Psychiatric News June 18, 2004
Volume 39 Number 12
© 2004 American Psychiatric Association
p. 43
Two Psychotherapy Types Effective For Personality Disorders
Joan Arehart-Treichel
Both short-term dynamic psychotherapy and short-term cognitive therapy
appear to improve cluster C personalities. The next step is to see whether the
treatments differ in their effects on patient subgroups.
Who says that you can't get people who are excessively preoccupied with
orderliness, are terrified of criticism or rejection, or rely excessively on
another person to change their ways and develop healthy behaviors?
Certainly not a study published in the May American Journal of
Psychiatry that found that two types of psychotherapy can improve the
personalities and behaviors of individuals with the so-called cluster C
personality disorders—notably obsessive-compulsive personality disorder,
avoidant personality disorder, and dependent personality disorder.
The study was headed by Martin Svartberg, M.D., Ph.D., an associate
professor of psychiatry at the University of Toronto.
The cluster C personality disorders are the most prevalent personality
disorders in the general population. One of every 10 persons is estimated to
have one. Curiously, though, only a handful of studies have been conducted on
the subject of psychotherapy for such disorders, and only one of those was a
randomized, controlled trial specifically designed to study the course of
these disorders during and after treatment.
In that study, conducted a decade ago by Arnold Winston, M.D., chair of
psychiatry at Beth Israel Medical Center in New York City, 81 subjects with
predominantly cluster C disorders either received 40 sessions of dynamic
psychotherapy or served as controls. The subjects getting the dynamic
psychotherapy showed significantly greater improvement regarding distress and
social functioning than controls did, and gains were maintained 18 months
later.
Thus Svartberg and his colleagues decided to extend the study by Winston
and his coworkers. They wanted to see how cluster C disorder patients
responded either to 40 sessions of dynamic psychotherapy designed for
personality problems or 40 sessions of a cognitive therapy intended for
patients with personality dysfunction. Fifty patients who met criteria for one
or more cluster C personality disorders, but not for any other personality
disorders, were randomly assigned to either treatment.
As for the dynamic psychotherapy technique used, Svartberg and his
colleagues explained in their study report, the therapist gently clarified
rather than confronted the patient's defenses, empathized with the patient and
exposed underlying, conflicted emotions, and helped the patient regulate
rather than provoke anxiety.
The three main objectives of the dynamic therapy were to help the patient
recognize and relinquish defenses, become desensitized to emotions through
exposure to conflicted feelings, and alter maladaptive conceptions of
themselves and others.
Regarding the cognitive therapy used, Svartberg and his team said, the
therapist helped the patient deal with any coexisting Axis I problems, taught
the patient to identify and evaluate key negative automatic thoughts, built a
collaborative and trusting relationship with the patient, employed guided
imagery to unravel the meaning of experiences, collaborated with the patient
in preparing homework assignments tailored to the patient's specific issues,
and applied particular restructuring techniques to help the patient dispute
core beliefs. The two main objectives of the cognitive therapy were to help
the patient develop new and more adaptive core beliefs and also more adaptive
problem-solving interpersonal behaviors.
The researchers then used three types of yardsticks to measure subjects'
psychological status at the start of therapy, midtherapy, end of therapy, and
up to two years after therapy had ended. The measures were the Global Severity
Index (to measure symptom distress); the Inventory of Interpersonal Problems
(to assess subjects' difficulties with assertiveness, intimacy, sociability,
submissiveness, control, and responsibility for others); and the Millon
Clinical Multiaxial Inventory (a 175-item questionnaire designed to assess
personality pathology as reflected in the cluster C personality
disorders).
Subjects in both treatment groups showed, on average, statistically
significant improvements on all measures during treatment compared with the
start of the study, and also during the two-year follow-up period after
treatment. Two years after treatment, 54 percent of the dynamic psychotherapy
subjects and 42 percent of the cognitive therapy subjects had recovered
symptomatically, whereas some 40 percent of subjects in both groups had
recovered in terms of interpersonal problems and personality functioning.
Perhaps most striking, the researchers noted, "unlike the patients in
many other psychotherapy outcome studies, the patients in this study on
average continued to improve significantly after treatment.... This finding of
continued improvement supports one of the original justifications for
short-term approaches articulated by short-term therapy
pioneers...."
Thus, "both short-term dynamic psychotherapy and cognitive therapy
have a place in the treatment of patients with cluster C personality
disorders," Svartberg and his team concluded.
Svartberg told Psychiatric News that he plans to analyze the data
further. "Since there were no significant differences between the two
treatments in terms of efficacy, treatment method may not be such an important
factor in bringing about change in these patients seen as a group," he
said. "Hence, we would like to be more specific in our examinations. Our
next step would be to see whether the two treatments differ in their effects
with certain subgroups of patients. For instance, would cognitive therapy do
better than short-term dynamic therapy with patients with avoidant personality
disorder, and conversely, would short-term dynamic therapy do better than
cognitive therapy with patients with obsessive-compulsive disorder?"
In the opinion of Winston, the study by Svartberg and his colleagues
provides "additional evidence of the efficacy of short-term dynamic
psychotherapy and cognitive therapy for patients with cluster C personality
disorders. It is impressive that patients continued to improve significantly
at two-year follow-up. More controlled trials of different types of
psychotherapy are sorely needed for this population."
The study was funded by the Norwegian Research Council.
The study, "Randomized, Controlled Trial of the Effectiveness
of Short-Term Dynamic Psychotherapy and Cognitive Therapy for Cluster C
Personality Disorders," is posted online at
<http://ajp.psychiatryonline.org/cgi/content/full/161/5/810>.
Am J Psychiatry 2004 161 810[Abstract/Free Full Text]
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