Paris, J. (2003) | References | Narcissus and the Child

What This Research Found

Joel Paris's Personality Disorders Over Time represents a paradigm shift in how psychiatry understands personality pathology. Published in 2003, this comprehensive synthesis of longitudinal research challenged the entrenched view that personality disorders were permanent, untreatable conditions—essentially life sentences imposed by flawed character. Paris demonstrated instead that personality disorders have developmental trajectories, natural courses that tend toward improvement, and modifiable outcomes.

The developmental emergence of personality pathology: Paris traces how personality disorders don't appear suddenly in adulthood but develop through identifiable precursors in childhood and adolescence. The rebellious, impulsive child with conduct problems doesn't randomly acquire antisocial personality disorder at eighteen—there is continuity, even if the diagnostic label changes. Similarly, the emotionally volatile adolescent with unstable relationships may meet criteria for borderline personality disorder by young adulthood. Narcissistic features emerge from childhood grandiosity and empathy deficits that become consolidated into a rigid defensive structure. Understanding personality disorders as developmental outcomes—not sudden appearances—has profound implications for both prevention and treatment. If we can identify precursors, we can potentially intervene before full syndromes crystallise.

The changing expression of traits over time: One of Paris's most important contributions is demonstrating that personality disorders are not static. Follow-up studies of borderline patients, for example, show that many no longer meet diagnostic criteria by their forties. This doesn't mean complete recovery—some symptoms typically persist—but the full syndrome often attenuates. Antisocial personality disorder shows marked decline in criminal behaviour with age, though interpersonal difficulties may continue. Even traits that persist tend to be expressed differently across the lifespan: the dramatic conflicts of youth may give way to quieter dysfunction in middle age. Paris synthesises evidence suggesting that personality disorders represent exaggerated versions of normal personality traits, subject to the same maturational processes that shape all personality development.

The diagnostic instability problem: Paris addresses a puzzling clinical observation: the same individual may meet criteria for different personality disorders at different points in time. "The rebellious adolescent with conduct disorder becomes the young adult with antisocial personality," as he notes, and diagnostic categories may shift again with further development. This instability reflects several realities. Cluster B disorders share underlying dimensions—emotional dysregulation, attachment disruption, identity disturbance—that manifest differently depending on developmental stage, environmental context, and which behaviours currently predominate. Current categorical diagnoses may capture surface presentations while missing deeper continuities. The same core pathology can look like borderline instability at twenty-five and narcissistic rigidity at forty-five.

Biological vulnerability and environmental activation: Paris integrates biological and environmental perspectives without reducing personality disorders to either. Constitutional vulnerabilities—temperamental emotional reactivity, impulsivity, aggression—have substantial genetic components and neurobiological correlates. But biology is not destiny. The same genetic vulnerability may lead to full personality disorder in one environment and normal functioning in another. Adverse childhood experiences—trauma, neglect, family dysfunction—interact with biological vulnerability to produce pathology. Treatment implications follow: both medication (addressing biological substrates) and psychotherapy (addressing environmental factors and learned patterns) may be necessary, and neither alone is sufficient.

How This Research Is Used in the Book

Paris's work provides essential context in Narcissus and the Child for understanding how personality disorders develop and change over time. In Chapter 2: The Four Masks, the book draws on Paris's research to explain the complex relationships between Cluster B disorders:

"Medical attitudes towards Cluster B have shifted over the past four decades. Clinicians once dismissed these conditions as untreatable character flaws but they now view them as pathological adaptations to developmental trauma."

This represents a sea change in clinical thinking—from viewing personality disorders as moral failings to understanding them as developmental outcomes shaped by the interaction of biology and environment. Paris's work was instrumental in this transformation.

The book also cites Paris to explain the puzzling phenomenon of diagnostic instability:

"Diagnoses prove temporally unstable too. The rebellious adolescent with conduct disorder becomes the young adult with antisocial personality."

This observation has profound implications for how we understand personality pathology. It suggests that the sharp diagnostic boundaries between different personality disorders may be somewhat artificial—different expressions of similar underlying vulnerabilities rather than truly distinct conditions.

