Rep36 Understanding Personality Disorder

3.2.2a Cognitive and cognitive behavioural
therapies 
Cognitive therapies for the personality disorders
are structured individual treatments that are
problem-focused and less intensive in terms of
time than either psychodynamic psychotherapy
or dialectical behaviour therapy. These
treatments have developed from cognitive
behavioural therapy for mental disorders such as
depression, which is widely practised in the UK.
Importance is placed on engaging the client in
therapy through a formulation of their problems
and forming a collaborative alliance with the
client. The first stage of therapy therefore
involves arriving at a formulation to understand
the client’s difficulties. This working hypothesis
ties together the client’s long-standing
problematic behaviours, interpersonal problems
and hypothesized underlying dysfunctional core
beliefs that may have arisen as a result of
childhood experiences. It also has a pragmatic
application in determining which strategies are
likely to be the most useful in promoting
effective change in the client. Cognitive
strategies are used to modify maladaptive core
beliefs about self and others. Behavioural
strategies are used to promote a reduction in
self-harm and other maladaptive behaviours, as
well as to help people to develop better ways of
coping with their difficulties. An abbreviated
manualised form of cognitive behavioural
therapy (MACT) has been shown to be a cost-
effective in patients who repeatedly self-harm, up
to 90 per cent of whom had personality
disturbance or disorder (Byford 
et al
., 2003;
Davidson 
et al
., 2004; Tyrer 
et al
., 2003). In
addition, therapist competence was shown to be
a moderator of clinical outcome (Davidson 
et al
.,
2004), indicating that high levels of competence
are required to treat those with personality
disorder effectively. There is now evidence of
effectiveness of CBT in the treatment of
borderline personality disorder from a
randomised controlled trial of one hundred and
six patients who received either cognitive
behavioural therapy in addition to their usual
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treatment or their usual treatment alone
(Davidson 
et al
., in press). Across both treatment
arms there was gradual and sustained
improvement, with evidence of benefit for the
addition of CBT on the positive symptom distress
index at one year (the end of the active therapy
period), and on state anxiety, dysfunctional
beliefs and the quantity of suicidal acts at two
year follow-up (Davidson 
et al
., 2005). 
DBT involves both individual therapy and a
group psycho-educational component. In the
group component, patients are taught self-
management skills, distress tolerance skills and
how to deal with interpersonal situations more
effectively. In the accompanying individual
therapy sessions, the therapist first focuses on
behavioural and supportive techniques to reduce
self-harm, before moving on to apply other
directive and supportive techniques to other
problem areas including any behaviour which
interferes with ongoing work in therapy. DBT
encourage patients to accept negative mood
states without resorting to self-harm or other
maladaptive behaviours.
DBT for women with borderline personality
disorder has been shown to be effective in
reducing self-harm during treatment (Linehan 
et
al
., 1991; Verheul, 2003). However, no
differences were found between those who had
DBT and those who had treatment as usual in
respect of reported levels of depression, suicidal
ideation, hopelessness and reasons for living at
the time of treatment (Linehan 
et al
., 1991,
1994). For those who had received DBT, the
positive effect of treatment on episodes of self-
harm continued for six months after treatment
ended, but during the subsequent six to twelve
months follow-up period, no differences were
found between the groups in the number of
suicide attempts (Linehan 
et al
., 1993). 
In a study of female military veterans (Koons
et al
., 2001), only 40 per cent of whom had an
episode of deliberate self harm in the previous
six-months, those who received DBT improved
on measures of depression and hopelessness
compared to those receiving treatment as usual
but no difference in rates of self-harm or
inpatient days during treatment were found
(Koons 
et al
., 2001). As there is only one study of
DBT with women with borderline personality
disorder that has followed-up patients after
treatment, more follow-up studies are needed to
assess the longevity of changes in self-harm.
However, from the evidence available, it does
appear that for women with borderline
personality disorder, DBT can be an effective
treatment for self-harm and differences between
the studies may be due to the different sample of
women selected, and particularly the frequency
of self-harm in the samples studied. 
Several studies have examined the efficacy of
an adapted form of DBT for women with
borderline personality disorder and comorbid
substance abuse (Linehan 
et al
., 1999; Linehan 
et
al
., 2002). During treatment, the results showed
few differences between DBT and treatment as
usual, but at follow-up, those who received DBT
showed important gains in terms of abstinence
from drugs and less parasuicidal behaviour.
However, when DBT was compared to a more
structured psychological treatment, namely
comprehensive validation therapy, no differences
were found in outcomes on any measure
(Linehan 
et al
., 2002). It may be that treatment
may need to be longer for some patients, and as
DBT has developed, more long-term contact has
been offered to patients. Positive findings need
to be replicated using larger numbers of patients
and in more independent studies.