If there is anything that personality disorder experts tend to agree on, it’s that attempting to help individuals with the illness can be challenging.
John Gunderson, M.D.: “These are people who can change more than we thought, and clinicians can be more helpful than they think in facilitating change.”
For example, a number of years ago, during his residency, John Gunderson, M.D., a professor of psychiatry at Harvard Medical School and a personality disorder expert, encountered his first borderline personality patients. “These were patients everybody was complaining to their supervisors about,” he related during a recent interview, “and nobody knew what to do for them. I published some descriptive comments about them because I wanted to place some control on the situation, which seemed scary to me. After that, colleagues started sending me patients with not just borderline, but with narcissistic personality disorder or with antisocial personality, because they thought I knew how to treat them. But I didn’t!”
“You have to have a thick skin in attempting to treat borderline patients,” stated Joel Paris, M.D., a professor of psychiatry at McGill University in Montreal, Canada. “These can be difficult patients. They tend to be emotional, sometimes contrary. They attempt suicide or threaten to. Some psychiatrists don’t want to deal with such behavior.”
Stuart Yudofsky, M.D.: “I believe that all people with personality disorders are treatable, even those with antisocial personality disorder.”
“Each personality disorder presents its own challenges,” pointed out Stuart Yudofsky, M.D., chair of psychiatry at Baylor College of Medicine and a personality disorder expert. “People with paranoid personality disorder have trouble trusting what the clinician advises. People with narcissistic personality disorder often feel that it is demeaning to acknowledge that they have a problem and need help from another person. People with borderline personality disorder are often unstable and moody.”
But during the past decade or two, evidence-based psychotherapies have become available to treat patients with some of the personality disorders.
“We had no evidence-based treatments for personality disorders at all until psychologist Marsha Lenahan published her first results regarding dialectical behavioral therapy [DBT] and borderline personality disorder in 1991,” Paris said. “DBT is a form of cognitive-behavioral therapy. Since then, evidence in this regard has become so strong that DBT has become kind of the gold standard for treating borderline.”
Gunderson agreed: “The strongest evidence base as far as borderline treatment is concerned is for DBT.”
“The psychotherapy with the next strongest evidence base is mentalization therapy, followed by transference-focused therapy,” said Kenneth Silk, M.D., a professor of psychiatry and director of the personality disorders program at the University of Michigan.
“More recently, Nancee Blum, L.I.S.W., a psychotherapist at the University of Iowa, and her colleagues have developed the STEPPS [Systems Training for Emotional Predictability and Problem Solving] program, which has gained tremendous traction for treating borderline personality disorder,” James Reich, M.D., a clinical professor of psychiatry at the University of California, San Francisco, told Psychiatric News. And as Paris explained, “STEPPS is a shorter therapy, similar to DBT, and is offered to groups to augment treatment in general clinics.”
“Evidence also suggests that schema therapy, which includes the extensive processing of negative childhood experiences with work to evoke emotions and facilitate emotional change, is effective for borderline personality,” Reich pointed out. “Schema therapy has also been found to benefit prison populations—which includes individuals with antisocial personality disorder.”
And a study published in the March American Journal of Psychiatry found that schema therapy could benefit patients with avoidant, dependent, obsessive-compulsive, histrionic, narcissistic, or paranoid personality disorders. “This study is of interest as it suggests that a therapy centered on re-experiencing trauma in a supportive treatment may be helpful in treating some forms of personality disorder,” noted Larry Siever, M.D., a professor of psychiatry at Mount Sinai School of Medicine.
“There is less evidence for psychodynamic forms of treatment than there is, for example, for behavioral forms of treatment. But that doesn’t necessarily mean that one is better than the other,” Yudofsky pointed out.
No medications have been approved by the Food and Drug Administration to treat personality disorders, but there is evidence that some medications can help in this domain.
“For instance, some interesting preliminary studies have suggested that the anticonvulsant Depakote can help with impulsive behavior,” Reich said. “Also, as avoidant personality disorder appears to be the same disorder, only more severe, than social anxiety disorder, medications that help social anxiety disorder will likely help avoidant personality disorder. There is good evidence that when anxiety or depression happens to be present at the same time as personality disorders, treating the anxiety or depression can help reduce the personality pathology.”
And low-dose antipsychotics “can calm people with borderline personality down a bit, but unfortunately they don’t produce remission,” Paris remarked.
“As for the emotional lability of borderline personality disorder, there is probably a tad more evidence for the use of mood stabilizers than for atypical antipsychotics,” said Silk.
Will the next decade bring more evidence-based treatments for personality disorders? Donald Black, M.D., who collaborated with Blum on the STEPPS program, is optimistic: “I think my experience is not unlike that of a number of other researchers in the personality disorder field. We are seeing an explosion of research, but often it is research that is not well supported by the government. It is work that we have had to figure out how to do without good sources of funding.”
In any event, Black said, “Hopefully we’ll have a better understanding of the psychotherapies that have been developed for personality disorders so that we can match patients to treatments. And hopefully we’ll also have a better sense of which patients respond to which type of medication. For example, perhaps one borderline patient would do better with a mood stabilizer, another might do better with an atypical antipsychotic, whereas another might do better with an SSRI antidepressant. And hopefully, the psychotherapy programs that are now evidence based will become more widely available so that people will be able to find those treatments available in their own regions.”
Meanwhile, personality disorder experts are urging their psychiatrist colleagues to use the tools available now to help patients with these disorders. “I think the most important thing is, these are patients who are treatable, but you have to make the diagnosis first,” Paris asserted.
“These are people who can change more than we thought, and clinicians can be more helpful than they think in facilitating change,” Gunderson observed.
“I believe that all people with personality disorders are treatable, even those with antisocial personality disorder,” said Yudofsky. “But the big thing is that the person must be engaged in treatment, which means that he or she must be motivated to change and willing to work with the therapist.” ■