Personality Disorders A personality disorder is identified by a pervasive pattern of experience and behavior that is abnormal with respect to any two of the following: thinking, mood, personal relations, and the control of impulses. The character of a person is shown through his or her personality -- by the way an individual thinks, feels, and behaves. When the behavior is inflexible, maladaptive, and antisocial, then that individual is diagnosed with a personality disorder. Most personality disorders begin as problems in personal development and character which peak during adolescence and then are defined as personality disorders. Personality disorders are not illnesses in a strict sense as they do not disrupt emotional, intellectual, or perceptual functioning. However, those with personality disorders suffer a life that is not positive, proactive, or fulfilling. Not surprisingly, personality disorders are also associated with failures to reach potential. The (American Psychiatric Association) defines a personality disorder as an enduring pattern of inner experience and behavior that deviates markedly from the expectation of the individual's culture, is pervasive and inflexible, has an onset in adolescence or early adulthood, is stable over time, and leads to distress or impairment. Currently, there are 10 distinct personality disorders identified in the DSM-IV: • Antisocial Personality Disorder: Lack of regard for the moral or legal standards in the local culture, marked inability to get along with others or abide by societal rules. Sometimes called psychopaths or sociopaths. •
Avoidant Personality Disorder: Marked social inhibition, feelings of inadequacy, and extremely sensitive to criticism.
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Borderline Personality Disorder: Lack of one's own identity, with rapid changes in mood, intense unstable interpersonal relationships, marked impulsively, instability in affect and in self image.
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Dependent Personality Disorder: Extreme need of other people, to a point where the person is unable to make any decisions or take an independent stand on his or her own. Fear of separation and submissive behavior. Marked lack of decisiveness and selfconfidence.
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Histrionic Personality Disorder: Exaggerated and often inappropriate displays of emotional reactions, approaching theatricality, in everyday behavior. Sudden and rapidly shifting emotion expressions.
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Narcissistic Personality Disorder: Behavior or a fantasy of grandiosity, a lack of empathy, a need to be admired by others, an inability to see the viewpoints of others, and hypersensitive to the opinions of others.
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Obsessive-Compulsive Personality Disorder: Characterized by perfectionism and inflexibility; preoccupation with uncontrollable patterns of thought and action.
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Paranoid Personality Disorder: Marked distrust of others, including the belief, without reason, that others are exploiting, harming, or trying to deceive him or her; lack of trust; belief of others' betrayal; belief in hidden meanings; unforgiving and grudge holding.
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Schizoid Personality Disorder: Primarily characterized by a very limited range of emotion, both in expression of and experiencing; indifferent to social relationships.
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Schizotypal Personality Disorder: Peculiarities of thinking, odd beliefs, and eccentricities of appearance, behavior, interpersonal style, and thought (e.g., belief in psychic phenomena and having magical powers).
Individuals with personality disorders have many things in common: • Self-centeredness that manifests itself through a me-first, self-preoccupied attitude •
Lack of individual accountability that results in a victim mentality and blaming others, society and the universe for their problems
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Lack of perspective-taking and empathy
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Manipulative and exploitative behavior
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Unhappiness, suffering from depression and other mood and anxiety disorders
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Vulnerability to other mental disorders, such as obsessive-compulsive tendencies and panic attacks
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Distorted or superficial understanding of self and others' perceptions, being unable to see his or her objectionable, unacceptable, disagreeable, or self-destructive behaviors or the issues that may have contributed to the personality disorder
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Socially maladaptive, changing the rules of the game, introducing new variables, or otherwise influencing the external world to conform to their own needs
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No hallucinations, delusions or thought disorders (except for the brief psychotic episodes of Borderline Personality Disorder)
It is important to note that some people diagnosed with borderline, antisocial, schizoid, and obsessive-compulsive personality disorders may be suffering from an underlying biological disturbance (anatomical, electrical, or neurochemical). A strong genetic link has been found in antisocial and borderline personality disorders.
Treatment of Personality Disorders Those suffering from personality disorders are difficult to please, block effective communication, avoid development of a trusting relationship, [and] cannot be relied upon for accurate history regarding problems or how problems arose (The Psychological Letter, February 2000). By reading the DSM-IV's definition of personality disorders, it seems that these conditions are not treatable. However, when individuals choose to be in control of their lives and are committed to changing their lives, healing is possible. Therapy and medications can help, but it is the individual's decision to take accountability for his or her own life that makes the difference. To heal, individuals must first have the desire to change in order to break through that enduring pattern of a personality disorder. Individuals need to want to gain insight into and face their inner experience and behavior. (These issues may concern severe or repeated trauma during childhood, such as abuse.) This involves changing their thinking--about themselves, their relationships, and the world. This also involves changing their behavior, for that which is not acted upon is not learned. Then, with a support system (e.g., therapy, self-help groups, friends, family, medication), they can free themselves from their imprisoned life. Specific treatment strategies 1. Psychotherapy. Two psychotherapeutic approaches have been shown in randomized controlled trials to have efficacy: psychoanalytic/psychodynamic therapy and dialectical behavior therapy. The treatment provided in these trials has three key features: weekly meetings with an individual therapist, one or more weekly group sessions, and meetings of therapists for consultation/supervision. No results are available from direct comparisons of these two approaches to suggest which patients may respond better to which type of treatment. Although brief therapy for personality disorders has not been systematically examined, studies of more extended treatment suggest that substantial improvement may not occur until after approximately 1 year of psychotherapeutic intervention has been provided; many patients require even longer treatment. Clinical experience suggests that there are a number of common features that help guide the psychotherapist, regardless of the specific type of therapy used. These features include: 1. building a strong therapeutic alliance 2. monitoring self-destructive and suicidal behaviors 3. create a hierarchy of priorities to consider in the treatment (e.g., first focusing on suicidal behavior) 4. validating the patient's suffering and experience 5. helping the patient take responsibility for his or her actions. 6. managing feelings (in both patient and therapist) 7. promoting reflection rather than impulsive action 8. diminishing the patient's tendency to engage in splitting 9. setting limits on any self-destructive behaviors.
