Personality Disorders Treatment

Treatment For Personality Disorders at BACA: Matching Treatment and Diagnosis

Mental health experts identify at least ten distinct types of personality disorders. Although the symptoms of some personality disorders become less severe over time, the same experts agree that all personality disorders have one thing in common:

With some exceptions, personality disorders are unlikely to fully resolve or remit without professional treatment and specialized support.

This makes early diagnosis and treatment essential. At BACA, our clinical team has the skill, training, and experience required to support patients with personality disorders. We work with the family unit as a whole, when possible and appropriate, but the primary challenge in treating a personality disorder is helping them find the perspective their disorder distorts.

Personality disorders cannot be diagnosed before age 18, and any coexisting mental health disorders must be stabilized before an accurate diagnosis is possible. We can, however, focus on features of these disorders in adolescents when present.

In some cases, an individual with a personality disorder seems to see no problem with their thoughts, feelings, and behaviors: they end up in treatment because of the impact of their maladaptive behavior on others, rather than personal discomfort with their emotions, behaviors, or relationships.In truth, there is always distress underneath, sometimes just deeply hidden – even from themselves.

Finding Perspective, Committing to Healing and Growth

That’s why the first step in treating most personality disorders is helping patients realize that in order to reduce distress, reduce conflict with others, improve relationships, and resolve the problems in their lives, they need to develop skills to manage their emotions and manage their behavior. In other words, the crucial first step is getting them to realize their emotions and behaviors are problematic, and they need to develop the skills necessary to process those emotions and manage their behaviors.

What are Personality Disorders?

The Merck Medical Reference Manual and the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-V) provide this definition of personality disorders:

“Personality disorders are mental health conditions that involve long-lasting, pervasive patterns of thinking, perceiving, reacting, and relating that cause the person significant distress and/or impair the person’s ability to function.”

When these patterns become rigid, fixed, and don’t change based on real circumstances or external feedback, they’re considered maladaptive. These maladaptive patterns can cause significant distress and conflict. When an individual consistently perceives themselves in ways that don’t match reality and continue to act on maladaptive beliefs in ways that have negative consequences, they may receive a diagnosis for a personality disorder.

Another complication of personality disorders is their frequent coexistence with other mental health disorders, including, but not limited to:

• Depressive disorders
• Bipolar disorder
• Anxiety disorders
• Alcohol/substance use disorders
• Feeding/eating disorders

Sometimes treatment of such coexisting conditions by itself results in resolution of what seems to have been a personality disorder but was actually a manifestation of the other condition.This is what makes diagnosis and treatment more challenging than with most mental health disorders. However, our clinical team has the skill, training, and experience to support patients with complex mental health diagnoses, including personality disorders that co-occur alongside other mental health disorders and/or alcohol/substance use disorders.

Types of Personality Disorders

The Diagnostic and Statistical Manual of Mental Disorder, Volume 5 (DSM-5) identifies ten types of personality disorders and divides them into three clusters. The disorders in each cluster are unique, but share some basic features.Note that none of these can be definitely diagnosed before age 18, however “features” of one or the other disorders may be made a focus of treatment in adolescents as well.Additionally, personality disorders cannot be definitely diagnosed until other coexisting disorders have been stabilized first.

Cluster A Personality Disorders: Eccentric Behaviors

Paranoid Personality Disorder

This type of personality disorder is characterized by a pattern of distrust and suspicion of others and involves consistently interpreting the motives and behavior of others as harmful or hostile.

To meet criteria for paranoid personality disorder, a patient must display at least four of the following behaviors/patterns of thinking by early adulthood:

• Suspicion that other people plan to exploit, harm, or deceive them.
• Preoccupation with suspicion of friends, family, and coworkers.
• Reluctance to confide in others, for fear of information being turned against them
• Misinterpretation of common and typical remarks or circumstances as insulting or belittling
• Holding grudges in response to perceived insult
• Immediate assumption that they’re under personal attack with immediate retaliation
• Unfounded suspicion of infidelity on the part of their partner or spouse

Evidence-based treatment for paranoid personality disorder includes:

• Cognitive behavioral therapy (CBT)
• Medication, in some cases

Schizoid Personality Disorder

This type of personality disorder is characterized by persistent detachment from others, a pervasive disinterest in social relationships, and minimal display of emotion in any relationship.

To meet criteria for schizoid personality disorder, a patient must display at least four of the following behaviors/patterns of thinking by early adulthood:

• Aversion to close relationships, including family
• Strong preference for solitary activities.
• Almost no interest in sexual activity with others
• Very few enjoyed activities
• No close friends, except close relatives (in some cases)
• Indifference to external praise or criticism
• Emotionally cold and detached/no emotional response or engagement with people or events

Evidence-based treatment for schizoid personality disorder includes:

• Cognitive behavioral therapy (CBT)

Schizotypal Personality Disorder

This type of personality disorder is characterized by discomfort with and limited capacity to form close relationships, distorted thoughts and perceptions, and atypical behavior. People with schizotypal personality disorder often believe they have magical powers, think they have magical control over people or events, or think common events have special meaning or occur only for them.

