Biological Psychiatry - Vol. 2

By Hugo D'Haenen; J.A. Den Boer et al. | Go to book overview

The Psychopharmacological Treatment
of Personality Disorders
Royce Lee and Emil Coccaro
This chapter will present available evidence on the psychopharmacological treatment of personality disorders. Clinical and theoretical implications of axis I/II and Axis II/II comorbidity in the treatment of patients with personality disorders will be discussed. Biological correlates of some of the major symptoms of personality disorders will provide the rationale for a review of the evidence for psychopharmacological treatment of personality disorders. These will be presented by medication class to facilitate an understanding of me evidence for the efficacy of these treatments.
The estimated prevalence of personality disorders in the community is approximately 6–11% (Samuels etal., 1994; Reich et al., 1989), with Cluster B personality disorders being the most common (4–5.4%), followed by cluster C (1.7–3.4%) and Cluster A (<0.1%). Evidence suggests that many personality-disordered people in the community who could benefit from treatment do not receive it. This holds true in clinical settings, where personality disorders, in general, are underdiagnosed (Zimmerman and Mattia. 1999).Paradoxically, personality disorders may be disproportionately represented in outpatient and inpatient treatment settings (Zimmerman and Coryell, 1989). This may be due to the significant morbidity associated with them. Personality-disordered patients tend to function at lower levels than those without such disorders (Mehlum etal., 1991), report more frequent adverse events in their lives (Maier et al., 1992), and have elevated rates of divorce, substance abuse, and suicide (Zimmerman and Coryell, 1989). This is the case despite relatively heavy use of clinical services by some, but not all, persons with Axis II diagnoses. A recent study of treatment utilization by patients with personality disorder found that those with borderline personality disorder, compared to depressives, were more likely to have received every class of psychopharmacological medication, from twice as many trials of antidepressants to 10 times as many trials of antipsychotic medications. They had also received more psychosocial treatments than the depressive comparison group with the exception of family/couples therapy and self-help groups (Bender et al., 2001). These results were consistent with earlier reports in persons diagnosed with borderline personality disorder (BPD) of more frequent hospitalization, a 20% lifetime incidence of suicide attempt (McGlashan et al., 1986), and extensive use of outpatient mental health services (Perry and Cooper, 1985; Skodol et al., 1983). Patients with personality disorders may also be more difficult to treat than most patients, with less treatment compliance (Bender et al., 2001), less favourable Axis I treatment outcomes (Reich etal., 1991), and more frequently aborted treatments. In research settings, it is not uncommon for up to two-thirds or more of personality-disordered subjects to drop out of treatment studies (Skodol et al., 1983), a finding which mirrors clinical reports of their intensive but intermittent contact with outpatient services (McGlashan et al., 1986).
Comorbidity in personality disorders may represent the random co-occurrence of independent disorders, co-occurrence of different disorders sharing a common aetiology or pathophysiology, or different disorders that have a causal relation between them (McGlashan et al., 2000). The frequency of Axis II/Axis II comorbidity may be in part due to the fact that psychiatric nosology since DSM-III has favoured a trend towards more frequent comorbidity through the use of operationalized criteria, structured diagnostic interviews, and less stringent exclusionary rules. In some cases as well, Axis I/II and Axis II/II comorbidity could reflect the limitations of categorical diagnoses in characterizing the behavioural dimensions, that may underlie them.Clinically, the possibility of the existence of comorbid conditions in the personality-disordered patient must be carefully evaluated for the following reasons:
1. to identify other conditions with relatively well-defined treatments — for example, the presence of a medical disorder, mood disorder, or anxiety disorder
2. to identify omer conditions whose symptoms may be aggravated by proposed treatments—for example, the presence of bipolar I disorder in a patient considering the trial of an antidepressant
3. to identify disorders whose symptoms may account for the set of behaviours in questions, including such disorders as posttraumatic stress disorder (PTSD) or social anxiety disorder
4. to identify conditions whose course may be complicated by the presence of a personality disorder, such as refractory depression
5. because comorbidity may be markedly more frequent in clinical settings than community settings, as shown by comparisons between the two (Samuels etal., 1994), possibly due to the selection for treatment of patients with more than one disorder and more functional impairment.


Schizotypal personality disorder is the most commonly encountered Cluster A personality disorder in clinical settings. It frequendy


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