Management of Severe
Personality Disorders
Dr. J. S. Parker
OPD
Lentegeur Hospital and UCT Dept of
Psychiatry and Mental Health
John.parker@westerncape.gov.za
Some General Principles
• Recognition is Key
• Managing oneself - mindfulness
• Developing the therapeutic alliance:
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Exploring diagnosis
Implications and risks
MI and PST
Metaphor
• Setting and securing the boundaries
• Playing the long game
Personality Disorder
• Defn: Patterns of inflexible and maladaptive traits
that cause subjective distress or significant
impairment in social or occupational functioning
or both.
• Foster vicious cycles
• Deviate markedly from cultural norms
• Generally safer to talk about “traits” than a
personality disorder
• Considered enduring and pervasive rather than
episodic
• DSM IV: Axis II but DSM V mono-axial system
DSM V
• Attempt at hybrid dimensional/categorical
approach abandoned at the last minute as
“too complicated”, but retained in section
III for reference
• New approach retained 6 types: Borderline,
Antisocial, Narcissistic, Avoidant, O-C and
Schizotypal
• New: Personality Disorder -Trait Specified,
allows for recognition of mixed traits
DSM V (cont)
• Reliability studies done on clinical
populations rather than general population
• Borderline PD criteria found to be highly
reliable, OCPD and ASPD found to be “of
questionable reliability”, insufficient
numbers for other studies
• Single axis
ICD 10
• Specific: Paranoid; Schizoid; Dissocial;
Emotionally Unstable (impulsive &
borderline types); Histrionic; Anankastic;
Anxious (avoidant); Dependent; Other
• Mixed disorders
• Enduring personality changes
DSM: Personality Disorder
Clusters
• A. “odd and eccentric”- Paranoid; Schizoid;
Schizotypal
• B. “dramatic; emotional and egocentric”Antisocial; Borderline; Histrionic;
Narcissistic
• C. “anxious and fearful”- Avoidant;
Dependant; Obsessive-Compulsive
Paranoid
• A pervasive mistrust and
suspiciousness of others .
• Suspects others are
exploiting them.
• Doubts the loyalty of
friends.
• Reluctant to confide in
others.
• Bears grudges
• Feels attacked by others
and reacts to this
• Suspects partner of
unfaithfulness.
Paranoid PD
• NB to establish a trusting and non-threatening relationship:
formal, honest and professional discussion.
• Caution! Avoid being too friendly, too warm or too
humorous, expect accusations and belittling comments.
• Avoid direct confrontation, MI and problem solving
techniques very useful
• CBT and Schema-based therapy
Schizoid PD
• Detachment from
relationships
• Restricted range of affect
• Few close friends
• Little sexual interest
• “Loner by choice”
• Allow space
• Avoid over-involvement
• Relatives often need
reassurance
• Exclude schizophrenia
Schizotypal PD
• Acute discomfort with
close relationships
• Cognitive or perceptual
distortions or
eccentricities of behaviour
• Ideas of reference
• Odd beliefs, thinking,
speech and affect
• Eccentric appearance opr
behaviour
• Differentiate from
schizophrenia
• Relatives may need advice
and reassurance
• NB! Cultural context
Antisocial PD
A pervasive pattern of
disregard for and
violation of the rights
of others.
Repeated acts that are
grounds for arrest
Deceitful, impulsive,
irritable and aggressive
Reckless
Irresponsible
Lack remorse
Conduct disorder
before age 15
Antisocial PD
• “Psychopath”: charm; intelligence; egocentric;
exploitative; lack remorse
• Malingering; substance abuse
• NB! Identify early: focus on parenting skills,
problem solving, emotional awareness, improved
self-concept, control of arousal and emotions
• Caution! Firm boundaries.
Borderline PD
• A pervasive pattern of instability of interpersonal
relationships, self-image and affects, and marked
impulsivity
• Abandonment issues
• Unstable and intense relationships
• Identity disturbance
• Impulsivity
• Suicidal behavior
• Affective instability
• Chronic feelings of emptiness
• Inappropriate anger
• Transient paranoia or dissociation under stress
(“micropsychotic episodes”)
Borderline PD
Borderline PD: Management
• Beware of idealization, be realistic about treatment
targets as well as risks and side effects.
• A cautious, structured approach, maximising
collaboration is key.
