The psychopharmacologic treatment of personality disorders

We have reviewed both the rationale for and approaches to the use of psychotropic medications in the treatment of personality disorders. Despite some studies that may provide the seeding crystals around which significant data bases regarding the drug treatment of personality disorders will develop, the pharmacologic treatment of personality disorder remains a clouded area governed more by opinion than fact. Clinicians must still be guided by basic clinical sense regarding the use of medications with these patients. Some questions to ask are the following: Has the patient responded to medications in the past? What are the risks for abuse or self-destructive acting out? What is the risk-to-benefit ratio for the introduction of a drug into a psychotherapeutic situation at a given time? Is hospitalization necessary to assess the potential benefits of medication to the patient while minimizing the potential to act out? Although these guidelines may seem inadequate, clinicians can take some solace in the fact that ongoing studies will lead to better informed psychopharmacologic choices for patients with personality disorders.     

The therapeutic alliance in the cognitive behavioral treatment of pediatric obsessive-compulsive disorder

Although cognitive-behavioral therapy (CBT) for pediatric obsessive–compulsive disorder (OCD) is considered a first-line treatment, not all youth have a positive treatment response, suggesting need for investigating factors that may enhance or reduce treatment effects. Few studies have investigated predictors of treatment response in pediatric OCD, and there is an absence of studies examining the influence of treatment process variables (e.g., therapeutic alliance [TA]) on treatment outcome. Using a multiple-informant and multiple-time point design, the current study examined the role of the TA in family-based CBT for pediatric OCD. Analyses examined (1) the predictive value of the TA on OCD symptom reduction and (2) whether changes in the TA over time predict treatment response. Findings indicated that (1) stronger child-rated, parent-rated, and therapist-rated TAs were predictive of better treatment outcome and (2) larger and more positive early alliance shifts (as rated by changes in child-rated TA between sessions 1 and 5) were predictive of better treatment outcome. Implications for the treatment of youth with OCD within family-based CBT are discussed.     

The therapeutic alliance in exposure therapy for anxiety-related disorders: A critical review

The therapeutic alliance has been the subject of a great deal of psychotherapy research, and evidence from numerous empirical studies suggests that a strong patient-therapist relationship predicts favorable treatment outcomes. Despite the consistency of the alliance outcome relationship across treatment modalities and diagnoses, little attention has been given to this potential prognostic indicator in exposure therapy for anxiety-related disorders. Given that exposure therapy requires patients to engage in challenging and distressing activities (e.g., confrontation with feared stimuli), a strong alliance between patient and therapist is conceptually relevant to treatment. Relatively few published exposure therapy trials have included the therapeutic alliance as a process variable, and no single review summarizes findings from this body of literature. Accordingly, the purpose of this review is to provide an overview and synthesis of existing research on the alliance-outcome relationship in exposure therapy. Methodological and conceptual considerations will be discussed, and future research priorities will be identified.     

The role of transference work, the therapeutic alliance, and their interaction in reducing interpersonal problems among psychotherapy patients with Cluster C personality disorders

The aim of the present study was to examine whether transference work, the therapeutic alliance, and their interaction predicted a reduction in interpersonal problems at treatment termination. Forty-nine patients with Cluster C personality disorders from a randomized controlled trial investigating the effectiveness of short-term dynamic psychotherapy and cognitive therapy were included. Transference work was measured with the Inventory of Therapeutic Strategies (Gaston & Ring, 1992), while the therapeutic alliance was measured with the Helping Alliance Questionnaire (Luborsky, Crits-Christoph, Alexander, Margolis & Cohen, 1983). Less emphasis on transference work predicted overall reduced interpersonal problems, whereas the effects of the therapeutic alliance did not reach statistical significance. An interaction effect was also demonstrated, indicating that greater emphasis on transference work performed on patients with lower therapeutic alliance ratings was associated with a smaller reduction in interpersonal problems at termination. However, the results also indicate that a low dose of transference work may be beneficial in reducing interpersonal problems.     

Pharmacological treatment of personality disorders

Therapists are only now just beginning to clear a way through the jungle of personality disorder and any recommendations about drug treatment have to be tentative and, to some extent, speculative. Nevertheless, it is reasonable to conclude that drug treatment, mainly in the form of antipsychotic agents, should be considered in borderline and antisocial personality disorders and also possibly in the schizotypal group. There is also growing evidence that two drugs used in the treatment of manic-depressive psychosis, lithium and carbamazepine, may have independent effects in controlling aggression and impulsiveness and be of value of borderline and antisocial personality disorders. In histrionic and dependent personality disorders, drug treatment is in general contraindicated and for the remaining group our ignorance of the possible benefit of the drugs is almost total. However, the negative effect of these personality disorders on response to treatment in the presence of depression, anxiety, and other abnormal mental state disorders suggests that drug treatment probably has little part to play in management of these particular personality disorders. A major deficiency in our knowledge, which can only be remedied by long-term studies that are extremely difficult to mount, is the recommended duration of treatment with drugs in personality disorder. No guidelines exist at present but now that some measure of efficacy has been established duration of treatment needs to be addressed.     