Paris's developmental perspective informs the book's discussion of how narcissistic personality emerges from childhood precursors—early grandiosity, empathy deficits, and identity disturbance that become consolidated into the rigid defensive structures of adult narcissistic personality disorder. Understanding this developmental trajectory helps explain why adult narcissists seem so resistant to change: their personality organisation developed as a protective adaptation in childhood and has been reinforced over decades.

Why This Matters for Survivors

If you have been in a relationship with someone with a personality disorder, Paris's research offers both hope and caution—and understanding the balance between them is crucial for making decisions about your own future.

Change is possible but not guaranteed. Paris demonstrates that personality disorders can improve significantly over time—many people who met full diagnostic criteria in their twenties no longer do so by middle age. This may offer hope if you're wondering whether the person who hurt you could ever be different. However, "possible" is not the same as "probable," and "improvement" is not the same as "cure." Most improvement occurs in those who engage seriously with treatment over extended periods. The very features of personality disorders—denial, blame-shifting, lack of insight—often prevent this engagement. Understanding that change is theoretically possible while remaining realistic about the specific person in your life requires holding complexity.

Age and maturation matter, but slowly. The natural course of personality disorders tends toward improvement with age—the impulsivity and drama of youth often attenuate by middle age. If you're in your twenties dealing with a personality-disordered partner or parent, this might seem to offer hope: perhaps they'll mellow with time. But "improvement" over decades is cold comfort when you're dealing with abuse now. Moreover, the improvement Paris documents often involves decreased behavioural expression rather than genuine personality change—the narcissist may become less overtly grandiose while remaining fundamentally incapable of empathy. Waiting for natural improvement is not a reasonable strategy for survivors; it is information about population trends, not individual prognosis.

Childhood experiences matter, but don't excuse. Paris's developmental perspective helps explain how personality disorders emerge from adverse childhood experiences—trauma, neglect, inconsistent parenting, attachment disruption. The narcissist who cannot see you as a separate person with your own needs likely experienced something similar in childhood; their parents couldn't see them either. Understanding this developmental history can help you make sense of their behaviour without excusing it. Having a difficult childhood explains the development of pathology but does not justify inflicting harm on others. Many people with adverse childhood experiences do not develop personality disorders; those who do still have choices about how they treat others.

You can't treat someone else's personality disorder. One implication of Paris's research is that effective treatment requires genuine engagement over extended periods—typically years of specialised psychotherapy. This is work that only the person with the disorder can do, and only if they recognise the need and commit to the process. No amount of love, patience, understanding, or sacrifice on your part can substitute for their own therapeutic work. If you've been trying to "fix" someone with a personality disorder through your relationship, Paris's research confirms what you may have sensed: it doesn't work that way. Your efforts, however well-intentioned, cannot produce the changes that only specialised treatment and personal commitment can achieve.

Clinical Implications

For psychiatrists, psychologists, and trauma-informed healthcare providers, Paris's longitudinal perspective has significant implications for assessment, treatment planning, and prognosis communication.

Developmental history is essential to assessment. Paris's framework emphasises that adult personality disorders have childhood precursors. Clinical assessment should trace developmental trajectories: When did problems first appear? How have symptoms evolved over time? What were the childhood temperament and attachment patterns? Understanding personality disorder as a developmental outcome rather than a sudden appearance changes how clinicians conceptualise the problem and helps identify both risk and protective factors. Conduct disorder history, childhood trauma, early attachment disruption, and family history of personality pathology all inform current presentation and future prognosis.

Prognosis should be honest but not nihilistic. Paris's research supports cautious optimism about personality disorder outcomes: many patients improve substantially over time, particularly with appropriate treatment. Clinicians should communicate this hope while being realistic about the difficulty and duration of the journey. Borderline personality disorder, in particular, shows good long-term prognosis for many patients—a message that can sustain both patient and clinician through the challenging early stages of treatment. Narcissistic personality disorder appears more stable, but this may partly reflect the difficulty of engaging narcissistic patients in treatment rather than inherent immutability.

