Behandlungsleitlinie Persönlichkeitsstörungen

The S2 guidelines for the treatment of personality disorders (PD) are summarized. In the diagnostic assessment of personality disorders a clinical interview should be supplemented by (semi-) structured clinical interviews and self-report measures for the categorical and dimensional assessment of PDs. The results of the assessment process should be communicated to the patient based on a psycho-educational framework. The diagnosis should always be linked to the patient’s individual history. Psychotherapy is the treatment of choice for personality disorders. A detailed analysis of the patient’s problems as well as the definition of a hierarchy of treatment goals are part of the process of treatment planning. For three PDs empirical evidence for treatment approaches is available: (1) dialectical behavior therapy, mentalization-based therapy, schema focused therapy and transference focused therapy all proved beneficial in the treatment of borderline personality disorder. Cognitive-behavior therapy proved helpful in the treatment of (2) dissociative personality disorder and (3) avoidant personality disorder. There is limited evidence for interpersonal therapy and psychodynamic therapies in the treatment of avoidant personality disorder.     

Diagnostik von Persönlichkeitsstörungen

Diagnosing and classifying personality disorders is complex and difficult from both the scientific and clinical perspectives. Dimensional and categorical models and assessment instruments of personality disorders, and different (behavioral and psychodynamic orientated) clinical procedures are described. Furthermore, an integrative view on clinical practice is presented.     

Psychotherapeutischer Prozess und Persönlichkeitsstörungen

This paper begins with a cursory overview of psychotherapy outcome research for personality disorders; however, relatively little is known about process research or process outcome relationships. It then focuses on relevant patient and therapist variables. Significant controversies in personality disorder treatment techniques are examined. Initially, studies generally associated transference interpretation with less favorable therapy outcomes. Recent work supports the possibility of differentiated correlations. There is increasing evidence that a moderate amount of transference interpretation and perhaps even a therapeutic alliance that is not so good, maybe indicative of an inner conflict with the therapist relationship, could ultimately be beneficial. This association most probably does not exist in cluster C personality disorders. A problem with this type of research is that clear definitions are often lacking. This complicates comparisons between studies and the influence of other mediating variables remains vague.     

Empathie und Persönlichkeitsstörungen aus neurobiologischer Sicht

In contrast to the vague application of the term empathy in general usage, the neurobiological literature differentiates between cognitive empathy and emotional empathy. The former includes cognitive recognition of the mental state of someone else due to reflexive acquisition of perspectives and theory of mind functions, the latter includes the reflexive intuitive sympathy and sharing the emotions of others. Both independent from each other and interindividual differently expressed facets can be assigned to different brain networks which process these events. Early evolutionary processes of emotional empathy are already developed in infants by mirror image imitation of mimicry and gestures of the primary contact person. They involve premotor regions, areas of the sensomotor cortex, the inferior parietal lobule and the anterior insular regions. Phylogenetically younger processes of cognitive empathy are represented in particular in midline structures, such as the medial prefrontal cortex, superior temporal sulcus, posterior cingulum or precuneus as well as in the temporoparietal junction. They have their beginning in shared attention processes in early dyadic processes. Both facets of empathy are involved in moral decision-making processes. In this context, neurobiological studies show that psychopaths have undisturbed cognitive empathic capabilities and are principally able to recognize and apply moral values but confer little attentional importance to them when they compete with own targets. Individuals with borderline personality disorders in contrast to psychopaths show impairments in cognitive empathy. The deficits affect mentalization functions, which involve the understanding of the mental state of others and oneself and are also the starting point for many misunderstandings in an interpersonal context. Additionally, individuals with borderline personality disorder have a tendency to share emotions with other people. They therefore succeed in showing sympathy and compassion although associated with the danger of diffusion of self and third party borders.     

Deutende Interventionstechniken bei Patienten mit schweren Persönlichkeitsstörungen

The growing influence of ego-psychology, self psychology, object relations theory, and interpersonal concepts on the psychoanalytic psychotherapy of patients with personality disorders is reflected in a preference of relational therapeutic strategies and in a controversial discussion of interpretative techniques. It is shown that interpretative strategies are of invaluable importance in many patients with personality disorders. However, modifications of technique necessary for this group of patients should be considered. Especially, transference interpretation in the here and now can be of great use even in the treatment of patients with severe personality disorders. It is of outstanding relevance for the therapist to understand the interactional message a patients infers from his interpretation and to take into account the patient's reaction to the interpretation.     

