Treatment outcome of personality disorders

Effectiveness of Delivering Dialectical Behavioral Therapy Techniques by Email in Patients With Borderline Personality Disorder: Nonrandomized Controlled Trial

BACKGROUND

Borderline personality disorder is a debilitating and prevalent mental health disorder, with often inaccessible treatment options. Electronically delivered dialectical behavioral therapy could be an efficacious and more accessible intervention.

OBJECTIVE

We aimed to evaluate the efficacy of electronic delivery of dialectical behavioral therapy in the treatment of individuals with symptoms of borderline personality disorder.

METHODS

Study participants diagnosed with borderline personality disorder were offered either an email-based or in-person group format dialectical behavioral therapy skill-building program. During each session, participants were provided with both the material and feedback regarding their previous week's homework. Electronically delivered dialectical behavioral therapy protocol and content were designed to mirror in-person content. Participants were assessed using the Self-Assessment Questionnaire (SAQ) and Difficulties in Emotion Regulation Scale (DERS).

RESULTS

There were significant increases in SAQ scores from pre- to posttreatment in the electronic delivery group (F_1,92=69.32, P<.001) and in-person group (F_1,92=60.97, P<.001). There were no significant differences observed between the groups at pre- and posttreatment for SAQ scores (F_1,92=.05, P=.83). There were significant decreases in DERS scores observed between pre- and posttreatment in the electronic delivery group (F_1,91=30.15, P<.001) and the in-person group (F_1,91=58.18, P<.001). There were no significant differences observed between the groups for DERS scores pre- and posttreatment (F_1,91=.24, P=.63). There was no significant difference in treatment efficacy observed between the 2 treatment arms (P<.001).

CONCLUSIONS

Despite the proven efficacy of in-person dialectical behavioral therapy in the treatment of borderline personality disorder, there are barriers to receiving this treatment. With the prevalence of internet access continuing to rise globally, delivering dialectical behavioral therapy with email may provide a more accessible alternative to treatment for individuals with borderline personality disorder without sacrificing the quality of care.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04493580; https://clinicaltrials.gov/ct2/show/NCT04493580.

Remnants and changes in facial emotion processing in women with remitted borderline personality disorder: an EEG study

According to longitudinal studies, most individuals with borderline personality disorder (BPD) achieve remission. Since BPD is characterized by disturbed emotion recognition, this study investigated behavioral and electrophysiological correlates of facial emotion classification and processing in remitted BPD. 32 women with remitted BPD (rBPD), 32 women with current BPD (cBPD), and 28 healthy women (HC) participated in an emotion classification paradigm comprising blends of angry and happy faces while behavioral and electroencephalographic (event-related potentials) data were recorded. rBPD demonstrated a convergence in behavior towards HC in terms of responses and reaction times. They evaluated maximally ambiguous faces more positively and exhibited faster reaction times when classifying predominantly happy faces compared to cBPD. Group × facial emotion interaction effects were found in early electrophysiological processes with post hoc tests indicating differences between rBPD and cBPD but not between rBPD and HC. However, BPD-like impairments were still found in rBPD in later processing (P300). Our results suggest a reduction in negativity bias in rBPD on the behavioral level and a normalization of earlier stages of facial processing on the neural level, while alterations in later, more cognitive processing do not remit. Early processing may be more state-like, while later impairments may be more trait-like. Further research may need to focus on these stable components.

Principles of managing patients with personality disorder

The management of individuals with personality disorder is one of the most challenging and sometimes controversial areas of psychiatry. This paper describes the principles involved in identifying the clinical problems and formulating a management plan for patients with personality disorder in everyday clinical practice. It demonstrates that the principles of assessing and managing personality disorders and the clinical skills required are no different from those of treating any other chronic mental disorder.

Personality Disorders: A Challenge for Transplantation

Evidence concerning personality disorders is limited in the transplant literature, but the existence of a personality disorder in a transplant candidate does appear to be a risk factor for poor outcome after transplantation. This article addresses the issue of personality disorders in transplantation, including a definition and diagnostic criteria of personality disorders and the value of possible interventions to treat patients with personality disorders. Directions for treating personality disorders as part of the broader clinical management of transplant recipients are also provided.

Frontiers in Cognitive Behaviour Therapy for Personality Disorders

Clinicians generally find individuals with personality disorders to be challenging to treat, especially compared to clients who have only a straightforward depression or anxiety disorder. In this article we will summarise research on the efficacy of cognitive behaviour therapy (CBT) for personality disorders. Then we will focus on the conceptualisation and treatment of CBT for personality disorders that is based on the work of Aaron Beck and colleagues; that is, it is predicated upon the cognitive model of psychopathology. Next, we will describe two other forms of treatment with cognitive behavioural roots: schema therapy and dialectical behaviour therapy. A final section will suggest future directions.

Mindfulness for personality disorders

PURPOSE OF REVIEW

Third-wave cognitive-behaviour therapies such as dialectical behaviour therapy have demonstrated effectiveness in the treatment of personality disorders, which are considered difficult to treat. These therapies typically incorporate some component of mindfulness practice. The current study examines current applications and effectiveness of mindfulness to the treatment of personality disorders.

RECENT FINDINGS

The majority of evidence available focuses on borderline personality disorder, and highlights positive associations between mindfulness practice and reduced psychiatric and clinical symptoms, less emotional reactivity, and less impulsivity. Fewer studies examine the other personality disorders, though emerging case studies have applied mindfulness techniques to treatment with antisocial, avoidant, paranoid, and obsessive-compulsive personality disorders.

