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Part I
Cognitive Behavior Therapy and Personality Disorders![]()
1
Cognitive Behavior Therapy and Personality Disorders
Basic Considerations
Whether or not clinicians are comfortable ascribing paradigm shift language to clinical practice, there is no denying that major changes in the treatment of the personality disorders have and are occurring. These changes involve not only radically different treatment methods, but also rather different perspectives, conceptualizations, criteria, and assessment methods. Many of these changes are based on clinical research on the personality disorders that has greatly increased in the past decade. This chapter begins by identifying a number of changes in conceptualizing, classifying, and treating the personality disorders. Then, it describes the four-stage treatment model that is basic to the evidence-based approach advocated in this book. Finally, it provides an overview of the remaining chapters of the book.
Changes in Conceptualizing Personality Disorders
Before 1980, personality disorders were typically conceptualized in âcharacter language,â such as the oral character or obsessive character. Although there was a biological tradition in the study of personality that emphasized temperament, the psychological tradition that emphasized character was in vogue for most of the 20th century. Descriptions of personality disorders in DSM-I and DSM-II reflected this emphasis on character and psychodynamics. Within the psychoanalytic community, character reflected specific defense mechanisms. Accordingly, from a character perspective, the obsessive-compulsive personality would be characterized by the defenses of isolation of affect, intellectualization, and rationalization.
Currently, personality disorders are conceptualized in a broader perspective that includes both character and temperament (Cloninger, Svrakic, & Przybeck, 1993; Stone, 1993). Character refers to the learned, psychosocial influences on personality. Character forms largely because of the socialization process, particularly regarding cooperativeness, and the mirroring process that promotes the development of self-concept and a sense of purpose in life (i.e., self-transcendence and self-responsibility).
Temperament refers to the innate, genetic, and constitutional influences on personality. Whereas character and schema reflect the psychological dimension of personality, temperament, or trait (or style, as it is used synonymously in this book) reflects the biological dimension of personality. Cloninger (2004) contends that temperament has four biological dimensions (novelty-seeking, harm-avoidance, reward-dependence, and persistence), whereas character has three quantifiable dimensions (self-directedness or self-responsibility, cooperativeness, and self-transcendence). Other researchers would describe impulsivity and aggressivity as additional dimensions of temperament (Costello, 1996). Another widely known of the temperament-based models is the Five Factor Model with its trait dimensions of neuroticism, extraversion, openness, agreeableness, and conscientiousness (Costa & McCrae, 1990). Section III of the DSM-5 provides a dimensional approach to the personality disorders that is based on these and other models. It consists of five temperament domains: negative affectivity, detachment, antagonism, disinhibition, and psychoticism (American Psychiatric Association, 2013). Accordingly, from a temperament perspective, the obsessive-compulsive personality would be characterized by inhibited emotional expression, behavioral inhibition, cognitive rigidity, and overconscientiousness.
Temperament and character can be assessed by interviews and self-report instruments. The relevance of distinguishing character and temperament for treatment planning is significant. Whereas insight-oriented psychotherapy might be focused on the character dimensions, psychotherapy can have little or no impact on temperament dimensions. However, the addition of focused skill training may sufficiently regulate or modulate temperament or style features such as emotional dysregulation, impulsivity, and distress intolerance.
Changes in the Classification of Personality Disorders
The DSM diagnostic system has undergone some major changes since the second edition of this book was published in 1996. Most of these changes have involved adding or removing diagnoses and criteria. These will be described in subsequent chapters. However, there are also some major changes in the structure of the DSM-5 (American Psychiatric Association, 2013), and these are briefly noted here.
The most obvious change in DSM-5 is the return to a single-axis diagnosis as it was in DSM-I and DSM-II. The multiaxial (5-axes) system was introduced in DSM-III and continued through DSM-IV-TR. Of particular relevance for the personality disorders were Axis II and Axis V. Axis II was added for the coding of personality disorders, while Axis V was added for coding the individualâs current level of functioning and impairment on the Global Assessment of Functioning Scale. There were several reasons for eliminating the multi-axial system. Among these was an unexpected drawback to adding Axis II. The opportunity to specify a diagnosis of a personality disorder became problematic for many clinicians. Out of concern that the diagnosis of a personality disorder would stigmatize an individual, some clinicians refused to specify an Axis II diagnosis when it was present. This was complicated by the mistaken notion among therapists and third-party payors that personality disorders were untreatable. As a result, some individuals who were diagnosed with personality disorders encountered problems securing treatment. Today, however, individuals who met the criteria for a personality disorder diagnosis may now find it easier to navigate mental health treatment, since they are less likely to be viewed as having a diagnosis that is more difficult to treat than of other disorders.
By eliminating Axis V, the Global Assessment of Functioning (GAF) score is gone. GAF was the numeric measure used by clinicians to rate an individualâs social, occupational, and psychological functioning and well-being. It is a subjective measure of the degree of adaptivity (well-being) or maladaptivity (impaired functioning) an individual demonstrates in dealing with various problems-in-living. In place of this largely unreliable measure of functioning and impairment, DSM-5 encourages the use of the World Health Organization Disability Assessment Schedule 2.0 (WHODAS 2.0). Nevertheless, GAF continues to be used by some clinicians. It provides a continuum (1âlowest to 100âhighest) on which to rate overall functioning and well-being.
Clinicians can also utilize the Level of Personality Functioning Scale (LPFS) that is included on pages 775â778 in Section III of DSM-5 (American Psychiatric Association, 2013). The LPFS is an objective measure for quickly and accurately determining the presence of a personality disorder. It is described in detail in Chapter 2 and used throughout this book in all case examples.
