Motivation for treatment in patients with personality disorders

The primary objective of the present study is to investigate the association between DSM-IV personality disorders and motivation for treatment in a large sample of patients admitting for a variety of psychotherapeutic programs (n = 1083). Second, we examine whether and to what extent this association is accounted for by other relevant patient variables (i.e., demographics, subjective distress, and treatment history). We developed a brief questionnaire to measure the motivation for treatment: the Motivation for Treatment Questionnaire (MTQ-8). The MTQ-8 consists of two subscales, i.e., Need for help and Readiness to change. The results show that patients with various personality disorders were significantly more motivated for treatment than those without. No differences across specific personality disorders were apparent. The association between personality disorders and motivation for treatment appeared to be partly accounted for by the level of symptom distress. It is concluded that, among treatment-seeking patients, personality disorders are associated with motivation for treatment and this association can best be understood by the higher symptom distress in patients with personality disorders as compared to those without personality disorders.     

Outpatient group psychotherapy following day treatment for patients with personality disorders

This prospective, naturalistic study evaluated the practice and effectiveness of an outpatient group therapy program following day treatment for patients with personality disorders (PDs). One hundred and eighty-seven patients (86% patients with PDs and 14% with no PDs), were treated in outpatient psychodynamic group therapy. Outcome was assessed by Global Assessment of Functioning, Symptom Check List 90-R, and Inventory of Interpersonal Problems-Circumplex, short version, at admission and discharge from day treatment, and at the end of outpatient group therapy. Average length of outpatient therapy was 24 months. Forty-three percent terminated in an irregular manner. Outcome of the continuation therapy was satisfactory for patients without PDs. For PD patients, the improvement from the day treatment was maintained during outpatient therapy, but further improvements were modest for symptoms and interpersonal distress, somewhat better for global functioning. Implications for further treatment development are discussed.     

The relationship between comorbid personality disorders and treatment received in patients with anxiety disorders

Few studies have addressed the relationship between the presence of a comorbid personality disorder and the amount of psychiatric treatment received by patients with an Axis I disorder. This issue has not been studied in patients with anxiety disorders. In a prospective, naturalistic, longitudinal study of anxiety disorders, 526 subjects were assessed with the Personality Disorder Examination, and types of treatment received in 1991 and 1996 were identified. In 1991, compared to subjects without a personality disorder, subjects with a personality disorder were as likely to receive medication and they received a greater number of medications. Subjects with borderline personality disorder were more likely to receive heterocyclic antidepressants and interventions characteristic of psychodynamic psychotherapy and cognitive therapy; they also reported receiving a greater number of medications and types of psychosocial treatment than other subjects. In 1996, subjects with borderline personality disorder were more likely to receive psychodynamic interventions. These findings suggest that in patients with an anxiety disorder, the presence of a comorbid personality disorder is associated with receiving a greater number of medications but not with a greater likelihood of receiving pharmacologic or psychosocial treatment. However, the presence of borderline personality disorder is associated with a greater likelihood of receiving, and receiving a greater number of, certain types of somatic and psychosocial treatments.     

Relationship between patient characteristics and treatment allocation for patients with personality disorders

Within a large multi-center study in patients with personality disorders, we investigated the relationship between patient characteristics and treatment allocation. Personality pathology, symptom distress, treatment history, motivational factors, and sociodemographics were measured at intake in 923 patients, who subsequently enrolled in short-term or long-term outpatient, day hospital, or inpatient psychotherapy for personality pathology. Logistic regressions were used to examine the predictors of allocation decisions. We found a moderate relationship (R(2) = 0.36) between patient characteristics and treatment setting, and a weak relationship (R(2) = 0.18) between patient characteristics and treatment duration. The most prominent predictors for setting were: symptom distress, cluster C personality pathology, level of identity integration, treatment history, motivation, and parental responsibility. For duration the most prominent predictor was age. We conclude from this study that, in addition to pathology and motivation factors, sociodemographics and treatment history are related to treatment allocation in clinical practice.     

Negative life experiences and the development of cluster C personality disorders: a cognitive perspective

Early negative experiences have long been thought to play an important role in the development of personality disorders. Most of the literature regarding these early life experiences has focused on borderline personality disorder, with only occasional focus on other personality disorders. Utilizing cognitive theory of personality disorders (Beck et al., 2004), the authors conceptualize cluster C personality disorders (avoidant, dependent, and obsessive-compulsive). They then critically review the relevant literature on early negative life experiences and later development of these disorders to determine whether the theory is supported by the empirical data. The theory regarding avoidant and dependent personality disorders has limited support, whereas data relating to obsessive-compulsive personality disorder are much weaker. Implications and future research suggestions are discussed.     