SUMMARY

Mindfulness is a promising clinical tool for the treatment of personality disorders, and appears to be adaptable to the unique features of different types of personality disorders. However, further empirical research with greater methodological rigour is required to clarify the effectiveness of mindfulness as a specific skill component, and to identify the underlying mechanisms that contribute to therapeutic change.

Systems Training for Emotional Predictability and Problem Solving (STEPPS): program efficacy and personality features as predictors of drop-out -- an Italian study

In this study we present a clinical application of the STEPPS model in an Italian sample of severely affected patients with borderline personality disorder (BPD) or personality disorder (PD) with prominent borderline features in comorbidity with a mood disorder. The aims of this work are: 1) to confirm our preliminary results in a larger sample and at a 12-month follow-up, and 2) to identify predictors of drop-out vs completion of STEPPS in order to understand which characteristics of patients make them suitable or not for this treatment. The sample is composed of 32 subjects recruited from a population of inpatients of the Mood Disorders Center, Department of Clinical Neurosciences, Hospital San Raffaele-Turro, Milan. To confirm STEPPS efficacy at 12-month follow-up, we selected the following outcome criteria: reduction in the number of hospitalizations related to self-harm acts; reduction in the number of suicidal attempts; reduction of perceived emotional intensity levels; changes in cognitive filter scores; changes in the scores on self-report questionnaires. To identify predictors of drop-out vs completion, we analysed the following variables: demographic features (sex, marital status, school level achieved, and job status); Axis-I diagnosis; Axis-II categorical and dimensional diagnosis; and personality features. Seventeen (53%) subjects completed the treatment successfully. The drop-out rate was 47%. Patients who completed the program show a significant decrease in the number of hospitalizations, both at the end of the treatment and at 12-month follow-up. Friedman ANOVA test shows a significant decrease in suicidal attempts during and after STEPPS, and at 12-month follow-up. Analysis of drop-outs showed no significant differences with regard to sex, marital status, school level and job status between the two groups. Axis-I and Axis-II categorical diagnoses did not discriminate between the two groups. Those patients who dropped differ significantly from completers in histrionic personality traits and magical thinking index, given by the interaction between low scores in Self-Directedness and high scores in Self-Transcendence.

How to measure quality of life for cost-effectiveness analyses of personality disorders: a systematic review

A systematic review was undertaken to assess the construct validity and responsiveness of four generic health-related quality of life (HRQL) measures in personality disorders (PDs). Ten databases were searched and reference lists scrutinized to identify relevant studies. Relevant data were extracted accordingly. A narrative synthesis was performed of the evidence on construct validity, including known groups validity (detecting differences in HRQL scores between two different groups), convergent validity (strength of association between generic HRQL), and other measures (e.g., symptom) and responsiveness (differences in generic HRQL measure scores in responders/nonresponders or correlation with changes in other measures). Ten studies were identified: six of the EQ-5D, two involving the SF-36, and another two the SF-12, but none with the SF-6D. Evidence indicated that the EQ-5D, SF-36, and SF-12 were probably valid measures with PDs. Four studies demonstrated that the EQ-5D Index was able to detect changes in patients. The authors conclude that generic HRQL measures appear appropriate for use with people with PDs in terms of psychometric performance. However, qualitative concerns remain as to whether they fully reflect the impact of the condition.

The relation between antisocial and borderline personality symptoms and early maladaptive schemas in a treatment seeking sample of male substance users

Individuals with substance use disorders are more likely to have antisocial and borderline personality disorder than non-substance abusers. Recently, research has examined the relations between early maladaptive schemas and personality disorders, as early maladaptive schemas are believed to underlie personality disorders. However, there is a dearth of research on the relations between early maladaptive schemas and personality disorders among individuals seeking treatment for substance abuse. The current study examined the relations among early maladaptive schemas and antisocial and borderline personality within in a sample of men seeking substance abuse treatment (n = 98). Results demonstrated that early maladaptive schema domains were associated with antisocial and borderline personality symptoms. Implications of these findings for substance use treatment and research are discussed.

KEY PRACTITIONER MESSAGE

Antisocial (ASPD) and Borderline (BPD) personality disorder symptoms are prevalence among individuals seeking substance abuse treatment. Early maladaptive schemas are believed to underlie the development of ASPD and BPD symptoms, and are also prevalence among individuals seeking substance use treatment. Findings from the current study suggest that specific early maladaptive schema domains predict ASPD and BPD symptoms in a substance abuse treatment seeking sample of adult males. The treatment of ASPD and BPD among men seeking substance use treatment may want to focus on early maladaptive schemas.

Exploring the clinical validity of borderline personality disorder components

Borderline personality disorder (BPD) is recognized as a complex syndrome, resulting in a heterogeneous diagnostic category. Besides the characteristics of the disorder itself, comorbid disorders play an important role in this complexity. The aim of the study is to analyze the clinical validity of 3 components for BPD Diagnostic and Statistical Manual of Mental Disorders criteria--called affective dysregulation, behavioral dysregulation, and disturbed relatedness--investigating differences in patterns of comorbidity. For this purpose, 365 patients with suspected BPD were included in the study. To test our hypothesis, patients were classified into 5 clusters using a K-cluster analysis to study the clinical validity of the 3 components based on the 3-factor model of BPD. Differences in comorbidity, previous suicide attempts, and self-harm behaviors among the defined clusters were analyzed. Between-cluster differences were observed for Axis I and Axis II disorders as well as in the frequency of suicide attempts and in self-harm behaviors. The study of BPD based on the 3 components seems to be more useful than the study of BPD as a unitary construct to help further our understanding of this complex disorder. In the present study, the 3 BPD components have allowed us to analyze the complex comorbidity of BPD patients. This solution could be considered an interesting way to clarify BPD etiology, diagnosis, and treatment efficacy.

