July 2006, Vol. XXIII, No. 8
Recent research has supported the use of psychosocial interventions for persons with various personality disorders. However, few empirically supported therapies (ie, treatments that outperform control conditions in at least 2 randomized controlled trials by independent research groups1) currently exist.
This article examines recent research on psychosocial treatments for persons with personality disorders, particularly focusing on randomized controlled trials and empirically supported therapies. The article then takes a closer look at dialectical behavior therapy (DBT),2,3 an empirically supported treatment for borderline personality disorder (BPD), as an example of a psychosocial intervention for patients with personality disorders.
RESEARCH ON PSYCHOSOCIAL TREATMENTS
Many of the randomized controlled trials of psychosocial treatments for personality disorder have focused on treatments for BPD, although other studies have also examined treatments for cluster C personality disorders, comorbid affective disorders and personality disorders, and personality disorders in general.
A recent review of treatment for BPD4 covered 8 randomized controlled trials of psychosocial treatments for BPD.5-12 Seven of these trials studied DBT and 1 studied psychoanalytic partial hospitalization.
Research on DBT has consistently indicated that it is an effective treatment for BPD. Indeed, studies of DBT indicate that it meets the criteria for an empirically supported therapy for BPD. The first randomized controlled trial for the treatment of BPD, by Linehan and colleagues,5 indicated that DBT was superior to a treatment-as-usual condition on the following outcomes:
- Percentage of patients with selfinflicted injuries (including suicide attempts)
- Number of self-inflicted injuries
- Medical risk of injuries
- Social and global adjustment
- Psychiatric inpatient days
- Treatment retention
Both patients receiving DBT and those receiving treatment as usual had decreases in depression, hopelessness, and suicidal ideation. A 1-year followup13 indicated that patients in DBT had:
- Higher global adjustment scores throughout follow-up
- Less self-injurious behavior, less anger, and better social adjustment scores throughout the first 6 months of follow-up
- Better interviewer-rated social adjustment and fewer psychiatric inpatient days during the final 6 months of treatment
Another randomized controlled trial compared DBT to treatment conducted by expert community psychotherapists (as opposed to treatment as usual).11 The researchers found that patients treated with DBT had half as many suicide attempts, lower medical risk of self-injuries, lower rates of treatment dropout and fewer psychiatric hospitalizations and psychiatric emergency department visits for suicidal behaviors. Patients in both conditions showed increases in reasons for living and decreases in depression and suicidal ideation.
Another study examined DBT as a treatment for BPD and comorbid substance use disorder.6 Patients were randomly assigned to DBT or a community treatment-as-usual condition. Patients treated with DBT had less drug use and less treatment dropout as well as better global adjustment and social adjustment than community treatment as usual.
Psychoanalytic partial hospitalization
Several other treatments have shown promise for the treatment of BPD; psychoanalytic partial hospitalization is one example. However, this approach has not reached the definition of an empirically supported therapy, since its findings have not been replicated by an independent research team.
In an 18-month randomized controlled trial, psychoanalytic partial hospitalization was compared with treatment as usual.12 Patients in the partial hospitalization program showed reductions in self-harm behaviors and number of inpatient days.
A number of treatments have shown equivalent outcomes in the treatment of BPD. In 1 study, patients were randomized to either a group therapy specifically tailored for BPD or individual psychodynamic therapy.14 There were no significant differences between the outcomes of the 2 groups, although patients in both groups showed significant improvements.
Other studies of psychosocial treatments for BPD, including an open, uncontrolled clinical trial of cognitive therapy15 and transference-focused therapy,16 indicated that these treatments may be promising, but further study through randomized clinical trials is required.
Cluster C personality disorders
In a study examining a psychosocial treatment targeting cluster C personality disorders, 50 patients with 1 or more cluster C personality disorders were randomized to either 40 sessions of dynamic psychotherapy or cognitive therapy.17 Patients in both groups showed significant improvement in symptom distress, interpersonal problems, and cluster C personality pathology scores during treatment and at 2-year followup. There were no significant differences on any measure of outcome between the 2 groups at any time. Treatments for cluster C personality disorders require further study.
Comorbid affective and personality disorders
Two treatments have shown promise for comorbid affective disorders and personality disorder. Researchers looked at DBT modified for the treatment of major depressive disorder with at least 1 comorbid personality disorder (although not necessarily BPD) in patients 55 years or older.18 Results showed that compared to antidepressant medication alone, patients receiving DBT plus medication had significantly better outcomes for interpersonal aggression and interpersonal sensitivity as well as a trend toward better depression remission rates.
Another controlled trial randomized patients with a comorbid affective disorder and personality disorder to either 18 weeks of psychodynamic day hospital treatment or a wait-list control group.19 Those in the day hospital treatment group had significantly greater improvements in severity, social functioning, family functioning, interpersonal functioning, mood, self-esteem, and life satisfaction than those in the control group. Thus, both DBT and psychodynamic day hospital treatment show promise for being effective in the treatment of mood and personality disorders.
Personality disorders in general
Several studies have examined psychosocial treatments of personality disorders in general. In one such study, 81 patients with any personality disorder were randomly assigned to 40 weeks of either brief adaptive psychotherapy or short-term dynamic therapy, or a wait-list control group.20 Patients in both treatment groups improved significantly more than patients in the control group on self-reported symptoms, social adjustment, and target complaint severity. There were no significant differences between outcomes of patients in the 2 active treatment groups.
In another randomized controlled trial, 156 patients with any personality disorder were randomized to either a community-based psychodynamic intervention or 40 sessions of supportive-expressive psychotherapy.21 No differences were found between treatments at the end of therapy, although patients in both conditions showed improved global functioning and had decreased personality disorder severity, rates of personality disorder diagnosis, and symptoms.