The treatment of personality disorders with psychotherapy

I attended another DSM 5 seminar at the weekend on the management of personality disorders which I found to be very informative. The Diagnostic and Statistical Manual of Mental Disorders (DSM) is the handbook developed by the American Psychiatric Association (APA). The manual is used by psychiatrists and other health care professionals as a diagnostic tool for the management of people with mental disorders. It is currently in its 5th iteration (released in May 2013) hence the term DSM 5 guidelines.  There are always further research sub-groups that are constantly evaluating the content and you can read their latest thinking here.

Some general points about personality disorders: it is estimated that between 70-80% of the prison population suffer from some form of personality disorder. GPs see 95% of people presenting with mental health problems within the NHS.  Psychiatrists will typically see the more chronic cases, given the way that GPs act as the gatekeepers to secondary care services. Indeed, it is estimated that between 30-50% of GP consultations comprise of mental health issues. It is also worth noting that people with mental health problems are more likely to be the victims of violence than the perpetrator.

In terms of treatment in psychotherapy, I was keen to investigate the transpersonal aspects of personality disorders. I wondered might patients be wrongly diagnosed if undergoing what Professor Stan Grof has in the past described as a form of transpersonal experience.  Professor Grof stated that such experiences can seem like psychiatric conditions, when they might represent a spiritual emergency. However, the DSM seminars tend not to have much debate.

Psychiatrists view personality disorder as an enduring pattern of inner experience and maladaptive behaviour that deviates markedly from the culturally expected and accepted range. There had been discussion about changing the method by which these individuals were diagnosed in the build up to the latest iteration but DSM 5 still uses the cluster model of grouping the disorders into A, B and C (as was the case with DSM 4).

For the diagnostic criteria for each disorder you can refer to this link.

Cluster A: Paranoid, Schizoid, and Schizotypal Personality Disorders

The APA clusters the odd and eccentric into a cluster and the common features of the disorders in cluster A are a domination of distorted thinking. Social awkwardness is also a feature resulting in behaviour that involves social withdrawal.

Paranoid personality disorder

Paranoid personality is when a person suffers from a pervasive exaggerated sensitivity to rejection, resentfulness, distrust and an inclination to distort experienced events. Behaviour that is impartial  from others are often misinterpreted as being hostile or contemptuous. These individuals often feel under attack and are often the ones making complaints, or become involved in legal disputes. They will be difficult to get along with and will have problems in close relationships. Michael Douglas portrayed this condition in the role of William Foster in the excellent film Falling Down. The William Foster character had suffered relationship breakdown, estrangement from his children and redundancy, which set him on a downward spiral.

The treatment of patients with this disorder is difficult as they typically do not engage well in psychological treatment because they are often touchy and suspicious of the therapist.

Schizotypal Personality Disorder

This condition has a high rate of co-morbidities and is characterised by a need for social isolation.  This disorder was portrayed by Robert de Niro in Taxi Driver in the character Travis Bickle. Individuals will often seek treatment for the associated symptoms of anxiety, depression, or other negative emotions rather than for the personality disorder features per se.  According to the Royal College of Psychiatrists this condition can develop into the mental illness ‘schizophrenia’. It can also be confused with PTSD.

The condition is best treated initially with individual psychotherapy. Individuals with this disorder usually distort their sense of reality so the therapy could involve reality testing and verbal disputing within a supportive containing environment.

Schizoid Personality Disorder

These individuals can be solitary and often work alone but can make good scientists. Parents are often the only people in their lives. The prevalence of this condition is estimated at less than 1% of the general population. They often do not seek psychological help.

Psychiatrists will be wary of making a diagnosis during the course of schizophrenic illness or mood disorder, or be due to the direct effect of drugs or another medical condition. If it occurs before the onset of schizophrenia then it can be termed as paranoid personality disorder (pre-morbid).

Cluster B is called the dramatic, emotional, and erratic cluster

The APA clusters Borderline Personality Disorder, Narcissistic Personality Disorder, Histrionic Personality Disorder, and Antisocial Personality Disorder together in one cluster as they share problems with impulse control and emotional regulation.