Treatment duration and premature termination of psychotherapy in personality disorders: predictive performance of psychodynamic personality functioning

OBJECTIVE

Little is known about predictors of treatment duration and premature termination of psychotherapy.

METHOD

Sociodemographic variables, descriptive DSM-IV psychiatric diagnoses, general symptom severity, and psychodynamic personality functioning were assessed in 148 inpatients with personality disorders who were receiving psychotherapy. Psychodynamic personality functioning was assessed using the Developmental Profile (DP). Predictive performance and incremental value over and beyond demographics and descriptive diagnoses were determined.

RESULTS

In contrast to DSM-IV diagnoses and symptom severity, psychodynamic variables and the level of personality functioning significantly predicted treatment duration and premature treatment termination. Longer treatment duration was predicted by adaptive DP levels of personality functioning, whereas shorter treatment duration was associated with maladaptive personality functioning (primitive DP levels, including fragmentation and self-centeredness). DP variables independently explained 6% of the variance.

CONCLUSION

In contrast to DSM-IV diagnoses and general symptom severity, psychodynamic personality variables significantly predicted treatment duration and premature discharge. These findings support the relevance of psycho-dynamic assessments in clinical practice, the DSM-5 proposals for the definition of personality functioning, and the predictive validity of the DP.

Long-term outcomes in borderline psychopathology: old assumptions, current findings, and new directions

Borderline personality disorder (BPD) and historical variants of the diagnosis were long held to represent an intractable syndrome of psychopathology consisting of interpersonal, intrapsychic, and affective disturbances. For years, patients labeled "borderline" were regarded pejoratively due at least in part to the lack of effective treatments. Prospective data from recent naturalistic follow-along studies along with the development of treatments with empirically demonstrated efficacy have changed how BPD is viewed. It is now less common to hide the diagnosis from the patient, and BPD has become a useful label to guide the treatment process and help the patient make sense of his or her suffering. Although it is now accepted that BPD is a treatment-responsive disorder and that remission is the norm, more work is needed to help patients achieve a higher level of functioning, and targeting persistent trait-like features suggests new directions for future efforts in treatment development.

Age and remission of personality pathology in the psychotic disorders compared to mood and/or anxiety disorders

In order to explore age-related differences in personality pathology between psychotic disorder (PSD) and mood and/or anxiety disorder (MAD) among psychiatric outpatients, 2,354 subjects were sampled randomly from outpatients in Shanghai and divided into two groups: PSD (N = 951) and MAD (N = 1403). Dimensional scores for personality disorder (PD) traits were assessed by using a self-reported personality diagnostic questionnaire (PDQ4+). Significant age differences were observed in most of the PD traits in MAD patients. Cluster B and C PD traits displayed an apparent decrease with age in MAD group, but such decline trend was not evident in PSD group. In both groups, the decline of self-reported Cluster A PD traits were less visible than the other clusters. Age-related mellowing of some PD traits such as "dramatic, erratic, anxious" occurred primarily in MAD patients; however the same traits in PSD patients appear to be less resistant to aging. Besides, "old eccentric" PD traits in both MAD and PSD patients seem to be maintained and less modified by aging.

Confirmatory Factor Analysis of Borderline Personality Disorder symptoms based on two different interviews: the Structured Clinical Interview for DSM-IV Axis II Disorder and the Revised Diagnostic Interview for Borderlines

The diagnostic criteria for Borderline Personality Disorder (BPD) are heterogeneous, and include an admixture of personality traits, behaviours, and symptoms. The BPD DSM factor structure has been extensively studied, even though results are not consistent. In this study we performed a confirmatory factor analysis (CFA) to compare the five-factor model reported by Oldham, a three-factor model, and a unidimensional model of BPD diagnosis criteria. This study validates the findings of previous studies by performing a CFA with the DSM-IV BPD criteria and information derived from the DIB-R. A sample of 338 patients referred to our outpatient BPD program participated in the study. Results of the CFA support both the hypothesized unidimensional and the three-factor models, whereas the five-factor model was not confirmed. However, the three-factor model fits better than the unidimensional model. Thus, although the DSM-IV BPD criteria conceptualize BPD as a unidimensional structure, our results give support to the idea that the three-factor model could offer a better approach to further improve the current treatment of BPD, as well as lead to a better understanding of its ethiopathogenesis and comorbidity analysis.

Personality traits as predictors of inpatient aggression in a high-security forensic psychiatric setting: prospective evaluation of the PCL-R and IPDE dimension ratings

The Dangerous and Severe Personality Disorder (DSPD) initiative in England and Wales provides specialized care to high-risk offenders with mental disorders. This study investigated the predictive utility of personality traits, assessed using the Psychopathy Checklist-Revised (PCL-R) and the International Personality Disorder Examination, with 44 consecutive admissions to the DSPD unit at a high-security forensic psychiatric hospital. Incidents of interpersonal physical aggression (IPA) were observed for 39% of the sample over an average 1.5-year period following admission. Histrionic personality disorder (PD) predicted IPA, and Histrionic, Borderline, and Antisocial PDs all predicted repetitive (2+ incidents of) IPA. PCL-R Factor 1 and Facets 1 and 2 were also significant predictors of IPA. PCL-R Factor 1 and Histrionic PD scores were significantly associated with imminence of IPA. Results were discussed in terms of the utility of personality traits in risk assessment and treatment of specially selected high-risk forensic psychiatric patients in secure settings.

