What difficulties do treatments of personality disorder face?

Translating research results into treatment for personality disorders is difficult due to heterogeneous study populations and the different assessment criteria used in different studies. There is a lot of comorbidity with other mental disorders, and symptomatic improvement of a comorbid disorder is difficult to distinguish from true underlying personality change. Moreover, the essential features of personality disorders are difficult to measure. Yet the treatment perspectives are not as bad as previously thought, especially for borderline personality disorder. Effective treatments must have an effect on core symptoms and associated long-term social adaptation. Cluster A is the least treatable, cluster B has variable treatment outcomes, and cluster C is the most treatable.

What treatment approaches are implemented?

The two main approaches in the treatment of personality disorders are psychosocial treatment and pharmacotherapy. Psychosocial intervention is recommended as primary treatment. Treatments range from rigorous behavior therapy to traditional psychoanalytic treatment. Different formats such as individual or group treatment are used. The severity of the personality disorder, the frequency of the sessions and the length of the treatment do not seem to be related to the treatment outcome. Siever, Davis and Soloff proposed four dimensions of psychopathology of personality disorders: affective instability, anxiety-inhibition, cognitive-perceptual disturbances and impulsivity aggression, which occur in all personality disorders. According to them, these dimensions should be studied and not the individual symptoms per disorder. There is no evidence for the validity of these dimensions, but the dimensions are used to measure the effect of medication. However, the effect of medication is hardly known because most research in this area has been done with borderline participants, and almost all are sponsored by the pharmaceutical industry. 

What are common comorbidities?

Most individuals with a personality disorder have at least one other personality disorder. There is also often at least one axis I comorbid disorder (in particular depression, anxiety, and substance abuse). Depression is very common in borderline, and the response to antidepressants is lower for patients with comorbid personality disorder than for those without comorbid personality disorder.

What are the goals of treatment?

Medication only focuses on specific aspects of a personality disorder, such as affective instability and cognitive-perceptual disturbances. Psychosocial treatment, mainly for borderline, aims to reduce acute life-threatening symptoms and improve distressing mental state symptoms. Research shows that the goal of reducing acute symptoms is often achieved, but that there is no improvement in the personality structure itself. The focus, context or the form of treatment does not seem to make any difference to these more complex outcomes.

What treatments are used for cluster A disorders?

People with cluster A disorders (schizoid, schizotypal and paranoid personality disorders) all experience social aversion, the inability to form close relationships and their relative indifference to these disabilities. They have poor self-awareness and empathic ability. They do not experience loneliness. Schizotypal disorder may be more related to schizophrenia than to personality disorders. People with a paranoid personality disorder are vigilant for the aggression and hostility of others, and are likely to perceive it even when it is absent. There is no good intervention for this. Patients with schizotypal personality disorder improve somewhat after using typical or atypical antipsychotics.

What treatments are used for cluster B disorders?

The cluster B disorders (borderline, antisocial, histrionic and narcissistic) share dramatic, emotional or erratic characteristics. Research focuses primarily on borderline and antisocial personality disorder. Previously, psychoanalytic therapy was mainly used in borderline, but nowadays more specific therapies are used. Dialectical behavior therapy and schema focused therapy are therapies that were adjusted for borderline. Psychoanalysis became transference focused, translating into transference focused psychotherapy. However, the problem is that borderline is common, and specialist treatments cannot be provided for all patients that admit to hospitals or are referred to outpatient care. These therapies also do not lead to improved social functioning. The different specialist treatments have the same effects, which drew attention to their common features. They are now deemed core requirements for effective treatments: a structured approach, patients are encouraged to assume control, therapists help to connect feelings and events and actions, therapists are active, validating and responsive, and therapists discuss cases with others. The APA guideline states that symptom targeted pharmacotherapy is an important adjunctive treatment for borderline. However, according to the NICE guidelines, medication should be avoided, except in crisis. Research shows that antipsychotics, SSRIs and mood stabilizers can be effective. Medication is often used in the treatment of borderline despite the lack of evidence.

What treatments work for antisocial personality disorder?

Most of the research into antisocial personality disorder has been done on prisoners. Cognitive behavior therapy in combination with training in social skills and problem solving gave the best results in terms of recidivism. Early intervention could be important, because disruptive behavior disorders in adolescents are linked to antisocial personality disorder. Little research has been done on medication, but the guidelines of the NICE are that medication should not be routinely used for antisocial personality disorder, but can be be used for comorbid mental disorders.

What treatments are used for cluster C disorders?

A meta-analysis showed that cognitive and psychodynamic therapy had medium to large positive effects in the treatment of cluster C disorders, but it was unclear which disorder benefited most from the treatment. There has been no research into medication in the treatment of cluster C disorders.

What can be concluded from research so far?

Most research has been done on borderline, which makes it difficult to draw conclusions. Psychosocial therapy is effective, especially for borderline. Treatment should be a structured partnership where patients are encouraged to assume control over themselves. Therapists must be active, validating and responsive, and well supervised. Pharmacotherapy should only be used if it is integrated into psychosocial therapy and if it is used for a short time and in a symptom-focused way.

BulletPoint Summary

• Translating research results into treatment for personality disorders is difficult due to heterogeneous study populations and the different assessment criteria used in different studies. Moreover, most research has been done on borderline, which limits generalization. There is a lot of comorbidity with other mental disorders, and symptomatic improvement of a comorbid disorder is difficult to distinguish from true underlying personality change. Moreover, the essential features of personality disorders are difficult to measure. 

• The two main approaches in the treatment of personality disorders are psychosocial treatment and pharmacotherapy. Psychosocial intervention is recommended as primary treatment. The effect of medication is hardly known because most of research in this area has been done with borderline participants, and almost all are sponsored by the pharmaceutical industry. 

• Most individuals with a personality disorder have at least one other personality disorder. There is also often at least one axis I comorbid disorder (in particular depression, anxiety, and substance abuse).

• Treatments used for cluster A. There is no good intervention for people with paranoid personality disorder and their vigilance for aggression and hostility in others. Patients with schizotypal personality disorder improve somewhat after using typical or atypical antipsychotics.

• Treatments used for cluster B. Research focuses primarily on borderline and antisocial personality disorder. As for borderline treatment, core requirements for effective treatments are: a structured approach, patients are encouraged to assume control, therapists help to connect feelings and events and actions, therapists are active, validating and responsive and therapists discuss cases with others. There is some evidence for antipsychotics, SSRIs and mood stabilizers being effective. Medication is often used in the treatment of borderline despite the lack of evidence. Cognitive behavior therapy in combination with training in social skills and problem solving gave the best results in terms of recidivism for antisocial personality disorder. Medication should according to NICE not be routinely used for antisocial personality disorder, but can be used for comorbid mental disorders.

• Treatments used for cluster C. A meta-analysis showed that cognitive and psychodynamic therapy had medium to large positive effects in the treatment of cluster C disorders, but it was unclear which disorder benefited most from the treatment. 

• General comment: pharmacotherapy should only be used if it is integrated into psychosocial therapy, if it is used for a short time and if it is used in a symptom-focused way.