Treatment Of Personality Disorders

The treatment of personality disorders is complex, as is their operational definition. The International Classification of Diseases defines personality disorders as problems in the functioning of the “self” that have persisted for a very long time. The disturbance manifests itself in maladaptive patterns of cognition, emotional expression, and behavior in a wide variety of situations. As a rule, the pattern of behavior begins in late adolescence or early adulthood.

DSM-5 proposes the existence of ten categories of TP. They would be grouped into clusters A (paranoid, schizoid, schizotypal, B (narcissistic, histrionic, borderline and antisocial) and C (avoidant, dependent and obsessive-compulsive). The overall prevalence of all personality disorders is estimated to be one 10% and 13%.

During the last decade, a great effort has been made to provide solid scientific evidence about the efficacy of psychological interventions in personality disorders. The number of scientific articles that have been published where the results of clinical trials with very varied designs are collected stands out.

Psychological treatment is considered an effective tool in the treatment of personality disorders, as the meta-analyzes published to date have shown (Cristea et al., 2017; Oud, Arntz, Hermens, Verhoef and Kendall, 2018).

Schema-Focused Therapy: The JE Young Model

Schema therapy is an innovative and integrative model of therapy developed by Young and his collaborators (Young, 1990, 1999). Delves into traditional cognitive-behavioral concepts and treatments. The therapy combines elements of the cognitive-behavioral, attachment, Gestalt, object relations, constructivist, and psychoanalytic schools. It offers a new psychotherapy system especially suitable for patients with chronic psychological disorders.

Schema therapy can be short, intermediate, or long-term, depending on the patient. Starting from cognitive-behavioral therapy, it expands to give importance to the childhood origins of psychological problems. It helps patients and therapists make sense of chronic and widespread problems and organize them in an understandable way.

The model tracks schemata from infancy to the present, with particular emphasis on the patient’s interpersonal relationships. The therapist allies with patients in their fight against early dysfunctional schemas, resorting to cognitive, affective, behavioral and interpersonal strategies.

When patients repeat dysfunctional patterns based on their schemata, the therapist empathically confronts them with the reasons for their change. Through “limited reparenting” the therapist provides many patients with a partial antidote to needs that have not been adequately met during childhood.

Linehan’s Dialectical Behavioral Therapy

Marsha Linehan’s Dialectical Behavioral Therapy is intended for people with Borderline Personality Disorder (BPD). It is specially formulated for the symptoms of impulsivity and instability that materialize in suicidal or parasuicidal acts. It is supported by the biosocial theory of borderline personality disorder.

In this therapy, different types of skills are trained : awareness skills, discomfort tolerance skills, social skills and emotional regulation skills. Within the tolerance to discomfort we find distraction tactics. Some examples would be getting involved in other activities or helping others to stop focusing on yourself.

In Linehan’s manual we find 7 examples of distraction skills. They would be helping others, making comparisons, generating opposing emotions, letting go of the negative situation, having distracting thoughts, and experiencing inner sensations.

In DBT, a series of basic agreements are established between the patient and the therapist, which are key to the proper functioning of the therapy. The first of these is a commitment to attend therapy for one year. A commitment to attend the sessions is established and specifies that if the patient misses more than 4 sessions for 4 consecutive weeks without just cause, the therapy is terminated until the end of the contract (one year), when it will be negotiated again admission.

Transference-focused psychotherapy

Transference-focused psychotherapy (Clarkin, Yeomans & Kernberg, 2007) is an evidence-based psychodynamic therapy designed for patients with personality disorders. He considers that the psychological structure is based on wrong images of oneself and other important people that have been internalized in the course of growth.

These images are not fully conscious within the individual and may contain distortions. They play an essential role in the way the patient adjusts to life. They are the lenses through which an individual interprets or “reads” what they are experiencing. Distorted or unrealistic internal images can cause problems in your mood and relationships with others.

These problems can be modified through psychotherapy. It is a long-term approach with two weekly sessions. The emphasis is on the dominant transference interpretations that emerge in the relationship between patient and therapist.

Mentalization-based therapy

Mentalization-based intervention (MBT) is an evidence-supported psychotherapeutic approach for borderline personality disorder. It derives both from traditional psychoanalytic concepts, as well as new discoveries from research on attachment and social cognition.

Mentalization simply describes the common psychological process that people use to understand mental states. It covers a wide territory of psychological activity that determines the way in which people handle their emotions and thoughts in a coherent way.

The stability, flexibility, benevolence, and honesty with which people mentalize is the basis of how their personality works. Therefore, mentalization is at the root of psychological health.

Mentalization as a basic process of identity

Fonagy and Allison expanded the formulation of borderline personality disorder and personality disorders in general as an epistemic trust problem. This refers to the ability to “trust the authenticity and personal relevance” of information presented in an interpersonal context.

This revised notion explains the rigidity of thinking that individuals with borderline personality disorder and other personality disorders have with interpersonal relationships. Due to a tendency towards epistemic mistrust, people with borderline personality disorder find it difficult to learn and change despite repeated patterns of painful interpersonal problems and efforts by others to teach them how to handle feelings less destructively.

Everything would have its origin in the construction of attachment. Secure attachment embodies a developmental process whereby the caregiver manages to reasonably imagine and interpret the child’s mental states, responding in a way that helps him understand and manage his own distress. This is the process by which secure attachment facilitates the development of mentalization.