Randomized trial of dual-focused vs. single-focused individual therapy for personality disorders and substance dependence

We conducted a randomized comparison of dual-focus schema therapy with individual drug counseling as enhancements to the residential treatment of 105 substance-dependent patients with specific personality disorders versus those without. Both therapies were manual-guided and delivered for 6 months by experienced psychotherapists intensively trained and supervised with independent fidelity assessment. Using the Cox proportional hazards model, we found no psychotherapy differences in retention (days in treatment). Hierarchical linear modeling indicated that participants with personality disorders started with higher psychiatric, interpersonal, and dysphoria symptoms and that both therapies reduced symptoms in 6 months. Contrary to predictions, individual drug counseling resulted in more sustained reductions than did dual-focus schema therapy in several symptoms for several personality disorders. Our findings raised important questions about the added value of integrative or dual-focus therapies for co-occurring personality disorders and substance dependence relative to empirically supported therapies focused more specifically on addiction symptoms.

The effectiveness of cognitive behavioral therapy for personality disorders

This article provides a comprehensive review of cognitive behavioral therapy (CBT) treatments for personality disorders (PDs), including a description of the available treatments and empirical support, drawing on research published between 1980 and 2009. Research generally supports the conclusion that CBT is an effective treatment modality for reducing symptoms and enhancing functional outcomes among patients with PDs, thereby making it a useful framework for clinicians working with patients with PD symptomatology. There is a clear need, however, to develop and evaluate CBT in order to provide specific and more unambiguous treatment recommendations with particular relevance for understudied PDs.

Exploratory factor analysis of borderline personality disorder criteria in monolingual Hispanic outpatients with substance use disorders

This study examined the factor structure of the Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV) criteria for borderline personality disorder (BPD) in Hispanic patients. Subjects were 130 monolingual Hispanic adults who had been admitted to a specialty outpatient clinic that provides psychiatric and substance abuse services to Spanish-speaking individuals. All were reliably assessed with the Spanish-Language Version of the Diagnostic Interview for DSM-IV Personality Disorders. After evaluating internal consistency of the BPD criterion set, an exploratory factor analysis was performed using principal axis factoring. Results suggested a unidimensional structure, and were consistent with similar studies of the DSM-IV criteria for BPD in non-Hispanic samples. These findings have implications for understanding borderline psychopathology in this population, and for the overall validity of the DSM-IV BPD construct.

The borderlines of bipolar affective disorder

This paper provides an overview of the major studies of bipolar affective disorder (BAD) and borderline personality disorder (BPD), and assesses whether the disorders might be better understood as variants of the same basic disorder. There is a shortage of research that delineates the features of both disorders within their representative samples. As a consequence the symptomatic overlap of the disorders, detected by categorical assessment instruments, is often misconstrued as an indication of the disorders' high rates of comorbidity (up to 81%). In paying particular attention to features of both disorders, eg. affective instability and impulsivity, the paper provides evidence that BPD attenuates bipolar disorder along the spectrum of affective disorders, from non-classical bipolar presentation through to severe BAD with borderline features. The paper cites clinical, research and pharmacologic support of the contention that BPD, rather than representing a distinct disorder, is merely an attenuation of Axis I disorders, most especially bipolar affective disorder. Borderline personality is evident across the bipolar spectrum and exacerbates symptomatology and leads to poorer recovery prognosis.

Personality disorder prevalence and treatment outcomes: a literature review

Personality disorder is argued to be the most prevalent psychiatric disorder and is considered to be a significant public health burden, yet there is little evidence that the disorder occupies a commensurate place in public health service planning, appropriate to such a burden. This paper reviews the prevalence and treatment outcome studies of individuals with personality disorder. The literature search highlighted prevalence studies and evidence based pharmacological, psychosocial, and alliance based interventions within this area. From this review, the place of mental health nurses within health service models is discussed.

Ten-year stability and latent structure of the DSM-IV schizotypal, borderline, avoidant, and obsessive-compulsive personality disorders

Evaluation of the validity of personality disorder (PD) diagnostic constructs is important for the impending revision of the Diagnostic and Statistical Manual of Mental Disorders. Prior factor analytic studies have tested these constructs in cross-sectional studies, and models have been replicated longitudinally, but no study has tested a constrained longitudinal model. The authors examined 4 PDs in the Collaborative Longitudinal Personality Disorders study (schizotypal, borderline, avoidant, and obsessive-compulsive) over 7 time points (baseline, 6 months, 1 year, 2 years, 4 years, 6 years, and 10 years). Data for 2-, 4-, 6- and 10-year assessments were obtained in semistructured interviews by raters blind to prior PD diagnoses at each assessment. The latent structure of the 4 constructs was differentiated during the initial time points but became less differentiated over time as the mean levels of the constructs dropped and stability increased. Obsessive-compulsive PD became more correlated with schizotypal and borderline PD than with avoidant PD. The higher correlation among the constructs in later years may reflect greater shared base of pathology for chronic personality disorders.

A review of effective interventions for reducing aggression and violence

This paper addresses the question of whether individual violence can be reduced in frequency or severity, if so to what extent and by which methods. It opens with a brief overview of the nature of personal violence and discussion of some key definitional and methodological problems. However, its principal focus is on the findings obtained from a series of meta-analytic reviews of structured programmes for adolescents and adults who have shown repeated aggression or been convicted of personal violence, drawing together the results of studies conducted in prison, probation, youth justice and allied services. Additional results are considered from a systematic review of studies of violence prevention among offenders with mental disorders. This incorporates the preliminary findings of a meta-analysis of controlled trials of psychosocial interventions with that population. Overall, it is concluded that there is sufficient evidence currently available to substantiate the claim that personal violence can be reduced by psychosocial interventions, but that much more research is required to delineate the parameters of effectiveness in this context. Proposals are made for future investigations with reference to the theoretical understanding of causal relationships and the design of experimental trials.

