Psychotherapy for Personality Disorders

Psychotherapy for Personality Disorders is a slim volume put out by the American Psychiatric Press as part of its Review of Psychiatry series. At first glance is seems too slim, given the amount that has been written about the treatment of these disorders. In professional books, I tend to look for the thick ones, assuming (immodestly) that for me to learn something new takes a lot more words. However, this book is a pleasant (and educational surprise).

The book is comprised of five chapters on different topics. Of these, I was most impressed with the first three. Chapter One focuses on the empirical studies of psychotherapy for personality disorders. It reviews the literature addressing several critical questions, including: (1) Does psychotherapy result in significant improvement? (2) Do some diagnoses respond to treatment better than others? (3) What changes occur during and after psychotherapy? The author's conclusions are hopeful-yes, psychotherapy works, to oversimplify. They also provide an object lesson to those who would like to advance the field. This lesson is that our research on treatment is inadequate in both quality and quantity.

Chapter Two focuses on psychotherapy for borderline personality disorder. Gunderson provides a thoughtful review of the treatment of these patients. He reviews the characteristics of both patient and therapist that contribute to the success of therapy, discusses the therapeutic alliance and outlines various phases of the treatment across time. I especially appreciated Gunderson's use of tables to summarize key points. His making a distinction between therapy and case management made me rethink the nature of the care I provide in treatment. Borderline patients are among the most challenging for therapists and access to a review such as this may be used by an experienced therapist who needs to reconsider his or her management of a difficult patient or by a trainee who is encountering such patients for the first time.

In Chapter Three, Glen Gabbard provides a similarly fine review of the issues related to combining medication with psychotherapy. As he points out, when treating personality disordered patients, the psychiatrist has to be constantly mindful of what he is prescribing and why. His approach to breaking down the reasoning behind prescribing to the personality disordered individual and reference to the literature to support such use is quite helpful.

I was less content with the final two chapters. The chapter on antisocial personality disorder did a nice job of breaking down this disorder into components related to treatability, but did little to encourage one to take on such a patient. Whereas the tone of the previous chapters was to educate the reader on how to treat, this chapter focused on who to treat. This is likely due to the limitations of the field, but the overall message is except for mild cases, don't bother.

Likewise, the final chapter could have been better developed and was not up to the promise of the first three chapters. It did not do justice to the promise of cognitive therapy in the treatment of personality disorders. Apparently a decision was made not to include dialectical behavioral therapy (DBT) in this volume. Although not technically a cognitive behavioral therapy, including an update on the latest data on the use of DBT would have greatly enhanced the last chapter.

Overall, despite the above complaints, I would definitely recommend this volume. It is quickly read, which is helpful to the busy clinician and trainee. Nonetheless, there is enough substance to make the reading worthwhile. The references can provide more specific information as needed. This book is clearly written for a professional audience and would likely have little appeal to other readers.

Shara L. Kronmal writes about herself:

I am a Child and Adolescent Psychiatrist with an interest in depressive and anxiety disorders in children, teens and adults. I have an outpatient practice of psychotherapy and medication management through MacNeal Hospital in Berwyn, Illinois. I received my M.D. and Ph.D. (in Molecular Genetics and Cell Biology) from the University of Chicago and completed residency and fellowship training in Psychiatry and Child and Adolescent Psychiatry at the University of Illinois at Chicago. I am an avid reader, hence my interest in the Metapsychology web site.

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