Advances in psychotherapy of personality disorders: A research update

This article reviews psychotherapy studies published between 2003 and 2006 directed at psychotherapy for personality disorders (PDs). Over the past 3 years, there has been a substantial increase in these studies compared with previous decades. Psychodynamic therapy, cognitive-behavioral therapy, and variants of these approaches have been evaluated and shown to have positive results. Borderline personality disorder continues to garner the most attention and has been shown to respond favorably to several types of therapeutic interventions on a range of outcomes. Avoidant personality disorder and obsessive-compulsive personality disorder also respond positively to psychotherapy. Although growing attention to the treatment of PDs is encouraging, further research is indicated. A summary of recent empirical findings and their implications for clinical practice are discussed.     

Psychiatric comorbidity in epilepsy

Many studies on psychiatric comorbidity in epilepsy have been performed using many different patient groups and diagnostic instruments. This methodological heterogeneity complicates comparison of the findings. In this article, psychiatric disorders in epilepsy are reviewed from the perspective of the DSM classification system. The empirical findings of axis I clinical disorders and axis II personality disorders are described separately. Furthermore, the existence and specificity of conditions such as interictal dysphoric disorder, interictal behavior syndrome, and psychosis of epilepsy are discussed. From the many studies that have been performed on this topic it can be learned that there is a need for well-controlled studies using representative patient groups and valid and standardized diagnostic instruments. So far, the majority of the studies have concerned axis I disorders; relatively little research has been performed on axis II personality disorders. More research on personality disorders, as well as on the relative contributions of the different (brain- and non-brain-related) factors to the relationship between epilepsy and psychiatric disorders, is recommended.     

Controversies in diagnosis, classification and treatment of borderline personality disorder

PURPOSE OF REVIEW: Borderline personality disorder is the most widely researched single personality disorder, and much research activity continues. This review covers empirical literature on diagnosis, classification and treatment of borderline personality disorder published during 2006 and 2007. Several of the issues that concern borderline personality disorder also concern personality disorders in general, and so the review is broadened in the diagnostic section to include the latter. RECENT FINDINGS: Integration of categorical and dimensional approaches to personality disorders is actively being sought for inclusion in the next revision of the psychiatric classifications. Although there are few new studies on pharmacotherapy for borderline personality disorder, many new findings on psychotherapy have been reported. They indicate that a variety of treatment modalities can influence borderline personality disorder, but the role of spontaneous improvement over time and established prognostic factors have not received sufficient attention. New modalities of psychotherapy have been tested by less stringent designs. SUMMARY: Research into classification, diagnosis and psychotherapy of borderline personality disorder is flourishing, but research activity in pharmacotherapy is limited.     

Suicide and deliberate self-harm in personality disorders

PURPOSE OF REVIEW: This article reviews literature published over the period January 2004-May 2005 on suicidal behaviour and self-harm in personality disorders. RECENT FINDINGS: Studies have confirmed that personality disorders and their co-morbidity with other psychiatric conditions are risk factors for both fatal and nonfatal suicidal behaviours, and self-mutilation. Negative life events, childhood sexual abuse, difficulties in social functioning, deficits in future-directed thinking and time perception, as well as familial and neurocognitive factors may be related to increased suicide risk in individuals with borderline and other personality disorders. Findings seem to confirm that suicidality and self-injurious behaviour are efficient DSM-IV diagnostic criteria for borderline personality disorder. Out of several psychosocial and pharmacological interventions for treating suicidality in personality disorders, only one randomized, controlled study has recently been published. Medico-legal concerns related to the clinical management of chronically suicidal patients, including hospitalization and alternative treatment approaches, are also discussed. SUMMARY: Although recent studies have contributed to the theoretical knowledge and clinical practice, there are unsettled questions that should be addressed in the future. More randomized, controlled trials evaluating the efficacy of interventions in suicidal individuals with personality disorders should be conducted. As the majority of studies conducted to date have concentrated on borderline personality disorder and antisocial personality disorder, the prevalence and risk factors for suicidal behaviours and self-mutilation in other personality disorders require further clarification. The introduction of unified nomenclature related to suicidal behaviours and self-mutilation would facilitate comparability of results across studies.     

Using the family history method to distinguish relatives of patients with dependent personality disorder from relatives of controls.

