Personality Disorder Patients Improve After Psychotherapy

People with personality disorders appear to be responsive to both psychodynamic and cognitive-behavioral therapy, according to a meta-analysis of studies looking at the effectiveness of both forms of psychotherapy.

The finding, reported in the July American Journal of Psychiatry, counters a belief among some clinicians that adult personality is stable and unchangeable and that personality disorders are largely untreatable.

“Both psychodynamic therapy and cognitive-behavioral therapy are effective treatments of personality disorders,” study author Falk Leichsenring, D.Sc., told Psychiatric News. Moreover, psychotherapy for individuals with personality disorders “is possible and effective and should be done.”

He is with the department of psychosomatics and psychotherapy at the University of Göttingen in Göttingen, Germany.

Leichsenring said the meta-analysis does not indicate that one form of therapy is necessarily better than the other—only that both appear to be effective.

“Psychodynamic therapy yielded larger effect sizes, but for direct comparisons, same experiment comparisons are necessary,” Leichsenring said. “The existing studies of psychodynamic therapy and cognitive-behavioral therapy differ in many variables, such as patient characteristics, therapy characteristics, therapist variables, or outcome measures.”

Leichsenring acknowledged that the relative dearth of studies on psychotherapy of both kinds for personality disorder is a significant limitation. Only 14 studies of psychodynamic therapy and 11 studies of cognitive-behavioral therapy published between 1974 and 2001 were included in the meta-analysis.

Criteria for inclusion of studies in the meta-analysis included use of standardized methods to diagnose personality disorders, application of reliable and valid instruments for the assessment of outcome, and data that allowed calculation of within-group effect sizes or assessment of personality disorder recovery rates.

Effect size is a summary measure of the magnitude of the difference or association found in a sample. Since there were only three randomized, controlled studies for psychodynamic therapy and five for cognitive-behavioral therapy, a specialized statistical method was used to calculate within-group effect sizes.

Several of the studies suggested a positive correlation between length of treatment and outcome, but again the small number of studies prohibited a definitive conclusion, he said.

Major barriers to psychotherapy research are “little funding and expensive studies,” Leichsenring said. “The focus of psychotherapy research has been on symptoms such as depression or anxiety, rather than on personality dysfunctioning.”

Experts on personality disorders agreed that the analysis, while limited in scope because of the small number of studies, provides confirmation of the treatable nature of people with personality disorders.

“This is a landmark study that demonstrates robust effects for psychodynamic psychotherapy and cognitive-behavioral therapy in the treatment of personality disorders,” said Lisa Mellman, M.D., chair of APA’s Committee on Psychotherapy by Psychiatrists. “It is a substantial contribution to the growing evidence-based literature on psychodynamic therapy, in addition to the treatment of personality disorders.”

She is an associate clinical professor of psychiatry at Columbia University College of Physicians and Surgeons and director of the psychotherapy clinic for training and research at the New York State Psychiatric Institute.

John Markowitz, M.D., an associate professor of psychiatry at Cornell Medical College and a research psychiatrist at the New York State Psychiatric Institute, told Psychiatric News that personality disorders have generally been thought to be difficult if not impossible to treat.

“What is encouraging about this is that the results look pretty good,” he said. “There are changes over time, and these patients are not untreatable.”

Thomas Widiger, Ph.D., a research coordinator for DSM-IV and a member of the personality disorders workforce for DSM-IV, agreed that there has been a “clinical lore” that personality disorders are unresponsive to treatment.

“The stereotype is due in part to a tendency in the field to commonly note that personality disorders are among the most difficult to treat,” said Widiger, a professor of psychology at the University of Kentucky. “But that doesn’t mean they are untreatable.”

Widiger acknowledged that outside of a treatment setting, personality changes little in the adult years.

“Most people try to find a niche and change their life situation rather than change themselves,” he said. “But in treatment, people are trying to make an effective change to themselves. There is substantial stability in personality, but that does not mean that maladaptive personality traits are unresponsive to treatment.”

He drew attention to a feature common to health services research on all kinds of conditions: even relatively small effects—measured individually—can add up to large, cost-saving effects when measured across a population.

“You are not going to turn an introvert into an extrovert or a person with antisocial personality disorder into Mother Theresa,” he said. “But the health care costs of personality disorders are large, and seemingly minor changes in these persons can have tremendous health care cost savings.” ▪