Problems treating personality disorders

[AryaStark]

Hi All,
Does anyone have any recommendations for good chapters/ articles on the issues and difficulties when doing psychotherapy (not assessment) with individuals diagnosed with personality disorders?

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[FuturePhD2]

Hi All,
Does anyone have any recommendations for good chapters/ articles on the issues and difficulties when doing psychotherapy (not assessment) with individuals diagnosed with personality disorders?

Depends on what the PD is. If it's BPD and it's possible to get them into a DBT program, then that's the best option (you can't really do DBT the way it should be done in individual therapy). Obviously Linehan's CBT for BPD book is a great resource if there is no DBT program available. Beck also has a nice book out on Cognitive Therapy for Personality Disorders.

 

[AryaStark]

Depends on what the PD is. If it's BPD and it's possible to get them into a DBT program, then that's the best option (you can't really do DBT the way it should be done in individual therapy). Obviously Linehan's CBT for BPD book is a great resource if there is no DBT program available. Beck also has a nice book out on Cognitive Therapy for Personality Disorders.

Thanks for the info! I just mean PDs in general, as a whole cluster (not one in particular). I have a general anecdotal understanding of what types of problems we might face (e.g., pervasiveness of problem, high drop out rates etc) when doing therapy with people diagnosed with an axis II disorder, but I don't have any expertise in PD at all. I was just hoping to see if anyone who has done research with PDs might have some names of people/specific articles that empirically investigate these phenomena. Most of my own research is with axis I disorders, and although anecdotal evidence is interesting, I always like to see data 🙂

 

[StudentBsMs11]

I would second the recommendation for Linehan's book on CBT for BPD. I know you're looking for something 'general' but the truth is, 90% of the time, you're going to be dealing with borderline personality disorder. Even when you're not, there's so much overlap between the PDs that those skills will probably come in handy anyway. Of course, some PDs you aren't going to see much; narcissistic PD people generally don't think they need help. I believe there's also some newer research applying ACT rather than DBT to borderline in particular, and possibly some of the others, but I don't know those off the top of my head and I think that research base is still accumulating. Hope that's helpful!

 

[FuturePhD2]

90% of the time, you're going to be dealing with borderline personality disorder.

Actually, the most common personality disorders are obsessive-compulsive and avoidant. Both are typically found to be more prevalent than borderline, although research tends to be mixed in terms of which is the most prevalent (avoidant vs. oc). There is no way that 90% of the personality disorder diagnoses you would see in clinical practice would be BPD unless you specialized in BPD. I think there is a tendency to label difficult clients as BPD when they are not, which is what the above statement sounds like to me.

 

[cara susanna]

Millon's book, I think it's called "Personality Disorders: DSM-IV and Beyond," has a chapter on each PD with a section devoted to treatment issues.

I've seen Axis II stuff (heck, that's one of my areas of interest) and I haven't run into the difficulties people talk about, though. Maybe I've been lucky so far. 😉 As for practice, I think people run into dependent and histrionic the most. Those are also two of the PDs that come close to a normal distribution on the MCMI.

 

[psychmama]

I second Millon's book. Another good book is McWilliams, Psychoanalytic Diagnosis. Even if you're not strictly psychoanalytic, the book does a good job of discussing the various types of personality organization (which at their most extreme are diagnosable on Axis II but in milder forms are seen in everyone you'll treat.)

 

[DrGachet]

Not a big fan of Millon and his particular way of organizing some disorders, though his introductory chapters do a good job of summarizing the basics. I second McWilliams, for the psychodynamically oriented. She seems to be a humanistic first, and her compassion shows. Some psychoanalysts are real asses, so dogmatic and conceited so McWilliams is a breath of fresh air.

Another point; there was an exchange between StudentBsMs11 saying "90% of the time, you're going to be dealing with borderline personality disorder" and FuturePhD2 replying: "Actually, the most common personality disorders are obsessive-compulsive and avoidant...I think there is a tendency to label difficult clients as BPD when they are not, which is what the above statement sounds like to me."

Here's my view: if we are to take StudentBsMs11's comment regarding BPD as a comment regarding emotional dysregulation, then his comment does not sound too far off from the truth, specially given that it is less likely for someone with OCPD to come for therapy. We can also talk about Kernberg's concept of borderline personality organization, which underlies the more severe personality disorders, ones that are more likely to be dysfunctional and result in a visit to therapist.

Ultimately it depends on where you work. If you charge $300/hr, see YAVIS patients, practicing in Manhattan, you'll not be seeing so many patients with BPD, no way. In a hospital setting, and working with self-injury or suicide, it's more likely.

 

[StudentBsMs11]

Actually, the most common personality disorders are obsessive-compulsive and avoidant. Both are typically found to be more prevalent than borderline, although research tends to be mixed in terms of which is the most prevalent (avoidant vs. oc). There is no way that 90% of the personality disorder diagnoses you would see in clinical practice would be BPD unless you specialized in BPD. I think there is a tendency to label difficult clients as BPD when they are not, which is what the above statement sounds like to me.