• Treat presenting pathology
• BUT: Know what you are dealing with, avoid “red
herrings” eg. “depression” “voices in the head”
• Be honest, consistent and non-judgmental
• Long-term perspective – NO QUICK FIXES
• BALANCE
Borderline PD: Treatment
• Pharmacotherapy (adjunct)
– Cochrane Review (2010):SSRI’s not recommended for
as first choice for affective dysregulation &
impulsivity, nor low dose antipsychotics for cognitiveperceptual symptoms
– SSRI only for MDD
– Affective dysregulation: topiramate, valproate,
lamotrigine, aripiprazole, olanzapine & haloperidol
– Impulsive-behavioural: lamotrigine & topiramate,
omega-3 fats, flupenthixol; aripiprazole
– Cognitive-perceptual: olanzapine, aripiprazole
– Self mutilation and suicidal behaviour: none.
Olanzapine unfavourable effect
Borderline PD: Treatment
• Psychotherapy (Mainstay) :
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DBT : suicide and affective dysregulation
Transference-based psychotherapy
Mentalization-based psychotherapy
Schema-focussed therapy
– General Principles
• Focus on patient-therapist relationship in the “here and now”
• Utilize countertransference to explore relationship
• Educate patients to recognise their affective reactions and what
triggers them
• Connect actions with thoughts and feelings, both their own and
others
(Kernberg; 2009)
Histrionic PD
• Excessive emotionality and
attention seeking
• Needs to be the center of attention
• Seductive or provocative
• Rapidly shifting, shallow expressed
emotions
• Uses physical appearance to draw
attention to self
• Impressionistic style of speech
• Exaggerates emotions
• Exaggerates intimacy of
relationships
• Need long-term consistent support
• NB when relationships lost
• Vulnerable to abuse
Narcissistic PD
• Grandiosity, need for
admiration and lack of
empathy.
• Self important
• Fantasies of unlimited
success
• Believes is special
• Requires excessive
admiration
• Sense of entitlement
• Arrogant and exploitative
• Lacks empathy
Narcissistic PD
• Persona a shield for internal vulnerability and
dysregulation. Can be powerfully expressed or a
more muted perfectionism.
• Relationship problems
• Substance abuse
• Mid-later life crises when no longer able to satisfy
inflated sense of self
• Depression
• Suicide
• Psychotherapy may be helpful but “need to be
ready”
Narcissistic PD
• Alliance building early on
is key - Flexible!
• Attention to motivational
focus, clarification of
experiences and
formulation of difficulties
• Must accommodate
difficulty with selfreflection, affect tolerance
and regulation of selfesteem
Dependent PD
•Need to be taken care of
•Excessive need for
support/nurturance
•Submissive and clingy
•Struggles to take initiative,
responsibility or to disagree
•Uncomfortable alone
•Preoccupied with fear of being
left alone
• Anxiety disorders and depression common, especially after
separation
• Vulnerable to abusive relationships
• Common pathology in stalkers
• Need long term support and structure
• CBT
Avoidant PD
•“Left out”
•Social inhibition, feelings of
inadequacy; hypersensitivity to
criticism
•Avoids people, relationships,
exposure, risks
•Views self as inept, unappealing or
inferior
•Preoccupied with rejection/ridicule
• Probably on a spectrum with social phobia.
• CBT
• SSRI’s, SNRI and RIMA’s
Obsessive-compulsive PD
• Order, perfection and control
at the expense of flexibility,
openness and efficiency
• Preoccupied with rules and
lists
• Inflexible moralists
• Cannot discard objects
• Excessively devoted to work
• Can be rigid and stubborn
•Thorough approach but NB to avoid focus on uncertainties and
variables
•Treat anxiety: psychotherapy; SSRI
Motivational Interviewing
1. Ask for permission to discuss the problem – raise
awareness
2. Elicit talk about change. Evoke ideas of advantages and
disadvantages of change possibilities and taking the first
step.
3. Importance check - rate readiness to change (scale: 1-10).
(Reinforces talk about change)
4. Ability check (1-10) (assess pt’s confidence in ability to
change and elicits possible barriers.)
5. End with summary of discussion points, what has been
agreed and what remains uncertain.
Problem Solving
1. Identify the problem. Specify and define.
2. Consider multiple solutions – brainstorm all possible
alternatives
3. Look at pros and cons and choose most suitable solutions.
4. Seek commitment with specific details (eg By when?)
5. Summarise and schedule follow up, acknowledging that
further barriers may be encountered and that solutions for
these will also be found.
Resources
• Valkenberg Hospital OPD: Tel 021
4403100
• Valkenberg Ward 1: Tel 021 4403100
• Lentegeur Hospital OPD: 0213701430
• Lentegeur Hospital Pathways (Wd 15):
0213701132
• Stikland Hospital: 0219404400