Psychotherapy of Personality Disorder

This chapter reviews the therapeutic process, strategies, and goals in psychotherapy of personality disorder that have been accepted by consensus. Psychotherapy can be thought of as environmental intervention that consistently trends in the right direction, proven capable of correcting the pathogenic impact of past environments or excessive neurobiology. The correction is both mental and structural. With personality disorder, psychotherapy must be transtheoretical, integrative, and eclectic in order to meet the uniquely multicausal and multidimensional nature of the syndrome. The chapter introduces Reconstructive Interpersonal Therapy (RIT), an integrative, transtheoretical psychotherapy of personality disorder drawing from psychoanalytic, cognitive, and humanist traditions. The RIT is presented in detail, with a comprehensive review of its basic principles and tools along with a number of practical tips in everyday therapeutic work. A detailed review of empirical studies of the efficacy and effectiveness of psychotherapy in personality disorder concludes the chapter.

What Is Personality?

This chapter reviews the neuroscience of brain and mind development. Recent advances in cognitive neuroscience, such as the concept of nonconscious working memory, support the psychanalytic concept of early object relations, which are believed to be the “elementary particles of the mind”: each contains a percept, a self-reflection, and the related affect and thus is not divisible to lower order units of mental experience. The functional brain networks giving rise to mental faculties (cognition, motivation, and emotions) are informed by these highly personal units of experience. Such “personalized” mental faculties self-organize into semistable subsystems within the mind, each providing a specific adaptive advantage to the mind as a whole. The impact of sociocultural transitions on human mental life, as well as the concepts of normal, postmodern, and fluid self in the context of conservativism, postmodernism, and liquid modernity, are discussed in detail.

Introduction

The term “fragmented personality” evokes the neuro-psychological essence of personality disorder (all variants), i.e., a suboptimal brain and mind integration within a person that leads to social maladaptation, together known as a personality disorder. Diagnostic aspects pivotal to the analysis of personality and its disorders are twofold. One aspect examines the level of mental functioning (a qualitative aspect of personality integration, i.e., “vertical” or in-depth diagnosis), while the second aspect is concerned with that individual’s habitual (mal)adaptive styles in relation to the environment (“horizontal diagnosis”). These two aspects provide answers to the three most important questions relevant to diagnosis and therapy: what (habitual patterns of behavior and relationships), how (characteristics of mental functioning), and why (factors in the development and maintenance of the observed patterns).

Pharmacotherapy of Personality Disorder

Relevant neuroscience to guide pharmacotherapy of personality disorder is reviewed. Pharmacotherapy is either (a) mechanism based, aimed at correcting heritable neurobiological trait vulnerabilities that increase the risk of personality disorder, or (b) symptom domain based, aimed at correcting clinical symptoms of personality disorder arranged into four domains. The novel concept of harnessing the brain’s homeostatic functions in order to deliver treatment is introduced, drawing analogy from serotonergic antidepressants. The dynamics of homeostatic optimization is the conceptual basis of the mechanism-based pharmacotherapy. Pharmacological modulation of trait vulnerability associated with excessive Harm Avoidance, Novelty Seeking, Persistence, and low Reward Dependence is reviewed. Pharmacotherapy of impulsive-affective aggression, which is the default affect state of personality disorder, is discussed in detail. Symptom-domain pharmacotherapy, the current standard of care, targets four symptom domains: (a) mood dysregulation, (b) behavior dysregulation, (c) emotional detachment; and (d) cognitive dysregulation. Pharmacotherapy of each is discussed in detail.

Dynamic Nosology and Clinical Assessment of Fragmented Personality

This chapter introduces a dynamic, personalized, context- and time-sensitive diagnosis of personality in health and disorder. Adaptive flexibility of the mind implies that its component subsystems and functions must also be flexible and semistable, including healthy personality and personality disorder. The model defines a 3D diagnostic space, in which each individual is uniquely and flexibly positioned. “Vertical diagnosis” is based on the duration, pervasiveness, and frequency of periods of fragmented functioning. It is cross-matched with “horizontal diagnosis,” based on the predominant adaptive style. Such dynamic nosology accounts for fluctuations in mental functioning as the individual “moves” in the diagnostic space. The approach captures the flexibility of the mind, self-reorganizing to adapt to changing conditions, and champions the positive connotation of change, challenging the widespread therapeutic nihilism about severe personality pathology. Clinical diagnosis of personality disorder, notably interpersonal (relational), behavioral, and intrapersonal approaches, together with psychological testing are discussed in detail.

What Is Personality Disorder?

The central problem with persons suffering from personality disorder is not their extreme behaviors but rather a fragmented substrate of personality, while extreme behaviors merely represent specific compensatory strategies. The pathodevelopment of personality disorder involves multiple interacting factors (e.g., biogenetic dispositions, early adversity), leading to aberrant brain and mind organization, notably a hypofunctional prefrontal cortex and fragmented object relations, respectively. Such fragmented personality is adaptively dysfunctional and thus vulnerable to disintegration, particularly under stress and strong affects. Consequently, these patients continue to need sources of organization, both internally (through fantasy and exaggerations) and interpersonally (through self-objects who define and maintain the pathological albeit compensatory self-image). Interpersonal conflicts are actively sought and reflect either trait aggression and/or alloplastic adaptation. Personality disorder can be thought of as a homeostatic attempt of the mind to heal itself, akin to callus formation, a form of psychological survival through mental deviance.