Dynamic Psychotherapy

To date, this is the most extensively investigated psychotherapeutic approach to personality disorder.

Day Hospital Programmes

Karterud et al. (1992) completed a prospective study of 97 patients in a psychodynamically orientated day hospital in Oslo; 76 % had an Axis II disorder. The treatment programme in the unit consisted of two daily community meetings, plus group and individual psychotherapy sessions. After a mean stay of six months treatment results were very good for patients with Axis I disorders only, good for Cluster C personality disorders, modest for patients with BPD and very modest for those with schizotypal personality disorder. The dropout rate for patients with BPD and SPD was 38 %. There were no suicides during the treatment period and only two suicide attempts; medication levels were moderate. The authors concluded that the programme adequately contained these patients; that a unit of this type needs backup from an acute ward; that the length of treatment was too short; and that postdischarge psychotherapy should be offered to those who complete the programme. Patients with BPD and SPD are now offered 12 to 18 months of treatment.

Piper et al. (1993) evaluated a dynamically orientated, intensive, group-focussed, 18-week day-treatment programme for individuals with affective and personality disorders. Sixty per cent of the total sample (N = 120) had personality disorders, with borderline and dependent types being most common. Patients were randomised to treatment or control (delayed treatment) conditions and assessed at baseline, end of treatment and eight months later. Outcome for the active treatment group was significantly better than for controls regarding social and family dysfunction, interpersonal behaviour, mood, life satisfaction, self-esteem and severity of disturbance relating to individual treatment goals. Benefits were maintained at follow-up in the 50 patients available for assessment.

More recently, a British RCT compared TAU with treatment in a psychoanalyti-cally informed day-hospital programme that included both individual and group therapy (Bateman & Fonagy, 1999). Thirty-eight individuals with BPD were included in the 18-month trial. The day hospital programme included individual and group psychotherapy, weekly expressive therapy using psychodrama techniques and weekly community meetings. All the therapy was delivered by psychiatric nurses with no formal psychotherapy qualifications. Patients in the day hospital programme showed a statistically significant improvement on all measures compared with the control group. The day hospital atten-ders engaged in less parasuicide/self-harm and required fewer admissions during the study period. They also reported more improvement in mood, interpersonal function and social adjustment relative to the TAU group, beginning at six months into treatment and continuing over the next 12 months. The dropout rate was low (12 %) and improvements were maintained or increased at three-year follow-up, although further treatment was received by many of these individuals during the follow-up period (Bateman & Fonagy, 2001).

Outpatient Treatment

Winston et al. (1991) compared short-term dynamic psychotherapy (STDP: N = 15) with brief adaptational psychotherapy (BAP: N = 17) over 40 weeks, against a waiting-list control condition. The authors describe STDP, based on the work of Davanloo, as more active and confrontational than BAP. The study included patients who met DSM-III criteria for compulsive, avoidant, dependent, or histrionic personality disorder, or more than one of these. The authors found no difference between therapies but patients in both groups were significantly improved compared with the waiting list condition on their primary complaint (Battle et al, 1966), the SCL-90 (Derogatis & Cleary, 1977) and the Social Adjustment Scale (Weissman & Bothwell, 1976). The original study by this group excluded patients with borderline and narcissistic features but a later study by the same group (Winston et al., 1994) incorporated some patients with Cluster B disorders and obtained similar results.

Stevenson & Meares (1992, 1999) reported on 48 outpatients with BPD treated with psychoanalytic therapy delivered by closely supervised trainee therapists twice weekly for one year. Thirty patients completed the course and showed significant reductions in self-harm, violent behaviour and impulsivity and time spent as inpatients in addition to other improvements. At the end of treatment, one-third of the sample no longer met criteria for BPD. Improvement was maintained over one year post-treatment and persisted over a five-year follow-up.

Monsen et al. (1995) conducted a prospective study of 25 outpatients in a unit specialising in personality and psychosis: 23 patients met DSM-III criteria for personality disorder at the outset. Treatment consisted of intensive psychodynamic psychotherapy, based on self-psychology and object relations, delivered over an average of 25.4 months. At the end of therapy 72 % of patients no longer met criteria for personality disorder and showed significant change in affect consciousness, characterological defences and symptoms as measured by the clinical scales of the Minnesota Multiphasic Personality Inventory and the Welsh Anxiety and Repression scales. At follow-up (mean period of 5.2 years) these changes remained generally stable.

Combined Inpatient and Outpatient Treatment

Chiesa & Fonagy (2000) report on a non-randomised prospective study conducted at the Cassel Hospital in collaboration with the psychoanalysis unit, University College London. The study compared a 'one-stage programme' of inpatient treatment (11 to 16 months) with no arranged follow-up and a 'two-stage programme' that offered a briefer inpatient stay (six months) plus 12 to 18 months' outpatient group psychotherapy with six months of concurrent community outreach nursing. The inpatient treatment included twice-weekly individual psychoanalytic psychotherapy. Ninety patients with DSM-III-R diagnoses of personality disorder were recruited over a five-year period: 70 % met criteria for BPD, 17 % for avoidant, 12 % for paranoid and 11 % for self-defeating personality disorder. Twelve months after admission patients in both samples had improved significantly on the Symptom Check List (SCL-90) (Derogatis, 1983), the Global Assessment Scale (GAS) (Endicott et al., 1976) and the Social Adjustment Scale (SAS) (Weissman & Bothwell, 1976). However, the two-stage sample fared significantly better than those in the one-stage programme according to the GAS and the SAS.

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