Treatment timing matters. Paris's developmental perspective suggests that personality disorders may be most amenable to intervention during certain windows—particularly in late adolescence and early adulthood when personality is still consolidating, and in periods of crisis that might motivate change. Clinicians should be alert to opportunities when patients may be more receptive to treatment engagement. The narcissist who has just experienced a major failure or the antisocial individual facing serious consequences may be temporarily more open to examining their patterns. However, crisis-driven engagement often fades as crisis resolves, so sustained treatment requires developing intrinsic motivation.

Environmental intervention is part of treatment. Paris emphasises that personality disorders develop through the interaction of biological vulnerability and environmental stress, and that improvement often requires environmental change. Treatment should address not just internal patterns but external circumstances: helping patients establish stable housing, employment, and relationships; reducing exposure to triggering stressors; building support networks. Patients who remain in chaotic, abusive, or unsupportive environments are less likely to improve regardless of therapeutic technique.

Countertransference management is critical. Working with personality-disordered patients evokes strong emotional reactions in clinicians—the idealisation-devaluation cycles of borderline patients, the entitled demands of narcissistic patients, the manipulation of antisocial patients. Paris's work implicitly supports the importance of consultation, supervision, and self-care for clinicians in this field. Understanding that improvement occurs over years, not months, helps clinicians maintain perspective during difficult periods. The patients who are most frustrating often have the most severe pathology and the most need for consistent, boundaried care.

Broader Implications

Paris's longitudinal perspective on personality disorders extends beyond individual clinical work to illuminate patterns across families, systems, and society.

The Intergenerational Transmission of Personality Pathology

Personality disorders tend to run in families, and Paris's developmental framework helps explain why. Parents with personality disorders create the very childhood environments—trauma, neglect, inconsistent attachment, emotional dysregulation—that produce personality pathology in the next generation. The borderline mother whose emotional storms terrify her children creates the attachment disruption that may produce borderline features in those children. The narcissistic father who treats his son as a narcissistic supply extension creates the identity disturbance that may produce narcissistic or codependent patterns. Understanding this intergenerational transmission suggests intervention points: supporting at-risk children, providing parenting interventions, and breaking cycles before they consolidate.

Diagnostic Systems and Their Limitations

Paris's observation that diagnoses prove temporally unstable—that the same person may meet criteria for different disorders at different times—has implications for how we conceptualise personality pathology. Current categorical systems (DSM-5) may impose artificial boundaries on what is actually dimensional variation. The sharp distinction between borderline and narcissistic personality disorder, for example, may not reflect underlying reality as much as current symptom presentation. This has driven interest in dimensional models of personality disorder (incorporated partially in DSM-5's alternative model) that assess personality functioning and traits rather than categorical diagnoses. Paris's work supports the view that personality disorders exist on spectrums, with more severe pathology representing greater dysfunction across multiple dimensions.

Treatment System Design and Access

If personality disorders are developmental conditions that improve with appropriate long-term treatment, then mental health systems should be designed to provide such treatment. Current systems often fail: personality disorder patients are frequently refused treatment, given only short-term interventions, or cycled through crisis services without access to the sustained specialised care that produces improvement. Paris's research supports arguments for developing personality disorder treatment tracks, training clinicians in evidence-based approaches (DBT, mentalization-based treatment, transference-focused psychotherapy), and providing the extended treatment courses that produce lasting change. The economic burden of untreated personality disorders—emergency services, hospitalisations, lost productivity, incarceration—likely exceeds the cost of effective treatment.

Criminal Justice and Rehabilitation

Antisocial personality disorder is common in prison populations, and Paris's finding that this condition tends to attenuate with age has criminal justice implications. The impulsive, antisocial young man may genuinely pose less risk by middle age—not because of successful rehabilitation but because of natural maturational processes. Sentencing policies that impose decades-long sentences on young offenders may keep people incarcerated long past the period of greatest risk. Understanding the natural course of antisocial personality suggests the value of treatment efforts in correctional settings, particularly for younger offenders who may be more amenable to intervention during the period when personality is still consolidating.

