estab-
lishing and maintaining strong interpersonal relations with
friends and family.
Variability in PD Criteria
As described earlier, PD diagnosis currently requires manifes-
tation of a certain number of diagnostic criteria. Importantly, PD
criteria vary in the degree to which they tap acute, dysfunctional
behaviors (e.g., recurrent suicidal behavior) that resolve in
shorter time periods versus more long-standing maladaptive
characteristics (e.g., preference for solitary activities), and
several studies have found significant variability in criterion
stability. For example, less stable criteria include odd behavior
and constricted affect (schizotypal PD), self-injury, and behav-
iors to avoid abandonment (borderline PD), avoiding interper-
sonal jobs and potentially embarrassing situations (avoidant
PD), and miserly and strict moral behaviors (obsessive-com-
pulsive PD), whereas paranoid ideation (schizotypal PD),
affective instability and anger (borderline PD), feeling inade-
quate and socially inept (avoidant PD), and rigidity and diffi-
culty delegating (obsessive-compulsive PD) are more stable
(Clark, 2007). Thus, the lower stability of PD manifestations
(compared to traits) may be due to changes in those criteria that
represent acute symptoms, which respond to treatment (e.g.,
suicidal behavior) or diminish with maturation or stress reso-
lution (e.g., impulsivity or unassertiveness, which also diminish
Volume 18—Number 1 29
Lee Anna Clark
with age in normal samples), whereas the observed degree of PD
stability is based in criteria that reflect more basic temperament
traits (e.g., chronic anger, stress reactivity). This intriguing
possibility clearly warrants further research.
Another way PD criteria vary is in the extent to which they
directly reflect the particular pervasive maladaptive trait pattern
that defines the diagnosis. For example, the criterion ‘‘has a
grandiose sense of self-importance’’ (p. 717) is directly related to
the defining pattern of narcissistic PD, ‘‘grandiosity in fantasy or
behavior’’ (p. 717), whereas the criterion ‘‘unwilling to get in-
volved with people unless certain of being liked’’ (p. 721) relates
less directly to one of the defining patterns of avoidant PD,
‘‘social inhibition’’ (p. 721). Studies that have assessed per-
sonality traits in addition to—and independently of—PD cri-
teria and examined relations between them have shown that
change in personality traits predicts PD change but not vice
versa (Warner et al., 2004). Thus, for example, individuals could
become more willing to get involved with people regardless of
their certainty of being liked without this change affecting their
overall level of social dominance, but if their level of social
dominance changed, they most likely would become more
willing to get involved with people.
A NEW, EMERGING VIEW OF PD
Due to these recent findings, researchers are beginning to think
differently about the stability of PD, and to view PD not as ‘‘set in
plaster’’ but as comprised of traits—some maladaptively ex-
treme—that show change within relative stability, together with
related, but less stable, dysfunctional behaviors. The latter—
which likely account for the lower stability of PD compared to
trait assessments—may be either less-direct trait manifestations
(as in the above example of interpersonal avoidance and social
inhibition), or they may develop as defensive or compensatory
coping behaviors in response to stress—both external events
and stress that is self-created by one’s own dysfunction. Relat-
edly, the persistent dysfunction of individuals with PD may be
manifestations of more stable personality traits that—being
extreme—take longer to normalize, even if they change in the
same way and at the same rate as do normal-range traits.
This emerging view of PD suggests that it would be fruitful to
revise PD diagnosis to distinguish more acute manifestations
from personality traits, and several strikingly similar proposals
have been made (Clark, 2007). Although they differ in partic-
ulars, they all suggest that PD diagnosis has two components:
(a) diagnosing disorder, that is, assessing the level of psycho-
logical and social/interpersonal dysfunction (e.g., integrated
sense of self; family and occupational stability) and its acute
manifestations (e.g., ideas of reference, aggression, hyperper-
fectionism, suicidality); and (b) describing individuals’ per-
sonality traits. Over time, disorders might come and go, much as
in depression, whereas personality traits would be expected to
change less, and less rapidly.
