Evidence based treatments of personality disorder

By: Anthony Bateman and Mary Zanarini

In general, the results of psychotherapeutic treatment of personality disorder are promising to the extent that patients show improvement but disappointing in that no existing treatment helps patients return back to a normal level of function. Although there are now a few randomized controlled trials of treatments there is very little evidence to suggest specificity of any one treatment. Avoidant personality disorder may respond to a limited extent to cognitive behavioural interventions.

Clearly the requirements needed to label a psychotherapeutic treatment as specific and efficacious in the treatment of personality disorder have not been met. Work is urgently needed to identify ways of both better defining and assessing patients. A dimensional approach is most promising. Personality can be formulated from a specific theoretical orientation, a treatment designed accordingly and measures tailored to areas targeted by the treatment.

Rather than comparing outcome of different approaches it may be better to ask what are the effective elements of each approach, how may they be combined to make the most efficient and effective treatment, and what is the best time for implementation, in what context and for how long? A match of patient profile and treatment strategy needs to be developed. There may need to be a staged approach of treatment with patients receiving a more supportive therapy as an inpatient or day patient followed by long-term outpatient therapy. 

Once behavioural stability has been achieved, for example, via DBT, a patient may consolidate the change and add depth through modified psychodynamic or psychoanalytic therapy and that in turn may be further enhanced by involvement in a therapeutic group that targets the interpersonal interactions. More attention should be given to process and dismantling studies as well as to carefully monitored single-case experiments.

Taken together, the results of pharmacological studies suggest several important findings. The first is that most of the medications studied in double-blind, placebo-controlled trials of BPD (and STPD) were found to be efficacious. The second finding is that most of these medications were found to be useful in treating symptoms of both affective dysregulation and impulsive aggression, which have been suggested to be the core dimensions of psychopathology underlying BPD (Siever & Davis, 1991).

This suggests that the choice of medication can be guided as much by tolerability and safety as by symptom presentation. It also suggests that the common practice of polypharmacy, which has no empirical support, may be unnecessary for most borderline patients. Clearly, more research in this area is needed, both for BPD and other axis II disorders that might be amenable to an adjunctive role for pharmacotherapy.

References

Peter Tyrer and Kenneth R. Silk, Cambridge Textbook of Effective Treatments in Psychiatry, Cambridge University Press 2008.

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