Recent Trends in the Treatment of Personality Disorders
Because the literature on personality disorders largely grew out of psychoanalytic contributions, the treatments recommended for these conditions have traditionally been psychoanalysis and extended psychodynamic psychotherapy. These treatments are still useful and effective for many of the personality disorders. However, these updated chapters reflect the fact that behavior therapies and cognitive therapies also have been used for personality disorders in recent years and that a growing literature supports their use. Pharmacotherapy has been used with increasing sophistication as an adjunct to psychotherapy, particularly in borderline personality disorder, schizotypal personality disorder, and avoidant personality disorder. With the knowledge that personality reflects a genetically based biological temperament as well as a constellation of internalized object relations, defenses, and self-constructs based on experiences with the environment, a rationale can be made for a more sophisticated combination of treatments. Certain aspects of personality disorder can be targeted by specific psychopharmacological agents, whereas other dimensions are the focus of psychotherapy. For many years, only long-term treatments were recommended for personality disorders, but we now know that at least with some conditions, such as avoidant personality disorder, brief behavior therapies may be useful in altering certain symptoms.
The long-term stability of personality disorders has been a protracted point of controversy. A recent investigation examined 250 subjects from a nonclinical university population for personality disorder features at three different time points with well-established instruments. Over a 4-year period, the features of personality disorder, viewed from a dimensional perspective, appeared to be relatively stable. Nevertheless, some follow-up research suggests that significant life events also may influence the course of some personality disorders.
Even though research has expanded considerably since the last edition of this text, only in a few instances can a specific treatment be considered a well-established modality that results in dramatic changes. Nevertheless, the available interventions do suggest that distress caused by personality disorders can be ameliorated to some extent, and there is reason for optimism in prescribing a treatment plan. Moreover, we now know that at least some personality disorders are extraordinarily costly in terms of their effect on society. Weekly psychotherapy extended over 12 months or more may be a relatively expensive and labor-intensive treatment, but in the long run, such interventions may be highly cost-effective. Long-term psychotherapy based on psychodynamic or dialectical behavior therapy principles has been shown to decrease the use of hospitalization substantially and therefore saved money in the case of borderline personality disorder when compared with samples of patients who did not receive such psychotherapy. Hence, in an era of quick-fix managed care approaches, extended psychotherapy may be the preferred treatment for personality disorders in many cases from the standpoint of both effectiveness and cost-effectiveness.
The chapters in this section vary in terms of the amount of recent literature devoted to them. A study that searched MEDLINE for articles on personality disorders found that more than one-half of the individual personality disorders had either a very small amount of literature or literature with negative growth rates. Borderline, antisocial, and schizotypal personality disorders were the only disorders with modestly growing literatures. Indeed, research on Axis II conditions is unbalanced, and readers will note the imbalance as they read through the chapters in this section. The fact that some disorders are not stimulating a great deal of research or clinical interest raises the possibility that the current classification needs to be reconsidered.
Personality Disorders (patient information)
John G. Gunderson, M.D.
Glen O. Gabbard, M.D.
Personality Disorders Introduction
Since the publication of Treatments of Psychiatric Disorders, Second Edition, advances in the diagnostic understanding and treatment of personality disorders have been substantial. As recent reviews (Gabbard 2000; Gunderson and Gabbard 2000; Perry et al. 1999) have emphasized, a growing empirical literature on psychotherapy for personality disorders has shown that at least some personality disorders are eminently treatable with psychotherapy. In a parallel way, the literature on pharmacotherapy and the biology of personality disorders also has been marked by several significant recent contributions (Cloninger 1999; Coccaro and Kavoussi 1997; Silk 1998). We have asked all the chapter authors in this section to incorporate recent empirical research as well as current knowledge stemming from contributions by expert clinicians into this new edition of the text.
A variety of treatment modalities are addressed in the chapters that follow: pharmacotherapy, group and family therapy, psychoanalysis, individual psychodynamic psychotherapy, cognitive-behavioral therapies such as dialectical behavior therapy, hospital and partial hospital treatment, and other treatments to the extent they are relevant. The treatment literature is still sufficiently limited that almost no head-to-head comparisons are available that would allow clinicians to determine which treatment is better for any specific personality disorder. Similarly, we know little about the relative efficacy of combined pharmacotherapy and psychotherapy versus either treatment alone. Hence, we have relied on expert opinion to summarize both the empirical literature and the available clinical wisdom to guide the reader through the treatment options in a way that should be useful in planning a comprehensive treatment approach for patients with personality disorders. It is important to keep in mind, however, that many patients who meet criteria for one personality disorder also meet criteria for one or more additional personality disorders. Therefore, clinicians may wish to develop their own creative combinations of treatments for a patient with aspects of more than one personality disorder.
When personality disorders surfaced as topics for psychiatric classification, the overriding descriptor of "psychopathy" was used to describe people with stable and severe, but not clearly symptomatic, forms of personal inadequacies or moral degeneracy. In that context, the term character disorder has often been used in a pejorative sense. More complicated usage for personality diagnoses evolved out of the psychoanalytic contributions of Freud and his successors. Although Freud's original model suggested that the accurate identification of unconscious conflict would lead to the resolution of neurotic symptoms, this result often failed to occur. Subsequent generations of psychoanalysts came to focus their attention on their patients' resistances to change, that is, their patients' defenses, now identified as important structures of personality. Wilhelm Reich paved the way for this shift in focus with his emphasis on "character armor" and "character analysis." Such personality structures were seen as arising out of "compromise formations" by early analysts, such as Abraham and Waelder, and as evolving out of the child's early experience with parents by later theorists, such as Sullivan, Erikson, and Fairbairn.
Concurrent with the idea within psychoanalysis that the personality embodies the resistances to conflict resolution and symptom reduction were efforts within descriptive psychiatry, most notably by Kurt Schneider, to define the overriding construct of personality disorders as stable maladaptive traits that were resistant to change from life experience and likely resistant also to any therapeutic interventions. Against this background of therapeutic pessimism, a series of pioneering clinicians suggested that specific forms of intervention could be effective. Reich presented a theory of therapy advocating persistent and repetitious interpretations of characterological defenses directed at making them more dystonic and eventually weaker. Maxwell Jones developed a model of sociotherapy that involved peer confrontation about maladaptive behaviors in the context of a milieu from which the person with a personality disorder could not easily avoid self-examination.
Nonetheless, until the late 1960s, the prevailing wisdom was that although "character neuroses" were treatable, more severe personality disorders were, at best, manageable. At that time, Kernberg (1967, 1968) popularized the concept of "borderline personality organization" (a construct encompassing most forms of major personality disorder) and suggested that patients with this personality organization were understandable and modifiable by long-term psychoanalytic psychotherapy. The resulting wave of ambitious psychodynamic, residential, family, and individual therapeutic efforts gave expression to a new and widespread interest in the therapeutic possibilities for such patients.