The Endowment for the Advancement of Psychotherapy

Personality Disorders Module

What are personality disorders?

Personality disorders are characterized by enduring pattern of behaviors and inner experiences deviating significantly from one’s culture. These harmful patterns, either to self or others or both, develop at a young age and are largely inflexible. As personality is defined by enduring behavioral or mental traits, a personality disorder is diagnosed when these enduring patterns result in significant emotional or interpersonal distress. When examining personality, it is important to take into account cultural factors contributing to its development. Therefore, some behaviors that may seem problematic in one culture may actually be considered the norm in another culture.

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In regards to the causes of personality disorders, both environmental and genetic factors likely play a role. Often, environmental factors may include difficulties in childhood such as abuse and neglect, unstable relationships with family or friends, or being a witness to violence. In regard to hereditary factors, the genetics of personality disorders are still being explored. However, for some types of personality disorders, such as borderline personality disorder, 42-68% of heritability can be attributed to genetic factors.1,2

The treatment of personality disorders largely involves psychotherapy with a possible role for medications in the management of specific associated symptoms. There are various types of psychotherapies that have been found to be effective including psychodynamic, dialectical behavioral therapy, interpersonal therapy, and cognitive behavioral therapy, which are described below. There is no medication found to cure personality disorders, although some medications may be helpful in managing specific symptoms such as anxiety, insomnia, emotion and mood dysregulation or depression. In some cases of severe personality disorders, frequent suicidal thoughts or self-harm may occur and necessitate admission to a hospital for more intensive treatment. As a contrast, in some less severe cases, people may improve without any formalized treatment. The majority of patients may be treated in an outpatient setting.

What are the types of personality disorders?

Personality disorders are divided into ten distinct types including borderline personality disorder, narcissistic personality disorder, histrionic personality disorder, avoidant personality disorder, antisocial personality disorder, obsessive-compulsive personality disorder, schizoid personality disorder, schizotypal personality disorder, paranoid personality disorder, and dependent personality disorder. As noted above, all personality disorders are characterized by enduring patterns of maladaptive behavior, thoughts, and emotions that are inflexible and associated with significant psychic, social or occupational distress. While there are many personality disorders, in this report a few will be focused on more closely as they have been shown to improve with psychodynamic psychotherapy. It is also noteworthy that it is common for people to have characteristics of several personality disorders at the same time without meeting full diagnostic criteria for one particular disorder. For more information on each specific disorder not discussed, please see the following website by the National Institute for Mental Health: http://www.nimh.nih.gov/health/statistics/prevalence/any-personality-disorder.shtml.

Borderline Personality Disorder

Borderline personality disorder is characterized by multiple symptoms including problems regulating emotions, impulsive or reckless behavior (spending sprees, unsafe sex, or substance abuse), unstable relationships with others, intermittent self-harm, and chronic feelings of emptiness. People who suffer from borderline personality disorder may feel that they have difficulty controlling their emotions with intense periods of sadness or anger that can fluctuate rapidly, often in the context of interpersonal relationships and the satisfaction or frustration with an important person. They may also have relationships characterized by frequent fluctuation between admiration (idealization) and dislike (devaluation).

People with borderline personality disorder may have symptoms triggered by seemingly minor events including perceived or actual separation from friends or family and criticism or frustration at the hands of others. Unfortunately, suicide and self-injurious behavior, along with substance use, are common in people with borderline personality disorder. In the past, borderline personality disorder was considered chronic and untreatable but more recent evidence suggests, with long and sometimes tumultuous psychotherapy treatment, symptoms can resolve in 45% of patients within 2 years and 85% of people within 10 years of treatment.3            

Narcissistic Personality Disorder

Narcissistic personality disorder is characterized by a pervasive pattern of needing admiration often coupled with an inflated sense of one’s importance. Individuals can have an inflated sense of entitlement that others do not share and can be interpersonally exploitive for the purpose of achieving their own goals. As with other personality disorders, these patterns in behaviors develop in childhood or early adulthood and lead to significant distress, often with difficulties finding satisfaction in relationships and in the ability to work due to conflict with others or a demanding nature based on a grandiose sense of their importance.

The prevalence of narcissistic personality disorder is roughly one percent in the general population but between 2 and 16 percent of the population seen by physicians.4 Despite an outward sense of importance, those with narcissistic personality disorder often have a severe sense of insecurity, inferiority, isolation, and loneliness. As a result of these behavior patterns, people with narcissistic personality disorder may lack close relationships with others as they are lacking the capacity for commitment because they are frequently searching for multiple others to validate an unstable sense of self-esteem.

Avoidant Personality Disorder

Avoidant personality disorder is characterized by a pervasive pattern of social inhibition, feelings of inadequacy, hypersensitivity to negative evaluation, and preoccupation with being criticized or rejected in social situations. The prevalence of avoidant personality disorder is 5.2% of the general population and may be common in those with social anxiety disorder.4

People with avoidant personality disorder may have intense feelings of loneliness, anxiety, and a feeling that they are not liked by others. They may also avoid social interactions entirely as they fear having poor social skills, being ridiculed, or being disliked. As a result, they may have significant difficulty in interpersonal relationships or in jobs that require frequent interactions with other people.