Strengthening the status of psychotherapy for personality disorders: an integrated perspective on effects and costs

OBJECTIVE

Despite scientific evidence of effectiveness, psychotherapy for personality disorders is not yet fully deployed, nor is its reimbursement self-evident. Both clinicians and health care policy-makers increasingly rely on evidence-based medicine and health economics when determining a treatment of choice and reimbursement. This article aims to contribute to that understanding by applying these criteria on psychotherapy as a treatment for patients with personality disorder.

METHOD

We have evaluated the available empirical evidence on effectiveness and cost-effectiveness, and integrated this with necessity of treatment as a moderating factor.

RESULTS

The effectiveness of psychotherapy for personality disorders is well documented with favourable randomized trial results, 2 metaanalyses, and a Cochrane review. However, the evidence does not yet fully live up to modern standards of evidence-based medicine and is mostly limited to borderline and avoidant personality disorders. Data on cost-effectiveness suggest that psychotherapy for personality disorders may lead to cost-savings. However, state-of-the-art cost-effectiveness data are still scarce. An encouraging factor is that the available studies indicate that patients with personality disorder experience a high burden of disease, stressing the necessity of treatment.

CONCLUSIONS

When applying an integrated vision on outcome, psychotherapy can be considered not only an effective treatment for patients with personality disorder but also most likely a cost-effective and necessary intervention. However, more state-of-the-art research is required before clinicians and health care policy-makers can fully appreciate the benefits of psychotherapy for personality disorders. Considerable progress is possible if researchers focus their efforts on evidence-based medicine and cost-effectiveness research.

The efficacy of various modalities of psychotherapy for personality disorders: a systematic review of the evidence and clinical recommendations

The aim of this paper is to review the level of empirical evidence for four different formats and settings that are available for psychotherapy delivery, i.e., group psychotherapy, out-patient individual psychotherapy, day hospital psychotherapy, and in-patient psychotherapy. The focus is on studies which include a wide range of DSM-IV-TR Axis II personality disorders. The results show that various psychotherapeutic treatments have proven to be efficacious with respect to reducing symptomatology and personality pathology, and improving social functioning in patients with Cluster A, B, C, or not-otherwise-specified personality disorders. This is especially true for cognitive-behaviorally or psychodynamically oriented out-patient individual psychotherapies. However, some evidence indicates that this also applies to (1) long-term, psychodynamically oriented group psychotherapy, (2) short-term, psychodynamically oriented psychotherapy in a day hospital setting, and (3) various duration variants of psychodynamically oriented, in-patient psychotherapy programmes. The available evidence mostly applies to borderline, dependent, avoidant and not-otherwise-specified personality disorder, and perhaps also paranoid, obsessive-compulsive, and schizotypal personality disorder. It is unknown whether these conclusions also apply to schizoid, antisocial, narcissistic, and histrionic personality disorder.

Advances in psychotherapy of personality disorders: a research update

This article reviews psychotherapy studies published between 2003 and 2006 directed at psychotherapy for personality disorders (PDs). Over the past 3 years, there has been a substantial increase in these studies compared with previous decades. Psychodynamic therapy, cognitive-behavioral therapy, and variants of these approaches have been evaluated and shown to have positive results. Borderline personality disorder continues to garner the most attention and has been shown to respond favorably to several types of therapeutic interventions on a range of outcomes. Avoidant personality disorder and obsessive-compulsive personality disorder also respond positively to psychotherapy. Although growing attention to the treatment of PDs is encouraging, further research is indicated. A summary of recent empirical findings and their implications for clinical practice are discussed.

Cluster A personality disorders: considering the 'odd-eccentric' in psychiatric nursing

Psychiatric nurses are familiar with the concept of personality disorder because of their contact with persons with the most common personality disorder in clinical settings - borderline type, who frequently engage mental health services. Perhaps it is this familiarity that has focused research and clinical attention on borderline personality disorder compared with the other personality disorders. The significance of cluster A personality disorders for nursing is multifaceted because of their severity, prevalence, inaccurate diagnosis, poor response to treatment, and similarities to axis I diagnoses. Despite this, literature reviews have established that relatively few studies have focused on the treatment of the cluster A personality disorders - paranoid, schizotypal, and schizoid - resulting in a dearth of evidence-based interventions for this group of clients. A discussion of these disorders in the context of personality disorder and their individual characteristics demonstrates the distinctive and challenging engagement techniques required by psychiatric nurses to provide effective treatment and care. It is also strongly indicated that the discipline of psychiatric nursing has not yet begun to address the care of persons with cluster A personality disorders.

The impact of obsessive-compulsive personality disorder on the suicidal risk of patients with mood disorders

BACKGROUND

The association of mood disorders with personality disorder is frequent and relevant in terms of clinical and therapeutic aspects. Personality disorders may modify the phenomenology of axis I psychiatric disorders, generating atypical clinical features, uncommon behavior or unusual patient attitudes.

SAMPLING AND METHODS

The paper describes the atypical symptoms of 7 patients affected by mood disorder associated with obsessive-compulsive personality disorder (OCPD) who made a near-lethal suicide attempt and were admitted to a psychiatric intensive care unit.

RESULTS AND CONCLUSIONS

The presence of OCPD associated with mood disorders may increase the risk of misdiagnosis, render some life events more stressful than usual for patients and increase the severity of the suicide attempt.

Exploratory factor analysis of borderline personality disorder criteria in hospitalized adolescents

OBJECTIVE

The authors examined the factor structure of borderline personality disorder (BPD) in hospitalized adolescents and also sought to add to the theoretical and clinical understanding of any homogeneous components by determining whether they may be related to specific forms of Axis I pathology.