It has long been established that some psychiatric disorders run in families, and as a result, the family history method has become an established part of clinical and research psychiatry. Although there is much literature on the Axis I disorders, there is relatively little on the personality disorders. There are now reports that dependent personality can run in families. This report demonstrates that a standardized family history method for the DSM-III personality disorder clusters can distinguish relatives of dependent personality disorder patients from relatives of normal controls on the anxious personality disorder cluster, but cannot distinguish them from relatives of a mixed anxiety/depression group who do not have personality disorders. Relatives of the mixed anxiety/depression group did show a different pattern from the relatives of the dependent personality disorder group when all three personality disorder clusters were examined. This is the first such finding reported in the literature. Implications for future research are discussed.     

Personality disorder assessment for psychiatric inpatients

The standardised criteria for DSM-III personality disorders encouraged the development of numerous multidimensional instruments to make the diagnosis of such disorders more objective and reliable compared with clinical judgement. Yet, there is no published research on the concordance between these instruments when used with psychiatric inpatients. Two such measures, the Millon Clinical Multiaxial Inventory (MCMI) and the Structured Interview for DSM-III Personality (SIDP), were chosen for this study. The MCMI identified a significantly greater number of personality disorders than the SIDP for each subject. Despite overall high interrater reliability with the SIDP, low agreement was found between the two instruments for most of the 11 DSM-III Axis II (personality disorders) categories. Different normative populations on which the instruments were developed, method variance, and theoretical differences between Millon and DSM-III, were all likely to contribute to the low concordance. Systematic research of possible confounding factors is suggested.     

Psychotherapy of personality disorders

This article reviews recent research examining the effectiveness of treating personality disorders with psychotherapy. Despite the prevalence and seriousness of these conditions, and the extensive clinical writings about them, research on the treatment of personality disorders has been limited. Much of the research is hampered by a multitude of difficult issues. Research from the past 3 years is reviewed, with an eye toward what new contributions the studies have made to the psychotherapy literature. Implications of their findings are considered and recommendations for future research are made.     

Personality traits,personality disorders,and migraine: a review

The personality trait of neuroticism has been associated with migraine, although research is needed to clarify potential moderators of this relationship and the extent to which neuroticism reflects a stable disposition or instead is a function of general somatic distress or situational influences. With the possible exception of harm avoidance, research has not consistently identified any other personality trait unique among migraineurs. Personality disorders have been researched less extensively, but existing data suggests that borderline personality disorder, in particular, is associated with increased negative impact of migraine, risk for medication overuse, and poor response to treatment that is likely of greater clinical importance than any personality trait per se.     

Skills training as an adjunctive treatment for personality disorders

Personality disorders are usually treated with either psychodynamic or supportive psychotherapy, with psychotropic medication often used as an adjunctive treatment. However, patients with personality disorders pose special treatment issues, because their problems are pervasive and long-standing and they have entrenched deficits in many areas of functioning. In this article, the authors consider the role of skills training in the treatment of personality disorders. They describe a two-pronged approach to the treatment of personality disorders based on a model of deficit compensation. Because skills training has only been investigated in a very limited way in personality disorders, the authors first review research on the use of skills training in Axis I disorders as background for a discussion of ways in which skills training may be applicable to the treatment of Axis II disorders. They describe a number of skills training approaches (social skills training, anger management, and conversational skills) that can be used for a variety of different Axis I disorders. Skills training approaches that are targeted to specific types of disorders (substance use disorders, schizophrenia, anxiety disorders, adolescent problems) are also described. The authors then review what is known about the use of skills training in borderline personality disorder and avoidant personality disorder, and propose skills training approaches that may be useful for patients with paranoid personality disorder and antisocial personality disorder. Case examples are provided to demonstrate how skills training for personality disorders can be applied in clinical practice.     

Is borderline personality disorder part of the bipolar spectrum?

In recent years, advances in the areas of both bipolar and borderline personality disorders have generated considerable interest in the clinical interface between these two conditions. Developments in the study of the neurobiology of borderline personality disorder suggest that many patients with this diagnosis have etiological features in common with those diagnosed with bipolar disorders. This claim is supported by new insights into the phenomenology of both disorders and by evidence that mood stabilizers are efficacious in the pharmacological management of borderline patients. This area of research is an important one because of the considerable morbidity and public health costs associated with borderline personality disorder. Since borderline patients can be so challenging to care for, it may be that a reframing of the disorder as belonging to the broad clinical spectrum of bipolar disorders holds benefits for patients and clinicians alike.     

Current issues in the assessment of personality disorders

Most patients will have clinically significant maladaptive personality traits. These personality traits can substantially complicate the effective treatment of other mental disorders, and they can also be the focus of effective treatment. The assessment of personality disorders is of considerable clinical importance. However, this assessment can also be highly problematic. This article discusses the major issues in the assessment of personality disorders (eg, differentiation from other mental disorders, from normal personality functioning, and gender bias) and summarizes existing research on the convergent and discriminant validity of the semistructured interviews and self-report inventories, which have been developed to improve the reliability and validity of personality disorder assessment.     