Note: this is not that hard to relate to at all. Consider the fact that millions of people around the world think that if they wear a special jersey or sit in a special spot on the couch, their favorite team will win the game.

To meet criteria for schizotypal personality disorder, a patient must display at least five of the following behaviors/patterns of thinking by early adulthood:

• Ideas of reference (common events relevant only to them)
• Magical thinking
• Distorted perceptions
• Atypical thought and speech
• Suspicion/paranoia
• Inappropriate or limited expression of emotion
• Atypical behavior/appearance
• Few close friends except for relatives
• Social anxiety driven by paranoia

Evidence-based treatment for schizotypal personality disorder includes:

• Cognitive behavioral therapy (CBT)
• Medication:
  • Antipsychotics
  • Antidepressants

Cluster B Personality Disorders: Dramatic/Erratic

Antisocial Personality Disorder

This type of personality disorder is characterized by persistent and pervasive disregard for consequences of behavior and for the rights, feelings, or reactions of others. This disorder is only diagnosed in people over age 18.In children and adolescents this is very analogous to a Conduct Disorder diagnosis.

To meet criteria for antisocial personality disorder, a patient must consistently ignore or disregard the rights of others and display at least three of the following patterns of thought or behavior:

• Disregard for law, and repeatedly engage in behavior that could lead to arrest
• Repeated deceitful, lying, use of false names aliases, and using/manipulating others for personal gain
• Impulsive behavior with no forethought
• Easily provoked into aggressive behavior resulting in numerous fights or physical assaults on others
• Reckless disregard for personal safety and the safety of others
• Consistently irresponsible behavior, such as not paying bills or quitting a job with no plan to get another
• Absence of remorse for harming others, indifference to/rationalization of mistreatment of others

Evidence-based treatment for antisocial personality disorder includes:

• Contingency management
  • Involves incentives and rewards for positive behavior
• Medication:
  • Mood stabilizers
  • Antidepressants

Antisocial personality disorder is difficult to treat. Therefore, clinicians focus on short-term, immediate goals, such as reducing harm to others and avoiding self-destructive or illegal behavior.

Borderline Personality Disorder

This type of personality disorder is characterized by persistent and pervasive pattern of unstable relationships, inconsistent self-image, volatile moods, and hypersensitivity to possible or perceived abandonment or rejection.

To meet criteria for borderline personality disorder, a patient must have a history of unstable mood, relationships, and self-image, a history of impulsivity, and display at least five of the following patterns of thought or behavior by early adulthood:

• Repeated, desperate efforts to avoid perceived or actual abandonment
• Unstable, intense relationships that unpredictably vacillate between love and hate
• Frequently change in self-image
• Impulsive, dangerous behavior of at least types, such as risky sex, reckless driving, or binge eating
• Persistent suicidality and self-harm, including suicide attempts and threats of suicide
• Rapid mood swings
• Chronic feelings of emptiness
• Inappropriate rage or anger, difficulty controlling anger
• Stress related paranoid thoughts/dissociative symptoms

Evidence-based treatment for borderline personality disorder includes:

• Psychotherapy:
  • Dialectical behavior therapy (DBT)
  • Systems training for emotional predictability and problem solving (STEPPS)
  • Psychodynamic approaches, including
    • Mentalization based psychotherapy
    • Transference-focused psychotherapy
    • Schema-focused psychotherapy
  • Supportive psychotherapy
• Medication:
  • Mood stabilizers
  • Second generation antipsychotics
  • Antidepressants

Histrionic Personality Disorder

This type of personality disorder is characterized by a persistent and pervasive pattern of attention-seeking, dramatic behavior, and excessive emotionality.

To meet criteria for histrionic personality disorder, a patient must have a history of attention-seeking and exaggerating emotions, and display at least five of the following behaviors or patterns of thought by early adulthood:

• Discomfort when not the center of attention
• Inappropriately seductive, sexual, or provocative behavior
• Rapidly shifting and vacillating emotional states that give the impression of superficiality
• Use of physical appearance to get attention
• Vague speech/talking that lacks detail
• Consistently dramatic, theatrical, exaggerated manner of expressing emotion
• Easily influenced by other people or external circumstances
• Inaccurate perception that some relationships are more intimate than they really are

Evidence-based treatment for histrionic personality disorder includes psychodynamic psychotherapy that helps patients realize their behavior is dramatic, atypical, and attention-seeking. Therapists help patients develop healthy, effective methods of communication and seeking attention.

Narcissistic Personality Disorder

This type of personality disorder is characterized by a persistent and pervasive need to be admired, coupled with a lack of empathy and an inflated view of self-worth, a.k.a. grandiosity.

