Discussion: Personality Disorders and Psychotherapy

Discussion: Personality Disorders and Psychotherapy

Discussion: Personality Disorders and Psychotherapy

Correspondence: Alexander Chapman, PhD, Department of Psychology, Simon Fraser University, 8888 University Drive, Burnaby, BC, V5A 4Z1 Canada. Tel: (778) 782-6932. Fax: (778) 782-3427. E-mail: alchapma@sfu.ca

(Received 7 April 2011 ; accepted 5 May 2011 )

Psychotherapy for personality disorders


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Department of Psychology, Simon Fraser University, Burnaby, British Columbia, Canada

Abstract Personality disorders are widely prevalent among those seeking mental health services, resulting in substantial distress and a heavy burden on public assistance and health resources. We conducted a qualitative review of randomized controlled trials (RCTs) of psychosocial interventions for personality disorders. Articles were identifi ed through searches of electronic databases and classifi ed based on the focus of the psychological intervention. Data regarding treatment, participants and outcomes were identifi ed. We identifi ed 33 RCTs that evaluated the effi cacy of various psychosocial treatments. Of these studies, 19 focused on treatment of borderline personality disorder, and suggested that there are several effi cacious treat- ments and one well-established treatment for this disorder. In contrast, only fi ve RCTs examined the effi cacy of treatments for Cluster C personality disorders, and no RCTs tested the effi cacy of treatments for Cluster A personality disorders. Although other personality disorders, especially Cluster A, place heavy demands on public assistance, and in spite of recommendations that psychosocial interventions should be the fi rst line of treatment for these disorders, our review underscored the dearth of treatment research for many of these personality disorders. We highlight some obstacles to such research and suggest directions for future research.


According to the DSM-IV, personality disorders (PDs) are defi ned as pervasive, non-normative patterns of thought and behaviour which are long- standing, and cause signifi cant impairment in rela- tionships and overall functioning (APA, 2000, p. 685). The DSM-IV includes ten PDs, organized into three clusters: Cluster A disorders, comprising schizoid, paranoid and schizotypal PDs, are charac- terized by odd or eccentric patterns of behaviour; Cluster B disorders, comprising antisocial, border- line, narcissistic and histrionic PDs, are character- ized by dramatic or impulsive patterns of behaviour; and Cluster C disorders, comprising avoidant, dependent, and obsessive – compulsive PDs, are char- acterized by anxious or fearful behaviours. PDs are highly prevalent, with 31 – 45% of psychiatric patients and 10 – 15% of the general adult population meeting criteria for at least one PD (Samuels et al., 2002; Zimmerman & Coryell, 1989).

Personality disorders are associated with substan-tial personal and interpersonal distress, functional impairment, and use of mental health resources (Perry, 1993; Perry & Vaillant, 1989; Skodol, Johnson, Cohen, Sneed, & Crawford, 2007). In fact, individuals with PDs make up a substantial portion of mental health service consumers (Fyer, Frances, Sullivan, Hurt, & Clarkin, 1988; Markowitz, Moran, Kocsis, & Frances, 1992; Oldham, Skodol, Kellman, & Hyler, 1995; Skodol et al., 1993; Vaughn et al., 2010). Further, early literature documenting limited gains in psychotherapy among individuals with PDs compared to those without PDs (Diguer, Barber, & Luborsky, 1993; Fahy, Eisler, & Russell, 1993; Hardy et al., 1995; Karterud et al., 1992; Shea, Pilkonis, Beckham, & Collins, 1990; Woody, McLellan, Luborsky, & O ’ Brien, 1985) fuelled the assumption that individuals with personality disor- ders may be ‘ untreatable ’ (Lewis & Appleby, 1988).

Although people who hold this assumption have been taken to task with the emergence of mounting evidence for the effi cacy of treatments for PDs, PDs are associated with signifi cant challenges for psycho- therapy. For example, interpersonal, self and identity dysfunction are often hallmark features of various PDs (Livesley, 2003); thus, it is not surprising that the formation and maintenance of a positive working alliance can be a challenging endeavour (Benjamin & Karpiak, 2002; Colson et al., 1985; Muran, Segal, Samstag & Crawford, 1994). Individuals with PDs

International Review of Psychiatry, June 2011; 23: 282–302

ISSN 0954–0261 print/ISSN 1369–1627 online © 2011 Institute of Psychiatry DOI: 10.3109/09540261.2011.586992

Psychotherapy for personality disorders 283

often present to therapy with a variety of challenging behaviours that require attention, including sub- stance use, eating disorders, self-injury, suicidality, and violent or aggressive behaviour (Grant et al., 2004). Moreover, patients with particular PDs pres- ent to treatment with an average of roughly three co-occurring Axis-I disorders (Harned et al., 2009; McMain et al., 2009), making it diffi cult to defi ne and prioritize treatment targets, and to ascertain meaningful ‘ progress ’ . The clinical complexity of these patients can lead to distress, demoralization and burn-out on the part of therapist (Chapman, 2009; Rossberg, Karterud, Pedersen, & Friis, 2008). Individuals with PDs are also more likely to prema- turely terminate therapy compared to those without PDs (Karterud et al., 1992; Skodol, Buckley, & Charles, 1983). Thus, it is not surprising that work with these individuals is sometimes marked by frus- tration on the part of both therapist and patient regarding the rate of therapeutic progress (Murphy & McVey, 2010; Watts & Morgan, 1994).

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