Personality disorder is common, rarely treated in its own right and often only considered as an irritating impediment to effective treatment of medical and psychiatric problems. However, there has been a significant shift from the view that personality disorder is untreatable.
We do have treatments that have at least some efficacy, and one of these is psychoanalytic psychotherapy. Psychoanalytically based therapies, subsumed in this article as psychodynamic therapy, are a treatment in their own right, and psychodynamic ideas can usefully inform treatment planning and may guide appropriate prescription of medication.
Psychodynamic psychotherapy has been modified to suit the particular problems associated with personality disorder and has an increasing evidence base for its effectiveness, with most interest surrounding its use in the treatment of borderline personality disorder (BPD). An analysis of results from 15 studies of all psychotherapies that reported pretreatment-to-posttreatment effects suggested mean pre-post effect sizes within treatments were large: 1.11 for self-report measures and 1.29 for observational measures (Perry et al., 1999). The authors suggested a future study should examine specific therapies for specific personality disorders This has now been done in an objective meta-analysis of the effectiveness of psychodynamic therapy and cognitive-behavioral therapy (CBT) in the treatment of personality disorders (Leichsenring and Leibing, 2003). The study found that psychodynamic therapy yielded a large overall effect size of 1.46, with effect sizes of 1.08 for self-report measures and 1.79 for observer-rated measures. This contrasted with CBT in which the corresponding values were 1.00, 1.20, and 0.87, respectively. In addition, the psychodynamic studies had a mean follow-up period of 1.5 years, compared to only 13 weeks for CBT. However, the research literature was not extensive enough to draw firm conclusions from meta-analysis, and the authors were able to include only 14 psychodynamic studies and 11 CBT studies. The effect sizes cannot be compared directly because the studies differ, even within the same therapy group, in terms of therapy content, patient populations, length of treatments, outcome assessments and other variables. In an important early study of dynamic therapy, Stevenson and Meares (1992) reported on 48 patients with BPD treated with twice-weekly psychoanalytic psychotherapy for one year. Patients acted as their own controls. Significant improvements in number of episodes of self-harm and violence, length of hospital admissions, and other measures were observed in the 30 patients who completed therapy. At the end of treatment, 30% of patients no longer fulfilled criteria of BPD. Improvement was maintained over one year and continued over five years with substantial saving in health care costs. The same authors compared the outcome of the same 30 patients with 30 further patients who were referred to the clinic but for whom no treatment was immediately available (Meares et al., 1999). Patients who received psychotherapy were significantly improved in personality disorder scores, while untreated patients showed no change. The therapy concentrated early on the development of a therapeutic alliance and a relative or close friend was seen at the start of treatment. Both these factors may have accounted for the low dropout rate of 16%.
The most recent experimental support for a psychodynamic approach, now operationalized as mentalization-based treatment (MBT), has come from a randomized study examining the effectiveness of a group and individual partial-hospitalization program with standard psychiatric care for patients with BPD (Bateman and Fonagy, 2001, 1999). This has confirmed the indicative evidence from noncontrolled studies of the utility of partial-hospital group treatment. There was significantly greater improvement on all outcome measures in those patients allocated to psychotherapy. The dropout rate for the study was low. Gains were maintained after a further 18 months, indicating that rehabilitative effects were stimulated during the treatment phase (Bateman and Fonagy, 2001). The treatment has also been found to be cost-effective (Bateman and Fonagy, 2003). In a further randomized controlled trial, an outpatient version of MBT is currently being evaluated for use in patients with BPD and antisocial personality disorder.
A dynamic therapy known as transference-focused psychotherapy (TFP) has exhibited promising results, although the outcome of a randomized controlled trial comparing TFP, dialectical behavior therapy (DBT) and supportive psychotherapy is not yet known. In a cohort study, 23 female patients with BPD were assessed at baseline and at the end of 12 months of treatment with diagnostic instruments, measures of suicidality, self-injurious behavior, and measures of medical and psychiatric service utilization (Clarkin et al., 2001). Compared with the year prior to treatment, the number of patients who made suicide attempts significantly decreased, as did the medical risk and severity of medical condition following self-injurious behavior. The treatment year also saw significantly fewer hospitalizations, as well as number and days of psychiatric hospitalization compared with the previous year. The dropout rate was 19.1%. Conference reports of a comparison study between patients treated with TFP and a matched untreated control group confirm the benefits of treatment (Clarkin, 2002). Costs have not yet been examined.
