The Treatment of Personality Disorders
In previous sections, we reviewed the way personalities are thought to form by a dynamic exchange between environmental and biological factors. We also reviewed several different psychological theories that attempt to explain how personality development may deviate off the path of healthy development and instead steers toward unhealthy development, or personality disorder. These theories may then be applied to develop specific strategies for repairing the damaged personality structure. These theoretical applications result in various forms of therapy which are then tested by research for efficacy. These research findings subsequently aid in the refinement of the theory and its application (psychotherapy). This process has produced modern methods of treatment for personality disorder that are highly effective and evidence-based. Today, we now know that people can, and do, heal and recover from these devastating disorders.
However, such was not always the case. As recently as the mid-20th century, people with personality disorders were viewed as willful, weak, and deviant, and were thought to be resistant to treatment. Thus, treatment for personality disorders was often not provided, or if offered, it was seen as a "heroic effort" based on the belief that the treatment was taxing on the clinician with little hope for a promising outcome. For a more thorough review of this interesting history please refer to the section "The history of the current diagnostic system.
Treatment of Personality Disorders and the Current State of Research1
It is important to note that despite all our progress in this important area, the research investigating the treatment of personality disorders is still somewhat in its infancy. Most of what is known about the treatment of a specific personality disorder cannot be generalized to all personality disorders. This is similar to research findings regarding any broad category of disorders. For instance, cancer is a broad category of disorders. While certain treatment protocols may apply to all cancer treatments, each specific type of cancer, such as breast cancer and bone cancer, will have unique and specific treatment protocols that do not apply to both. Researchers do not generally study cancer, but rather study specific types of cancers. The same is true of personality disorders.
For this reason, we know a good deal more about some disorders, but not others. For instance, there is little, if any, literature on treatment of Paranoid Personality Disorder, Schizoid Personality Disorder, or Schizotypal Personality Disorder. People with these disorders tend to be distrustful and avoid relationships with others. Thus, it may be that the very nature of these disorders prevents people with these disorders from seeking treatment. Therefore, both clinicians and researchers rarely encounter people with these particular disorders. What little we do know about the treatment of these disorders is based on reports describing the treatment of individual cases. While helpful, these individual case studies do not provide sufficient scientific evidence to draw conclusions about the treatment of the disorder in general.
Only a few studies have been conducted on treatment of Avoidant Personality Disorder. There is some indication that cognitive-behavioral therapy can be an effective treatment for Avoidant Personality Disorder (Herbert, 2007). Similarly, there is only very limited research on the treatment of Narcissistic Personality Disorder. The results of these studies are very tentative and remain speculative. It appears that people with Narcissistic Personality Disorder may benefit from psychotherapy, but the data also suggests that people with this disorder are extremely likely to drop out of treatment (Levy, Reynoso, Wasserman & Clarkin (2007) making research efforts difficult. Likewise, treatment of the Antisocial Personality Disorder has been characterized as difficult and full of pitfalls. Many experts are guarded about the prognosis for the treatment of this disorder. The general recommendation is a treatment that combines pharmacotherapy and psychotherapy, particularly cognitive-behavioral therapy (National Institute for Health & Clinical Excellence, 2009).
In sharp contrast, there is a large amount of research on the treatment of Borderline Personality Disorder. However, this does not necessarily mean that Borderline Personality Disorder has a higher prevalence rate than other personality disorders. In fact, Bender (2004) found the highest prevalence rate for Obsessive-Compulsive Personality Disorder, followed by Paranoid Personality Disorder, and Anti-social Personality Disorder.
It may seem troubling that there isn't much research about these more commonly occurring disorders. However, the reasons for this are quite simple. Researchers must have access to the populations they wish to study. Therefore, if people with these disorders do not present themselves for treatment (as is quite often the case), then research cannot easily be designed to study these disorders. Likewise, it isn't practical or sensible for clinicians and researchers to develop treatment protocols for populations that don't seek treatment. The reverse of this is also true: if certain disorders are more likely to present for treatment than others, they are more likely to be studied. It makes more practical sense to develop treatments for people who are frequently presenting for these services. Indeed this is quite likely the case with the Borderline Personality Disorder. For instance, the high rates of self-injury and other self-destructive behaviors, coupled with chaotic interpersonal relationships may cause people with this disorder to seek treatment more frequently. There is sufficient research evidence to suggest that certain types of psychotherapy, particularly transference-focused psychotherapy, dialectical behavior therapy, and mentalization-based therapy are very effective in treating Borderline Personality Disorder (Paris, 2008).
1 This article was released for publication in January 2011 and revised in December 2013.