Prevention and Early Intervention

If personality disorders develop from identifiable childhood precursors, prevention becomes possible. Paris's developmental framework supports early identification of at-risk children—those with temperamental vulnerabilities, attachment disruptions, or adverse childhood experiences—and targeted intervention before full personality disorder consolidates. School-based programs teaching emotional regulation, family interventions improving parenting, and clinical treatment of childhood conduct and emotional problems may prevent adult personality pathology. The economic and human cost of prevention is almost certainly less than the cost of untreated adult personality disorders.

Reducing Stigma While Maintaining Accountability

Paris's research humanises personality disorders by placing them in developmental context—these conditions emerge from the interaction of biological vulnerability and adverse experience, not from moral failing. This perspective can reduce the stigma that prevents treatment-seeking and limits clinical engagement. However, understanding developmental origins does not eliminate personal accountability. Adults with personality disorders still make choices about how they treat others, and those choices have consequences. Maintaining this balance—compassion for developmental history combined with accountability for current behaviour—is essential for both clinical work and public understanding.

Limitations and Considerations

Paris's influential work has important limitations that warrant acknowledgment.

Longitudinal research is inherently challenging. Following people with personality disorders over years or decades is difficult and expensive. Many studies have high attrition rates—the most severely affected individuals are often the hardest to follow, potentially skewing results toward those with better prognosis. The improvement Paris documents may partly reflect who researchers were able to re-contact rather than true population trends.

Diagnostic criteria have changed over time. The criteria for personality disorders have evolved through successive DSM editions, making longitudinal comparisons complex. Someone who met criteria for borderline personality disorder in 1980 may or may not meet current criteria, and vice versa. Paris synthesises studies conducted under different diagnostic regimes, requiring appropriate caution about comparability.

Narcissistic personality disorder is less well-studied. Most longitudinal research has focused on borderline and antisocial personality disorders. Narcissistic personality disorder has received less research attention, partly because narcissists rarely seek treatment and thus are harder to study. Paris's conclusions about personality disorders generally may apply less well to NPD specifically.

Treatment effectiveness varies. While Paris documents improvement over time, much of this improvement occurs in patients receiving treatment. Untreated personality disorders may have worse natural courses, but ethical constraints prevent randomised untreated control groups over extended periods. The relative contributions of treatment versus natural maturation remain somewhat unclear.

Cultural and demographic limitations. Most longitudinal personality disorder research has been conducted in Western, developed nations. The generalisability to other cultural contexts, where personality expression and social structures differ, remains uncertain.

Historical Context

Personality Disorders Over Time appeared in 2003 during a transformative period in personality disorder research and treatment. For most of the twentieth century, personality disorders were considered essentially untreatable—fixed aspects of character that psychotherapy could not modify. Clinicians frequently refused to work with these patients, and those who did often approached treatment with low expectations.

Several developments had begun to challenge this therapeutic nihilism by the time Paris wrote. Marsha Linehan's Dialectical Behaviour Therapy, developed in the 1980s and validated through randomised controlled trials in the 1990s, demonstrated that borderline personality disorder was treatable. Long-term follow-up studies, particularly the McLean Study of Adult Development, were showing that many borderline patients improved substantially over time. Brain imaging research was revealing neurobiological abnormalities in personality disorders, suggesting these were real conditions with biological substrates rather than moral failings.

Paris synthesised this emerging evidence into a coherent developmental framework. His argument—that personality disorders have natural courses, that they often improve with age and treatment, and that understanding their developmental origins can inform intervention—provided theoretical grounding for the clinical optimism that was emerging from empirical research.

The book influenced how a generation of clinicians approached personality disorder treatment. By demonstrating that improvement was possible and even expected, Paris countered therapeutic nihilism while maintaining appropriate caution about prognosis. His emphasis on developmental origins supported the growing recognition that personality disorders often emerged from childhood trauma and attachment disruption, connecting personality pathology to the broader literature on developmental psychopathology.

Paris has continued to write prolifically on personality disorders, contributing both academic research and accessible books for clinicians and the public. His work has been characterised by intellectual honesty, willingness to challenge orthodoxy, and commitment to empirical evidence over theoretical assumption.

Personality Disorders Over Time: Precursors, Course, and Outcome

APA Citation