Angstzustände bei Patienten mit schweren Persönlichkeitsstörungen

States of anxiety are very common problems in patients with severe personality disorders. All phenomena of anxiety can be observed. In this connection a continuum of the severity of impairment of structural personality organisation can be postulated. In many cases proper anxiety disorders exist as comorbid disorders. Anxiety is esteemed to be the central affective problem of borderline patients. In spite of these relations, states of anxiety in patients with personality disorders are often underdiagnosed or misdiagnosed. For the treatment of neurotic anxiety disorders (for example panic disorders), there exist disorder-specific therapy manuals that proceed from behavioural as well as psychodynamic perspectives. Nevertheless, for the treatment of anxiety states in personality disordered patients, the techniques that focus heavily on symptomatology appear often contraindicated. In our opinion, treatment of these typically severe anxieties must be contained within a therapeutic framework, which essentially takes into account the personality organisation of this group of patients. Such treatment makes special demands on the therapist for working with transference and countertransference processes. From a disorder-specific psychodynamic perspective recommendations are given for psychotherapy.     

Narzisstische Persönlichkeitsstörung

Narcissism is a multifaceted term which encompasses traits of normal personality as well as a specific personality disorder. While much research has been concerned with narcissism as a trait there are only few empirical studies on narcissistic personality disorder (NPS). The current diagnostic system of NPS according to DSM-5 (section II) focuses on grandiose narcissism whereas vulnerable narcissism, which is emphasized by clinicians and researchers, has not yet been recognized. While treating NPD patients an increased suicide risk has to be taken into consideration. Psychotherapy of narcissistic patients mainly focuses on processes during patient-therapist interactions, the analysis and processing of grandiose and vulnerable schemas, emotion regulation techniques and a correction of narcissistic behavior in favor of prosocial interactions.     

Therapiekonzeption für traumatisierte Patienten mit schweren Persönlichkeitsstörungen

Comorbidity between severe personality disorder and posttraumatic stress disorder is a frequent clinical problem. Severe personality disorders are characterized by an impaired regulation of emotions, a low mentalization capacity and deficits in personality integration. For severe personality disorders and posttraumatic stress disorder, a variety of evidence-based treatment approaches of psychodynamic and cognitive-behavioral origin are available. However, a closer inspection of these treatment concepts shows that they do not sufficiently take the respective comorbid condition into account. No single concept is able to cover all problem areas presented by patients with this comorbidity. Therefore, an attempt is made to present an integrative psychodynamically oriented therapy concept for traumatized patients with personality disorders which contains elements from psychodynamic, cognitive-behavioral and other concepts. The phase structure of the concept clarifies the sequence hierarchy of the therapeutic interventions. The content of the five phases are: (1) safety, holding and strengthening of coping capacities, (2) emotion regulation and self-care, (3) mentalization and development of stable representations, (4) gentle trauma processing and (5) conflict-oriented psychotherapy and treatment of maladaptive relationship patterns.     

Persönlichkeitsstörung und Intelligenzminderung

There have previously been only few objective investigations on the combined occurrence of intellectual disability and personality disorder. Despite this difficulty, from the current clinical viewpoint there is no doubt that at least people with mild intellectual disability can also develop personality disorders. In slight degrees of intellectual disability it is possible to psychopathologically describe the typical symptoms objectively. For the disorder symptomatic of combined personality disorder in people with an intellectual disability, there are no confirmed facts, publications or diagnostic rules. The diagnostic assignment of behavioral abnormalites as combined personality disorder with dependent and infantile components in people with intellectual diasabilities still does not seem to be justified. In people with medium to severe mental disorders only the comprehensive term “behavioral abnormalities” should be applied.     

Wie wirksam sind psychoanalytisch orientierte Therapie und Verhaltenstherapie bei Persönlichkeitsstörungen?

This meta-analysis adresses the effectiveness of psychodynamic therapy and cognitive-behavioral therapy in personality disorders. Included were 14 studies of psychodynamic therapy and 11 studies of cognitive-behavioral therapy from 1974 to 2001. There is evidence that both psychodynamic therapy and cognitive-behavioral therapy are effective treatments of personality disorders. As the number of studies that could be included in this meta-analysis was limited, the conclusions that can be drawn are only preliminary. Further studies which examine specific forms of psychotherapy in specific types of personality disorders using criteria of core psychopathology are necessary. Both longer periods of treatment and follow-up studies should be included.