Jan 22, 2020
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
- 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
- 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.
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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