ESSENTIALS OF DIAGNOSIS
- Long history dating back to childhood.
- Recurrent maladaptive behavior.
- Low self-esteem.
- Minimal introspective ability with a tendency to blame others for all problems.
- Major difficulties with interpersonal relationships or society.
- Depression with anxiety when maladaptive behavior fails.
- An individual’s personality structure, or character, is an integral part of self-image.
- It reflects genetics, interpersonal influences, and recurring patterns of behavior adopted to cope with the environment.
- The classification of subtypes of personality disorders depends on the predominant symptoms and their severity.
- The most severe disorders that bring the patient into the greatest conflict with society tend to be classified as antisocial psychopathic)or borderline.
- Personality disorders can be considered a matrix for some of the more severe psychiatric problems (eg,schizo-typal, relating to schizophrenia, and avoidance types, relating to some anxiety disorders).
Classification&Clinical FindingsSee Table (IMAGE) Next page
- Patients with personality disorders tend to show anxiety and depression when pathologic coping mechanisms fail, and their symptoms can be similar to those disorders.
- Occasionally, the more severe cases may decompensate into psychosis under stress and mimic other psychotic disorders.
- Social and therapeutic environments such as day hospitals, halfway houses, and self-help communities utilize peer pressures to modify self-destructive behavior.
- The patient with a personality disorder often has failed to profit from experience, and difficulties with authority impair the learning experience.
- The use of peer relationships and the repetition possible in a structured setting of a helpful community enhance the behavioral treatment opportunities and increase learning.
- When problems are detected early, both the school and the home can serve as foci of intensified social pressure to change the behavior, particularly with the use of behavioral techniques.
- The behavioral techniques used are principally operant conditioning and aversive conditioning.
- The former simply emphasizes the recognition of acceptable behavior and its reinforcement with praise or other tangible rewards.
- Assertive responses usually mean punishment, although this can range from a mild rebuke to some specific punitive responses such as deprivation of privileges.
- Extinction plays a role in that an attempt is made not to respond to inappropriate behavior, and the lack of response eventually causes the person to abandon that type of behavior.
- Pouting and tantrums, for example, diminish quickly when such behavior elicits no reaction.
- Dialectical behavioral therapy is a program of individual and group therapy specifically designed for patients with chronic suicidality and borderline personality disorder.
- It blends mindfulness and a cognitive-behavioral model to address self-awareness, interpersonal functioning, affective lability, and reactions to stress.
- Psychological intervention is best conducted in group settings. Group therapy is helpful when specific interpersonal behavior needs to be improved.
- This mode of treatment also has a place with so-called “acting-out” patients, ie, those who frequently act impulsively and inappropriately.
- The peer pressure in the group tends to impose restraints on rash behavior.
- The group also quickly identifies the patient’s types of behavior and helps improve the validity of the patient’s self-assessment.
- so that the antecedents of the unacceptable behavior can be effectively handled, thus decreasing its frequency
- Individual therapy should initially be supportive, ie, helping the patient to restabilize and mobilize coping mechanisms.
- If the individual can observe his or her behavior, a longer-term and more introspective therapy may be warranted.
- The therapist must be able to handle countertransference feelings(which are frequently negative), maintain appropriate boundaries in the relationship（no physical contacts, however well-meaning), and refrain from premature confrontations and interpretations
- Hospitalization is indicated in the case of serious suicidal or homicidal danger.
- In most cases, treatment can be accomplished in the day treatment center or self-help community.
- Antidepressants have improved anxiety, depression, and sensitivity to rejection in some patients with a borderline personality disorder.
- SSRIs also have a role in reducing aggressive behavior in impulsive aggressive patients(eg, fluoxetine 20-60 mg orally daily or sertraline 50-200 mg orally daily)
- Antipsychotics may be helpful in targeting hostility,agitation,and as adjuncts to antidepressant therapy(eg,olanzapine [2.5-10 mg/d orally,risperidone [0.5-2 mg/d orally,or haloperidol [0.5-2 mg/orally,split into two doses])
- In some cases, these medications are required only for several days and can be discontinued after the patient has regained a previously established
- level of adjustment they can also provide ongoing support.
- In other patients, carbamazepine,400-800 mg orally daily in divided doses, decrease the severity of behavioraldyscontrol
Antisocial and borderline categories generally have a guarded prognosis. Those patients with a history of parental abuse and a family history of mood disorder tend to have the most challenging treatments.
- Ingenhoven T et al.Effectiveness of pharmacotherapy for severe personality disorders: meta-analyses of randomized controlled trials.J Clin Psychiatry.2010 Jan;71(1):14-25.[PMID:19778496]
- Stoffers JM et al.Psychological therapies for people with a borderline personality disorder.Cochrane Database Syst Rev.2012 Aug 15;8:CD005652.[PMID:22895952]