METHOD

Subjects were 123 adolescent inpatients, who were reliably assessed with structured diagnostic interviews for Diagnostic and Statistical Manual of Mental Disorders, Revised Third Edition Axes I and II disorders. Exploratory factor analysis identified BPD components, and logistic regression analyses tested whether these components were predictive of specific Axis I disorders.

RESULTS

Factor analysis revealed a 4-factor solution that accounted for 67.0% of the variance. Factor 1 ("suicidal threats or gestures" and "emptiness or boredom") predicted depressive disorders and alcohol use disorders. Factor 2 ("affective instability," "uncontrolled anger," and "identity disturbance") predicted anxiety disorders and oppositional defiant disorder. Factor 3 ("unstable relationships" and "abandonment fears") predicted only anxiety disorders. Factor 4 ("impulsiveness" and "identity disturbance") predicted conduct disorder and substance use disorders.

CONCLUSIONS

Exploratory factor analysis of BPD criteria in adolescent inpatients revealed 4 BPD factors that appear to differ from those reported for similar studies of adults. The factors represent components of self-negation, irritability, poorly modulated relationships, and impulsivity--each of which is associated with characteristic Axis I pathology. These findings shed light on the nature of BPD in adolescents and may also have implications for treatment.

Persönlichkeitsstörungen nach stationärer psychodynamischer Psychotherapie/ Personality Disorders after Inpatient Psychodynamic Psychotherapy

OBJECTIVES

The following paper presents the results of a post-treatment examination on inpatients with personality disorders who received psychodynamic psychotherapy. The examination was carried out approximately 3.3 years after the patients were discharged.

METHODS

Of a group of 110 patients with personality disorders (ICD-10), 72 patients underwent follow-up examination. A comprehensive catamnesis was compiled for 59 former patients; 13 former patients answered by post. Treatment success was evaluated on the basis of the Symptom Checklist 90-R, Inventory of Interpersonal Problems and Questionnaire of Social Support. These surveys show no significant statistical difference between the data of the subgroups of participants and non-participants of the post-treatment examination at the start and end of therapy (Mann-Whitney-U-Test, p > 0.05). Treatment success was also examined using the Global Assessment of Functioning Scale, the Impairment-Score as well as an analysis of the patient's use of psychiatric and inpatient psychotherapeutic care and the medication received.

RESULTS

Due to the reduction in general mental stress and interpersonal problems, and the increase in perceived social support, the patients showed a positive development. After being discharged 41% of the patients received outpatient psychotherapy without further psychiatric and inpatient psychotherapeutic care.

CONCLUSIONS

The above results demonstrate that patients with personality disorders benefit from inpatient psychodynamic psychotherapy.

Two-year prevalence and stability of individual DSM-IV criteria for schizotypal, borderline, avoidant, and obsessive-compulsive personality disorders: toward a hybrid model of axis II disorders

OBJECTIVE

This study tracked the individual criteria of four DSM-IV personality disorders-borderline, schizotypal, avoidant, and obsessive-compulsive personality disorders-and how they change over 2 years.

METHOD

This clinical sample of patients with personality disorders was derived from the Collaborative Longitudinal Personality Disorders Study and included all participants with borderline, schizotypal, avoidant, or obsessive-compulsive personality disorder for whom complete 24-month blind follow-up assessments were obtained (N=474). The authors identified and rank-ordered criteria for each of the four personality disorders by their variation in prevalence and changeability (remission) over time.

RESULTS

The most prevalent and least changeable criteria over 2 years were paranoid ideation and unusual experiences for schizotypal personality disorder, affective instability and anger for borderline personality disorder, feeling inadequate and feeling socially inept for avoidant personality disorder, and rigidity and problems delegating for obsessive-compulsive personality disorder. The least prevalent and most changeable criteria were odd behavior and constricted affect for schizotypal personality disorder, self-injury and behaviors defending against abandonment for borderline personality disorder, avoiding jobs that are interpersonal and avoiding potentially embarrassing situations for avoidant personality disorder, and miserly behaviors and strict moral behaviors for obsessive-compulsive personality disorder.

CONCLUSIONS

These patterns highlight that within personality disorders the relatively fixed criteria are more trait-like and attitudinal, whereas the relatively intermittent criteria are more behavioral and reactive. These patterns suggest that personality disorders are hybrids of traits and symptomatic behaviors and that the interaction of these elements over time helps determine diagnostic stability. These patterns may also inform criterion selection for DSM-V.

Personality as a mediator of demographic risk factors for suicide attempts in a community sample

The aim of this study was to determine whether personality might partially explain associations between sociodemographic factors and self-reported suicide attempts. This analysis was motivated by reports that certain personality traits are logical targets for intervention, whereas sociodemographic characteristics are not generally modifiable. Data were from a postal survey sent to community residents who were previously selected at random (N = 912). Age, gender, health-insurance status, education, self-reported health, and marital history were identified as relevant sociodemographic predictors of having made one or more lifetime suicide attempts. Risk associated with each of these variables was mediated by the personality traits of self-directedness (SD) and harm avoidance (HA). In a multiple logistic-regression analysis constrained to sociodemographic predictors, only young age, female sex, poor self-reported health, and Medicaid status remained as predictors of suicide attempts. When personality factors were added to the model, all of the sociodemographic predictors except Medicaid status were rendered nonsignificant or marginally significant. Risk associated with gender was primarily related to HA, risk associated with poor self-reported health was mediated by both HA and SD, and the risk associated with young age was primarily mediated by SD; the last was the largest mediation effect observed. In contrast, risk associated with receipt of Medicaid, presumed to indicate low socioeconomic status, was not mediated by personality. We conclude that risk associated with certain nonmodifiable demographic factors is often mediated by potentially modifiable intrapersonal factors, such as SD.

