In episode 99 of the Psychcast, Frank Yeomans, MD, PhD, clinical associate professor of psychiatry at the Weill Medical College of Cornell University, Ithaca, N.Y., spoke with Dr. Norris at the Group for the Advancement of Psychiatry (GAP) fall 2019 meeting about treating patients with personality disorders.

Characteristics of personality disorders

• A personality disorder affects the quality of a person’s experience and his or her ability to deal with challenges in life, including comorbid psychiatric disorders. A personality disorder is not based on symptoms alone and determines how people engage with their environment; it is a part of the biological side of psychiatry.
• The DSM traditionally relied on a traits-based definition of personality disorders. Yet, in the “emerging measures and models” section, the DSM-5 describes a dimensional/categorical model of personality disorders, which looks at personality disorders as combinations of core impairments in personality functioning with specific configurations of problematic personality traits. This harkens back to the concept of borderline personality organization as outlined by Otto F. Kernberg, MD.
• The dimensional model suggests that individuals with personality disorders benefit from behavioral therapies, such as cognitive-behavioral therapy (CBT) and dialectical behavior therapy (DBT), to treat problematic traits. Exploratory and insight-focused psychotherapies can help individuals understand their personality organization. Ideally, the treatments for personality disorders would be sequenced, starting with CBT or DBT and transitioning into exploratory therapy.
  • Much like borderline personality disorder, at the core of narcissistic personality disorder is a fragmented sense of self, but in the latter disorder, a self-centered narrative exists that is coherent to the person but does not support reality. If mental health is defined as the ability to adapt to the different circumstances of life, people with narcissism cannot adapt and instead, develop a grandiose narrative to soothe the fragmented self.
    • Therapeutic interventions for narcissism focus on disrupting the narrative in a gentle way that allows patients to understand the model in which they currently experience the world and then reconstitute an adaptive narrative.
  • An effective treatment approach is psychodynamic therapy, with a focus on a treatment contract and specific, explicitly agreed-upon goals. Try to focus more on the interaction with the patient than on the narrative content of the session. The therapy must focused on how the patient acts in therapy, and their adaptations and reactions, because these are the actions that negatively affect their relationships and daily lives.
  • The biological part of a person is processed at the psychological level, so psychiatrists must be interested in psychological aspects of treatment.

References

Sharp C et al. The structure of personality pathology: Both general ('G') and specific ('S') factors? Abnorm Psychol. 2015 May;124(2):387-98.

Gunderson JG. Borderline personality disorder: Ontogeny of a diagnosis. Am J Psychiatry. 2009 May 1;166(5):530-9.

Caligor E et al. Narcissistic personality disorder: Diagnostic and clinical challenges. Am J Psychiatry. 2015 May;172(5):415-22.

Morey LC et al. Personality disorders in DSM-5: Emerging research on the alternative model. Curr Psychiatry Rep. 2015 Apr;17(4):558.

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