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.
Pharmacology vs. Psychotherapy for the Treatment of Personality Disorders by Maggie McCracken
In this post I will review the most common pharmaceutical and psychotherapeutic treatments for the the personality disorders. Some common pharmaceutical treatments for personality disorders include antidepressants and antipsychotics in comparison to psychotherapeutic treatments that include dialectical behavior therapy, group therapy, and cognitive behavior therapy. How effective they are and the personality disorders that benefit most for each treatment varies in a symptom based approach to treating personality disorders. In a symptom based approach, medication is used according to a balance of symptoms and results are best when symptoms of the personality disorder are related to problems of cognitive and perceptual disturbances, affective dysregulation, impulsivity, and aggression.
In order to treat cognitive and perceptual disturbances in personality disorders, antipsychotics are typically prescribed. These cognitive and perceptual disturbances may include suspiciousness, odd, muddled or magical thinking, distortions of reality, and paranoid ideation. Various antipsychotics such as Haldol, Thiothixene, Zyprexa and Risperdal are just a few that have been tested for the treatment of personality disorders.
Although antipsychotics have been studied more than any other drug for the treatment of personality disorders, their effectiveness is still in question. Early studies of antipsychotics have reported that using a low dosage of an antipsychotic can be effective in treating personality disorders. However, many of those studies have failed to be replicated. However, the studies that were replicated resulted in placebo effects. This means that antipsychotics may play a role in the treatment of personality disorders but the jury is still out on the efficacy as a treatment and more research is needed.
Personality Disorder(s) of Choice
Antipsychotics are a common treatment option for people with symptoms of aggression and impulsivity in a borderline personality disorder, or may be at risk for losing touch with reality because they have distorted thinking and frequent cognitive and perceptual disturbances which is common in schizotypal personality disorder. Antipsychotics may even be used to treat psychotic episodes commonly found in people with paranoid personality disorder or other Cluster A disorders.
Antidepressants such as selective serotonin reuptake inhibitors (SSRIs) are often prescribed to treat depression and impulsive behavior in personality disorders. In a symptom based approach, impulsivity may also include sensation seeking, recklessness, and affective dysregulation. Other antidepressants such as monoamine oxidase inhibitors (MAOIs) are used to alleviate social phobias within the personality disorder. Some common psychopharmacological treatments to have positive results for treating these symptoms in personality disorders include Phenelzine, Amitriptyline, and Fluoxetine.
Majority of the studies researching antidepressants such as Phenelzine, Fluoxetine and Amitriptyline have had positive effects in treating symptoms of depression, resentment, and anger. In a double blind comparison of antidepressants, they were superior to the placebo for alleviating these symptoms. However, these benefits were also associated with a likelihood of overdose. Therefore, it is recommended that prescribing antidepressants be limited.
Personality Disorder(s) of Choice
Antidepressants are prescribed to reduce depression, anxiety, risk-taking, affective dysregulation and impulsivity which are symptoms commonly found in antisocial, schizoid and borderline personality disorders. However, antidepressants are commonly prescribed to people with schizoid and avoidant personality disorders to help manage anxiety and social phobias that may arise in a psychotherapeutic situation.
Although medication has come a long way for the treatment of personality disorders, research efficacy is minimal and prescribing a particular medication should be handled with caution. Also, certain people with personality disorders do not always have the option to take medication. Treatment with medication is not recommended for people who have histrionic or narcissistic personality disorders. Some patients, more specifically those who hold grudges, act hostile and constantly worry about being deceived, are more susceptible to think that their doctor is prescribing them medication as a coercive treatment intended to control or subdue them may not be an option. Medication that could be potentially addictive is not recommended for dependent, borderline, or antisocial personality disorders. Therefore, this leaves psychotherapy as an option for treatment of personality disorders.
Cognitive Behavioral Therapy (CBT)
CBT is a psychotherapeutic treatment that helps people understand how their thoughts and feelings are influencing their behaviors. This is especially helpful for people diagnosed with a personality disorder and because of this, it is a widely used approach to treating symptoms associated with personality disorders. CBT is an established therapeutic approach, working by helping individuals identify and change negative thought patterns and beliefs in order to modify self-harming behaviors.