Psychotherapy integration in the treatment of personality disorders: a commentary

Whereas research on the treatment of personality disorders over the past several decades has focused primarily on comparing the efficacy of various treatment packages associated with different theoretical models, there is increasing evidence that the field would benefit from focusing more attention on developing integrative treatments that are both informed by research and capable of scientific verification. The articles assembled for this special section each propose a different approach to integrative treatment for personality disorders. In this commentary, we outline a number of reasons for making such a shift to more integrative treatments, consider some of the potential challenges to integration, and discuss the different approaches to integration illustrated in these articles. We highlight some of the difficult tradeoffs that must be made in developing an integrative approach and discuss similarities and differences in the response to such challenges by the contributors to this special section. Finally, we point to several areas for future research that we believe will contribute to the development of increasingly effective treatments for individuals with personality disorders.     

Dangerous and severe personality disorders: a new personality concept from the United Kingdom

In 1998, we in England were shocked by the apparently motiveless murders of a mother and two of her children when they were traveling home from school in a rural area. Subsequently a patient with personality disorder, being monitored by the forensic psychiatric services, was convicted of their murders. The government was determined to prevent this type of offense from recurring and in 1999 introduced a new concept, dangerous and severe personality disorder (DSPD). This subsequently became a treatment and assessment program for individuals who satisfy three requirements: (1) have a severe disorder of personality, (2) present a significant risk of causing serious physical or psychological harm from which the victim would find it difficult or impossible to recover, and (3) the risk of offending should be functionally linked to the personality disorder. The implications of this program are discussed with regard to international systems of classification and service provision. We also attempt to place DSPD in the wider context of psychiatric participation in the management of personality disordered offenders.     

Longitudinal studies of personality disorders: four lessons from personality psychology

The three longitudinal projects described in this special section of the Journal of Personality Disorders raise a number of intriguing questions concerning the natural history of personality disorders and offer more than their share of surprises. In addition, they underscore several valuable lessons derived from the literature on normal-range personality traits. Drawing in part from the writings of the American trait psychologist Gordon Allport, I describe four such lessons: (1) change and continuity of personality traits and disorders can and do coexist, (2) the covariation among personality traits helps to account for the "comorbidity" among personality disorders, (3) personality traits and disorders influence how individuals interpret life events, and (4) personality traits must be distinguished from behavioral adaptations to these traits. These lessons remind us that the science of personality disorders must be informed by the basic science of personality.     

A developmental perspective on personality disorders: lessons from research on normal personality development in childhood and adolescence

Recent work on normal personality development in children and adolescents points to several conclusions that are relevant for understanding personality pathology. First, child temperament and adult personality traits share many features in common. Second, youths' individual differences can be described in terms of the Big Five personality traits observed in adults; an integrative taxonomy of individual differences in childhood and adolescence is articulated in this article. Third, personality is already moderately stable by the preschool years, but considerable personality change occurs well into the adult years. Taken together, these findings suggest that childhood personality functioning can and should be integrated into developmental research and applied work on personality disorders.     

Beliefs in personality disorders: a test with the personality disorder belief questionnaire

The hypothesis that each personality disorder (PD) is characterized by a specific set of beliefs was tested in a sample of 643 subjects, including non-patient controls, axis-I and axis-II patients, diagnosed with SCID-I and -II interviews. Beliefs of six PDs (avoidant, dependent, obsessive-compulsive, paranoid, histrionic, borderline) were assessed with the Personality Disorder Belief Questionnaire (PDBQ). Factor analyses supported the existence of six hypothesized sets of beliefs. Structural equation modeling (SEM) supported the hypothesis that each PD is characterized by a specific set of beliefs. Path coefficients were however in the medium range, suggesting that PDs are not solely determined by beliefs. Nevertheless, empirically derived cutoff scores of the six belief subscales were reasonably successful in classifying subjects, percentages ranging form 51% to 83%. It appeared that there was a monotonical increase in scores on each belief subscale from non-patient controls, to patients without any PD, to patients with PDs (other than the pertinent PD), to patients with the pertinent PD. This suggests that PD-related beliefs are at least partly associated with (personality) psychopathology in general. Another explanation is that many patients' position on the underlying dimensions is not high enough to lead to a DSM PD diagnosis, but high enough to lead to an elevated belief score.     

Self-esteem in patients with borderline and avoidant personality disorders

This study compared self-esteem in patients with avoidant personality disorder (APD) and borderline personality disorder (BPD). Patients diagnosed with one or more personality disorders answered the questionnaire Index of Self Esteem as part of a comprehensive evaluation within the setting of a treatment trial. Our hypotheses were that (1) both patients with APD and patients with BPD would report low levels of self-esteem, (2) patients with APD would report lower self-esteem than patients with BPD. We further expected that (3) patients with higher levels of depression would report lower levels of self-esteem, but that (4) both borderline and avoidant personality pathology would contribute to explained variance in self-esteem beyond what would be accounted for by depression. All of our hypotheses were supported. The results from our study showed a significant difference in self-esteem level between the two personality disorders, patients with APD reporting lower self-esteem than patients with BPD. Subjects with both disorders were measured to have self-esteem levels within the range that presumes clinical problems. Self-esteem represents an important quality of subjective experience of the self, and the study of self-esteem in PDs can offer new and important knowledge of PDs as self-pathology.     

