This post is part of a series of guest posts on GPS by the graduate students in my Psychopathology course during Spring 2014. As part of their work for the course, each student had to demonstrate mastery of the skill of “Educating the Public about Mental Health.” To that end, each student has to prepare two 1,000ish word posts on a particular class of mental disorders, with one of those focusing on evidence-based treatments for those disorders and the other focused on a particular myth or misunderstanding about mental illness.
Evidence-based Treatments for Personality Disorders by Brooke Kuns
What is a personality disorder and how do you treat it? An individual with a personality disorder can best be described as someone who is considered deviant in thinking from one’s culture. This condition is chronic and is maladaptive to one’s surroundings. This behavior is seen in the individuals thinking and behavior and has a negative impact on their quality of life. There are biological and psychosocial aspects that play a role in the presentation and diagnosis of personality disorders. Currently there are 10 specific personality disorders listed in the DSM-5:
- Paranoid Personality Disorder
- Schizoid Personality Disorder
- Schizotypal Personality Disorder
- Antisocial Personality Disorder
- Borderline Personality Disorder
- Histrionic Personality Disorder
- Narcissistic Personality Disorder
- Avoidant Personality Disorder
- Dependent Personality Disorder
- Obsessive-Compulsive Personality Disorder
They are arranged into three separate clusters based on similarities. Cluster A disorders can be classified as eccentric or odd, Cluster B disorders are often over dramatic and emotional, and Cluster C disorders are fearful and avoidant. It is estimated that approximately 15% of the population in the United States could qualify for at least one personality disorder diagnosis. According to the DSM-5 in order for an individual to quality for a General Personality Disorder diagnosis they would be required to meet the following criteria:
- Experiencing an enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual’s culture. This pattern is manifested in two (or more) of the following areas: cognition, affectivity, interpersonal functioning, and impulse control.
- The enduring pattern is inflexible and pervasive across a broad range of personal and social situations.
- The enduring pattern leads to clinically significant distress or impairment in social, occupational, or other important areas of functioning.
- The pattern is stable and of long duration, and its onset can be tracked back to at least adolescence or early childhood.
- The enduring pattern is not better explained as a manifestation or consequence of another disorder.
- The enduring pattern is not attributable to the physiological effects of a substance or other medical condition.
Once an individual meets at least two or more of these areas they can be clinically diagnosed with generalized personality disorder. However, for each different disorder there are separate criteria an individual must meet. For example, Paranoid Personality Disorder will have different criteria than Antisocial Personality Disorder but characteristically they will all display patterns of deviation from society’s norm.
Historically, it was thought that personality disorders were untreatable. However, that is not the case. There have been several evidence based treatments or practices used to help an individual overcome most personality disorders. So what is evidence based treatment or practice? Evidence based practice or treatment was formally introduced in 1992. It began in the medical field and quickly spread to other types of practices, psychology being one of them. Evidence based practice/treatment means that clinicians base treatment practices on the most beneficial methods supported by research and other resources. This information can be accessed through journals or educational courses. Currently, there are numerous options for evidence based treatment of personality disorders available for clinicians use.
Cognitive Behavior Therapy or CBT is based on the idea that cognitions can influence behaviors. This treatment is made up of two separate aspects, the cognition therapy as well as behavior therapy. With this treatment method, clinicians are able to help individuals recognize harmful thoughts or behaviors. This is the cognition aspect. Once the harmful thoughts or behaviors are clear to the individual, then the clinician helps the individual concentrate on changing this behavior which makes up the behavior therapy aspect. For example, an individual who has been diagnosed with paranoid personality disorder often feels that their family or peers intentions are meant to be harmful or deceitful. They often feel that the majority of interactions with acquaintances are meant to discredit their personality in some way. There is an obvious lack of trust for friends or family. With CBT, the clinician will guide the individual to begin to understand that friends and family do not have harmful intentions towards them and help the individual alter their thinking and begin trusting people. CBT is currently one of the most utilized treatments in psychology.
A specifically developed type of CBT called Dialectical Behavior Therapy was put into practice in the 1980s by Dr Marsha Linehan for people with Borderline Personality Disorder (BPD). It focuses on four specific skills – mindfulness (the practice of being fully aware and present in this one moment), distress tolerance (how to tolerate pain in difficult situations, not change it), interpersonal effectiveness (how to ask for what you want and say no while maintaining self-respect and relationships with others), and emotion regulation (how to change emotions that you want to change). A large body of literature shows DBT’s effectiveness in the treatment of BPD.
Schema Therapy is an evidence based practice that is utilized in the treatment of personality disorders. This specific treatment has had outstanding success when used on individuals who have been diagnosed with BPD. This treatment is based upon recognizing maladaptive schemas from an individual’s earlier life that has manifested into a disorder over time. This means an event that occurred during one’s childhood that was considered damaging has negatively affected their quality of life as an adult. With Schema Therapy, the clinician helps the individual address schemas that were damaging in childhood and adapt their thinking into a positive thought. For someone with BPD, they have a fear of abandonment. This may be due to an incident from their childhood that has altered their thinking as an adult. Schema Therapy will encourage the individual alter their thinking and recognize all the situations in their lifetime where a meaningful individual in their lifetime did not leave them. Overtime, this will help the individual overcome that fear and decrease the presence of BPD.
Acceptance and Commitment Therapy (ACT) is a form of CBT which encourages the individual to focus on positive thoughts and behaviors even while experiencing distressful ones. There are six core processes when utilizing ACT. To begin, the individual must learn to accept uncomfortable or distressing thoughts or feelings. Then the individual must recognize the distressing thought or feeling and learn not to attach any emotion to them. Next the individual must recognize and concentrate on the present not the past. They must push all focus to the here and now. The individual must continue to be aware at all times of the possibility of distressing thoughts or feelings but recognize that their values are important and strive to meet those. The main focus of ACT is for the individual to control the uncomfortable experience. ACT has been utilized in treating many different personality disorders.
New research and technology has allowed the world of psychology to expand its treatment options for personality disorders. There are many more treatments than the few mentioned in this article. Daily there is evidence based research taking place to expand the treatment base for psychological disorders. They continue to be tested and refined to broaden the field of psychology. Clinicians must always stay up to speed with the latest and greatest of treatment options available to them and to broaden their knowledge of psychological disorders in their entirety.