Two Psychotherapy Types Effective For Personality Disorders

Who says that you can't get people who are excessively preoccupied with orderliness, are terrified of criticism or rejection, or rely excessively on another person to change their ways and develop healthy behaviors?

Certainly not a study published in the May American Journal of Psychiatry that found that two types of psychotherapy can improve the personalities and behaviors of individuals with the so-called cluster C personality disorders—notably obsessive-compulsive personality disorder, avoidant personality disorder, and dependent personality disorder.

The study was headed by Martin Svartberg, M.D., Ph.D., an associate professor of psychiatry at the University of Toronto.

The cluster C personality disorders are the most prevalent personality disorders in the general population. One of every 10 persons is estimated to have one. Curiously, though, only a handful of studies have been conducted on the subject of psychotherapy for such disorders, and only one of those was a randomized, controlled trial specifically designed to study the course of these disorders during and after treatment.

In that study, conducted a decade ago by Arnold Winston, M.D., chair of psychiatry at Beth Israel Medical Center in New York City, 81 subjects with predominantly cluster C disorders either received 40 sessions of dynamic psychotherapy or served as controls. The subjects getting the dynamic psychotherapy showed significantly greater improvement regarding distress and social functioning than controls did, and gains were maintained 18 months later.

Thus Svartberg and his colleagues decided to extend the study by Winston and his coworkers. They wanted to see how cluster C disorder patients responded either to 40 sessions of dynamic psychotherapy designed for personality problems or 40 sessions of a cognitive therapy intended for patients with personality dysfunction. Fifty patients who met criteria for one or more cluster C personality disorders, but not for any other personality disorders, were randomly assigned to either treatment.

As for the dynamic psychotherapy technique used, Svartberg and his colleagues explained in their study report, the therapist gently clarified rather than confronted the patient's defenses, empathized with the patient and exposed underlying, conflicted emotions, and helped the patient regulate rather than provoke anxiety.

The three main objectives of the dynamic therapy were to help the patient recognize and relinquish defenses, become desensitized to emotions through exposure to conflicted feelings, and alter maladaptive conceptions of themselves and others.

Regarding the cognitive therapy used, Svartberg and his team said, the therapist helped the patient deal with any coexisting Axis I problems, taught the patient to identify and evaluate key negative automatic thoughts, built a collaborative and trusting relationship with the patient, employed guided imagery to unravel the meaning of experiences, collaborated with the patient in preparing homework assignments tailored to the patient's specific issues, and applied particular restructuring techniques to help the patient dispute core beliefs. The two main objectives of the cognitive therapy were to help the patient develop new and more adaptive core beliefs and also more adaptive problem-solving interpersonal behaviors.

The researchers then used three types of yardsticks to measure subjects' psychological status at the start of therapy, midtherapy, end of therapy, and up to two years after therapy had ended. The measures were the Global Severity Index (to measure symptom distress); the Inventory of Interpersonal Problems (to assess subjects' difficulties with assertiveness, intimacy, sociability, submissiveness, control, and responsibility for others); and the Millon Clinical Multiaxial Inventory (a 175-item questionnaire designed to assess personality pathology as reflected in the cluster C personality disorders).

Subjects in both treatment groups showed, on average, statistically significant improvements on all measures during treatment compared with the start of the study, and also during the two-year follow-up period after treatment. Two years after treatment, 54 percent of the dynamic psychotherapy subjects and 42 percent of the cognitive therapy subjects had recovered symptomatically, whereas some 40 percent of subjects in both groups had recovered in terms of interpersonal problems and personality functioning.

Perhaps most striking, the researchers noted, “unlike the patients in many other psychotherapy outcome studies, the patients in this study on average continued to improve significantly after treatment.... This finding of continued improvement supports one of the original justifications for short-term approaches articulated by short-term therapy pioneers....”

Thus, “both short-term dynamic psychotherapy and cognitive therapy have a place in the treatment of patients with cluster C personality disorders,” Svartberg and his team concluded.

Svartberg told Psychiatric News that he plans to analyze the data further. “Since there were no significant differences between the two treatments in terms of efficacy, treatment method may not be such an important factor in bringing about change in these patients seen as a group,” he said. “Hence, we would like to be more specific in our examinations. Our next step would be to see whether the two treatments differ in their effects with certain subgroups of patients. For instance, would cognitive therapy do better than short-term dynamic therapy with patients with avoidant personality disorder, and conversely, would short-term dynamic therapy do better than cognitive therapy with patients with obsessive-compulsive disorder?”

In the opinion of Winston, the study by Svartberg and his colleagues provides “additional evidence of the efficacy of short-term dynamic psychotherapy and cognitive therapy for patients with cluster C personality disorders. It is impressive that patients continued to improve significantly at two-year follow-up. More controlled trials of different types of psychotherapy are sorely needed for this population.”

The study was funded by the Norwegian Research Council.

The study, “Randomized, Controlled Trial of the Effectiveness of Short-Term Dynamic Psychotherapy and Cognitive Therapy for Cluster C Personality Disorders,” is posted online at<http://ajp.psychiatryonline.org/cgi/content/full/161/5/810>.▪

Am J Psychiatry 2004 161 810