From the Guidelines
Assessment and treatment of personality disorders should prioritize a comprehensive evaluation and dialectical behavior therapy (DBT) as the primary approach, particularly for borderline personality disorder, as it has been shown to reduce suicidality and improve emotional regulation. When evaluating personality disorders, it is essential to use structured clinical interviews and validated assessment tools to identify specific personality traits, patterns of behavior, and functional impairments 1.
Key Components of Treatment
- Psychotherapy is the primary approach, with DBT being particularly effective for borderline personality disorder, while cognitive-behavioral therapy (CBT), schema therapy, and mentalization-based therapy are beneficial for various personality disorders 1.
- Medication is generally used as an adjunct to address specific symptoms rather than the personality disorder itself; for example, selective serotonin reuptake inhibitors (SSRIs) like fluoxetine (20-80 mg daily) or sertraline (50-200 mg daily) may help with mood instability and impulsivity, while low-dose antipsychotics such as quetiapine (25-300 mg daily) might be prescribed for cognitive-perceptual symptoms.
- Treatment should be long-term, typically lasting at least 12-18 months, with regular reassessment of progress 1.
- A collaborative, multidisciplinary approach involving psychologists, psychiatrists, and social workers is often necessary, with attention to building a strong therapeutic alliance.
Recent Developments in Classification
The recent changes from ICD-10 to ICD-11 have introduced a more dimensional approach to personality disorders, replacing the categorical approach with a single personality disorder diagnosis characterized by problems in functioning of aspects of the self and/or interpersonal dysfunction, further differentiated according to severity into mild, moderate, and severe 1. This shift towards dimensionality aims to improve clinical utility and simplicity in the diagnosis and treatment of personality disorders.
Importance of Dimensional Assessment
The use of dimensional symptom specifiers and course specifiers, as seen in the ICD-11, allows for a more detailed description of the patient's symptomatology and longitudinal course, enabling mental health professionals to provide more targeted and effective treatment 1. By prioritizing a comprehensive evaluation and DBT as the primary approach, clinicians can improve treatment outcomes and reduce morbidity and mortality associated with personality disorders.
From the Research
Assessment of Personality Disorder
- The assessment of personality disorder involves a comprehensive evaluation of the individual's symptoms, behavior, and functioning 2.
- A systematic framework for treating personality disorder proposes an eclectic approach that combines interventions from different therapeutic models and delivers them in an integrated and systematic manner 2.
Treatment Recommendations
- Psychotherapies are recommended as first-line treatments for personality disorders, particularly borderline personality disorder (BPD) 3, 4.
- Dialectical behavior therapy (DBT), mentalization-based therapy, and schema therapy have been found to be effective in treating BPD 4, 5.
- Systems training for emotional predictability and problem solving has been found to be more effective than treatment as usual (TAU) for the treatment of BPD 3.
- Cognitive behavioral therapy (CBT) and psychodynamic approaches have also been found to be effective in treating personality disorders 4, 6.
Phases of Treatment
- Treatment of personality disorder can be conceptualized as progressing through a series of phases, including safety, containment, regulation and control, exploration and change, and integration and synthesis 2.
- Each phase addresses different problems with different specific interventions, with structured behavioral and cognitive interventions and medication predominating in the earlier phases 2.
- Later in treatment, less structured psychodynamic, interpersonal, and constructionist strategies are used to explore and change maladaptive interpersonal patterns, cognitions, and traits 2.
Limitations and Future Directions
- There is a lack of research on the treatment of Cluster A and Cluster C personality disorders, which limits the conclusions that can be drawn 5, 6.
- Further studies are needed to evaluate the effectiveness of psychotherapies for personality disorders, particularly for Cluster A and Cluster C disorders 5, 6.
- The high drop-out rate for patients with borderline PD highlights the need for more research on strategies to improve treatment retention 5.