Learning Objectives
- Describe treatment options for personality disorders.
Cluster A
Individuals with personality disorders within Cluster A often do not seek out treatment as they do not identify themselves as someone who needs help (Millon, 2011). Of those that do seek treatment, the majority do not enter it willingly. Furthermore, due to the nature of these disorders, individuals in treatment often struggle to trust the clinician as they are suspicious of the clinician’s intentions (paranoid and schizotypal personality disorder) or are emotionally distant from the clinician as they do not have a desire to engage in treatment due to lack of overall emotion (schizoid personality disorder; Kellett & Hardy, 2014, Colli, Tanzilli, Dimaggio, & Lingiardi, 2014). Because of this, treatment is known to move very slowly, with many patients dropping out before any resolution of symptoms.
When patients are enrolled in treatment, cognitive-behavioral strategies are most commonly used with the primary intention of reducing anxiety-related symptoms. Additionally, attempts at cognitive restructuring—both identifying and changing maladaptive thought patterns—are also helpful in addressing the misinterpretations of other’s words and actions, particularly for individuals with paranoid personality disorder (Kellett & Hardy, 2014). Schizoid personality disorder patients may engage in CBT techniques to help experience more positive emotions and more satisfying social experiences, whereas the goal of CBT for schizotypal personality disorder is to evaluate unusual thoughts or perceptions objectively and to ignore the inappropriate thoughts (Beck & Weishaar, 2011). Finally, behavioral techniques such as social-skills training may also be implemented to address ongoing interpersonal problems displayed in the disorders.
Cluster B
13.5.2.1. Antisocial personality disorder. Treatment options for antisocial personality disorder are limited and generally not effective (Black, 2015). Like Cluster A disorders, many individuals are forced to participate in treatment, thus impacting their ability to engage in and continue with treatment. Cognitive therapists have attempted to address the lack of morality and encourage patients to think about the needs of others (Beck & Weishaar, 2011).
13.5.2.2. Borderline personality disorder. Borderline personality disorder is the one personality disorder with an effective treatment option—Dialectical Behavioral Therapy (DBT). DBT is a form of cognitive-behavioral therapy developed by Marsha Linehan (Linehan, Armstrong, Suarez, Allmon, & Heard, 1991). There are four main goals of DBT: reduce suicidal behavior, reduce therapy interfering behavior, improve quality of life, and reduce post-traumatic stress symptoms.
Within DBT, five main treatment components collectively help to reduce harmful behaviors (i.e., self-mutilation and suicidal behaviors) and replace them with practical, life-enhancing behaviors (Gonidakis, 2014). The first component is skills training. Generally performed in a group therapy setting, individuals engage in mindfulness, distress tolerance, interpersonal effectiveness, and emotion regulation. Second, individuals focus on enhancing motivation and applying skills learned in the previous component to specific challenges and events in their everyday life. The third, and often the most distinctive aspect of DBT, is the use of telephone and in vivo coaching for DBT patients from the DBT clinical team. It is not uncommon for patients to have the cell phone number of their clinician for 24/7 availability of in-the-moment support. The fourth component, case management, consists of allowing the patient to become their own “case manager” and effectively use the learned DBT techniques to problem-solve ongoing issues. Within this component, the clinician will only intervene when absolutely necessary. Finally, the consultation team, is a service for the clinicians providing the DBT treatment. Due to the high demands of borderline personality disorder patients, the consultation team offers support to the providers in their work to ensure they remain motivated and competent in DBT principles to provide the best treatment possible.
Support for the effectiveness of DBT in borderline personality disorder patients has been implicated in several randomized control trials (Harned, Korslund, & Linehan, 2014; Neacsiu, Eberle, Kramer, Wisemeann, & Linehan, 2014). More specifically, DBT has shown to significantly reduce suicidality and self-harm behaviors in those with borderline personality disorders. Additionally, the drop-out rates for treatment are extremely low, suggesting that patients value the treatment components and find them useful in managing symptoms.