Evidence-based assessment of personality disorders

The purpose of this article is to provide a foundation for the development of evidence-based guidelines for the assessment of personality disorders, focusing in particular on integrated assessment strategies. The general strategy recommended herein is to first administer a self-report inventory to alert oneself to the potential presence of particular maladaptive personality traits followed by a semistructured interview to verify their presence. This strategy is guided by the existing research that suggests particular strengths of self-report inventories and semistructured interviews relative to unstructured clinical interviews. However, the authors also consider research that suggests that further improvements to the existing instruments can be made. The authors emphasize, in particular, a consideration of age of onset, distortions in self-perception and presentation, gender bias, culture and ethnicity, and personality change.

Two-year stability of personality disorder in older adolescent outpatients

The 2-year stability of categorical and dimensional personality disorder (PD) in an older adolescent psychiatric outpatient sample was examined. One hundred and one 15-18-year-old participants were assessed using the Structured Clinical Interview for DSM Axis II Disorders (SCID-II) at baseline and 97 were re-interviewed, face-to-face, at 2 years. Of those with a categorical PD diagnosis at baseline, 74% still met criteria for a PD at follow-up, with marked gender differences (83% of females and 56% of males). Kappa for specific PDs was low for all except antisocial. Rank order and mean level dimensional stability ranged from high (antisocial, schizoid) to moderate (borderline, histrionic, schizotypal) to low (other PDs), with no decline in PD scores over the 2 years. There was no substantial influence upon stability of dimensional PD from the presence of Axis I disorder at baseline or from outpatient or inpatient treatment. However, categorical PD endured in 100% of those receiving inpatient care. The study supports that, in late teenage outpatients, the 2-year stability of the global category of PD is high and the stability of dimensionally rated PD appears to be similar to that found in young adults in a variety of settings, especially for some cluster A and B PDs. Diagnosis and early intervention appears to be justified in this age group.

Two-year stability and change of schizotypal, borderline, avoidant, and obsessive-compulsive personality disorders

The authors examined the stability of schizotypal (STPD), borderline (BPD), avoidant (AVPD) and obsessive-compulsive (OCPD) personality disorders (PDs) over 2 years of prospective multiwave follow-up. Six hundred thirty-three participants recruited at 4 collaborating sites who met criteria for 1 or more of the 4 PDs or for major depressive disorder (MOD) without PD were assessed with semistructured interviews at baseline, 6, 12, and 24 months. Lifetable survival analyses revealed that the PD groups had slower time to remission than the MDD group. Categorically, PD remission rates range from 50% (AVPD) to 61% (STPD) for dropping below diagnostic threshold on a blind 24-month reassessment but range from 23% (STPD) to 38% (OCPD) for a more stringent definition of improvement. Dimensionally, these findings suggest that PDs may be characterized by maladaptive trait constellations that are stable in their structure (individual differences) but can change in severity or expression over time.

Personality disorders in a Dutch forensic psychiatric sample: changes with treatment

BACKGROUND

Evidence on the effectiveness of treatment for personality disorder (PD) is mixed, and there are very few data at all on outcomes for offender patients with PD. In the Netherlands there is nevertheless commitment to treating such people in specialized forensic psychiatric hospitals.

AIMS/HYPOTHESES

The main aim was to determine the extent to which, if at all, patients detained under the Dutch TBS provision in the Dr Henri Van der Hoeven Hospital changed during inpatient treatment.

METHODS

The study followed a naturalistic design. On admission, the Structured Interview for DSM Personality Disorders (SIDP-R) and the Personality Diagnostic Questionnaire-Revised (PDQ-R) were used to assess DSM axis-II personality disorder pathology. After two years of intensive treatment they were reassessed using self-report questionnaires.

RESULTS

Fifty-nine patients (54 men and five women) completed both ratings. At follow-up, group mean indicated a significant reduction in personality disorder pathology as measured by the PDQ-R. Analysis of changes in individual subjects according to a method described by Jacobson and Truax (1991) showed that almost 40% improved reliably (by more than two standard deviations) and more than one quarter of the sample improved to a reliable and clinically significant extent in personality disorder features.

CONCLUSIONS AND CLINICAL IMPLICATIONS

The findings of the study are encouraging in terms of reduction of personality disorder psychopathology. Limitations to the study design are acknowledged. Further, it is not known whether this change constitutes substantial reorganization of personality, or whether it reflects a change at a more superficial level. Further follow-up of the patients is necessary to investigate whether the positive changes remain after release from hospital.

Motivating factors for male forensic patients with personality disorder

INTRODUCTION

Treatability is currently a crucial component for detention under the Mental Health Act (England and Wales) for the Psychopathic Disorder (personality disorder) classification and there is continuing debate about the nature and assessment of treatability of individuals with personality disorder. Previous research has identified motivation to engage in treatment as a significant factor in the assessment of treatability; however, motivation is not a static predictor but a state of readiness or eagerness to change, which may fluctuate from one time or situation to another. While previous studies have explored factors within the individual that are used to assess treatability, this study aims to explore what, if any, aspects of an inpatient forensic setting influence patients' motivation to engage in treatment.

METHOD

The study examines patients' experiences of engaging in treatment in an inpatient forensic Personality Disorder Directorate using a qualitative approach to identify possible service-, ward- and therapist-level influences on patients' motivation to engage.

RESULTS

Preliminary categories were identified across the data, including: support, treatment, safety, external belief, belonging, internal motivation and therapeutic relationship.

CONCLUSIONS

Implications for the service are identified and areas for further qualitative exploration are highlighted.

