The strongest literature clearly related to Borderline personality disorder for which there are multiple evidence-based models, recently in fact reviewed at the American Psychiatric Association Meetings last week in New York (see APA website for more).

See references by Bateman and Fonagy on Mentalization-Based Therapy (MBT), Brief Psychodynamic Psychotherapy as further developed by Kernberg and Clarkin into a manualized treatment, Dialectical Behavior Therapy (DBT) as developed by Linehan.

Other personality disorders such as Narcissistic, Histrionic (Cluster B of DSM) do also respond to the first 2 of these treatments. Less is evidence-based for the anxious-avoidant PDs,, antisocial PD of course and the schizotypal/schizoid and paranoid PDs. However, in my experience the particular constellation of comorbidity, personality characteristics including competencies (ego strengths), culture, and relationship-contexts shape what kind of intervention works for whom. This is also not to neglect the patient-therapist match, as it is within this relational context that the process takes place of course.

Dear Daniel

Thank you for your contribution. Indeed I am especially interested in the influence of comorbidity, personality characteristics including competencies (ego strengths), culture and SES and how this patient related variables influence the development of the working alliance in the context of different treatments. Why? I'm not convinced of the superiority manualized therapy models. For this purpose, you could run stuff. The emprical data emphasize the importance of "suitability" or "treatment aptitude" research (Norcross et al., 2011). For example: Bender (2005) suggested that different types of personality disorders (cluster A, B, C) require different dynamics of interaction (Negotiations) in forming the alliance.

Bender, D. S. (2005). The therapeutic alliance in the treatment of personality disorders. J Psychiatr Pract 11 (2), 73-87.

Norcross, JC, & Wampold, B. E. (2011). What works for splat: Tailoring psychotherapy to the person. [Introductory]. J Clin Psychol, 67 (2), 127-132. doi: 10.1002/jclp.20764

greetings

Egon

My thoughts pretty much align with Dr. Schechter's. The two personality disorders that have received the most research attention over the years are Antisocial and Borderline. the consensus on Antisocial is that there is no generally effective treatment, though a subset of cases with comorbid depression or pressing medical issues may be partial exceptions. The outlook for Borderline PD is much more hopeful. Linehan's DBT has enjoyed some good empirical support since the early 1990s. The object relations approach promulgated by Kernberg's team is older, but took longer to validate. Now termed "transference focused" psychodynamic psychotherapy, it appears to be about equal to DBT in outcome. Young's schema-focused therapy has some support, but I don't think it has fared quite as well (yet).

Moving beyond Borderline PD, there is a fair amount of support for the short-term dynamic therapies (such as the Beth Israel model: see McCullough or Winston for example) in treating milder PDs such as obsessive-compulsive, avoidant, histrionic, and dependent. And there is, I think, some support for the cognitive approach favored by Beck and his followers. In most cases, the evidence for these treatments comes from open trials, often conducted in regular clinics, rather than tightly controlled RCTs.

The closest thing I can think of to an empirically validated approach to Schizotypal PD would be the work on prevention of (or very early intervention in) schizophrenia. That is, if you look at young adults who display the schizotypal syndrome, they are at high risk of developing schizophrenia (up to 30% will decompensate). There is some work being done toward intervening at this stage to prevent conversion into the full-blown psychotic syndrome.

I do not know of any empirical studies of treatment for Narcissistic PD, though Dr. Schechter's clinical hunch that DBT and transference-focused approaches would work here is probably spot on.

Dear colleagues

I am familiar with the literature on evidence-based treatments of personality disorders. Thanks for the posts. In a second step I am interested in results about the "suitability research" ie, which patient or interaction variables of personality disorders have which impact on the most important effect factor of Treatment, namely the development of "working alliance"?