To meet criteria for narcissistic personality disorder, a patient must have a history of grandiosity and lack of empathy, and display at least five of the following behaviors or patterns of thought by early adulthood:

• Exaggerated, unfounded sense of importance and talent
• Preoccupation with fantasies of influence, power, intelligence, beauty, or love.
• Belief they’re special and should associate only with other special people
• Need to be admired
• Extreme sense of entitlement
• Regularly exploit others for personal gain
• Absence of empathy for others
• Envy of others, believe others envy them
• Persistent arrogance/haughtiness

Evidence-based treatment for narcissistic personality disorder includes various forms of psychotherapy, such as:

• Psychodynamic approaches, including:
  • Mentalization-based psychotherapy
  • Transference-focused psychotherapy
• Cognitive behavioral therapy (CBT)

Cluster C Personality Disorders: Anxious/Fearful

Avoidant Personality Disorder

This type of personality disorder is characterized by a persistent avoidance of interpersonal contact due to fear of being rejected, criticized, or humiliated/embarrassed.

To meet criteria for avoidant personality disorder, a patient must persistently avoid social contact, fear rejection, feel rejection, and display at least four of the following behaviors or patterns of thought by early adulthood:

• Avoid job-related activities involving interpersonal contact out of fear of rejection/criticism
• Avoid getting involved with others unless they can guarantee being accepted/liked
• Reserved in relationships out of fear of ridicule or humiliation
• Preoccupied by fear of criticism/rejection in social situations
• Inhibited by fear of inadequacy in new social situations
• See themselves incompetent or unappealing
• Reluctance to try new activities out of fear of embarrassment

Evidence-based treatment for avoidant personality disorder includes:

• Psychotherapy:
  • Social skills-based cognitive behavioral therapy
  • Psychodynamic psychotherapy
  • Social skills-based Group therapy
• Medication:
  • Antidepressants
  • Anxiolytics, a.k.a. anti-anxiety medication

Dependent Personality Disorder

This type of personality disorder is characterized by a pervasive need to be taken care of, which results in excessively submissive/dependent behavior.

To meet criteria for dependent personality disorder, a patient must have a persistent and excessive need to be taken care of, and show at least five of the following behaviors or patterns of thought by early adulthood:

• Difficulty making typical daily decisions in the absence of outside advice
• Desire to give others responsibility for all important aspects of life
• Avoid conflict for losing support/ approval
• Problems with independent tasks due to lack of confidence in personal judgment or ability
• Will put themselves in difficult situations/circumstance in order to get help from others
• Feelings of helplessness when alone due to fear they can’t take care of themselves
• If a close relationship ends, they immediately find another to replace/provide the support they need
• Preoccupation with fear of having to take care of themselves

Evidence-based treatment for dependent personality disorder includes two forms of psychotherapy:

• Cognitive behavioral therapy (CBT)
• Psychodynamic psychotherapy

Obsessive-Compulsive Personality Disorder

Obsessive-compulsive personality disorder is not obsessive-compulsive disorder (OCD). To learn about OCD, please visit our OCD Treatment Page.

This type of personality disorder is characterized by a persistent and pervasive preoccupation with perfectionism, control, and orderliness that interferes with completion of tasks.

To meet criteria for obsessive-compulsive personality disorder, a patient must show a persistent need for orderliness and control and show at least four of the following behaviors or patterns of thought by early adulthood:

• Preoccupation with details, rules, schedules, organization, and lists
• Perfectionism interferes with ability to complete task
• Devoted to work and productivity at the expense of personal wellbeing and interpersonal relationships
• Excessively conscientious and inflexible on issues of ethics, morals, and values
• Resist throwing out old/worthless object
• Reluctant to delegate responsibility or work with others unless they have total control over situation
• Reluctant to spend money because they feel they need to save it for future emergencies
• Rigid, stubborn, inflexible

Evidence-based treatment for obsessive-compulsive personality disorder includes:

• Psychotherapy:
  • Cognitive behavioral therapy (CBT)
  • Psychodynamic psychotherapy
• Medication:
  • Antidepressants (SSRIs)

Treatment For Personality Disorders at BACA: Psychosocial Support and Innovative Techniques

As we indicate above, each type of personality disorder requires a specific combination of therapeutic techniques. In some cases, both psychotherapy and medication are effective. In others, one or the other is most effective. And in still others, like antisocial personality disorder, the goal of treatment is to reduce harmful/illegal behavior with an approach like contingency management.

Our goal for patients with a personality disorder is to use any and all therapeutic approaches that:

• Decrease or reduce acute distress
• Help patients see their challenges are internal
• Reduce maladaptive behavior
• Manage or modify behaviors or traits that cause problems

Treatment Plans for Personality Disorders at BACA

At BACA, our treatment plans include most, but not all, of the following:

• Individual, group, and family therapy
• Weekly individual psychiatry sessions
• Education about attachment disorders:
• Lifestyle changes, including:
  • Healthy eating
  • Exercise
  • Mindfulness
• Classes and workshops for family:
  • Parent skills workshops
  • Parent training sessions
• Psychiatry, if needed
• Medication, if needed

At BACA, we take the time to learn about each patient and understand what works for them. We design a treatment plan the leverages strengths, improves challenge areas, and gives each individual the greatest chance of managing the symptoms of depression and achieving stable, sustainable, long-term recovery.

BACA MATH:

EXPERINCED, INTIUITIVE CLINCIANS + COMPREHENSIVE SUPPORT +FULL PATIENT AND FAMILY COMMITTMENT = SUCCESSFUL TREATMENT FOR PERSONALITY DISORDER