By: Anthony Bateman and Mary Zanarini
Whilst many of the research protocols could be considered as studying mixed personality disorders, there are some studies that recruit a wide range of personality disordered individuals. In an early randomized trial, Winston et al. (1991) showed no difference between short-term dynamic psychotherapy and brief adaptational psychotherapy in a mixed group of personality disorders but both were somewhat superior to a waiting-list control. This study specifically excluded patients with borderline and narcissistic features, although a later study that included some Cluster B disorders produced similar results (Winston et al., 1994).
The
relative effectiveness of three psychodynamically orientated treatment models for a mixed
group of personality disorders: (a) long-term residential treatment using a
therapeutic community approach; (b) briefer inpatient
treatment followed by community-based dynamic therapy
(step-down programme); and (c) general community psychiatric treatment, has been studied. Initial results
suggest that the brief inpatient therapeutic community
treatment followed by outpatient dynamic therapy is
more effective and more cost-effective than both long term
residential therapeutic community treatment and general
psychiatric treatment in the community on most
measures including self-harm, attempted suicide and readmission rates to general psychiatric admission wards (Chiesa et al., 2002, 2004). Follow-up at 36 months has confirmed that patients in the step-down programme continued to show significantly greater improvement than the inpatient group on social adjustment and global assessment of mental health. In addition, they were found to self-mutilate, attempt suicide, and be readmitted significantly less at 24- and 36-month follow-up (Chiesa & Fonagy, 2003). However, the study was not a randomized trial and the groups were not strictly comparable.
measures including self-harm, attempted suicide and readmission rates to general psychiatric admission wards (Chiesa et al., 2002, 2004). Follow-up at 36 months has confirmed that patients in the step-down programme continued to show significantly greater improvement than the inpatient group on social adjustment and global assessment of mental health. In addition, they were found to self-mutilate, attempt suicide, and be readmitted significantly less at 24- and 36-month follow-up (Chiesa & Fonagy, 2003). However, the study was not a randomized trial and the groups were not strictly comparable.
Vaglum
et al. (1990) and Karterud
et al. (1992)
prospectively studied 97 patients, many with personality disorder, (76% had an axis II DSM-III-R diagnosis), treated in a
psychodynamically orientated day hospital. The
programme was 5 days per week, 7 hours per day
and consisted of dynamic, cognitive and
expressive therapy. Primary outcome measures were SCL-90 and the Health
Sickness Rating Scale. After a mean treatment
time of nearly 6 months, symptom outcome was
very good for patients with Axis 1 disorders
only, good for Cluster C personality disorders,
modest for borderline patients, and very modest for
schizotypal and other Cluster A patients. They concluded that the containing
capacity of a day hospital therapeutic community is substantial and that it may
reduce the need for inpatient treatment.
Three-year follow-up showed that the gains were
maintained but borderline patients, along with
schizotypal PD, failed to show improvement in
social functioning.
The
Norwegian group have also demonstrated that day treatment programmes for PD are
generalizable to settings other than University research centres. All
patients (n ¼ 1244)
consecutively admitted to eight different treatment centres in the Norwegian Network of
Psychotherapeutic Day Hospitals were screened with the SCID-II. One thousand and ten patients were diagnosed
as having PD with avoidant (20%), borderline
(22%), and paranoid (12%) being the most frequent. Outcome, as
assessed on symptom measures, quality of life, work
functioning, and parasuicidal behaviour, was best for BPD, cluster C patients, and PD NOS and poorer for Cluster A
patients. Specifically, BPD without a Cluster A
co-morbid diagnosis had markedly better outcomes
than those with additional paranoid
presentations. High dosage of treatment appeared to give no better outcome than
low treatment dosage (10 hours per week) and the University unit did no better than units at local hospitals or mental health
centres (Karterud et al., 2003).
The
MACT study of borderline and anti-social patients described above led to a much larger
study but it was not specifically on personality disorder. Seven sessions of
MACT were offered to those with recurrent self-harm, 42% of whom had a personality disorder. It differed
from 672 A. Bateman & M. Zanarini
other
studies in being large (n ¼ 480), being
multi-centred (five
centres in Scotland and England), using ordinary therapists (trained in the approach) in the course of their
normal work, and offering no special service for those
in the trial. The results were, in general,
negative in terms of efficacy compared with
treatment as usual (which included psychotherapy
and problem-solving treatment).
Only
60% of patients attended for face-to-face sessions of MACT and for the primary outcome,
proportion of patients repeating self-harm, 39% of those allocated to
MACT repeated compared with 46% allocated to treatment
as usual (TAU) (P ¼ 0.20). There
were seven suicides, 5
in the TAU group (Tyrer et al., 2003). Frequency
of self-harming behaviour was also reduced by 50% in the MACT group compared with TAU, but there was
great variation in episodes of self-harm (Tyrer et al., 2004). There was
no difference in any of the secondary
outcomes.
However, important differences between some of
these outcomes have been shown between
therapists judged as competent after assessment
of taped interviews in the study compared with those who were less competent
(Davidson et al., 2004). However
this simply shows that there are competent and incompetent therapists and presumably the same applies to therapists offering the control
treatment. MACT led to a cost-saving of £900 per patient compared with TAU at 6
months but this did not remain significant at 12
months (Byford et al., 2003).
Interestingly, in
BPD, MACT increased total costs and had less satisfactory results in reducing
self-harm in contrast to its effect in other
personality disorders (Tyrer et al., 2004).
References
Peter
Tyrer and Kenneth R. Silk, Cambridge Textbook of Effective Treatments in
Psychiatry, Cambridge University Press 2008.
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