Major changes were expected in how DSM-5 would characterize the personality disorders. It was anticipated that at least four of the DSM-IV-TR personality disorders would be dropped purportedly because of limited research support. In addition, the diagnosis of all personality disorders were expected to shift to a dimensional focus, rather than categorical focus as it had been in previous editions. However, when DSM-5 appeared in May 2013, the same criteria found in DSM-IV-TR were retained, and the anticipated changes appeared in Section III in a chapter entitled âAlternative DSM-5 Model for Personality Disorders.â It appears that this, or some version of the âAlternative Model,â may be incorporated in subsequent editions (DSM-5.1 or 5.2). For now, clinicians are expected to continue using the same criteria and the categorical method of making diagnoses to which they are already familiar. However, they have the option of using the alternate criteria specified in Section III.
Also retained in DSM-5 was the earlier DSM definition of a personality disorder as an âenduring patterns of inner experience and behaviors that deviate markedly from the expectations of the individualâs culture, is pervasive and inflexible⌠is stable over time, and leads to distress or impairmentâ (American Psychiatric Association, 2013, p. 645). While previous diagnostic criteria have been retained, there has been some updating of description of the various disorders. However, there is one substantive change. The diagnosis of Personality Disorder Not Otherwise Specified (NOS) has been replaced with Other Specified Personality Disorder (301.89) and Unspecified Personality Disorder (301.9).
Changes in the Treatment of Personality Disorders
In comparison to previous approaches to generic treatment of personality, treatment methods today tend to be considerably more focused and structured, with the clinician taking a more active role. Many of these treatment approaches and intervention strategies are theory-based and have been researched in clinical trials in comparison with other treatment approaches and modalities.
Cognitive Behavior Therapies
For the last three decades, Behavior Therapy, Cognitive Therapy, and Cognitive Behavior Therapy (CBT) were the treatment of choice for the psychosocial treatment of personality disorders. While research did not consistently support the efficacy of these traditional approaches, it has for newer, more focused approaches such as Dialectical Behavior Therapy (DBT) and Mindfulness-Based Cognitive Therapy (MBCT). Interestingly, DBT and MBCT, along with Acceptance and Commitment Therapy (Hayes, 2004), constitute what is being called the âthird waveâ of Behavior Therapy (Hayes, Follette, & Linehan, 2004).
The first wave refers to traditional Behavior Therapy, which endeavors to replace problematic behaviors with constructive ones through counterconditioning and reinforcement. Cognitive therapy is the second wave of Behavior Therapy. It works to modify problem behaviors by changing the thoughts that cause and perpetuate them. In the third wave, treatment tends to be more experiential and indirect and utilize techniques such as mindfulness, dialectics, acceptance, values, and spirituality. More specifically, third wave approaches are characterized by âletting go of the attempts at problems solving, and instead standing back to see what it feels like to see the problems through the lens of non-reactivity, and to bring a kindly awareness to the difficultyâ (Segal, Williams, Teasdale, & Williams, 2004, p. 55). Unlike the first and second wave, third wave approaches emphasize second-order change, i.e., basic change in structure and/or function, and are based on contextual assumptions including the primacy of the therapeutic relationship. These approaches appear to be particularly germane to treating personality disorders. Extended discussions of standard DBT and Radically Open DBT in the treatment of a wide range of personality disorders appears in Chapters 2 and 4 and are selectively referenced in Chapters 5â10.
Medication
Traditionally, the use of medication in the treatment of personality disorders was viewed as limited. Medication tended to be utilized only for a concurrent clinical disorder such as Bipolar Disorder or a target symptom like insomnia. This view is rapidly changing. Today, a growing number of psychopharmacologists believe that psychopharmacological treatment can and should be directed to basic dimensions that underlie the personality. Psychopharmacological research on treatment of selected personality disorders has grown rapidly in the past few years (Reich, 2002; Sperry, 2003). Until recently, medication treatment of personality-disordered individuals has been largely empirical, that is largely trial and error. The reason is that there are still no specific drug treatments for DSM-5 personality disorders except for avoidant and borderline personality disorder (Black et al., 2014; Silk & Fuerino, 2013).
Combined Treatment
There is growing consensus, among all segments of the mental health community, that effective treatment of the personality disorders involves combining treatment modalities and integrating treatment approaches (Sperry, 2006). In many treatment centers, this means individual therapy is combined with group therapy or psychoeducation groups, and it may include medication or other modalities. Combining medication with individual and group modalities tends to increase effectiveness. Such efforts to integrate various approaches, as well as to combine treatment modalities, would have been considered heretical just a few years ago. Now, integrating and combining treatments is an emerging consensus that reflects the immensity of the âparadigm shiftâ that is occurring (Beitman et al., 2003; Sperry, 2003).
An Effective Treatment Strategy
The treatment strategy proposed in this book is rather straightforward. Treatment must be specifically planned with regard to the four stages of the treatment process, and it must be specifically tailored on the basis of the individualâs needs, style, level of readiness, and expectations of treatment. This section describes the stages of the treatment process and tailoring treatment.
Stages of the Treatment Process
The process of change and the types of interventions required for the effective treatment of the personality disorders is similar to the general therapeutic processes and interventions used with symptom disorders, but it differs in focus and emphasis. Beitman (1991; Good & Beitman, 2006) has articulated the general change processes and compatible interventions in both psychotherapy and psychopharmacotherapy. The Beitman model articulates four developmental stages of the treatment process: engagement, pattern search, change, and termination. As applied to the treatment of personality disorders, these stages need to be somewhat modified. The stages of engagement, pattern identification, pattern change, and pattern maintenance are described below and will be illustrated in subsequent chapters with...