This approach also suggests that initial treatment should focus
on more acute, changeable PD manifestations, whereas broader,
long-lasting outcomes may need to be effected through personal-
ity-trait change. Interestingly, one of the most well-established PD
treatments, dialectical behavior therapy, may succeed because it
is congruent with this emerging view of PD. Specifically, it first
targets specific behaviors that are life threatening, interfere with
treatment, and/or lower one’s quality of life, and later shifts its
focus to developing adaptive life skills (e.g., anger management)
and to resolving longstanding, problematic interpersonal dynam-
ics (likely based, at least partly, on personality traits).
CHALLENGES AND FUTURE RESEARCH DIRECTIONS
The convergence of this emerging view of PD and the impending
revision of the DSM presents significance challenges and great
opportunities. To facilitate a major revision in PD diagnosis,
assessment researchers need to delineate the components of
PD—underlying personality traits, acute dysfunctional behav-
iors, and persistent psychological and social/interpersonal
dysfunction. Psychopathology researchers need to learn how
these components are interrelated structurally and, together
with personality researchers, they need to understand better the
processes that underlie both the relative stability of personality
traits and the greater changeability of acute dysfunction.
Applied research also is needed, to learn how this reconceptu-
alization can be utilized in clinical settings, perhaps by focusing
first on changing the least stable PD elements. Finally, we need
to learn more about normative personality-change processes and
consider how they may inform treatment of patients with PD.
Recommended Reading Caspi, A., Roberts, B.W., & Shiner, R.L. (2005). (See References). A
comprehensive review of current knowledge about the develop-
ment of personality structure; behavioral genetics of personality;
the normative timeline of life-span personality development;
and the interplay of personality with social relations, social status,
Robins, C.J., Schmidt, H., & Linehan, M.M. (2004). Dialectical be-
havior therapy: Synthesizing radical acceptance with skillful
means. In S.C. Hayes, V.M. Follette, & M.M. Linehan (Eds.),
Mindfulness and acceptance: Expanding the cognitive-behavioral tradition (pp. 30–44). New York: Guilford. An overview of the five core elements of dialectical behavior therapy focused on the
characteristics that most distinguish this approach from more
standard behavioral treatments.
Shea, M., Stout, R.L., Yen, S., Pagano, M.E., Skodol, A.E., Morey, L.C.,
et al. (2004). Associations in the course of personality disorders
and Axis I disorders over time. Journal of Abnormal Psychology, 113, 499–508. An exploration of the longitudinal interrelations of four PDs (borderline, schizotypal, avoidant, and obsessive-com-
pulsive) with the mood and anxiety disorders, including consid-
eration of causation; also provides multiple references to other
publications of the Collaborative Longitudinal Personality Study.
30 Volume 18—Number 1
Stability and Change in Personality Disorder
Widiger, T.A., Trull, T.J., Clarkin, J.F., Sanderson, C., & Costa, P.T., Jr.
(2002). A description of the DSM-IV personality disorders with the five-factor model of personality. In P.T. Costa, Jr., & T.A. Widiger
(Eds.), Personality disorders and the five-factor model of personality (2nd ed., pp. 89–99). Washington, DC: American Psychological
Association. A thorough yet accessible treatment of how the DSM- IV personality disorders can be understood from the perspective of the five-factor model of personality.
Zanarini. M.C., Frankenburg, F.R., Hennen, J., Reich, B., & Silk, K.R.
(2005). The McLean Study of Adult Development (MSAD):
Overview and implications of the first six years of prospective
follow-up. Journal of Personality Disorders, 19, 505–523. An overview of the first 6 years of an intensive, longitudinal study,
begun in the early to mid-1990s, focused on examining the course
and outcome of serious personality pathology, specifically bor-
American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text revision). Washington, DC: Author.
Bohus, M., Haaf, B., Simms, T., Limberger, M.F., Schmahl, C., Unckel,
C., et al. (2004). Effectiveness of inpatient dialectical behavioral
therapy for borderline personality disorder: A controlled trial.
Behaviour Research and Therapy, 42, 487–499.
Caspi, A., Roberts, B.W., & Shiner, R.L. (2005). Personality develop-
ment: Stability and change. Annual Review of Psychology, 56, 453–484.