Dependent Personality Disorder

Dependent personality disorder is characterized by a pervasive and excessive need to be taken care of that leads to submissive and clinging behavior and fears of separation from others. As with other personality disorders, these patterns in behaviors develop in childhood or early adulthood and can lead to significant distress. However, it is also possible that dependent people can find satisfaction in a relationship with another who gains satisfaction and self-esteem from being the decision-maker and caretaker. With the loss of such a person in one’s life, the dependent person often is vulnerable to depression and anxiety. Difficulties often appear in relationships and in one’s ability to work.

The prevalence of dependent personality disorder is 0.6% of the general population and is more common in victims of spousal abuse.4 Other symptoms may include feeling helpless when alone leading to fear of being left alone, needing others to assume responsibility for most decision in their lives, and fear of disagreeing with others for fear of loss of support or approval. People with dependent personality disorder may have difficulty leaving unhealthy relationships for fear of not being able to take care of themselves.

Obsessive-Compulsive Personality Disorder

Obsessive-Compulsive personality disorder (OCPD) is characterized by pervasive and enduring patterns of preoccupation with orderliness, perfectionism, and mental or interpersonal control at the expense of flexibility and efficiency. The disorder is often confused with obsessive compulsive disorder (OCD) which is characterized by intense preoccupations (obsessions, such as cleanliness) and associated behaviors to relieve anxiety related to those preoccupations (compulsions, such as hand washing to decrease contamination fears).

People with OCPD are often so preoccupied with perfectionism that that may have problems completing normal, everyday tasks. For example, a person may work incredibly long and hard to prepare the perfect presentation, to the degree that they may neglect other parts of their lives including paying bills or maintaining relationships. The prevalence of OCPD is 2.6% of the general population.4 As a result of frequent fear of losing control, a general pattern of inflexibility or increased attention to detail, people with OCPD may have problems completing their work or maintaining healthy relationships.

What does psychodynamic psychotherapy look like in the treatment of personality disorders?

Psychodynamic psychotherapy for personality disorders is both similar to and unique to other types of psychotherapies. As characterized by all psychodynamic psychotherapy, the client will meet with a psychotherapist often once a week, most likely for at least several months, during which time he or she will be encouraged to speak openly about their past history of symptoms, past and current relationships, work history and life experiences. The length of time of therapy is believed to be necessary to achieve sustained help with a person’s difficulties. With people who suffer from personality disorders, the personality characteristics or behaviors in question were likely developed as helpful coping mechanisms during childhood. However, in adulthood, these same behaviors may lead to difficulties in relationships, difficulties in managing everyday stresses and problems with work life. Therefore, the treatment of personality disorders is focused on understanding the feelings that maladaptive behaviors are protecting so that a person can have more control over their inner lives and behavior. Crucial to psychodynamic psychotherapy is the development of a trusting and therapeutic relationship with a therapist who can help in maintaining ongoing treatment as people with personality disorders often have difficulty in maintaining relationships, even or especially with their therapists. In fact, sometimes the awareness of difficulties in the relationship with the therapist can lead to greater understanding, and therefore strategies of repair, in relationships in the patient’s life.

More generally, the treatment of personality disorders is largely with psychotherapy and sometimes with medications to treat specific psychiatric symptoms. There are various types of psychotherapy that may be helpful including psychodynamic psychotherapy, cognitive behavioral therapy (CBT), dialectical behavioral therapy (DBT), mentalization based therapy (MBT). For psychotherapy to be effective, it is helpful that the person is actively engaged and committed to the treatment, not always easy for some people. While there is no medication that cures personality disorders, they are at times prescribed in addition to psychotherapy. Medications may have a role in treating associated anxiety, depression, impulsivity, mood fluctuation or other symptoms that are often present with personality disorders. Treatment of personality disorders is largely conducted in an outpatient setting although for some, brief inpatient hospitalization or residential treatment may be necessary particularly if people develop serious intent to harm themselves or others. In all treatment settings, many personality disorders have shown to improve with mental health treatment.

Is psychodynamic psychotherapy effective in the treatment of personality disorders?

Psychodynamic psychotherapy has been shown to be efficacious in the treatment of several personality disorders including borderline personality disorder, avoidant personality disorder, obsessive compulsive personality disorder, and dependent personality disorder. A description of the evidence for psychodynamic psychotherapy for these types of personality disorders will be reviewed. However, several personality disorders including schizoid, schizotypal and paranoid personality disorders do not currently have sufficient evidence to conclude that psychodynamic psychotherapy (or any other treatment) is effective.