Psychotherapeutic treatment of personality disorders

Treating patients with personality disorders presents a major challenge due to their maladaptive interpersonal styles which affect the therapeutic relationship. A number of therapeutic approaches using psychodynamic, behavioural, and other origins have been developed to treat patients with personality disorders, most of them dealing with borderline personality disorder. Overall, only a few controlled therapy studies have been carried out to document therapy effectiveness. However, available research indicates that psychotherapy has substantial effects even in personality disorders. From a vast literature based on case reports, therapeutic recommendations are presented for specific personality disorders.     

Psychopharmacologic treatment of personality disorders

There is only a paucity of studies concerning the pharmacological treatment of personality disorders per se. On the other hand the clinical use of medication in these conditions is quite high, although there is no effective psychopharmacological treatment of distinct personality disorders. The psychopharmacological treatment of patients suffering from a personality disorder focuses on distinct symptoms and its comorbidity. Some symptoms could also be associated with other disorders like depression or psychosis, which often makes an exact differentiation of these disorders and a personality disorder difficult. Since symptoms of personality disorders are ego-syntonic, chronic and very often dependent on psychosocial factors, it is unlikely that a solely psychopharmacological treatment will be successful in most patients with a personality disorder. However, severe syndromes like depressive, impulsive, aggressive, dissociative, anxious or psychotic features may render a pharmacotherapy necessary. For the treatment of depressive syndromes or impulsivity a medical therapy with serotonin reuptake inhibitors, for the treatment of psychotic syndromes a medication with atypical antipsychotics is recommended. Impulsive or aggressive behaviour could be treated with mood stabilizers as well. Furthermore, there are indications for the use of alpha2-agonists, micro-opiate-antagonists and omega-3 fatty acid. The general use of benzodiazepines should be avoided as well as polypragmasy. Advantages versus potential damage of a high dose pharmacotherapy should be carefully weighed against each other. This article gives an overview over the today's most common psychopharmacological treatment possibilities in patients with a personality disorder.     

Relationships among client-therapist personality congruence, working alliance, and therapeutic outcome

Despite the importance of the working alliance in therapeutic outcome, little is known about the factors associated with its formation. We advance that personality similarity between client and therapist is one such factor pertinent to the working alliance. In this study, personality similarity in 32 client-therapist dyads was examined for its relations to the bond, task, and goal elements of the working alliance (Bordin, 1979, Psychotherapy: Theory, Research, and Practice, 16, 252-260) and therapeutic outcome. Personality similarity was conceptualized using Holland's (1997, Making vocational choices [3rd ed.]) congruence construct. Therapists completed the Self-Directed Search pretreatment and clients completed the Working Alliance Inventory-Short Revised and Self-Directed Search after the third session. Results indicated that (a) client-therapist personality congruence was associated with the bond, (b) bond was associated with task and goal, and (c) task and goal were associated with therapeutic outcome. Congruence was not associated with task, goal, or therapeutic outcome. Holland's theory provides a framework for adapting to clients of varying personality types. By understanding how client-therapist personalities relate to each other in therapy, client-therapist bonds may be more efficiently realized.     

Developing a therapeutic alliance in the hospital treatment of disturbed adolescents

Establishing a working therapeutic relationship with psychiatrically hospitalized adolescents presents special challenges to the hospital treatment team. Many adolescent patients deny their problems or any responsibility for them, and defy efforts to engage them in active collaboration. However, once the treatment team understands the specific clinical and developmental reasons for their reluctance to participate, most patients can become profitably involved in treatment. The author discusses the concept of the therapeutic alliance, suggesting that many hospitalized disturbed adolescents do not reach this optimal level of involvement. Clinical vignettes illustrate the precursors to and levels of genuine collaboration, as well as interventions that facilitate collaborative behavior.     