Borderline Personality Disorder

Borderline Personality Disorder (BPD) is an emotional dysregulation, and can involve a form of extreme thinking. It can also involve “splitting”, and individuals with this condition often have chaotic relationships. It only became an official diagnosis in DSM 3 in 1980. In extreme cases, this disturbance in the sense of self can lead to periods of dissociation. It can also be easily confused with bi-polar.

This disorder was portrayed by Glenn Close in the film Fatal Attraction. The character of Hedy has also been cited as an example of borderline personality disorder.

In terms of treatment, patients do not generally respond to exploratory psychotherapy. Group treatment, such as DBT,has the advantages that the transference relationships are spread over the group. The Rapid, Assessment, Interface and Discharge (RAID) model is a specialist multidisciplinary mental health service, working within all acute hospitals in Birmingham, for people aged over 16 and has been shown to be affective in treating people with this condition.

Interpersonal therapy should be time limited rather than open-ended. It could be more appropriate where the personality is recognised in the therapy, but not the focus. It is better to offer interpersonal rather than cognitive-behavioural or intrapsychic.

Commissioners will often allude to the cost of providing one to one psychotherapeutic services to this client group but perhaps they need to be reminded about the costs associated with people attending A&E as a result of their crisis management.

Narcissistic Personality Disorder

This condition involves an extreme focus on oneself.  The term was first used in 1971. The interesting thing to note is that ICD-10 does not specifically define this condition as it is classified in the category “other specific personality disorders”.  We all perhaps have some narcissistic traits and indeed perhaps as a society we need high powered and ruthless people to take the high risk decisions.  Indeed, psychiatrists regard it as a relatively stable condition when experienced as a primary disorder. However, with the recent financial crisis when individuals, often men, lose their jobs and their high income, they become less guarded and might end up seeking psychiatric help when their defences break down.

In Kohut’s treatment model for NPD, clients are allowed to exhibit their grandiosity and be allowed to idealise the therapist.  For Kohut, by seeking to continue and stay with an approach that is empathetic, it might be possible to adjust the client’s self-appraisal, as well as the interpersonal appraisal. According to this treatment model, patients learn to take on-board their own limitations as well as those of the therapist.  This approach has the potential to heal the developmental arrest.

By contrast, for Kernberg, NPD is viewed as resulting from structural damage in the psyche of the child. This is rooted in the child’s rearing in an emotionally deprived environment. The child projects its rage onto the parents who are seen as sadistic and depriving. As a result, the child takes refuge in some aspects of themselves that the parents valued.

The therapy could help to re-establish a corrective relationship in which the mirroring of archaic grandiosity needs to have room in the therapy. This can hopefully transform into a more mature and appropriate self-appraisal. The therapy with a patient like this requires a commitment of time for the client to recognise their own weaknesses. This necessitates an empathic approach. Narcissism is a condition of the mind so working within a transpersonal framework with such clients can be difficult. Some psychiatrists regard it as a relatively stable condition when experienced as a primary disorder.

From a transpersonal perspective, Schwartz-Salant suggests that narcissism has an archetypal background where there is a similarity between the characteristics of the alchemical Mercurius and narcissism. This involves the polarities, contradictions (Self versus False Self), (feeling worthless versus grandiosity). It could also be seen as the ‘shadow’ of Mercurius. The pathological state of Mercurius become brittle and unable to bear psychological pressure.

Antisocial Personality Disorder

People with this condition will often not see themselves as aggressively minded. Their anger will be seen by them in the context of it being a dream. People will see their violent outburst almost as if it was a dream. Psychiatrists will typically ask their patient if there has been any trouble with the police, or whether they have engaged in any behaviour likely to involve the police.  This forensic history taking can be a clue to the diagnosis.

Individuals will have a common disregard for social rule, norms and cultural codes, in addition to impulsive behaviour and an indifference to the rights and feelings of others. It is a condition more common in men than women. However, it can often be confused with ADHD.

Effective treatment for this condition is difficult given that the transference with the therapist can manifest as resistance very early in the relationship. DBT in groups can offer another way of working. These patients do not respond well to in-patient treatment as it can recreate the prison environment for them internally. Early child and adolescent interventions are crucial to help these individuals to see the consequences of their actions.

Histrionic Personality Disorder

This condition is diagnosed more commonly in females where there is a pattern of excessive emotionality and attention seeking,including an excessive need for approval and inappropriate seductiveness.