For borderline personality disorder, research has found psychodynamic psychotherapy to be an effective treatment. There have been numerous high quality studies examining psychodynamic psychotherapy over the past several decades supporting its efficacy in reducing symptoms, maladaptive patterns and behaviors and general patient difficulties. Doering et al. published a study in 2010 examining psychodynamic psychotherapy which found that it lead to significant improvements in psychological functioning, symptoms of borderline personality disorder (see above), and a reduction in admissions to hospitals.5 In another study by Clarkin and Levy, a type of psychodynamically informed psychotherapy, transference-focused psychotherapy (TFP), was examined. After a course of the treatment including twice weekly sessions for one year, psychodynamic psychotherapy was found to be effective at reducing suicidality and anger.6,7 These two symptoms are often some of the most distressing and lead to problems with social and occupational functioning. In yet another study, psychodynamic psychotherapy was examined in the treatment of persons with both borderline personality disorder and alcohol use disorder, a not infrequent occurrence. The study found that psychodynamic psychotherapy was effective in reducing alcohol use, hospitalizations, and suicidal behavior.8 Of note, other types of psychotherapies are frequently used in borderline personality disorder that have been shown to be effective including dialetical behavioral therapy, cognitive behavioral therapy, and interpersonal psychotherapy. These types of psychotherapy have both similarities and differences in the approaches although all rely on a trusting relationship with a therapist and an examination of patterns of thoughts and behaviors. In summary, psychodynamic psychotherapy can be considered an efficacious approach in the treatment of borderline personality disorder and associated behaviors including anger, psychological distress, and suicidal behaviors.

For avoidant, dependent, and obsessive compulsive personality disorders (also called Cluster C personality disorders), current research supports the use of psychodynamic psychotherapy. Although there is available research supporting the use of psychodynamic psychotherapy, it is notable that more large-scale studies are needed to fully confirm these results. There have been several studies finding that psychodynamic psychotherapy was more effective than routine treatment, also referred to as patient management.9, 10 Furthermore, one of these studies found that the improvement in symptoms was almost twice as large for psychodynamic psychotherapy than for cognitive behavioral therapy.9 Somewhat contrary to these studies was a smaller investigation looking at only avoidant personality disorder, one of the Cluster C disorders. The researchers found that short-term results for a cognitive behavioral treatment was comparable or better than a short course of psychodynamic psychotherapy treatment. 71    Academic researchers have wondered if this is due to the need for a longer course of psychodynamic psychotherapy to enable an enduring impact. Psychodynamic psychotherapy has been found to be effective even without comparing to cognitive behavioral therapy. Further research may help to further confirm its efficacy in specific personality disorders within the Cluster C group.

Citations:

  1. Distel MA, Willemsen G, Ligthart L et al. Genetic covariance structure of the four main features of borderline personality disorder. J Pers Disor. 2010; (24):427-444.
  2. Gunderson JG, Zanarini MC, Choi-Kain LW, et al. Family study of borderline personality disorder and its sectors of psychopathology. Arch Gen Psych. 2011; 68(7): 753-762.
  3. Gunderson JG, Stout RL, McGlashan TH, et al. Ten year course of borderline personality disorder: psychopathology and function: from the Collaborative Longitudinal Personality Disorders Study. Arch Gen Psychiatry. 2011; 68(8): 827-837.
  4. Lenzenweger MF, Lane MC, Loranger AW, Kessler RC. DSM-IV personality disorders in the National Comorbidity Survey Replication. Biol Psychiatry. 2007; 62(6): 553-564.
  5. Doering S, Horz S, Rentrop M, Fischer-Kern M, et al. Transference-focused psychotherapy v treatment by community psychotherapists for borderline personality disorder: randomized controlled trial. Br J Psychiatry. 2010; 196; 389-395.
  6. Clark JF, Levy KN, Lenzenweger MF, Kernberf, OF. The Personality Disorder Institute/Borderline Personality Disorder Research Foundation randomized control trial of for borderline personality disorder: Rationale, methods, and patient characteristics. 2004. J Personality Disorders. 2004; 18: 52-72.
  7. Levy KN, Meehan KB, Kelly KM, Reynoso JS, et al. Change in attachment patterns and reflective function in a randomized control trial of transference-focus psychotherapy for borderline personality disorder. J Consult Clin Psychol. 2006; 74: 1027-1040.
  8. Gregory RJ, Chlebowski S, Kang D, Remen AL, et al. A controlled trial of psychodynamic psychotherapy for co-occuring borderline personality disorder and alcohol use disorder. Psychotherapy. 2008; 45-41.
  9. Svartberg M, Stiles T, Seltzer MH: Randomized, controlled trial of the effectiveness of short-term dynamic psychotherapy and cognitive therapy for cluster C personality disorders. Am J Psychiatry. 2004; 161:810-817.
  10. Muran JC, Safran JD, Samstag LW, et al. Evaluating an alliance-focused treatment for personality disorders. Psychotherapy. 2005; 45:543=545.
  11. Emmelkamp PM, Benner A, Kuipers A, et al. Comparison of brief dynamic and cognitive-behavioral therapies in avoidant personality disorder. Br J Psychiatry. 2006; 189:60-64.

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