Axe I,Axe II ou Troubles mentaux et Troubles de la personnalité

Objectives

Since the publication of the third edition of the American classification the Diagnostic and Statistical Manual of mental disorders (DSM-III), psychiatric clinical syndromes and personality disorders appear in two distinct axes, axis I and II. In the fifth revision of the manual (DSM-5), published in May 2013, this distinction no longer exists and personality disorders now appear among other mental disorders. The aim of this paper is to try to pinpoint the clinical and epistemological stakes therein.

Method

The particular interest of this distinction was to attract the attention of the practitioners on the personality of the patients, independently of their psychiatric diagnoses. However today, its scientific justification appears insufficient. Numerous arguments are in favour of a continuity between the two axes and the nosographical reorganisation of anxiety, depression and personality disorders. This clarification summarises the principle tendencies that have emerged over the past ten years regarding the classification of personality disorders, with increasing dissatisfaction with the traditional categorical model and a growing interest in a dimensional perspective. These tendencies are illustrated by the recommendations drawn up by the DSM-5 task force on personality and personality disorders.

Results

The criticisms of the scientific world regarding theses recommendations have been strong. This article summarises the main arguments developed here and there, and the evolution of the task force's reflections up to the final decisions that were published in December 2012. No real consensus exists on the best dimensional model to be retained; even if the system most studied is, without doubt, the five-factor model, known as the ‘Big Five’.

Discussion

This system was studied above all in psychology, and its applicability to psychopathology, which could obviously be envisaged, requires adjustments and further validation studies before being finally adopted.

Conclusion

The return to a single axis perspective for personality disorders also justifies in depth reflection on the limits of normality and on the general definition of a mental disorder that has never been the subject of a true consensus in our profession.     

Personality disorders and forensic psychiatry

Personality problems of various kinds make a significant impact on the practice of forensic psychiatry. Clusters of personality problems that amount to clinical syndromes should be treated as such and not discriminated against. ‘Psychopathic’ is a confusing term and currently in the UK may be best reserved for legal purposes. Treatment for personality disorders is akin to treatment for other chronic disabling disease such as schizophrenia. Patients with severe personality disorders should have just as much access to inpatient services as patients with other diseases. Such access should include access to compulsory care as well as to voluntary care. British mental health law allows, indeed encourages, such an approach. Prison care for personality disordered patients has an important role to play in their management, but prison management should not be the mainstay of treatment for personality disorders any more than it is for any other disease. The task for forensic psychiatry is to conduct research into personality disorders and to reduce the negativity associated with this term.     

Assessing pathology in the separation-individuation process by an inventory. A preliminary report

There is growing clinical evidence implicating disturbances in the separation-individuation phase of child development to adult psychopathology, particularly the borderline personality disorder. The clinical manifestations of such disturbance have been described by several clinicians and theoreticians. The authors have developed an inventory, based on these observations, designed to assess adult manifestations of disturbances in the separation-individuation process. The inventory was given to subjects meeting DSM-III criteria for borderline personality disorders and to a random university employee control group. The subject group had significantly higher scores than the control group. Although more research is needed to further establish the inventory's validity and reliability and to better define its scoring, the preliminary data indicate that it does assess adult manifestations of pathology in this developmental process.     

Chronic depression

Recent research has enabled clinicians to reclassify many patients who formerly were diagnosed as having personality disorders as instead suffering from chronic depression. The American Psychiatric Association now recognizes two subtypes of such depression: (1) residual (partly remitted) major depression and (2) dysthymia. As a result of these developments, an increasing number of psychiatrists now treat selected chronically depressed patients with full trials of a broad range of thymoleptic agents, thus alleviating the suffering of many patients who had previously been deemed refractory. The author summarizes his research efforts to establish the clinical legitimacy of chronic depression and suggests that supportive psychotherapeutic and psychoeducational approaches can enhance the therapeutic gains achieved through pharmacotherapy.     

The value of therapeutic communities in the treatment of personality disorder: a suitable place for treatment?

