Rep36 Understanding Personality Disorder

3.2.3 Final thoughts
Historically, there has been a tendency to assume
that people with personality disorder are
untreatable, as if treatability were a characteristic
of those given this label rather than reflective of
our current state of knowledge. Treatment
evaluation is hampered by methodological
difficulties and inadequacies. In particular,
people with personality disorder are often hard
to engage in treatment and research, and drop
out rates are high. Despite these difficulties,
literature reviews suggest that there are some
promising psychological treatments for the
personality disorders, including therapeutic
communities, and psychoanalytic, cognitive
behavioural and dialectical behaviour therapy
approaches.
The poorer overall response to treatment
found with this client group may indicate that
their problems are more deep rooted and
require more intense and extensive treatment
This idea is supported by research, which found
that individuals with personality disorder require
more therapy to produce the same effect as
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neurotic subjects (Dolan, 1998; Lipsey, 1995).
Similarly, personality disorder symptoms improve
less with psychotherapy and at a slower rate than
symptoms of acute or chronic distress (Kopta,
Howard, Lowry & Beutler, 1994). The presence
of personality disorder also predicts poorer
outcome in treatments for other mental health
difficulties (Reich & Vasile, 1993). There are few
studies that have measured changes to core
pathology as a result of treatment. Those studies
that have, however, indicate that treatment can
have a clinically significant effect in changing
personality (Dolan, Warren, & Norton, 1997). 
Research suggests that no psychological
model or treatment is superior to any other.
Developing a range of psychological treatments
encompassing a diverse range of models would
therefore have advantages in attempting to
Jane
Jane was 13 years old when she first came to the attention of psychiatric services as a result of
taking a serious overdose. When admitted, many scars were noted on her wrists and abdomen
where she had cut herself. She was keen to leave hospital as soon as possible, and resisted attempts
to obtain a history of her difficulties or involve her in therapy. This was the first of many brief
admissions following self-harm and suicide attempts. When 18, she became pregnant and had an
abortion. She became severely depressed and was again admitted to hospital following a nearly
fatal overdose. She settled in hospital, but whenever her discharge from hospital was discussed, she
began a pattern of self destructive behaviour involving absconding from hospital and putting
herself in dangerous situations, drinking excessively, taking drugs and attempting suicide, for
instance by running in front of cars. Her behaviour on the ward also started deteriorating, with
increasingly frequent episodes of self-harm leading to her being given increasing doses of
medication. Many different types of medication were tried without success. By the age of 20 she
needed constant supervision by two members of staff in an unsuccessful attempt to prevent her
self-harm. Staff were at their wits end, and ward rounds were often the scene of angry
disagreement about how she should be managed.
Psychological assessment using the Personality Diagnostic Questionnaire (PDQ-4; Hyler et al,
1992) revealed that she scored within the clinical range on a number of personality disorder
diagnoses, in particular borderline, histrionic, paranoid and anti-social types. On the Beck
Depression Inventory she scored as moderately depressed, and on the Spielberger State-Trait
Anxiety Inventory she scored highly on both current and trait anxiety. Additionally, when referred
for CBT, assessment using Young’s Schema Questionnaire showed dysfunctional thinking on all
schemas assessed. Although she attended the assessment, she was unwilling to give a full history
and failed to attend further appointments. A behavioural management programme was
constructed to try to reduce her self-harm, but merely led to an increase.
Jane eventually agreed to be referred to a residential therapeutic community to attempt to
break the destructive cycle of her behaviour. The benefits were seen as shifting responsibility for
her behaviour to herself rather than staff, and providing her with an environment in which she
could be supported by peers with similar problems 24 hours a day. Additionally, the tight daily
structure and clear rules existing provided her with supportive boundaries and offered alternative
ways for her to manage her distressing emotions and impulses. In this environment she was able
for the first time to talk about her experiences of sexual and physical abuse as a child, gaining an
understanding of why she felt compelled to harm herself. She also found that she could be helpful
to others in the community, increasing her self-esteem. Seeing others making changes to their
behaviour also gave her hope and encouragement. Although she continued to act destructively at
times, her self harm ceased after a few weeks, and after a years treatment she was able to leave
therapy and pursue her education.