Conflict begets conflict: Executive control,mental state vacillations,and the therapeutic alliance in treatment of borderline personality disorder

This study evaluated the psychometric properties of the 4 scales of the Behavioral Health Questionnaire-20 (BHQ-20): Global Mental Health, Well-Being, Symptoms, and Life Functioning. Four samples were used: community adults, college students, college students in counseling, and adults in outpatient psychotherapy. Support was found for internal consistency and 2-week test-retest reliability. For construct validity, the BHQ-20 scales distinguished levels of pathology among the samples and were sensitive to improvement across 3 psychotherapy sessions. Concurrent validity correlations with the scales of established measures were at least moderately high. Higher correlations were also found between the BHQ-20 scales and the nonanalogous scales of the established measures. These results, along with high correlations among the BHQ-20 scales, indicated the presence of 1 primary mental health dimension accounting for the variance. The BHQ-20 was proven to be a generally reliable, valid questionnaire that is distinguished by the efficiency with which it assesses mental health.     

Therapist self-disclosure and the therapeutic alliance in the treatment of eating problems

Evidence is mixed regarding the potential utility of therapist self-disclosure. The current study modelled relationships between perceived helpfulness of therapist self-disclosures, therapeutic alliance, patient non-disclosure, and shame in participants (n = 120; 95% women) with a history of eating problems. Serial multiple mediator analyses provided support for a putative model connecting the perceived helpfulness of therapist self-disclosures with current eating disorder symptom severity through therapeutic alliance, patient self-disclosure, and shame. The analyses presented provide support for the contention that therapist self-disclosure, if perceived as helpful, might strengthen the therapeutic alliance. A strong therapeutic alliance, in turn, has the potential to promote patient disclosure and reduce shame and eating problems.     

Conceptualization and treatment of personality disorders

Abstract

Résumé

There is an emerging consensus that the essence of personality pathology consists of difficulties with self-identity and chronic interpersonal dysfunction. The nature of normal and abnormal attachment to others, attention control, affect regulation, and the autobiographical self are related developmentally to the early caregiving context. Psychotherapeutic intervention for adults with personality disorders across many schools of psychotherapy is focused on changing the individual's dysfunctional internal models of self and others. Future research will examine how cognitive, cognitive–behavioral, interpersonal, and psychodynamic treatments accomplish this task. Advances in neurobiology, laboratory tasks, and interview techniques will assist in the measurement of personality organization and identification of subgroups of patients for more refined treatments. Our future treatment development must be differentiated and multifaceted, respecting subgroups of patients with severe personality disorders.

Zusammenfassung

Die Konzeptualisierung und Behandlung von Persönlichkeitsstörungen

Die Ansicht, dass Persönlichkeitsstörungen i. A. durch Probleme der Selbstidentität und eine chronische interpersonelle Disfunktion geprägt sind, setzt sich immer mehr durch. Die Art der normalen und anormalen Bindung an andere, der Aufmerksamkeitskontrolle, der Affektregulierung und des autobiographischen Selbst sind im Kontext der frühkindlichen Versorgung zu sehen. Psychotherapeutische Interventionen bei Erwachsenen mit Persönlichkeitsstörungen sind über viele Psychotherapieschulen hinweg darauf konzentriert, die disfunktionalen inneren Modelle vom Selbst und von anderen zu verändern. Zukünftige Forschung wird herausfinden, wie kognitive, kognitiv-verhaltensmäßige, interpersonelle und psychodynamische Behandlungen dieses Ziel erreichen. Fortschritte in der Neurobiologie, bei experimentellen Aufgaben und bei Interviewtechniken werden die Messung von Persönlichkeitsorganisation unterstützen und die Identifikation von Untergruppen ermöglichen und so zu einer Verfeinerung der Behandlung führen können. Die zukünftige Entwicklung von Behandlungen muss, vom Tatbestand von Untergruppen bei schweren Persönlichkeitsstörungen ausgehend, darauf ausgerichtet sein, einen differenzierten und multiperspektivischen Zugang anzustreben .

Conceptualisation et traitement des troubles de personnalité

Un consensus émerge sur le fait que l'essence de la pathologie de la personnalité consiste autour de difficulté de l'identité de soi et des dysfonctions interpersonnelles chroniques. la nature de l'attachement normal et anormal aux autres, le contrôle de l'attention , la régulation affective, et le soi autobiographique sot reliés avec le contexte de soin précoce. Les interventions psychothérapeutiques pour les adultes présentant des troubles de la personnalité sont dans de nombreuses écoles de psychothérapies focalisées sur leurs modèles internes dysfonctionnels de soi et de l'autre. Les recherches futures ont à examiner comment les traitements comportementaux, cognitifs-comportementaux, interpersonnels et psychodynamiques accomplissent cette tâche. Les progrès en neurobiologie, dans les tâches de laboratoire ainsi que dans les techniques d'entretien vont assister la mesure de l'organisation de la personnalité et l'identification de sous-groupes de patients pour des traitements plus affinés. Notre développement du traitement doit être à l'avenir différencié et à multiples facettes, respectant des sous-groupes de patients avec des troubles sévères de la personnalité.

