Task 7. Treatment in PD
1. What appear to be some of the most promising treatment approaches for Cluster-C PD?
What is the conceptual model on which the treatment is based and what are the main
methods that each treatment uses to achieve therapeutic change? What is the existing
evidence about whether these methods are effective
Davey, G. (2014). Personality disorders, in: Psychopathology: research, assessment and
treatment in clinical psychology. Chichester: BPS Blackwell, pp 440-448.
Treating people with a diagnosis of personality disorder
There are numerous important factors that make treating personality disorders problematic
and means that they require a different approach than those for many other disorders.
Firstly, personality disorders can be enduring patterns of behaviour that an individual has
usually deployed from childhood into adulthood. As a consequence, the individual usually
cannot see that their behaviour is problematic and they are unlikely to believe they need to
change their behaviour. Secondly, individuals with personality disorders usually possess
patterns of behaviour that are likely to make them susceptible to a range of other psychiatric
disorders (e.g., anxiety, depression). It is often for treatment of the comorbid problems that
an individual with personality disorders is first referred for treatment. To add to these
problems, disorders that are comorbid with a personality disorder are difficult to treat
successfully and there may be many reasons for these difficulties. These include:
1. such individuals are significantly more disturbed and may require more intensive
treatment than individuals with other types of psychiatric disorder alone;
2. many personality disorders consist of ingrained behavioural styles that are likely to
continue to cause future life difficulties that may trigger symptoms of other disorders
3. many of the personality disorders have features which make such individuals
manipulative and unable to form trusting relationships and this makes the development
of a working, trusting relationship between therapist and client very difficult
Thirdly, it is worth asking what it is about personality disorders that is disordered and
requires treatment - especially if the behavioural styles typical of the personality disorders
are really only extremes of what otherwise might be considered to be normal personality
dimensions. Because individuals with personality disorders exhibit extremes of behaviour on
normal personality dimensions (such as extraversion/introversion, conscientiousness,
agreeableness/antagonism), it may be more realistic to try to moderate the existing
behaviours of such individuals rather than try to change them completely. For example, the
behaviours of individuals with obsessive compulsive personality disorder may be quite
adaptive in some circumstances and situations but inappropriate and maladaptive in others.
Taking this into account, the therapist may be more successful in trying to ‘normalize’ the
extreme behavioural styles of the individual with a personality disorder rather than trying to
change their ingrained behaviour patterns completely. Even given that these factors are
taken into account when devising interventions for personality disorders, 37% of people
undergoing treatment for personality disorders still fail to complete, and factors associated
with non-completion include young age, lower education levels, unemployment, having
juvenile convictions, and emotional neglect in childhood.
Finally, the scope of the personality disorders and their varied behavioural
characteristics mean that treatments are very often geared towards the requirements of
,individual disorders. However, in general, individuals with personality disorders will need to
(1) acquire a range of life skills, (2) learn emotional control strategies, and (3) acquire the
skill of mentalisation, which is the ability to reflect on their experiences, feelings and
thoughts and to assess their meaning and importance. These are all goals of therapy that can
be identified across a range of conceptually different treatments for the personality
disorders.
Drug treatments
Drugs are frequently used in an attempt to treat individuals with personality disorders, but
they tend to be used to tackle symptoms of any comorbid disorder rather than the
symptoms of the personality disorder itself. Individuals with comorbid anxiety disorders can
be prescribed tranquilizers (e.g., benzodiazepine); those with comorbid depression may
receive antidepressants (e.g., SSRI’s); those with comorbid bipolar disorder may receive
lithium chloride in order to stabilize their moods and reduce antisocial behavior.
Antipsychotic drugs (e.g., risperidone) can also be effective in reducing the symptoms of
Cluster A personality disorders, and atypical antipsychotic drugs (e.g., quetiapine) have
been shown to reduce impulsivity, hostility, aggressiveness, irritability and rage outbursts in
individuals with antisocial personality disorder. In terms of drug treatment for direct
symptoms of the personality disorders themselves, antidepressants have been found to be
effective with Cluster C symptoms (avoidant personality disorder and obsessive compulsive
personality disorder). Drugs for dealing with aggression and impulsivity, including lithium,
beta-blockers, carbamazepine, antipsychotic drugs and SSRIs have also been found to reduce
symptoms in Cluster B disorders. There are very few RCT’s that have looked at the effects of
medication on personality disorder symptoms, and what little evidence is available is often
equivocal, poorly controlled or conducted on only small numbers of participants.
