Emerging Models of Personality Disorders Aimed to Improve Treatment
Abstract
Eve Caligor, M.D., is a clinical professor of psychiatry at Columbia University College of Physicians and Surgeons. She is the co-author of Psychodynamic Therapy for Personality Pathology: Treating Self and Interpersonal Functioning from APA Publishing. APA members may purchase the book at a discount.
It is an exciting time for clinicians hoping to better understand and more effectively manage patients with personality disorders. The field is in the midst of a major paradigm shift, moving from a categorical perspective focusing on discrete personality disorders defined on the basis of characteristic traits and symptoms toward a dimensional approach focusing on severity of personality pathology as it is expressed in impairments in central aspects of personality functioning.
In particular, impairments in self functioning (self-definition, stability of self-esteem, consistency of interests and values) and interpersonal functioning (ability to sustain relationships, capacity for intimacy, empathy) have emerged as core domains, or “general factors,” in the personality disorders. While personality traits, or “specific factors,” remain central to developing conceptualizations of specific personality disorder diagnoses, the new emphasis on self and interpersonal functioning highlights core features shared by all personality disorders, while contrasting the personality disorders with normal personality functioning.
This new framework is represented in the Alternative Model for Personality Disorders in Section III of DSM-5 and dovetails with psychodynamic object relations theory perspectives on personality pathology. Both approaches emphasize the dimension of severity of pathology; patients with personality disorders can be classified dimensionally on the basis of severity of impairment of self and interpersonal functioning. Both the validity and clinical utility of this approach to classification are supported by an accumulating empirical literature that points to severity of pathology as a robust predictor of prognosis, more so than either dominant traits or categorical DSM-5 diagnosis.
Thus, classification according to severity of self and interpersonal pathology may offer psychiatrists a practical and useful approach that can
Add a dimensional perspective to standard assessment practices.
Determine prognosis based on severity of illness.
Aid in determining treatment recommendations, including recommendations for specific types of psychotherapy or medication.
Help in managing clinical situations that require both pharmacologic and psychotherapeutic interventions.
Bolster necessary risk management techniques, which are essential when treating patients with personality disorder pathology.
Presentation of Self Functioning and Interpersonal Functioning
A basic understanding of normal self and interpersonal functioning, and of how impairments in these domains typically present in the personality disorders, can facilitate rapid identification of personality disorders in the course of routine clinical evaluation. Normal personality functioning is associated with an experience of self and of significant others that is continuous across time, realistic, and characterized by depth and specificity, with a capacity to identify and pursue longer-term goals guided by personal values and ideals. Relationships are characterized by mutuality and a capacity for intimacy, empathy, and concern.
In contrast, the personality disorders are characterized by difficulty identifying or consistently pursuing long-term goals in the absence of consistent personal values or ideals and an experience of self and others that is discontinuous across time, more or less distorted, often vague, superficial, or caricature-like. Relationships are characterized by failure of mutuality, difficulties with intimacy, and impaired capacity for empathy and concern. These distinctions typically emerge quite naturally in the course of routine psychiatric evaluation and can be highlighted by expansion of the social history portion of standard psychiatric assessment, focusing in particular on discussion of the patient’s current relationships and work history. Degree of impairment in self and interpersonal functioning can be characterized across a range of severity, defined in the DSM-5 Section III in terms of “level of personality functioning.”
Treatment Planning
Regardless of whether one is treating a patient for personality pathology per se or a disorder (for example, affective illness, anxiety disorder, substance misuse, eating disorder) co-occurring with a personality disorder, a patient’s level of personality functioning has profound implications for treatment planning. Individuals at higher levels of personality functioning (for example, those with avoidant personality disorder or obsessive-compulsive personality disorder) have a good to excellent prognosis. They are able to establish healthy relationships and to pursue long-term goals, enabling them to form a therapeutic alliance with relative ease and to do well in a wide variety of treatments.
In contrast, individuals at lower levels of personality functioning (for example those with borderline personality disorder or certain subtypes of narcissistic personality disorder) have a more measured prognosis. Significant impairment in interpersonal functioning may be reflected in difficulty establishing a therapeutic alliance, while impairments in self functioning are reflected in difficulty consistently participating in a goal-directed treatment. These patients are familiar to the clinician who finds that some patients with significant personality disorder pathology fail to stay in a much-needed treatment, while others stay in treatment but are not able to progress in a meaningful way. Individuals with lower levels of personality functioning do poorly in unstructured treatments but can do well in treatments organized in relation to specific treatment goals and structured to minimize the risks of premature dropout and destructive acting out.
Treatment Development
The emerging focus on self and interpersonal functioning has significant implications for treatment development. Recent studies comparing general and specific factors in personality disorders suggest that, for the most part, general factors correlate more highly with overall psychosocial functioning than do specific factors and are more likely to change longitudinally and in relation to life circumstances. Given both the centrality of self and interpersonal pathology to psychosocial functioning and their apparent fluidity across time, it is compelling to pursue treatments specifically organized to enhance functioning in these domains. Among existing treatments, transference-focused therapy (TFP), a well established, evidence-based psychodynamic therapy developed for borderline personality disorder, has enhanced identity integration and improved interpersonal functioning as goals. TFP has recently been extended (TFP-E) and developed as a trans-diagnostic treatment model for self and interpersonal pathology across the range of personality pathology. In the TFP-E model, basic clinical principles are applied across the personality disorders, with modifications introduced to tailor treatment to the individual patient and level of severity. The overall objective of treatment is to help patients with personality pathology attain higher levels of personality functioning, improving their sense of self, their capacity to pursue long-term vocational and personal goals, and their ability to enjoy satisfying relationships. ■