Therapy with these patients can be exhausting for the therapist as there is often a lack of dialogue.

Cluster C: the anxious, fearful cluster

The APA clusters the Avoidant, Dependent, and Obsessive-Compulsive Personality Disorders together in this grouping as it believes that they share a high level of anxiety.

Obsessive-Compulsive Personality Disorder

Individuals with this condition are more perfectionist than people with OCD. They do not generally feel the need to repeatedly perform ritualistic actions, unlike OCD. They conform to rules and procedures rigidly. They may hoard money for future use, keep their home perfectly organised, or be anxious about delegating tasks for fear that they won’t be completed correctly.

Freudian theory would suggest that it originates in the same disturbances of early development (those at the anal stage) as those that cause obsessional symptoms. Treatment involves individual psychotherapy and self help.

Avoidant Personality Disorder

This disorder is marked by social inhibition, general feelings of inadequacy with an extreme sensitivity to negative evaluation. There is also an avoidance of social interaction. Patients often consider themselves to be socially inept or unappealing and avoid social interactions. They present as loners and have a feeling of isolation from society.

The management of the disorder can involve social skills training, CBT, exposure treatment to gradually increase social contacts and group therapy for practicing social skills.

Dependent Personality Disorder

This was previously known as asthenic personality. The main characteristic of the disorder is over-reliance on others that leads to submissive and clinging behaviour and fears of separation. However, it is also vital to note that dependent behaviour may be developmentally normal in children and adolescents.Individuals with this condition are at increased risk of suffering from depression. They are also at risk of suffering from alcohol and,or, drug abuse; in addition to risks of physical, emotional, or sexual abuse.

See Also

Bateman, A. and Tyrer, P. (2004) Psychological treatment for personality disorders. Advances in Psychiatric Treatment, 10 (5), 378-388.
Bateman, A. and Tyrer, P. (2004) Services for personality disorder: organisation for inclusion. Advances in Psychiatric Treatment, 10 (6): 425-433.
National Institute for Health and Clinical Excellence: 2009: Borderline personality disorder: treatment and management (CG78) and Antisocial Personality Disorder (CG77).
MIND – National charity exists to make sure no one has to face a mental health problem alone.
Patient.co.uk is the UK’s leading independent health site with more than 16m visits a month. It is used as a trusted source of information for both patients and health professionals nationwide.
Rethink Mental Health – Helping to reshape opinions on mental health
Samaritans – 24 hour helpline

Therapy in the NHS

I have been continuing with my placement in an NHS Mental Health Trust and it seems that with every visit I learn something new.  I had been familiar with Cognitive Behavioural Therapy (CBT) before the start of my placement through my lectures and my own prior knowledge. However, this week I attended a team meeting in a sexual behaviour unit in a forensics unit and learned about the Dialectical behaviour therapy treatment programme.

Dialectical behaviour therapy (DBT), a cognitive behavioural therapy, was developed by Marsha Linehan, PhD, at the University of Washington, and is a type of psychotherapy (sometimes called “talking therapy”) for borderline personality disorder (BPD). Of course I get reminded that in psychiatry one is often dealing with the treatment of sometimes severe mental illnesses.  In psychotherapy, especially private practice, one is less likely to encounter clients with the onset of such illnesses. Mentalization-based treatment (MBT) is a type of psychotherapy created to treat people with borderline personality disorder. Reflecting back group psychotherapy is also a new concept to me. However, it is apt that I am about to start group process work on my course when compulsory attendance is required for the  duration of the work.

I am often asked why I don’t offer a critique of these models in my blog posts.  However, whilst I might have some preliminary thoughts and views, I need to gain exposure of how these models work in practice before I can comment on the effectiveness of these models. One thing for sure is that awareness of more treatment models is helpful for devising short term treatment models for my new placement in a counselling centre in West London which offers clients 6 sessions, in the first instance.  This will be a great  opportunity to blend theory with practical application.

My NHS placement also offers invaluable insight into how treatments such as ECT and pharmacological treatment work for depressed patients.    More about this in future posts …..

Resources:
Psychotherapy in the NHS
OCD
Borderline Personality Disorder (BPD)
Eating Disorders