TREATMENT OF PERSONALITY DISORDERS

TREATMENT OF PERSONALITY DISORDERS

TREATMENT OF PERSONALITY DISORDERS Edited by Jan Derksen University of Nijmegen Nijmegen, The Netherlands and Free University of Brussels Brussels, Belgium Cesare Maffei Vita-Salute San Raffaele University and Scientific Institute San Raffaele Milan, Italy and Herman Groen Forensic Psychiatric Institute "Oldenkotte" Rekker, The Netherlands Springer Science+Business Media, LLC

Library of Congress Cataloging in PubHcation Data Treatment of personality disorders/edited by Jan Derksen, Cesare Maffei, and Herman Groen. p. cm. "Including contributions from the First European Congress on Disorders of Personality, held June 14-17, 1994, Nijmegen, The Netherlands, and the Second European Congress on Personality Disorders, held June 26-29, 1996, Milan, Italy"-T.p. verso. Includes bibliographical references and index. ISBN 978-1-4419-3326-3 ISBN 978-1-4757-6876-3 (ebook) DOI 10.1007/978-1-4757-6876-3 1. Personality disorders. I. Derksen, Jan, 1953- II. Maffei, Cesare, 1951- III. Groen, Herman. RC554.T72 1999 616.85'8-dc21 99-047601 Including contributions from the First European Congress on Disorders of Personality, held June 14-17, 1994, Nijmegen, The Netherlands, and the Second European Congress on Personality Disorders, held June 26-29, 1996, Milan, Italy ISBN 978-1-4419-3326 3 1999 Springer Science+Business Media New York Originally published by Kluwer AcademicIPlenum Publishers, New York in 1999 http://www.wkap.nl 10987654321 A C.I.P. record for this book is available from the Library of Congress All rights reserved No part of this book may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, microfilming, recording, or otherwise, without written permission from the Publisher

PREFACE It has been almost twenty years since DSM-III created a major shift in psychiatric classification procedures and in diagnostic and treatment practice by introducing the multi-axial system and, for our patients specifically, the Axis II: Personality Disorders. Researchers and clinicians were forced to focus on many issues related to the field of personality and its disorders. This meant an immense impetus for research, both empirical and theoretical. Many recent developments are described in this book, as reviews or as original articles. This book also covers developments in Europe as well as in North America. Important questions still remain unanswered, such as: What is the relationship between the different clusters: A, B, & C? Are we talking about dimensions, categories, or typologies? What can be done for patients who have more than one personality disorder? Is a pro typical approach required? Consequently, is a multiconceptual approach in treatment and research required? The authors contribute to this discussion and provide guidelines for further thinking in research and treatment planning. For clinicians, it is of major importance to know whether the disorder can be influenced by treatment, and whether permanent change is really possible. A very important question is whether a person indeed has a personality disorder, and how this diagnosis affects clinical practice. We have to differentiate between the genotypical and phenotypical, between biological and psychological, nature and nurture, trait and state. Differentiation implies the use of diagnostic procedures, which as you will find, are promising. It also implies different treatment strategies, depending on the phase of treatment for the same disorder, and the orientation of the therapist. Accurate diagnoses can allow us to distinguish between different treatment strategies for various disorders. Within the framework of a DSM personality disorder, further differentiation then becomes possible. For example, good diagnostic procedures will allow distinction between an impulsive and a dissociative borderline personality disorder. Research is suggesting the first might better be influenced by biological! psychopharmacological treatment, and the latter by focusing in a cognitive or psychodynamic way on early childhood (sexual) trauma. It is also important to find out whether the symptomatology we meet in clinical practice is caused by the personality disorder itself, (an Axis I disorder) or whether this is the result of the interaction between the two, complicated by problems and dysfunctioning on Axes IV and V. v

