Enduring Personality Change after a Catastrophic Experience
This is a genuine, lasting change to a person's character that develops in the wake of an extreme stress, either a catastrophic external experience or a severe episode of psychiatric illness, even one that has since fully resolved. Unlike the other entries in this domain, this is not a lifelong trait pattern present since adolescence; it is a new personality that emerges afterward, in someone whose personality was not disordered beforehand. Following a catastrophic experience, the picture is usually one of social withdrawal, combined with a hostile or mistrustful attitude to the world, alongside feelings of hopelessness, estrangement, and a chronic sense of being constantly on edge or under threat. Following a severe episode of psychiatric illness instead, the picture is more often one of dependency, a demanding attitude toward others, reduced interests, passivity, and persistent claims of illness, together with low mood and impaired occupational and social functioning.
This has traditionally required, for the diagnosis to be made, that the personality change has lasted more than two years, that there was no personality disorder present beforehand, and that a clear causal event, either a catastrophic experience or a severe episode of psychiatric illness, can be identified.
Recognition features
- A genuine change in personality traceable to a specific catastrophic experience or a severe episode of psychiatric illness, in someone without a premorbid personality disorder
- After a catastrophic experience: social withdrawal, a hostile or mistrustful attitude to the world, feelings of hopelessness and estrangement, and a chronic sense of being constantly on edge, as if permanently under threat
- After a severe psychiatric illness: dependency, a demanding attitude toward others, reduced interests, passivity, persistent claims of being ill along with illness behaviour, low mood, and impaired occupational and social function
- Persistence of the change for more than two years is required before the diagnosis is made
Eliciting it at interview
- Take a careful history establishing the person's personality before the identified catastrophic experience or illness episode, to confirm there was no pre-existing personality disorder
- Establish the timing and duration of the change carefully, since more than two years of persistence is required before this diagnosis can be considered
- Where the trigger was a catastrophic experience, ask specifically about hostility, mistrust, hopelessness, estrangement, and a chronic sense of threat
- Where the trigger was a severe psychiatric illness, ask specifically about dependency, demandingness, reduced interests, passivity, and persistent illness-related complaints
- Actively screen for chronic post-traumatic stress disorder, since it commonly precedes this picture and can be difficult to separate from it
Distinguishing features
- Differs from every other entry in this domain in not being a lifelong pattern present since adolescence, but a genuine change in character with an identifiable onset following a specific catastrophic event or illness episode
- Difficult to differentiate from chronic post-traumatic stress disorder, which may itself precede and evolve into this picture
- Requires, by definition, the absence of any pre-existing personality disorder, distinguishing it from a simple worsening or unmasking of a longstanding personality pattern
Common misconceptions
- That any personality change following a difficult life event qualifies for this diagnosis; a duration of more than two years and the absence of a pre-existing personality disorder are both required
- That this picture is the same as post-traumatic stress disorder; the two are closely related and can be difficult to separate, and chronic post-traumatic stress disorder may itself precede this diagnosis, but they remain distinct categories
- That this category has settled, uncontested validity; the book notes that further study is required to confirm it, given how comparatively recently it was introduced into major classification systems
Related phenomena
Related defences
Identification with the Aggressor
Diagnostically relevant to
Posttraumatic Stress Disorder (PTSD) (links open the DSM-5 Learning Lab)
Practice this
A previously outgoing, trusting man develops, in the three years since surviving a violent hostage situation, a lasting and pervasive change in character: he has become socially withdrawn, hostile and mistrustful of others, and describes a constant, chronic sense of being under threat, with no personality difficulties of any kind documented before the event. What is this? · A woman has shown a hostile, suspicious, and socially withdrawn manner for as long as anyone who knows her can remember, tracing back to her teenage years, with no identifiable triggering event or illness at any point. Before revealing the answer: is this enduring personality change after a catastrophic experience? · A patient shows a lasting change in character following a severe stressor. Before revealing the answer, decide what distinguishes enduring personality change after a catastrophic experience from a personality disorder in the general sense. · You suspect enduring personality change after a catastrophic experience in a patient. Before revealing the answer, decide how you would assess for this. · Explain why enduring personality change after a catastrophic experience is described as producing two different characteristic pictures depending on its trigger.
Illustration
Three years after surviving a building collapse that killed several colleagues, a previously sociable and easy-going man remains withdrawn, mistrustful of new acquaintances, and describes a persistent feeling of being 'braced for the next disaster' even in ordinary, safe situations, a change his family says is simply not who he used to be.
References
- Casey, P. & Kelly, B. (2019). Fish's Clinical Psychopathology, 4th ed. Ch. 10, 'Personality Disorders'.