Clark, L.A. (2005). Stability and change in personality pathology:
Revelations of three longitudinal studies. Journal of Personality Disorders, 19, 524–532.
Clark, L.A. (2007). Assessment and diagnosis of personality disorder:
Perennial issues and emerging conceptualization. Annual Review of Psychology, 58, 227–257.
Critchfield, K.L., & Benjamin, L.S. (2006). Principles for psychosocial
treatment of personality disorder: Summary of the APA Division 12
Task Force/NASPR Review. Journal of Clinical Psychology, 62, 661–674.
Fraley, R.C., & Roberts, B.W. (2005). Patterns of continuity: A dynamic
model for conceptualizing the stability of individual differences in
psychological constructs across the life course. Psychological Review, 112, 60–74.
Gabbard, G.O. (2000). Psychotherapy of personality disorders. Journal of Psychotherapy Practice & Research, 9, 1–6.
Grilo, C.M., Sanislow, C.A., Gunderson, J.G., Pagano, M.E., Yen, S.,
Zanarini, M., et al. (2004). Two-year stability and change of
schizotypal, borderline, avoidant, and obsessive-compulsive per-
sonality disorders. Journal of Consulting & Clinical Psychology, 72, 767–775.
Harpur, T.J., & Hare, R.D. (1994). Assessment of psychopathy as a
function of age. Journal of Abnormal Psychology, 103, 604–609.
James, W. (1950). The principles of psychology. New York: Dover. (Work originally published 1890)
Johnson, J.G., Cohen, P., Kasen, S., Skodol, A.E., Hamagami, F., &
Brook, J.S. (2000). Age-related change in personality disorder trait
levels between early adolescence and adulthood: A community-
based longitudinal investigation. Acta Psychiatrica Scandinavica, 102, 265–275.
McFarland, B.R., & Klein, D.N. (2005). Mental health service use by
patients with dysthymic disorder: Treatment use and dropout in a 7
1/2-year naturalistic follow-up study. Comprehensive Psychiatry, 46, 246–253.
Morana, H.C.P., & Camara, F.P. (2006). International guidelines for the
management of personality disorders. Current Opinion in Psychi- atry, 19, 539–543.
Morey, L.C., Hopwood, C.J., Gunderson, J.G., Zanarini, M., Skodol,
A.E., Shea, M.T., et al. (2007). Comparison of diagnostic models
for personality disorders. Psychological Medicine, 37, 983– 994.
Roberts, B.W., & DelVecchio, W.F. (2000). The rank-order consistency
of personality traits from childhood to old age: A quantitative re-
view of longitudinal studies. Psychological Bulletin, 126, 3–25.
Roberts, B.W., & Mroczek, D. (2008). Personality trait change in
adulthood. Current Directions in Psychological Science, 17, 31–35.
Roberts, B.W., Walton, K.E., & Viechtbauer, W. (2006). Patterns of
mean-level change in personality traits across the life course: A
meta-analysis of longitudinal studies. Psychological Bulletin, 132, 1–25.
Roberts, B.W., Wood, D., & Caspi, A. (2008). The development of
personality traits in adulthood. In O.P. John, R.W. Robins, & L.A.
Pervin (Eds.), Handbook of personality: Theory and research (3rd ed., pp. 375–398). New York: Guilford.
Skodol, A.E., Pagano, M.A., Bender, D.S., Shea, M.T., Gunderson, J.G.,
Yen, S., et al. (2005). Stability of functional impairment in patients
with schizotypal, borderline, avoidant, or obsessive-compulsive
personality disorder over two years. Psychological Medicine, 35, 443–451.
Warner, M.B., Morey, L.C., Finch, J.F., Gunderson, J.G., Skodol, A.E.,
Sanislow, C.A., et al. (2004). The longitudinal relationship of
personality traits and disorders. Journal of Abnormal Personality, 113, 217–227.
Widiger, T.A., & Frances, A.J. (2002). Personality disorders and the
five-factor model of personality. In P.T. Costa, Jr., & T.A. Widiger
(Eds.), Personality disorders and the five-factor model of personality (2nd ed., pp. 23–44). Washington, DC: American Psychological
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