Psychodynamic and insight approaches
Psychodynamic approaches have a long history of attempting to explain the development of
personality disorders. Problematic relationships with parents and childhood neglect and
abuse are factors that are prominent, and exploring and resolving these developmental
experiences is seen as an important role for psychodynamic therapies. Such therapists view
insight as the important mechanism of change in personality disorders. This approach is
particularly important when treating individuals with borderline personality disorder (BPD)
because these individuals represent a serious challenge to therapists. Individuals with BPD
are manipulative and will frequently game-play with the therapist in order to ascertain how
special they are to the therapist, or they will make dramatic gestures to seek attention. They
also lack trust which will make it difficult to develop a working therapist-client relationship.
Finally, BPD is typical of most of the Cluster B personality disorders in that the individual will
view the causes of their problems as external to them (i.e. the fault of other people).
However, psychodynamic therapists have tended to take a more active approach to treating
personality disorders and have attempted (1) to identify and block manipulative behaviours
at an early stage, and (2) to expose the ‘weak ego’s and fragile self-image that usually
underlie many of the personality disorders. As a particular example of psychodynamic
treatment, object-relations psychotherapy attempts to strengthen the individual’s weak ego
so that they are able to address issues in their life without constantly flipping from one
extreme view to another (Kernberg). In the case of BPD, for example, object-relations
psychotherapy will (1) attempt to show the client how their normal way of behaving is
, defensive (e.g. when they blame others for problems in their life), (2) how their judgements
are often simplistic and fall into simple dichotomous categories ( ‘good’ or ‘bad’) that cause
them to swing regularly from positive to negative ways of thinking, and (3) provide the client
with more adaptive ways of dealing with important life issues by (e.g., teaching them that
other people may possess both good and bad characteristics rather).
While it is difficult to assess the effectiveness of psychodynamic approaches to
treatment, there is some evidence that psychodynamic psychotherapies do have a beneficial
effect on the symptoms of personality disorders. Some studies have suggested that clients
do show significant improvements in symptoms during treatment and that short-term
psychodynamic therapy is at least as effective as CBT and a range of other treatments-as-
usual, including general community-based psychiatric treatment.
Dialectical behavior therapy
One particular form of therapy that has been successfully used to treat individuals with
personality disorders is dialectical behavior therapy (Linehan). This approach takes the
client-centred view of accepting the client for what they are but attempts to provide them
with insight into their dysfunctional ways of thinking about and categorising the world, and it
is designed to provide them with the necessary skills to overcome these problematic ways of
thinking and behaving. The dialectical behaviour therapist has to convey complete
acceptance of what the client does to enable a successful dialogue to ensue about the
client’s problems and difficulties. Dialectical behaviour therapy subsequently includes skills
training designed to teach individuals to be mindful of their maladaptive ways of thinking
about the world, to learn to solve problems effectively, to control their emotions, and to
develop more socially acceptable ways of dealing with their life problems.
Dialectical behaviour therapy can be split into four distinct stages: (1) addressing
dangerous and impulsive behaviours and helping the client to learn how to manage these
behaviours, (2) helping the client to moderate extremes of emotionality, (3) improving the
client’s self-esteem and coaching them in dealing with relationships, and (4) promoting
positive emotions such as happiness.
This approach has been particularly successful with individuals with BPD; it has been
shown to have long-lasting positive effects on suicidal and non-suicidal self-harm behaviours,
depression, interpersonal functioning, anger control and re-hospitalization; and it is
particularly effective as a treatment for BPD over the longer term when combined with
appropriate medication.
Cognitive behavior therapy
Because of the resistance of many personality disorders to ‘insight’ therapies, it was
originally felt inappropriate to try to apply CBT. However, over the past 10 years, there has
been significant progress in developing CBT in ways that are directly relevant to the
behavioural, emotional and cognitive problems found in personality disorders. Applying CBT
to the treatment of people with a diagnosis of personality disorder was arguably first
pioneered by Beck. This meant exploring the range of logical errors and dysfunctional
schemata that might underlie problematic behaviour (and cause emotional distress) within
individual personality disorders. In the case of OCPD, the individual may have developed
beliefs that everything has to be done correctly and when one thing is not done properly this
causes emotional distress and anxiety. In most cases the way in which CBT is constructed
depends very much on the individual personality disorder diagnosed and on the cognitive