13.5.2.3. Histrionic personality disorder. Individuals with histrionic personality disorder are more likely to seek out treatment than other personality disorder patients. Unfortunately, due to the nature of the disorder, they are very difficult patients to treat as they are quick to employ their demands and seductiveness within the treatment setting. The overall goal for the treatment of histrionic personality disorder is to help the patient identify their dependency and become more self-reliant. Cognitive therapists utilize techniques to help patients change their helpless beliefs and improve problem-solving skills (Beck & Weishaar, 2011).
13.5.2.4. Narcissistic personality disorder. Of all the personality disorders, narcissistic personality disorder is among the most difficult to treat (with maybe the exception of antisocial personality disorder). Most individuals with narcissistic personality disorder only seek out treatment for those disorders secondary to their personality disorder, such as depression (APA, 2022). The focus of treatment is to address the grandiose, self-centered thinking, while also trying to teach patients how to empathize with others (Beck & Weishaar, 2014).
Cluster C
While many individuals within avoidant and OCPD personality disorders seek out treatment to address their anxiety or depressive symptoms, it is often difficult to keep them in treatment due to distrust or fear of rejection from the clinician. Treatment goals for avoidant personality disorder are similar to that of social anxiety disorder. CBT techniques, such as identifying and challenging distressing thoughts, have been effective in reducing anxiety-related symptoms (Weishaar & Beck, 2006). Specific to OCPD, cognitive techniques aimed at changing dichotomous thinking, perfectionism, and chronic worrying help manage symptoms of OCPD. Behavioral treatments such as gradual exposure to various social settings, along with a combination of social skills training, have been shown to improve individuals’ confidence prior to engaging in social outings when treating avoidant personality disorder (Herbert, 2007). Antianxiety and antidepressant medications commonly used to treat anxiety disorders have also been used with minimal efficacy; furthermore, symptoms resume as soon as the medication is discontinued.
Unlike other personality disorders where individuals are skeptical of the clinician, individuals with dependent personality disorder try to place obligations of their treatment on the clinician. Therefore, one of the main treatment goals for dependent personality disorder patients is to teach them to accept responsibility for themselves, both in and outside of treatment (Colli, Tanzilli, Dimaggio, & Lingiardi, 2014). Cognitive strategies such as challenging and changing thoughts on helplessness and inability to care for oneself have been minimally effective in establishing independence. Additionally, behavioral techniques such as assertiveness training have also shown some promise in teaching individuals how to express themselves within a relationship. Some argue that family or couples therapy would be particularly helpful for those with dependent personality disorder due to the relationship between the patient and another person being the primary issue; however, research on this treatment method has not yielded consistently positive results (Nichols, 2013).
Key Takeaways
You should have learned the following in this section:
- Individuals with a Cluster A personality disorder do not often seek treatment and when they do, struggle to trust the clinician (paranoid and schizotypal) or are emotionally distant from the clinician (schizoid). When in treatment, cognitive restructuring and cognitive behavioral strategies are used.
- In terms of Cluster B, treatment options for antisocial are limited and generally not effective, borderline responds well to dialectical behavioral therapy (DBT), histrionic patients seek out help but are difficult to work with, and finally narcissistic are the most difficult to treat.
- For Cluster C, cognitive techniques aid with OCPD while gradual exposure to various social settings and social skills training help with avoidant. Clinicians use cognitive strategies to challenge thoughts on helplessness in patients with dependent personality disorder.
Review Questions
- What is the process in Dialectical Behavioral Therapy (DBT)? What does the treatment entail? What disorders are treated with DBT?
- Given the difference in personality characteristics between the three clusters, how are the suggested treatment options different between cluster A, B, and C?
Module Recap
Module 13 covered three clusters of personality disorders: Cluster A, which includes paranoid, schizoid, and schizotypal; Cluster B, which includes antisocial, borderline, histrionic, and narcissistic; and Cluster C which includes avoidant, dependent, and obsessive-compulsive. We also covered the clinical description, epidemiology, comorbidity, etiology, and treatment of personality disorders.