I apologize if I sounded like I was quoting an actual statistic; that wasn't my intention. What I was trying to say was that I think most of the time in clinical practice, what you see is either BPD or a mix with some borderline features. (Again, my comment about the overlap between PD diagnoses being relevant here). This is something I've heard from other clinicians as well; I'm really curious about cara susanna's comment about running into a lot of dependent and histrionic the most, as I haven't heard that before and haven't seen that myself. Either way, a lot of the research focus is on borderline personality disorder, and a good deal of the literature is going to address BPD specifically, so it makes sense to start there, at least to me.

 

[FuturePhD2]

I think most of the time in clinical practice, what you see is either BPD or a mix with some borderline features. (Again, my comment about the overlap between PD diagnoses being relevant here). This is something I've heard from other clinicians as well.

I was just pointing out that the actual data on prevalence would not really support this. I really don't think it would be the case that the majority of personality issues one would see in practice would be BPD unless you worked in a specific population with a higher rate of occurrence. We know more about BPD (and in my program were taught more about it than any of the other PDs), so maybe it's that people can more easily recognize these traits (and don't as easily recognize other personality traits that are problematic in their clients due to less knowledge about them).

Also, clients are often inaccurately labeled. For example, I know many who would automatically assume a client that cuts themselves has BPD (or features). The literature suggests that this is not necessarily the case and that self-harm exists outside of the spectrum of someone having borderline symptoms.

 

[PsyDetective]

I think that one of the most difficult aspects of working with individuals who suffer from personality disorders is that they often cannot conceive of any OTHER pattern of thinking/feeling/behaving. It causes some individuals great distress to consider changing even small aspects of their behavior, because it's like you're asking them to walk a tight rope over the grand canyon with you as their coach saying, "trust me."

.02

p.s. I tend to see mostly antisocial, borderline, dependent, and histrionic. (I am in a forensic context.) For what it's worth, I believe antisocial and borderline are the most often misdiagnosed of them all. Self-injury does not equal BPD. Committing a crime does not equal antisocial.

 

[psychmama]

I second McWilliams, for the psychodynamically oriented. She seems to be a humanistic first, and her compassion shows. Some psychoanalysts are real asses, so dogmatic and conceited so McWilliams is a breath of fresh air.


We can also talk about Kernberg's concept of borderline personality organization, which underlies the more severe personality disorders, ones that are more likely to be dysfunctional and result in a visit to therapist.


Ultimately it depends on where you work. If you charge $300/hr, see YAVIS patients, practicing in Manhattan, you'll not be seeing so many patients with BPD, no way. In a hospital setting, and working with self-injury or suicide, it's more likely.

1. Having studied with McWilliams, I'd agree she's as much of a humanist as an analyst.

2. Agree about the borderline organization concept -- and people at this level of functioning have a poorly integrated sense of self but come in various "styles", from obsessive to histrionic.

3. True, but there seem to be some "high functioning" patients out there with a lot of BPD characteristics.😉

 

[cara susanna]

I do see Borderline clients more than I would expect, but that may be because, again, that's one of my areas of interest.

When I say dependent and histrionic, I don't necessarily mean pathology. I mean styles or traits. Remember too that I'm a Millon-ist here. 😉

 

[docma]

McWilliams and Linehan do the best job of helping you keep a compassionate view of the client and tolerate your own impatience, distress and frustration with the fact that true developmental work is often slow, repetitive and progress is see later in the process. In mentoring lots of students through learning to work with Axis II disorder, I'd say the most important thing is to find ways to see the developmental origins of the condition but then to focus on how having been "held back" at that stage needs to inform how you do the treatment. eg: someone with lots of early trauma/neglect will need a more concrete/structuring treatment than someone whose development got "bent" or interrupted in latency/adolescence when they had more cognitive skills/complexity online. Good developmental psychology reading is the best base for this work.

 

[Therapist4Chnge]

I believe antisocial and borderline are the most often misdiagnosed of them all. Self-injury does not equal BPD. Committing a crime does not equal antisocial.

This was one of my biggest pet peeves when I worked in-patient. So many borderline and/or bipolar Dx's, with little to no supportive data. Self-injury is a very misunderstood area amongst the "typical" clinician (MD, Ph.D., etc), as is the impact of substance abuse on rational/irrational behavior and thinking. Deferring Dx. until after detox seems obvious, but it rarely happens in practice.

McWilliams and Linehan do the best job of helping you keep a compassionate view of the client and tolerate your own impatience, distress and frustration with the fact that true developmental work is often slow, repetitive and progress is see later in the process.

I think utilizing Kernberg's conceptualization of BPD and Narcassism is a good place to start. He has a few articles/texts that really should be required reading for every clinical student. I think one of the most difficult parts of treatment is being consistant and firm. Trainees struggle with the pushback and lability often associated with personality disorders.