Current issues in the assessment of personality disorders

Most patients will have clinically significant maladaptive personality traits. These personality traits can substantially complicate the effective treatment of other mental disorders, and they can also be the focus of effective treatment. The assessment of personality disorders is of considerable clinical importance. However, this assessment can also be highly problematic. This article discusses the major issues in the assessment of personality disorders (eg, differentiation from other mental disorders, from normal personality functioning, and gender bias) and summarizes existing research on the convergent and discriminant validity of the semistructured interviews and self-report inventories, which have been developed to improve the reliability and validity of personality disorder assessment.

Personality disorder and Axis I psychopathology: the problematic boundary of Axis I and Axis II

The confusion of personality disorders with Axis I disorders can be traced in part to inadequacies of assessment instruments and diagnostic criterion sets. However, it also reflects the absence of adequate conceptualization. If Axis I continues to include early onset, chronic impairments that characterize everyday functioning, then there is unlikely to be a clear or meaningful distinction. Inherent and unique to personality disorders is that they concern a person's sense of self and identity. They are disorders of everyday functioning. Personality disorders have an early onset, characterize everyday functioning, and relate closely to personality functioning evident within the general population; Axis I disorders, in contrast, have an onset throughout adult life, are episodic, and are readily distinguishable from normal personality functioning.

Practice-based outcomes of dialectical behaviour therapy (DBT) targeting anger and violence, with male forensic patients: a pragmatic and non-contemporaneous comparison

OBJECTIVE

To examine the effectiveness of an eighteen-month treatment based on dialectical behaviour therapy (DBT) targeting anger and violence, on a group of male forensic patients.

METHOD

Eight male forensic patients in a high security hospital who met the criteria for borderline personality disorder measured by the Personality Assessment Inventory underwent 18 months of treatment. They completed three psychometric tests at pre-, mid- and post-treatment and at a six-month follow up. A comparison group (TAU) of nine patients, assessed as having similar personality disorders, received the usual treatment available in the hospital but excluding DBT. They completed the same tests at the same time intervals corresponding to the pre-, mid- and post-testing of the DBT group. In both groups, all instances behaviours related to anger and violence were monitored for three six-month periods, prior to, during and post-treatment.

RESULTS

Overall, patients in the DBT group made greater gains than patients in the TAU group in reducing the seriousness of violence-related incidents, and in self report measures of hostility, cognitive anger, disposition to anger, outward expression of anger and anger experience.

CONCLUSION

The results suggest a potential for DBT to impact positively and lastingly on violent behaviour and components of anger in male forensic patients when compared with standard treatment. The power of the current study to detect group differences was reduced by small ns, large confidence intervals, and a non-contemporaneous comparison group. Cost-effective strategies are proposed to take forward research on DBT with this population.

The aetiology, presentation and treatment of personality disorders

Personality disorders are a heterogeneous collection of conditions with common features, which may include an exaggerated self-centred nature, little regard for the feelings of others, or the regular fabrication of stories to explain the behaviour of self or others. Whilst such features might be recognized as being present in many people at different times of their lives, it is the persisting nature and extremes of personality traits that distinguishes those who have personality disorders from those who do not. Apart from the problems that personality disorders bring on their own (such as dysfunctional relationships), when they coexist with mental disorders it makes the latter more difficult to treat. People with personality disorders are often depicted as being dangerous, yet only a few are and it is this minority group that attract public attention. Personality disorders are recognized as belonging to the group known as the serious mental illnesses, a group that mental health nurses are being encouraged to focus their attentions on, but it is accepted that there is a paucity of education and training in appropriate interventions for this group of people. This article provides an overview of the aetiology and presentation of personality disorders together with an examination of evidence-based therapeutic interventions.

Neurotransmitters, temperament and social functioning

Dimensional models can be usefully employed to describe both normal and disordered personality. Studies in molecular genetics, receptor binding, peripheral monoamines and pharmacological challenges have investigated the neurochemical basis of personality. Substantial evidence now exists to support a psychobiological model but the specificity of Cloninger's theory has not always been confirmed. Clinical studies have shown both temperament and character dimensions to improve with pharmacological treatment especially in treatment responders. Some personality changes are found to be independent of clinical effects and even to occur in normal subjects. Models of personality can help in predicting treatment outcome but individual dimensions may not be useful. It is hypothesised that social adaptation is related to the character dimensions and different sources of evidence link these to serotonergic actions. However, recent clinical studies have shown a specific effect of noradrenaline on self-perception and social motivation. Drugs with specific actions on different neurotransmitters may exert a distinctive pattern of effects on personality and social behaviour.

Psychotherapy of personality disorders

This article reviews recent research examining the effectiveness of treating personality disorders with psychotherapy. Despite the prevalence and seriousness of these conditions, and the extensive clinical writings about them, research on the treatment of personality disorders has been limited. Much of the research is hampered by a multitude of difficult issues. Research from the past 3 years is reviewed, with an eye toward what new contributions the studies have made to the psychotherapy literature. Implications of their findings are considered and recommendations for future research are made.

Addicted patients with personality disorders: traits, schemas, and presenting problems

We evaluated the association of Structure Clinical Interview for the DSM-IV Axis II (SCID-II) severity and personality traits, early maladaptive schemas, and presenting symptoms in 41 methadone-maintained patients meeting criteria for either antisocial, borderline, avoidant, or depressive personality disorder. Correlational analyses indicated that the severity of each personality disorder was associated with a unique profile of presenting problems and underlying traits and schemas. The evaluation of multiple psychological indicators appears to be a useful method for case conceptualization and planning interventions within a promising individual therapy model that focuses both on substance abuse and psychiatric symptoms and maladaptive schemas and coping styles.