Elsevier

The Lancet

Volume 385, Issue 9969, 21–27 February 2015, Pages 735-743
The Lancet

Series
Treatment of personality disorder

https://doi.org/10.1016/S0140-6736(14)61394-5Get rights and content

Summary

The evidence base for the effective treatment of personality disorders is insufficient. Most of the existing evidence on personality disorder is for the treatment of borderline personality disorder, but even this is limited by the small sample sizes and short follow-up in clinical trials, the wide range of core outcome measures used by studies, and poor control of coexisting psychopathology. Psychological or psychosocial intervention is recommended as the primary treatment for borderline personality disorder and pharmacotherapy is only advised as an adjunctive treatment. The amount of research about the underlying, abnormal, psychological or biological processes leading to the manifestation of a disordered personality is increasing, which could lead to more effective interventions. The synergistic or antagonistic interaction of psychotherapies and drugs for treating personality disorder should be studied in conjunction with their mechanisms of change throughout the development of each.

Introduction

Translation of present research into robust clinical recommendations for the treatment of personality disorder is beset with difficulties.1 Study populations are heterogeneous,2 a natural result of the present classification of personality disorder and the different assessment criteria used by different studies. Personality disorder has much comorbidity with other mental disorders.3, 4, 5 Symptomatic improvement of a comorbid disorder during treatment is difficult to distinguish from true underlying personality change. Little agreement on core outcomes and measures makes meta-analyses of treatment outcome studies difficult to do, although they have been attempted.6, 7, 8 Methodological issues, for example masking of participants and personnel, are frequent, and most studies are done by treatment developers, which is known to affect outcomes in psychological and pharmacological research. Finally, the essential features of personality disorder, substantial impairment of interpersonal function, identity problems, and recognisable social dysfunction, are all difficult to measure. No convincing evidence exists that these core domains of the diagnosis improve significantly or reliably with treatment. Patients might lose a standardised diagnosis of personality disorder during treatment, but even if a formal diagnosis is not present, their vocational and social adaptation remain impaired irrespective of treatment.9, 10, 11

Despite all these caveats, reasons for optimism in personality disorder treatment remain. The old notion that these disorders are necessarily long term, stable over time, and associated with poor outcomes can no longer be sustained, particularly for borderline personality disorder, in which the serious epiphenomena, such as suicide attempts, risk taking, misuse of services, and aggressive outbursts improve markedly with treatment. These improvements are substantial in view of the cost of these behaviours for the individual, health services, and society. However, despite these improvements interpersonal dysfunction and social disturbance can continue unabated and identity problems will probably remain. In the long term, patients often continue to feel miserable about their lives, struggle to manage constructive intimate relationships, and under-function in complex social contexts such as employment and education. These difficulties persisting in the long term despite treatment are particularly prominent in patients with severe personality disorder, who also have a high risk of causing harm to themselves or others (particularly those with borderline and antisocial personality disorder), which is of concern. For treatment to be deemed effective it needs to have a robust effect on the core symptoms of a disorder and on the associated social adaptation over the long term. At present, long-term follow-up of treatment is limited.11, 12

A further difficulty in the appraisal of treatment for personality disorder is that research is concentrated on a few personality disorders, principally borderline and to a lesser degree antisocial, and as a result any review is necessarily biased towards them. No agreement exists about the discrete nature of the categories of personality disorder, but this Series paper is organised around the three clusters that were used by the American Psychiatric Association to organise the categorical personality disorder classification systems in the Diagnostic and Statistical Manual of Mental Disorders (DSM)-III, DSM-IV,13 and now DSM-5.14 Each cluster has observable similarities and was perceived to have a hierarchical order in terms of severity of adaptive failure and treatability: cluster A, the odd, eccentric, socially aversive types, are thought least adaptive and least treatable; cluster B, the emotionally and behaviourally dysregulated types, have major social adaptational difficulties and variable treatability; and cluster C, the anxious, neurotic types, have the least severe adaptive failures (ie, are the best functioning) and are thought to have the best outlook and treatability. This Series paper retains clusters because most of the evidence of efficacy or effectiveness derives from them.

Section snippets

Treatment approaches

The two main approaches to the treatment of personality disorder are psychosocial treatment and pharmacotherapy. Psychosocial intervention is recommended as the primary treatment for borderline personality disorder15 and other personality disorders.16 The rationale for psychosocial intervention, albeit mainly rooted in tradition, lies in the fact that personality and its disorders arise from a complex interaction between genetic determinants and developmental processes, affected by adverse life

Comorbidity

Comorbidity remains a major concern in the interpretation of even the scarce available data about personality disorders. Most individuals diagnosed with one personality disorder meet criteria for at least one other personality disorder.27 A substantial proportion of patients have at least one axis I comorbid disorder, particularly depression, anxiety, and alcohol and drug disorders,28 but in all studies about these disorders the research reports of change in axis I disorders have little detail.

Aims of treatment

The aims of treatments for personality disorder are more parsimonious than often suggested. Drug treatment only focuses on specific aspects of personality disorder's pathological effects, such as affective instability and cognitive–perceptual disturbances. Psychosocial treatments, mainly for borderline personality disorder, aim to reduce acute life-threatening symptoms29 and improve distressing mental state symptoms. Some psychosocial treatments target practical issues only,30 leaving other

Cluster A personality disorders

People with cluster A disorders (schizoid, schizotypal, and paranoid personality disorders) are united by their social aversion, their failures to form close relationships, and their relative (compared with other clusters) indifference to these disabilities. These patients have poor self-awareness and empathic ability. Mental health professionals have made little effort to study or treat people with cluster A disorders; partly because, except perhaps those with schizotypal disorder, they do not

Cluster B personality disorders

Cluster B personality disorders (borderline, antisocial, histrionic, and narcissistic) share dramatic, emotional, or erratic characteristics. Research interest is focused on borderline and antisocial personality disorder at present.

Psychosocial treatment of cluster C personality disorders

An early randomised controlled trial of patients with mixed cluster C disorders suggested that psychodynamic therapy improved social function and reduced distress compared with wait-list controls and that changes were maintained throughout follow-up.82 A subsequent randomised controlled trial comparing short-term psychodynamic therapy with cognitive therapy with a 2 year follow-up showed significant improvements in both groups, with no differences in outcomes between them, although recorded

Conclusion

The evidence base for the treatment of personality disorders is limited by the focus on borderline personality disorder, the small sample sizes and short follow-up in clinical trials, the use of a wide range of outcome measures, and poor control of coexisting psychopathology. Nevertheless, some general conclusions are possible. Psychosocial treatment gives grounds for optimism, especially for borderline personality disorder. Treatment should be a structured (usually manual directed) partnership

Search strategy and selection criteria

We searched PubMed and Medline for original research or review articles published in English between Jan 1, 2008, and March 31, 2014. We used a combination of the following search terms: “personality”, “personality disorder”, “treatment”, “psychosocial”, “borderline”, “antisocial”, “dissocial”, “pharmacotherapy”, and other named personality disorders (“paranoid”, “schizoid”, “emotionally unstable”, “impulsive”, “histrionic”, “anxious”, “avoidant”, “dependent”, “mixed”, “schizotypal”,

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