Are you diagnosing a personality disorder (PD) in half of your patients? If not, you probably are not asking enough questions. Studies have found that the prevalence among psychiatric patients of any PD is about 50%, but that clinicians relying on their standard interviews diagnose half that many, about 25% (Zimmerman M et al., Psychiatr Clin North Am 2008 Sep;31(3):405-20). About 10% of people in the general population have a PD.
Dr. James Morrison, in his recent book, Diagnosis Made Easier (Guilford Press, 2007) points out that one reason PDs tend to escape diagnosis is that “with most other disorders, we need to notice what has changed about a person; when discerning the pattern of a PD, however, we must instead pay attention to the lifelong background of attitudes and behaviors” (p. 249). There are 10 DSM-IV personality disorders, and two additional PDs proposed in Appendix B for further study (depressive PD and passive-aggressive PD). Personality Disorder NOS can be used for patients who have personality features that cause clinically significant distress but do not meet criteria for any specific PD.
Recently, a British team of researchers came up with an eight-question screening test for PDs, the Standardised Assessment of Personality – Abbreviated Scale (SAPAS)(see Figure, page 2). To validate the instrument, they administered it to 60 psychiatric patients, comparing the results with the gold-standard structured interview, the SCID-II. They found that 33 of 60 patients had a PD on SCID-II (55%). A score of 3 or 4 on the SAPAS correctly identified the presence of a personality disorder in over 80% of participants (Moran P et al., The British Journal of Psychiatry (2003) 183: 228-232). The SAPAS will not give you a precise diagnosis, but it will give you a sense for how likely it is that your patient has any PD, and then it is up to you to open up your DSM-IV and go through the questions, one by one.
Borderline Personality Disorder
Joel Paris, M.D., has a modest suggestion: make borderline personality disorder an Axis I disorder. Paris is Professor of Psychiatry at McGill University, and recently wrote an excellent book called Treatment of Borderline Personality Disorder (Guilford Press, 2008). In it, he points out that while Axis II was originally created in order to make sure we don’t overlook PDs, this has backfired, and disorders like BPD are placed in an “Axis II ghetto, where they can safely be ignored.” He also advocates rewriting the criteria to require that more symptoms be present to make a diagnosis. This would describe a more homogeneous group of patients who would more likely benefit from the same form of treatment.
Speaking of treatment, Paris has an excellent section on the increasingly confusing issue of the psychotherapy of BPD. Who hasn’t become confused by the alphabet soup of psychotherapies available: DBT, CBT, TFT, MBT, STEPP, and maybe more.
Dr. Paris reviews a series of clinical trials in which Dialectic Behavioral Therapy (DBT) was shown to be more effective for diminishing suicidal behaviors and hospitalization than the control condition, “treatment as usual” (TAU). But such studies do not prove that there is a specific ingredient in DBT that makes it effective. In 2006, the DBT team tried to prove the specificity of DBT by comparing it with a treatment termed CTBE, or “community treatment by experts.” These were therapists nominated by psychiatry department heads as being the most skilled in the community for treating suicidal patients. Compared to this high standard, DBT still came out ahead, although the difference narrowed significantly from previous studies (Linehan M et al., Arch Gen Psychiatry 2006;63:757-766). Meanwhile, a confusing array of new therapeutic options have been introduced for treating BPD. One recent study randomly assigned 90 BPD patients to DBT, “transference-focused therapy” (TFT), and general supportive therapy. TFT is a version of standard psychodynamic therapy focusing on interpreting the transference between patient and therapist. After one year of treatment, patients in all three therapies improved, with no clear differences in outcome among the treatments (Clarkin JF et al., Am J Psychiatry 164:922-928, June 2007). The surprise in this study was that supportive therapy was as effective as DBT and TFT, both of which entailed twice weekly sessions and a great deal of therapist training and experience. Supportive therapy was delivered weekly and was described as providing “emotional support – advice on the daily problems facing the patient with borderline personality disorder.” If this is as effective as the DBT then a lot of effort has been wasted; of course, we would need to see this finding replicated to draw such a conclusion.
Another new approach for BPD, STEPPS (Systems Training for Emotional Predictability and Problem Solving), is a group treatment program consisting of 20 two hour sessions of psychoeducation. It is supposed to be an adjunct to individual treatment. In a study in which 124 patients were randomly assigned to either treatment as usual (TAU) or STEPPS plus TAU, patients in the STEPPS program had more improvement in borderline symptom scores, but did not have fewer suicide attempts, self-harm episodes, or hospitalizations (Blum N et al., Am J Psychiatry 2008; 165:468-478).
Finally, MBT, or mentalization-based therapy, focuses on helping patients accurately observe their own emotions and those of others, and take both into account in their actions. Dr. Paris describes it has a hybrid of psychodynamic therapy and CBT. In one 18-month-long trial, it helped BPD patients more than TAU (see his book for references).
Which technique to use? After studying the literature, Paris suggests that the key ingredients of all successful BPD therapies are therapeutic alliance, self-observation, and problem solving in the present. In the second half of his book, he outlines a treatment approach that includes these techniques as well as tips he has learned from his own extensive experience doing therapy with BPD.
Here are his key suggestions:
Getting a Life. Real therapy, says Paris, is not “the dramatic discovery of a past event [that] produces an instant cure. Real therapy is more like watching grass grow. The process is one of slow but steady learning.” He notes that all effective BPD therapies encourage patients to put the past behind them and to “get a life” in the present. Ways to get a life include getting a job, returning to school, having a relationship, having children. None of these is perfect, and all may fail. “You would not put all your money into a single investment. In the same way, you need more than a job, more than an intimate relationship, more than one friend.”
Managing emotional dysregulation. This is the skill made famous by DBT, and is a key coping ability that you must teach patients with BPD. This entails identifying and labeling affect, and then modifying the affect in various ways, including through mindfulness, distress tolerance, and a variety of problem solving strategies.
Dealing with impulsivity. Paris recommends using behavioral analysis, in which you work with the patient to trace impulsive acts (such as overdosing) to their origin. Paris emphasizes teaching patients how to slow down before acting. He describes a woman who overdosed after an argument with her boyfriend. She was encouraged to delay this behavior in the future to give herself time to examine the pros and cons of that action and to come up with alternatives.
Transient psychosis. Dr. Paris believes that hallucinations and dissociative experiences are more common in BPD than many clinicians realize. While he uses neuroleptics occasionally, he finds that these symptoms often go away as the patient builds a trusting alliance with the therapist.
Interpersonal conflict. BPD patients often end up in pathological relationships with the wrong people. As an example, he describes a 21 year old woman living with a gangster who imported drugs for a living. He finds that it usually does not work to challenge these relationships directly. Instead, he suggests encouraging patients to broaden their sources of satisfaction, in the hopes that they will realize they don’t need a damaging relationship for emotional survival.
Splitting. Keep an ear out for examples of patients seeing situations in black and white. One of Paris’ patients required that her relationship with her mother be completely honest, otherwise it was hypocrisy. This led to violent quarrels every Christmas. Seeing the relationship in shades of gray meant being able to tolerate a disappointing relationship with her mother in the service of preventing a hair-raising holiday experience.