Treatment

Persons with personality disorders generally do not recognize the inner source of their difficulties. They tend to blame others and their environment and make those around them feel badly. Only 20 percent of persons with personality disorders actually seek psychiatric treatment.

Treatment usually consists of psychotherapy in some form. In some specific instances psychopharmacology has been used. Success has been claimed for various types of psychotherapy. Individual, group, couples, and family treatments all have been employed. Despite differences in techniques and orientations, most psychotherapists emphasize the importance (and initial difficulty) of establishing a trusting relationship. The goals tend to be to identify inner sources of maladaptive behavior. From a psychodynamic standpoint this means that the painful feelings which are being avoided need to be identified and their causes traced. Cognitive-behavioral therapists will try to identify the faulty assumptions, lack of foresight regarding consequences of behavior, and ineffectiveness of the existing coping repertoire, with an eye to teaching more useful behavior.

As a broad generalization patients with “dramatic” presentations (borderline, antisocial, histrionic, narcissistic) tend to require a more intrusive, confrontative, limit-setting posture by the therapist. More specifically, antisocial personality probably cannot be treated in an outpatient setting and requires a containing enviroment (e.g., prison, inpatient unit). In such a setting groups emphasizing mutual interdependence and confrontation appear to produce some success. Regarding the treatment of borderline persons, psychiatrists are divided as to whether a supportive “here and now” versus intensive exploration work best. In either instance, treatment is often punctuated by prolonged periods in which the patient expresses negative feelings toward the therapist, makes suicide attempts, or undergoes psychotic decompensation requiring hospitalization.

In contrast to this more intrusive posture, patients whose personalities fit into the “fearful” and “odd” clusters may benefit from a more gentle, accepting, and clarifying approach.

Psychotherapy tends to be a long-term enterprise, lasting many years. Therapists can expect to feel frustrated, angry, helpless, and inadequate at times. Clinical reports of major improvements are many, but controlled outcome studies are practically nonexistent. This reflects continuing problems in achieving reliable diagnoses and in general methodologic issues in outcome research, especially in prospective studies spanning many years.

There is increasing evidence that psychopharmacologic intervention may be helpful for some of the personality diagnoses.