Sommario

Concettualizzazione e trattamento dei disturbi di personalità.

Esiste un consenso emergente che l'essenza della patologia di personalità consista in difficoltà con l'identità di sè e la disfunzione interpersonale cronica. La natura di un normale ed anormale attaccamento agli altri, il controllo dell'attenzione, la regolazione affettiva ed il sé auto autobiografico sono relativi all'accrescimento iniziale nel contesto di cure parentali. L'intervento psicoterapeutico per gli adulti con i disturbi di personalità attraverso molte scuole della psicoterapia si focalizza sul cambiare i modelli interni disfunzionali dell'individuo e degli altri. La ricerca futura esaminerà come i trattamenti cognitivi, cognitivo-comportamentale, interpersonale ed i trattamenti psicodinamici compiono questa operazione. Gli avanzamenti nella neurobiologia, nei compiti e tecniche di interviste aiuteranno nel misurare l'organizzazione di personalità e nell'identificazione dei sottogruppi di pazienti per trattamenti più raffinati. Il nostro sviluppo futuro di trattamento deve essere differenziato e sfaccettato, rispettando i sottogruppi di pazienti con gravi disturbi di personalità.

Resumen

Conceptualización y tratamiento de los desórdenes de personalidad

Existe un consenso progresivo acerca de que la esencia de la patología de la personalidad consiste en dificultades con la propia identidad y con disfunciones crónicas en las relaciones interpersonales. La naturaleza del apego tanto normal como anormal, el control de la atención, la regulación del afecto y el self autobiográfico están relacionados con el contexto de cuidados tempranos. La intervención psicoterapéutica de adultos con desórdenes de la personalidad según diversas escuelas de psicoterapia está focalizada en cambiar los modelos internos disfuncionales del self y de los otros. La investigación futura examinará cómo los tratamientos cognitivo, cognitivo-comportamental, interpersonal y psicodinámico pueden lograrlo. Los avances en la neurobiología, los trabajos de laboratorio y las técnicas de entrevista ayudarán en la evaluación de la organización de la personalidad y en la identificación de subgrupos de pacientes asignables a tratamientos más refinados. Nuestro desarrollo terapéutico futuro debe ser diferenciado y multifacético respecto de los subgrupos de pacientes con desórdenes severos de la personalidad.

     

Relaxation and merging in the treatment of personality disorders

A behavioral intervention specifically designed to merge split self-representations was found helpful as an adjunct to the psychotherapy of personality-disordered patients. The method, which is introduced only after signs of split self-representation have been identified through exploratory psychotherapy, consists of a series of steps. Patients are first taught a relaxation technique and are asked to practice at home. Once they are able to relax in the session, they are asked for visual images of first one and then another of the conflicting self-representations. After clear images have been elicited and discussed, they are encouraged to merge them. Finally, they are asked "Who's watching" or some similar question designed to elicit a statement about a unified self. Twenty-four of 27 patients meeting criteria for personality disorders in Clusters B and C of DSM-III-R responded with greater compliance, reduced resistance, and improved relationships at work and elsewhere. Comparison is made to the merging intervention commonly used in the treatment of Multiple Personality Disorder.     

Diagnosis and treatment of personality disorders

This article touches on four current areas of controversy in the field of the personality disorders — definition, etiology, assessment, and treatment. There is a tremendous amount of disability, personal distress, and public health expense as a result of the personality disorders. We are seeing steady progress in each of these areas. The implications of this progress are enormous, and the interest in this area is widespread, not just among psychiatric health professionals or among patients and their families and friends, but also among the public at large.     

The use of metaphors in the service of the therapeutic alliance and therapeutic communication

The use of metaphor as a conceptual and clinical tool in the treatment situation can enhance the therapeutic alliance and strengthen the effectiveness of therapeutic communication. The evolution of a special metaphoric system of communication in the course of the treatment situation enhances the positive alliance between patient and therapist. In a way analogous to the poetic use of metaphor, the therapeutic use of appropriate metaphors can be a powerful tool because a metaphor is a symbol that represents a condensation of multiple impulses, conflicts, fantasies, and affects. Case material will be presented to illustrate the use of metaphoric communication in the clinical situation.