Treating Personality Disorders

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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 for Treating Personality Disorders

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.

Medications

People with personality disorders often experience serious mental and emotional strain, causing additional mental health problems such as depression, phobia and panic. Medications may help alleviate these related conditions, but they can't cure the underlying disorder. Therapy aimed at building new coping mechanisms must be the cornerstone of treatment.

Medications that may offer support during therapy include:

• Antidepressants. Doctors commonly prescribe selective serotonin reuptake inhibitors (SSRIs) such as fluoxetine (Prozac, Sarafem), sertraline (Zoloft), escitalopram (Lexapro) and paroxetine (Paxil) or the related antidepressant venlafaxine (Effexor) to help relieve depression and anxiety in people with personality disorders. Less often, monoamine oxidase inhibitors such as phenelzine (Nardil) and tranylcypromine (Parnate) may be used.
• Anticonvulsants. These medications may help suppress impulsive and aggressive behavior. Your doctor may prescribe carbamazepine (Carbatrol, Tegretol) or divalproex (Depakote). Your doctor may also prescribe topiramate (Topamax), an anticonvulsant that's being studied as an aid in managing impulse-control problems.
• Antipsychotics. People with borderline and schizotypal personality disorders are at risk of losing touch with reality. Antipsychotic medications such as risperidone (Risperdal) and aripiprazole (Abilify) can help improve distorted thinking. For severe behavior problems, doctors may prescribe haloperidol (Haldol).
• Other medications. Doctors sometimes prescribe anti-anxiety medications such as alprazolam (Xanax) and clonazepam (Klonopin) and mood stabilizers such as lithium (Eskalith, Lithobid) to relieve symptoms associated with personality disorders.

Complications

People with personality disorders are at significantly increased risk of:

• Social isolation. An inability to forge and maintain healthy relationships, lack of desire for closeness, or extreme shyness may cause those with personality disorders to be socially disconnected.
• Suicide. The risk of self-inflicted injury and suicide is highest among people with cluster B personality disorders, including histrionic, narcissistic, antisocial and borderline personality disorders.
• Substance abuse. Those with cluster B personality disorders are at especially increased risk of alcohol and drug addiction.
• Depression, anxiety and eating disorders. People with all types of personality disorders are at increased risk of developing other psychiatric problems.
• Self-destructive behavior. People with borderline personality disorder are particularly at risk of engaging in dangerous behaviors such as risky sex and gambling. Those with dependent personality disorder — who may tolerate mistreatment in order to stay in a relationship — are at increased risk of physical, emotional and sexual abuse.
• Violence and homicide. Aggressive behavior is a significant risk among those with paranoid and antisocial personality disorders.
• Incarceration. People with antisocial personality disorder are at increased risk of committing serious crimes. The condition is common among prisoners.

The intensity of the symptoms of personality disorders may change over time. The symptoms of cluster A and cluster B personality disorders may become less severe later in life. Those with cluster C personality disorders often experience worsening symptoms as they age.

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Reviewed: 04/2006