Research on CBT for treatment of personality disorders found it was most beneficial in changing interpersonal problems through skills training, especially to target shyness and anxiety for people diagnosed with a personality disorders, more specifically, those from Cluster C. The individuals who participated in the CBT skills training program were considered more skilled in social settings when compared to those who did not participate in the skills training. Although CBT has resulted in the largest sample size in research regarding treatment for personality disorders, the overall efficacy of CBT as treatment is still questionable because majority of research has been from one research group.
Personality Disorders of Choice
Since CBT is known for changing patterns within an individual, those diagnosed with dependent personality disorders benefit from this psychotherapy technique because it provides them with the focus on pattern analysis by creating patterns for changes needed to for their health self-concept. Also, people with avoidant personality disorder benefit because of the CBT techniques that help them overcome fears in social settings while also increasing their self-concept.
Dialectical Behavior Therapy (DBT)
DBT is a newer form of psychotherapy that blends traditional cognitive behavioral therapy with an eastern philosophical approach – Zen Buddhism. It is designed to treat self-injurious behavior originally in women diagnosed with borderline personality disorders. DBT combines behavioral interventions, exposure, problem solving and cognitive techniques to enhance skills of mindfulness, emotion regulation, interpersonal effectiveness and distress tolerance. Made up of different stages, DBT uses the first stage for people to gain control of their behavior by decreasing suicidal threats and risk taking, followed by other stages intended to address behavior that impacts quality of life as well as increasing appropriate behavior skills.
DBT incorporates an intense program of weekly individual and group sessions in order to reduce the self-injurious behavior on an individual basis while learning how to interact socially within a group. Previous research claims that treatment after a year led to less suicidal attempts. Follow-ups at 6 months to a year after treatment, resulted in less suicidal attempts and less days in a hospital compared to the control group. Although much hype has stemmed over this approach to treating borderline personality disorder specifically, researchers suggest more studies be done about the long term effectiveness and the amount of dropout rates during the program.
Personality Disorder(s) of Choice
DBT’s common use as treatment of self-injurious behavior means that it is commonly used for people diagnosed with borderline personality disorder. It is beneficial for people diagnosed with borderline personality disorder because it works off of the idea that when an individual has difficulty regulating their emotions in an environment they do not trust, then their symptoms become worse. DBT provides the skills training to get rid of this type of thinking.
Group therapy is exactly what it appears to be. A group of people are gathered together to be seen by one or more therapists at the same time to provide a form of psychotherapeutic treatment for people (in this case) diagnosed with personality disorders. Group therapy can be used in combination with many psychotherapeutic approaches such as DBT and CBT treatment for people diagnosed with personality disorders. It is beneficial to individuals with personality disorders because it provides a safe place where they can establish a trusting environment and gain a sense of belonging, while feeling needed. Therefore, increasing their self-concept.
In order for group therapy to be effective, previous research recommends having members all be diagnosed with the same personality disorder and at different stages of treatment in one session. Doing so prevents members in the group from becoming lost. When comparing group therapy to individual therapy, both had similar results. In a randomized controlled study of individual and group therapy focusing on relationship management, both had equivalent results in improvement of symptoms associated with the personality disorders. While both group and individual therapy resulted in the same amount of efficacy, group therapy is recommended as the most cost effective treatment option for personality disorders when compared to individual and other forms of therapy.
Personality Disorder(s) of Choice
Group therapy is a treatment option for many personality disorders. People diagnosed with antisocial personality disorder can benefit from group therapy because it typically motivates them to change from the peer pressure within the group. This is also seen as an outcome for people with histrionic personality disorder where their motivation comes from within the group. Group therapy offers people with avoidant personality disorder a sense of belonging as well as a feeling of being wanted; which helps boost their ego. Also, people diagnosed with dependent personality benefit from group therapy because it gives them a new way of self-expression with the people in the group
Although less well established that treatments for the mood and anxiety disorders, there are some promising approaches to evidence-based treatment for those with personality disorders. While much more research is needed, we do have a solid start