The relative effectiveness of three psychodynamically oriented treatment models for a mixed group of personality disorders--long-term residential treatment using a therapeutic community approach, briefer inpatient treatment followed by community-based dynamic therapy (step-down program) and general community psychiatric treatment--has been studied.
Results suggest that brief inpatient therapeutic community treatment followed by outpatient dynamic therapy is more effective than both comparator treatments (Chiesa et al., 2002). Follow-up at 36 months has confirmed this finding (Chiesa and Fonagy, 2003).
In a dynamically related therapy using interpersonal group psychotherapy (IPG) to dilute some of the strong transference reactions found in patients with BPD, Monroe-Blum and Marziali (1995) found equivalent results between group and individual therapy, concluding that on cost-effectiveness grounds group therapy is the treatment of choice.
Further studies are needed to confirm all these experimental findings.
APA (2001), Practice Guideline for the Treatment of Patients with Borderline Personality Disorder. Washington, D.C.: American Psychiatric Press.
Bateman A, Fonagy P (1999), Effectiveness of partial hospitalization in the treatment of borderline personality disorder: a randomized controlled trial. Am J Psychiatry 156(10):1563-1569 [see comment].
Bateman A, Fonagy P (2001), Treatment of borderline personality disorder with psychoanalytically oriented partial hospitalization: an 18-month follow-up. Am J Psychiatry 158(1):36-42 [see comment].
Bateman A, Fonagy P (2003), Health service utilization costs for borderline personality disorder patients treated with psychoanalytically oriented partial hospitalization versus general psychiatric care. Am J Psychiatry 160(1):169-171.
Bateman A, Fonagy P (2004), Psychotherapy for Borderline Personality Disorder - Mentalization-Based Treatment. Oxford, U.K.: Oxford University Press.
Bender DS, Dolan RT, Skodol AE et al. (2001), Treatment utilization by patients with personality disorders. Am J Psychiatry 158(2):295-302.
Chiesa M, Fonagy P (2003), Psychosocial treatment for severe personality disorder. 36-month follow-up. Br J Psychiatry 183:356-362.
Chiesa M, Fonagy P, Holmes J et al. (2002), Health service use costs by personality disorder following specialist and nonspecialist treatment: a comparative study. J Personal Disord 16(2):160-173.
Clarkin JF (2002), The New York borderline psychotherapy project: further developments. Presented at the 5th ISSPD European Congress on Personality Disorders. Munich, Germany; July 4-7.
Clarkin JF, Foelsch P, Levy KN et al. (2001), The development of a psychodynamic treatment for patients with borderline personality disorder: a preliminary study of behavioral change. J Personal Disord 15(6):487-495.
Clarkin JF, Yeomans FE, Kernberg OF (1998), Psychotherapy for Borderline Personality. New York: Wiley.
Gabbard GO (2000), Combining medication with psychotherapy in the treatment of personality disorders. In: Psychotherapy for Personality Disorders, Gunderson JG, Gabbard GO, eds. Washington, D.C.: American Psychiatric Press, pp65-94.
Gunderson JG (2001), Borderline Personality Disorder: A Clinical Guide. Washington, D.C.: American Psychiatric Publishing.
Leichsenring F, Leibing E (2003), The effectiveness of psychodynamic therapy and cognitive behavior therapy in the treatment of personality disorders: a meta-analysis. Am J Psychiatry 160(7):1223-1232 [see comment].
Marziali E, Munroe-Blum H (1994), Interpersonal Group Psychotherapy for Borderline Personality Disorder. New York: Basic Books.
Meares R, Stevenson J, Comerford A (1999), Psychotherapy with borderline patients: I. A comparison between treated and untreated cohorts. Aust N Z J Psychiatry 33(4):467-472 [see comments].
Monroe-Blum H, Marziali E (1995), A controlled trial of short-term group treatment for borderline personality disorder. J Personal Disord 9(3):190-198.
Perry JC, Banon E, Ianni F (1999), Effectiveness of psychotherapy for personality disorders. Am J Psychiatry 156(9):1312-1321.
Stevenson J, Meares R (1992), An outcome study of psychotherapy for patients with borderline personality disorder. Am J Psychiatry 149(3):358-362 [see comment].
Zanarini MC, Frankenburg FR, Hennen J, Silk KR (2004), Mental health service utilization by borderline personality disorder patients and Axis II comparison subjects followed prospectively for 6 years. J Clin Psychiatry 65(1):28-36.