greetings

Egon

We are talking about the personality disorders as if there was agreement as to what they are. But there is no agreement and the recent events around DSM V and ICD11 (plans - see Tyrer et al, 2011) illustrate how complex and changeable the field is and that Shorter is right in his assertion that personality disorder is a cultural construct. I like the term 'ego structural disorders' but even that implies assumptions which probably are in need of spelling out. For me a personality consists of many different aspects (maybe 'traits') and in my experience the disordered personality is just a person where normal variance of personality traits has developed into an unhelpful constellation of personality exacerbations, usually in response to adverse childhood experiences. Presentations are complex and there is no one single diagnosis of a personalty disorder, usually, that adequately describes the person. Evidence suggests that most people are eligible for more than one personality disorder label, and more recent evidence from Bateman et al. suggest that the 'pure' borderline is less responsive to their treatment package than those with more severe disorders and multiple labels (when numbers of labels become indicators of severity). Having used the MCMI III clinically it seems clear to me that these are reasonable findings, but also that people qualifying for the same categorical personality disorder label as another might differ in many and often quite fundamental aspects presenting different needs for engagement, developing motivation and for the change process. I have become very respectful of the difficulties of assessment, and how much I can miss when working with a patient. I have taken to routinely using the MCMI III (there maybe other, equally or better suited instruments) to supplement my assessment interviews, and both the punters and I can be quite surprised at what it makes us discuss in the further work. Certainly, mentalisation-based approaches are useful as the capacity to reflect is crucial in being able to improve people's satisfaction with life. However, other approaches such as cognitive-analytic therapy with their reflective reformulations, or mindfulness approaches might achieve similar results in individual work if reasonably used, and have some evidence base. Attachment issues seem to figure ever larger in mental health research (see Sitko et al in their most recent meta-analysis of associations of psychotic symptoms and specific childhood adversities) and certainly should be core to any therapeutic approach. Systemic work with personality disorder does not have any evidence base but I have seen and have experienced good outcomes with narrative approaches so we need to await further evaluation of these.

Greetings,

Michael.

PS: I like the MCMI III because of its attention to detail, and the psychometric qualities. I think the language of the test manual is totally abominable, and the constructs are badly in need of revision. But I do not know a personality disorder test that would not qualify for seriously critical comments including the famous five (Widiger's model).

Dear Michael

I dont have any practical experiences with MCMI III because we dont have a german version.

I share with you the position that the diagnostic term 'ego structural disorders' will be more appropriate. Wie use operationalized psychodynamic diagnosis OPD axis III and IV. OPD allows a more dimensional diagnostics.

greetings Egon

Just some input on Schema Therapy developed by Young and colleagues and then widely used in Europe particularly Holland. There are some impressive RCTs and the model is integrative and flexible:

References

Bamelis, L. M., Evers, S.,M.A.A., Spinhoven, P., & Arntz, A. (2014). Results of a multicenter randomized controlled trial of the clinical effectiveness of schema therapy for personality disorders. Psychiatry, 171, 305-322. doi:10.1176/appi.ajp.2013.12040518

Dickhaut, V., & Arntz, A. (2014). Combined group and individual schema therapy for borderline personality disorder: A pilot study. Journal of Behavior Therapy and Experimental Psychiatry, 45, 242-251.

Farrell, J. M., Shaw, I. A., & Webber, M. A. (2009). A schema-focused approach to group psychotherapy for outpatients with borderline personality disorder: A randomized controlled trial. Journal of Behavior Therapy and Experimental Psychiatry, 40(2), 317-328.

Giesen-Bloo, J., Van Dyck, R., Spinhoven, P., Van Tilburg, W., Dirksen, C., Van Asselt, T., . . . Arntz, A. (2006). Outpatient psychotherapy for borderline personality disorder: Randomized controlled trial of schema-focused therapy vs transference-focused psychotherapy. Archives of General Psychiatry, 63, 649-658.

Jacob., G., & Arntz, A. (2013). Schema therapy for personality disorders: A review. International Journal of Cotnitive Therapy, 6, 171-185.

Nadort, M., Arntz, A., Smit, J. H., Giesen-Bloo, J., Eikelenboom, M., Spinhoven, P., . . . van Dyck, R. (2009). Implementation of outpatient schema therapy for borderline personality disorder with versus without crisis support by the therapist outside office hours: a randomized trial. Behaviour Research and Therapy, 47, 961-973.

I am very pleased that this thread continues but I think there is also an issue of 'diagnosis' - the words we use are our toolbox and determine to some degree outcome so I would really value it if we could turn our mind to the scientific exploration of this more:

The recent controversy around the diagnosis of Breivik has brought that into focus ( see Nilsson LS. Pierre Riviere versus Anders Breivik: is history repeating itself? Rationality, madness, and psychopathology in the 19th and 21st century. Program and abstracts of the 2014 American Psychiatric Association Annual Meeting; May 3-7, 2014; New York, New York. Poster NR1-95).

I know that this is a difficult area but has anyone anything to say about this as it influences what constitutes valid evidence?

Michael.

My favorite was not yet mentioned here:

Ulrich Streeck, Psychotherapie komplexer Persönlichkeitsstörungen, Grundlagen der psychoanalytisch-interaktionellen Methode, Klett-Cotta

I just don`t know whether it is available in English

Dear Eva,

I know the book. I am german speaking.

Thank you very much.

greetings Egon