In the United Kingdom, a government program investigating the links between offending and personality disorder has stimulated renewed interest in the treatment of personality disorders. One psychosocial treatment option for patients with personality disorders is the therapeutic community (TC). In 2000, the authors conducted a small qualitative study with a sample of psychiatrists which suggested that TCs were not well understood and that the status of evidence on efficacy might be partly responsible for low referral numbers. This article reviews the evidence for the efficacy and cost-effectiveness of TCs as a treatment for personality disorders and considers which types of disorders are amenable to TC treatment. We conclude that there is a strong case for more rigorous evaluation and that some of the difficulties anticipated in applying randomized clinical trial (RCT) methodology to the study of TCs could be overcome.     

Co-occurrence of mood and personality disorders: a report from the Collaborative Longitudinal Personality Disorders Study (CLPS)

The purpose of this study was to examine the relationship of subtypes and particular clinical features of mood disorders to co-occurrence with specific personality disorders. Five hundred and seventy-one subjects recruited for the Collaborative Longitudinal Personality Disorders Study (CLPS) were assessed with the Structured Clinical Interview for DSM-IV Axis I Disorders (SCID-I) and the Diagnostic Interview for DSM-IV Personality Disorders (DIPD-IV). Percent co-occurrence rates for current and lifetime mood disorders with personality disorders were calculated. Logistic regression analyses examined the effects of clinical characteristics of depressive disorders (e.g., age at onset, recurrence, symptom severity, double depression, and atypical features) on personality disorder co-occurrence. In comparison with other DSM-IV personality disorders, avoidant, borderline, and dependent personality disorders (PDs) were most specifically associated with mood disorders, particularly depressive disorders. Severity and recurrence of major depressive disorder and comorbid dysthymic disorder predicted co-occurrence with borderline and to a lesser extent research criteria depressive personality disorders. The results are consistent with the view that a mood disorder with an insidious onset and recurrence, chronicity, and progression in severity leads to a personality disorder diagnosis in young adults.     

Gender Patterns in Borderline Personality Disorder

Gender differences in patients with borderline personality disorder are potentially relevant because they may guide clinicians in assessment and treatment. To date, a number of clinical features in borderline personality disorder have been examined for gender differences. As for prevalence, earlier research concluded that a higher proportion of women than men suffer from borderline personality disorder, although more recent research has determined no differences in prevalence by gender. In addition, there may not be gender differences in borderline personality disorder with respect to specific types of self-harm behavior, such as self-cutting or levels of psychological distress at clinical presentation. However, current evidence indicates that there are notable gender differences in borderline personality disorder with regard to personality traits, Axis I and II comorbidity, and treatment utilization. With regard to personality traits, men with borderline personality disorder are more likely to demonstrate an explosive temperament and higher levels of novelty seeking than women with borderline personality disorder. As for Axis I comorbidity, men with borderline personality disorder are more likely to evidence substance use disorders whereas women with borderline personality disorder are more likely to evidence eating, mood, anxiety, and posttraumatic stress disorders. With regard to Axis II comorbidity, men with borderline personality disorder are more likely than women to evidence antisocial personality disorder. Finally, in terms of treatment utilization, men with borderline personality disorder are more likely to have treatment histories relating to substance abuse whereas women are more likely to have treatment histories characterized by more pharmacotherapy and psychotherapy.     

A multidimensional scaling of the DSM-III personality disorders

The DSM-III employs a categorical model for the classification of personality disorders. A dimensional model provides certain advantages, but there has not yet been an empiric attempt to identify an optimal set of dimensions. We systematically assessed the presence of each of the symptoms for the personality disorders in 84 patients. The number of symptoms of each of the personality disorders possessed by each patient was correlated across patients, and the correlations were subjected to a multidimensional scaling program. A three-dimensional solution was compared with the placements of the personality disorders predicted by dimensions published previously.     

Eating disorders in children and adolescents: an update

PURPOSE OF REVIEW: Children and adolescents with eating disorders frequently present to child mental health and paediatric services and have significant morbidity, psychosocial impairment and mortality. Efforts to treat these individuals have been hampered by a poor evidence base for effective interventions. This article reviews research published during 2004 with a primary focus on this challenging clinical area. RECENT FINDINGS: Research published during 2004 has replicated past epidemiological findings and expanded our understanding of the relationship of family meal structure and disordered eating. Research has provided assistance in the well known clinical conundrums of excessive exercising in anorexia nervosa and predicting when return of menses will occur. There has also been clarification of adolescent bingeing. Potential advances include a new, noninvasive method of measuring body composition and investigations in adolescents on leptin, neuro and gastrointestinal peptides. Importantly, further evidence of the effectiveness of family therapy for anorexia nervosa and short-term benefits from intervention programs have been published. SUMMARY: The research base that will influence clinical practice in child and adolescent eating disorders is increasing. More research is required in all areas of intervention.