Because patients with personality disorders may exhibit a broad array of strengths and weaknesses, flexibility is a crucial aspect of effective therapy. Other components of effective therapy for patients with borderline personality disorder include Individual psychotherapy with concomitant group therapy or other partial hospital modalities. Group approaches are usually used in combination with individual therapy and other types of treatment. The published literature on couples therapy is limited but suggests that it may be a useful and, at times, essential adjunctive treatment modality. However, it is not recommended as the only form of treatment for patients with borderline personality disorder. While data on family therapy are also limited, they suggest that a psychoeducational approach may be beneficial. Published clinical reports differ in their recommendations about the appropriateness of family therapy and family involvement in the treatment; family therapy is not recommended as the only form of treatment for patients with personality disorders. 2. Pharmacotherapy and other somatic treatment. Pharmacotherapy is used to treat state symptoms during periods of acute decompensation as well as trait vulnerabilities. Symptoms exhibited by patients with personality disorders often fall within three behavioral dimensions: a) affective dysregulation 1. Treatment of affective dysregulation symptoms. Patients with personality disorders displaying this dimension exhibit mood lability, rejection sensitivity, inappropriate intense anger, depressive "mood crashes," or outbursts of temper. These symptoms should be treated initially with a selective serotonin reuptake inhibitor (SSRI) or related antidepressant such as venlafaxine. Studies of tricyclic antidepressants have produced inconsistent results. When affective dysregulation appears as anxiety, treatment with an SSRI may be insufficient, and addition of a benzodiazepine should be considered, although research on these medications in patients with borderline personality disorder is limited, and their use carries some potential risk. When affective dysregulation appears as disinhibited anger that coexists with other affective symptoms, SSRIs are also the treatment of choice. Clinical experience suggests that for patients with severe behavioral dyscontrol, low-dose neuroleptics can be added to the regimen for rapid response and improvement of affective symptoms. Although the efficacy of monoamine oxidase inhibitors (MAOIs) for affective dysregulation in patients with personality disorders has strong empirical support, MAOIs are not a first-line treatment because of the risk of serious side effects and the difficulties with adherence to required dietary restrictions. Mood stabilizers (lithium, valproate, carbamazepine) are another second-line (or adjunctive) treatment for affective dysregulation, although studies of these approaches are limited. There is a paucity of data on the efficacy of ECT for treatment of affective dysregulation symptoms in patients with borderline personality disorder. Clinical experience suggests
that while ECT may sometimes be indicated for patients with comorbid severe axis I depression that is resistant to pharmacotherapy, affective features of borderline personality disorder are unlikely to respond to ECT. b. impulsive-behavioral dyscontrol 1. Treatment of impulsive-behavioral dyscontrol symptoms. Patients with personality disorders displaying this dimension exhibit impulsive aggression, self-mutilation, or self-damaging behavior (e.g., promiscuous sex, substance abuse, reckless spending). SSRIs are the initial treatment of choice. When behavioral dyscontrol poses a serious threat to the patient's safety, it may be necessary to add a low-dose neuroleptic to the SSRI. Clinical experience suggests that partial efficacy of an SSRI may be enhanced by adding lithium. If an SSRI is ineffective, switching to an MAOI may be considered. Use of valproate or carbamazepine may also be considered for impulse control, although there are few studies of these treatments for impulsive aggression in patients with personality disorders. Preliminary evidence suggests that atypical neuroleptics may have some efficacy for impulsivity in patients with personality disorders. c. cognitive-perceptual difficulties-for which specific pharmacological treatment strategies can be used. 1. Treatment of cognitive-perceptual symptoms. Patients with personality disorders displaying this dimension exhibit suspiciousness, referential thinking, paranoid ideation, illusions, derealization, depersonalization, or hallucination-like symptoms. Low-dose neuroleptics are the treatment of choice for these symptoms. These medications may improve not only psychotic-like symptoms but also depressed mood, impulsivity, and anger/hostility. If response is suboptimal, the dose should be increased to a range suitable for treating axis I disorders. Special features influencing treatment Treatment planning and implementation should reflect consideration of the following characteristics: comorbidity with axis I and other axis II disorders, problematic substance use, violent behavior and antisocial traits, chronic self-destructive behavior, trauma and posttraumatic stress disorder (PTSD), dissociative features, psychosocial stressors, gender, age, and cultural factors. Risk management issues Attention to risk management issues is important. Risk management considerations include the need for collaboration and communication with any other treating clinicians as well as the need for careful and adequate documentation. Any problems with transference and countertransference should be attended to, and consultation with a colleague should be considered for unusually high-risk patients. Standard guidelines for terminating treatment should be followed in all cases. Psychoeducation about the disorder is often appropriate and helpful. Other clinical features requiring particular consideration of risk management issues are the risk of suicide, the potential for boundary violations, and the potential for angry, impulsive, or violent behavior.
