31st January 2024

Management

From a “Bio-Psycho-Social” perspective, managing disorders of the personality can be classified under 3 main strategies:

Psychotherapy

This is largely the treatment of choice for personality disorders. Psychotherapeutic interventions should be individualised to each patient. The main types of psychotherapeutic interventions are:

• Dialectical Behavioural Therapy (Marsha Linehan): Skills training and mindfulness.
• Cognitive Behavioural Therapy (Aaron Beck): Collaborative restructuring of unhelpful beliefs.
• Cognitive Analytical Therapy (Anthony Ryle): Combined CBT and analytic approaches.
• Mentalisation-Based Therapy (Antony Bateman): Mutual understanding of feelings and behaviour.
• Acceptance and Commitment Therapy (Steven Hayes and Robert Zettle): Structured acceptance and mindfulness.
• Schema-Focused Therapy (Jeffrey Young): Changing maladaptive patterns of feelings and behaviour.
• Transference-Focused Therapy (Otto Kernberg): Self-understanding in relationships.
• Systems Training for Emotional Predictability and Problem Solving “STEPPS” (Nancee Blum)
• Nidotherapy (Peter Tyrer): Environmental manipulation based on the fact that environment is critical in both helping and hindering the recovery of mental health illness.

Pharmacological Treatment

There are currently no licensed medications for treatment of any personality disorders. According to the UK NICE guidelines, drug treatment should be avoided except in crisis, and even then, it should only be for no more than a week. Despite that, in clinical practice, clinicians use a wide range of psychotropic medications for managing symptoms of personality disorders. It is, however, acceptable and, in fact, mandatory to use medications to treat comorbidities. The range of medications used for treatment of comorbid disorders are antidepressants, antipsychotics, mood stabilisers and anxiolytics.

Lifestyle Changes 

Like any other psychiatric (or physical health) disorder, lifestyle modifications are key to management and symptom control. 

• Physical exercises
• Sleep training/interventions
• Addressing smoking, alcohol and substance misuse
•  Maintaining a healthy and balanced diet

References

• Tyrer P, Mulder R. Personality disorder: from evidence to understanding. Cambridge University Press; 2022 Feb 24.
• Tyrer P. Nidotherapy: a cost‐effective systematic environmental intervention. World Psychiatry. 2019 Jun;18(2):144.
• Bozzatello P, Rocca P, De Rosa ML, Bellino S. Current and emerging medications for borderline personality disorder: is pharmacotherapy alone enough? Expert Opinion on Pharmacotherapy. 2020 Jan 2;21(1):47-61.
• National Institute for Health and Care Excellence. Borderline personality disorder: recognition and management [Internet]. [London]: NICE; 2009 [updated 2022 May; cited 2022 Oct 29]. (Clinical guideline [CG78]). Available from: https://www.nice.org.uk/guidance/cg78
• Firth J, Solmi M, Wootton RE, Vancampfort D, Schuch FB, Hoare E, Gilbody S, Torous J, Teasdale SB, Jackson SE, Smith L. A meta‐review of “lifestyle psychiatry”: the role of exercise, smoking, diet and sleep in the prevention and treatment of mental disorders. World Psychiatry. 2020 Oct;19(3):360-80.