vi Preface Once we have established an accurate diagnosis, we can offer a range of treatments, simultaneously or separately: psychopharmacological treatment together with psychoanalytical and/or cognitive treatment. Given the state of the art of the psychobiological foundations involved, we analyze genetics, with a view to finding out how the carriers of our existence influence our being. TIle genetic loading can explain some, but not all of the characteristics influencing personality disorders. This has implications for biological research, especially when foeuse d on treatment and in examining the psychobiology of personality disorders. If we accept that phenotypical characteristics represent the same genetic pattern as influenced by its environment, and if we accept that the relevant environment for human species is not only biological but also psychological, then psychobiology gets a far more existential meaning and therefore is of great interest to clinicians and researchers interested in personality disorders from all perspectives. Within this genotypical/phenotypical perspective, considerations on the psychological foundations of development and psychodynamic research will become dynamic in itself. Attachment and the development of the self, vis-a-vis the disorders of personality, is of great importance, as is the occurrence of psychological, sexual, and physical trauma in early childhood. These issues are of clinical importance because human beings grow through childhood and adolescence and beyond. As is shown by PETscanning even the brain can change functionally through psychological treatment. So we are not a victim of our genes and the phenotypical outlook created in childhood. Even with animals, this is not the case. It is important for researchers and clinicians to decide on which position to take. This position should be clear so that patients are aware of how their therapist views their disorcer, and what outcomes for treatment are perceived. Consequently, our therapeutic acts are affected by this position. Categorical thinking almost always introduces the handicap model; dimensional and typological thinking creates room for optimism with possible change from severe to less severe. We have created an empirical and theoretical framework, aware that we were not primarily interested in conceptual answers to questions such as: Is a personality disorder defined by 5, 9, 12... factors? Are personality disorders within the continuum of Axis I disorders and therefore, by definition an Axis 1 disorder? among others. We created a framework for clinical practice, trying to give clinicians a colorful background on which basis they might be better able to give their work more depth using innovative and creative therapies for these complex patients and their psychopathologies. We think that with more alternative approaches, treatment will be less frustrating. One should and cannot adhere to one ideology, especially not with the very serious, rigid, personality-disordered patient. Such a patient does, with respect to his psychopathology, everything possible to preserve his homeostasis; not doing so is fearful, as well as dangerous because of the lack of other possibilities in feelings and behavior. Finding a way, creating a safe, holding environment, requires flexibility. There is no final advice, nor concluding remarks, because we think that the theoretical orientation and the way the therapist is trained, is too diverse throughout Europe as well as throughout North America. Instead, the framework that we have created, consisting of elements/modules for each individual patient is to be used by every individual therapist according to his own frame of reference. Jan Derksen Cesare Maffei Herman Groen

CONTENTS Part I: Biological Foundations of Personality Disorders 1. Genetics of Personality Disorders... 1 Svenn Torgersen and Marco Battaglia 2. Psychobiology of Personality Disorders: Implications for the Clinic 17 Larry 1. Siever 3. The Implications of Recent Research on the Etiology and Stability of Personality and Personality Disorder for Treatment... 25 W. John Livesley Part II: Psychological Foundations of Personality Disorders 4. Psychodynamic Research Can Help Us to Improve Diagnosis and Therapy for Personality Disorders: The Case of Defense Mechanisms... ' 39 1. Christopher Perry, Vittorio Lingiardi, and Floriana Ianni 5. Attachment, the Development of the Self, and Its Pathology in Personality Disorders... 53 Peter Fonagy 6. Trauma and Personality... 69 Fabio Madeddu and Adolfo Pazzagli 7. Adolescence and Personality Disorders: Current Perspectives on a Controversial Problem... 77 Enrico de Vito, Fran~ois Ladame, and Alvise Orlandini Part III: Diagnostic Models of Personality Disorders 8. Integrative Perspectives on the Personality Disorders Theodore Millon 97 vii

viii Contents 9. A Multidimensional Approach to Personality Disorders and Their Treatment... 107 Joel Paris 10. The Structure of DSM-IV Borderline Personality Disorder and Its Implications for Treatment... 119 Cesare Maffei and Andrea Fossati 11. The Relationship between Anxiety Disorders and Personality Disorders: Prevalence Rates and Comorbidity Models... 129 Carol 1. M. Van Velzen and Paul M. G. Emmelkamp Part IV: Treatment of Personality Disorders 12. Psychodiagnostics and Indications for Treatment in Cases of Personality Disorder: Some Pitfalls... 155 1. Derksen and H. Sloore 13. The Psychotherapeutic Treatment of Borderline Patients Otto F. Kernberg 167 14. Functional Analysis of Borderline Personality Disorder Behavioral Criterion Patterns: Links to Treatment... 183 Jennifer Waltz and Marsha M. Linehan 15. Psychopharmacological Treatment of Personality Disorders: A Review 207 Peter Moleman, Karin van Dam, and Veron Dings 16. New Drugs in the Treatment of Borderline Personality Disorder... 229 F. Benedetti, C. Colombo, L. Sforzini, C. Maffei, and E. Smeraldi 17. The Narcissistic Personality Disorder and Addiction.................. 241 PerVaglum 18. Pharmacotherapy for Patients with Personality Disorders: Experiences from a Group Analytic Treatment Program..................... 255 S. Friis, T. Wilberg, T. Dammen, and 0. Urnes 19. A New Interpersonal Theory and the Treatment of Dependent Personality Disorder... 269 John Birtchnell and Giuseppe Borgherini 20. HIV Infection, Personality Structure, and Psychotherapeutic Treatment... 289 R. Visintini, E. Campanini, A. Ama, R. Alcorn, S. Corbella, S. Gessler, D. Miller, L. Nilsson Schonnesson, and F. Staracel Index 305