Treatment / Management

People with personality disorders may be difficult to treat. However, while the condition is not ‘curable’ in a traditional medical sense, the person can be considerably helped to have more fulfilling life, and well-managed general support can greatly improve maladaptive behaviour.

Specialised treatment results in substantial improvement in over a third of patients. Specialised treatment is only available from dedicated personality disorder services, but these are not yet available throughout the country

Drug treatment

There is no good evidence that medication helps the long term course or prognosis of personality disorder. Some of the symptoms may be alleviated by judicious use of suitable medication.

Short term treatment may include anxiolytic or neuroleptic drugs given for limited periods or at times of severe stress. Discrete courses of selective serotonin reuptake inhibitor antidepressants may help if there are prolonged episodes of low mood of sufficient severity. Long term treatment with antipsychotic medication can be helpful in severe cases of paranoid and schizotypal disorders.

Psychosocial interventions

The aim of most treatments is to enable people to understand their condition, in ways that allowing them to take responsibility for making changes that will improve their overall functioning, and achieve a better sense of well-being. This can be at the level of coping better with symptoms, of understanding and controlling their emotions in various ways, or intensive therapy with the aim of producing substantial personal and emotional development.

Psychological management for symptom relief include-:

• Assertiveness training and anxiety management, mainly cluster C disorders.
• Techniques for managing anger in people with aggressive behaviour.
• People with habit disorders may benefit from involvement with organisations such as Gamblers Anonymous or Narcotics Anonymous.
• Self help organisations such as befriending services or voluntary agencies may support people with the anxious and avoidant cluster C disorders and reduce their need for protracted involvement with the health services.
• Occupational and vocational therapies can be effective.

Definitive psychological treatments, mainly for establishing better emotional regulation in cluster B disorders, include-:

• Cognitive behavioural therapy-: particularly focuses on unhelpful ways of thinking about problems.
• Cognitive analytic therapy-: sees problems as emotional traps and snags which are examined and understood in the therapy.
• Mentalisation-based therapy-: develops awareness of one’s own and others’ mental states, and healthier attachment patterns.
• Dialectical behaviour therapy-: particularly helpful for borderline conditions where self-harm is a major problem.
• Group psychotherapy-: focuses on the way relationships are problematic and how to get better support from others.
• Numerous other psychotherapies (systemic, humanistic, creative, arts and others) can all help in specific instances, or be useful parts of coordinated programmes of therapy.

Intensive treatments include-:

• Long term individual psychodynamic or psychoanalytic psychotherapy (several years, sometimes more than once per week): to gain deep insight and understanding of why somebody is like they are, and changing it. Occasionally, this is done as part of an inpatient treatment programme.
• Residential therapeutic communities: intensive programmes of 1-2 years duration, using group therapy and day-to-day living to confront and change problematic thoughts, emotions and behaviour.
• Non-residential therapeutic communities: run similarly, but for between one and five days per week.

Management of deliberate self harm

There is no consensus as to the best management of deliberate self harm in people with personality disorders. Empathic listening and trying to understand the circumstances can help, if done sensitively; criticism and instructions to stop are inevitably experienced as unhelpful. However, clearly understood boundaries which are consistently enforced by all staff are essential to prevent being split into friends (who are sympathetic) and foes (who are persecuting), and all the problems in staff teams that can then follow.

Admission to hospital may actually worsen self harm, particularly if the admission is unfocused and not part of an overall plan. In this case, it should be agreed and signed by the patient in advance with clear criteria and limits (eg length of stay, acceptable and unacceptable behaviour whilst in hospital); then staff may be able to provide a structure within which help can be offered and received.

Management of aggressive behaviour

Aggressive behaviour has been shown to respond to carbamazepine therapy. Psychological techniques for managing anger are useful for people who can tolerate a therapeutic relationship or environment, and can openly discuss their own behaviour. The immediate and direct issues are to identify triggering situations and modify the reactive pattern of aggressive behaviour.

Amended June 2008