Outcome and epidemiological research on personality disorders: implications for classification

The construct of personality disorder has an overall definition that describes chronicity. However, the findings of outcome research indicate that while many patients stop meeting criteria for specific categories of disorder over time, they often continue to suffer from dysfunctional traits. One can also interpret epidemiological findings on personality disorders as overestimating disorders due to a failure to distinguish them from traits. Taken together, these findings point to the need for a revision of the classification of personality disorders that would separate enduring traits from reversible symptoms.     

Diagnosis of personality disorders: a case study

In this article, I report a case highlighting diagnostic uncertainty about psychopathology on both Axes I and II. It concerns in part the problem of comorbidity in relation to diagnostic classification of Axis II personality disorders. After commenting on these uncertainties in relation to categorical and dimensional models, I also consider a psychoanalytic explanation to illustrate an example in which a theoretical model informs diagnostic interviewing. I emphasize how the clinical information that unfolds from an interview based on this theoretical model generates inferences about psychopathology that extend clinical understanding beyond the formal diagnostic assessment of Axes I and II disorders and assessment by self-report.     

Progress and innovation: personality disorders and the vanguard of psychopathology research

Important progress in our understanding of the natural course of personality disorders (PDs) is documented in the articles for this special section. This progress could set the stage for ideas developed in the study of PDs to play a central role in research on psychopathology more broadly conceived. The Collaborative Longitudinal Personality Disorders Study (Skodol et al., this issue), the Children in the Community Study (Cohen, Crawford, Johnson, & Kasen, this issue), and the McLean Study of Adult Development (Zanarini, Frankenburg, Hennen, Reich, & Silk, this issue) reveal the importance of personality in understanding psychopathology, and point toward a dimensional approach to conceptualizing psychopathology that could also frame categorical clinical decision making processes.     

Cognitive coping and defense styles in patients with personality disorders

This study investigates the associations between cognitive coping (as measured with the Cognitive Emotion Regulation Questionnaire; CERQ), defense mechanisms (as measured with the Defense Style Questionnaire-60; DSQ-60) and personality disorders (PDs; as measured with the SIDP-IV interview) in a large sample of patients with PDs (n = 1,435). Explorative factor analyses indicated that the nine CERQ subscales can be clustered into three higher-order factors (adaptive coping, non-adaptive coping and external attribution style). When compared to a general population sample, the PD sample particularly scored higher on nonadaptive coping styles. A higher number of PDs was related to a particularly higher level of nonadaptive coping and less mature defensive functioning, but also to lower levels of adaptive coping and external attribution. This study is the first to suggest that three higher-order coping styles can be identified among PD patients, and that these coping styles are related to the presence and number of PDs.     

Pathological gambling and personality disorders: a pilot-study with the MCMI-II

In this paper, the most frequent personality disorders related to pathological gambling are described. A sample of 50 pathological gamblers, who were assessed with the MCMI-II before treatment, and of 50 normative subjects from general population with the same demographic features (age, sex and socioeconomic level) was selected. According to the results, the 40% of clinical sample (versus the 14% of normative sample) showed at least one personality disorder. The most prevalent one was the Narcissistic (32%), followed by the Antisocial and Passive-Aggressive (16% each one of them). Furthermore, the gamblers with personality disorders presented an average of 2.2 disorders and tended to be more impulsive. Likewise pathological gamblers abused of alcohol, showed a mild anxiety and were not so adapted to everyday life as much as the control group. Finally, implications of this study for clinical practice and future research in this field are commented upon.     

Addicted patients with personality disorders: traits, schemas, and presenting problems

We evaluated the association of Structure Clinical Interview for the DSM-IV Axis II (SCID-II) severity and personality traits, early maladaptive schemas, and presenting symptoms in 41 methadone-maintained patients meeting criteria for either antisocial, borderline, avoidant, or depressive personality disorder. Correlational analyses indicated that the severity of each personality disorder was associated with a unique profile of presenting problems and underlying traits and schemas. The evaluation of multiple psychological indicators appears to be a useful method for case conceptualization and planning interventions within a promising individual therapy model that focuses both on substance abuse and psychiatric symptoms and maladaptive schemas and coping styles.     

The growing evidence for personality change in adulthood: Findings from research with personality inventories

Theories of adult development all agree that adulthood is a time of important changes in goals, resources, and coping. Yet, impressed with the rank-order stability of individual differences in personality, many researchers interested in personality traits and personality assessment doubt that personality changes in meaningful and systematic ways during adulthood. This article reviews large studies of mean-level change in personality characteristics measured with broad-band personality inventories, and includes both cross-sectional and cross-cohort longitudinal research. The results show considerable generalizability across samples, cohorts, and studies. In particular, people score higher with age on characteristics such as conscientiousness, agreeableness, and norm-adherence, and they score lower with age on social vitality. These findings provide evidence that personality does change during adulthood and that these changes are non-negligible in size, systematic, not necessarily linear, and theoretically important.