Treatment of personality disorders

Treating a personality disorder takes a long time. Personality traits such as coping mechanisms, beliefs, and behavior patterns take many years to develop, and they change slowly. Changes usually occur in a predictable sequence, and different treatment modalities are needed to facilitate them. Reducing environmental stress can quickly relieve symptoms such as anxiety or depression. Behaviors, such as recklessness, social isolation, lack of assertiveness, or temper outbursts, can be changed in months. Group therapy and behavior modification, sometimes within day care or designed residential settings, are effective. Participation in self-help groups or family therapy can also help change socially undesirable behaviors. Behavioral change is most important for patients with borderline, antisocial, or avoidant personality disorder.

Interpersonal problems, such as dependency, distrust, arrogance, or manipulativeness, usually take > 1 yr to change. The cornerstone for effecting interpersonal changes is individual psychotherapy that helps the patient understand the sources of his interpersonal problems in the context of an intimate, cooperative, nonexploitative physician-patient relationship. A therapist must repeatedly point out the undesirable consequences of the patient's thought and behavior patterns and must sometimes set limits on his behavior. Such therapy is essential for patients with histrionic, dependent, or passive-aggressive personality disorder. For some patients with personality disorders that involve how attitudes, expectations, and beliefs are mentally organized (eg,
narcissistic or obsessive-compulsive types), psychoanalysis is recommended, usually for >= 3 years.

General principles: Although treatment differs according to the type of personality disorder, some general principles apply to all. Family members can act in ways that either reinforce or diminish the patient's problematic behavior or thoughts, so their involvement is helpful and often essential.

Drugs have limited effects. They can be misused or used in suicide attempts. When anxiety and depression result from a personality disorder, drugs are only moderately effective. For persons with personality disorders, anxiety and depression may have positive significance, ie, that the person is experiencing unwanted consequences of his disorder or is undertaking some needed self-examination.

Because personality disorders are particularly difficult to treat, therapists with experience, enthusiasm, and an understanding of the patient's expected areas of emotional sensitivity and usual ways of coping are important. Kindness and direction alone do not change personality disorders.