Is there empirical support for CT and CBT with personality disorders?

If you have been following the recent discussion regarding critiques of Schema Therapy you know that Jeff Young and I have a difference of opinion regarding the extent to which there is empirical support for the use of CT and CBT in the treatment of personality disorders. In that discussion I offered to post my most recent review of empirical research into the efficacy of CT and CBT as treatments for personality disorders so that readers could form their own opinions as to whether I am unrealistically positive in concluding that there is decent (not wonderful but decent) empirical support for CT and CBT. The following excerpts are from my chapter “Cognitive-behavioral approaches to the treatment of personality disorders” which appears in Carlo Perris and Patrick McGorry’s 1998 book “Cognitive psychotherapy of psychotic and personality disorders: Handbook of theory and practice” published by Wiley:

THE EFFICACY OF COGNITIVE-BEHAVIOR THERAPY AS A TREATMENT FOR PERSONALITY DISORDERS

Cognitive-behavior therapy has been found to provide effective treatment for a wide range of Axis I disorders. However, most research into the effectiveness of Cognitive Therapy and related approaches as treatments for individuals with personality disorders is of recent vintage, and the empirical evidence regarding the effectiveness of cognitive-behavioral approaches to treating individuals with personality disorders is fairly limited. Table 1 provides an overview of the available evidence regarding the effectiveness of cognitive-behavioral interventions in the treatment of individuals diagnosed as having personality disorders. It is immediately apparent from this table that there have been many uncontrolled clinical reports which assert that cognitive-behavioral therapy can provide effective treatment for personality disorders, many of which propose specific treatment approaches. However, there are few controlled outcome studies to provide support for these assertions. This has led some to be concerned about the risks associated with a rapid expansion of theory and practice which has outstripped the empirical research (Dobson & Pusch, 1993).

Effects of Co-morbid Personality Disorders on the Treatment of Axis I Disorders

A number of studies have examined the effectiveness of cognitive-behavioral treatment for Axis I disorders with subjects who are also diagnosed as having personality disorders and have found that the presence of an Axis II diagnosis greatly decreases the likelihood of treatment's being effective. For example, Turner’s (1987) study cited previously found that socially phobic patients without personality disorders improved markedly after a fifteen-week group treatment for social phobia and maintained their gains at a one-year follow-up. However, patients with personality disorder diagnoses in addition to social phobia showed little or no improvement both post-treatment and at the one-year follow-up. Similarly, Mavissakalian and Hamman (1987) found that 75% of agoraphobic subjects rated as being low in personality disorder characteristics responded well to a time-limited behavioral and pharmacological treatment for agoraphobia, while only 25% of the subjects rated as being high in personality disorder characteristics responded to this treatment.

A number of other studies have also found that well-established cognitive-behavioral treatments are less effective with individuals who have personality disorders in addition to their Axis I diagnoses (e.g., Black, Wesner, Gabel, Bowers, & Monahan, 1994; Giles, Young, & Young, 1985; Tyrer, Seivewright, Ferguson, Murphy, et al., 1993). However, the evidence regarding of the impact of co-morbid personality disorders on the treatment of Axis I disorders is more complex than this. Some studies have found that the presence of personality disorder diagnoses did not influence outcome (Dreesen, Arntz, Luttels, & Sallaerts, 1994; Mersch, Jansen, & Arntz, 1995). Other studies have found that personality disorder diagnoses influenced outcome only under certain conditions (Fahy, Eisler, & Russell, 1993; Felske, Perry, Chambless, Renneberg, & Goldstein, 1996; Hardy, Barkham, Shapiro, Stiles, Rees, & Reynolds, 1995), that clients with personality disorders are likely to terminate treatment prematurely but that those who persist in treatment can be treated effectively (Persons, Burns, & Perloff, 1988; Sanderson, Beck, & McGinn, 1994), and that some personality disorders predicted poor outcome while others did not (Neziroglu, McKay, Todaro, & Yaryura-Tobias, 1996).

Some studies provide evidence that focused treatment for Axis I disorders can have beneficial effects on co-morbid Axis II disorders as well. For example, Mavissakalian and Hamman (1987) found that four of seven subjects who initially met diagnostic criteria for a single personality disorder diagnosis no longer met criteria for a personality disorder diagnosis following treatment. In contrast, subjects diagnosed as having more than one personality disorder did not show similar improvement. A major limitation of the studies which have examined the effectiveness of cognitive-behavioral treatment for Axis I disorders with individuals who also have personality disorders is that the treatment approaches used in these studies typically did not take the presence of personality disorders into account. This leaves unanswered the question of whether treatment protocols designed to account for the presence of personality disorders would prove to be more effective.

Studies of Cognitive-Behavioral Treatment of Axis II Disorders

A number of studies have focused specifically on cognitive-behavioral treatment of individuals with personality disorders. Turkat and Maisto (1985) used a series of single-case design studies to investigate the effectiveness of individualized cognitive-behavioral treatment for personality disorders. Their study provides evidence that some clients with personality disorders could be treated effectively, but the investigators were unsuccessful in treating many of the subjects in their study. A recent study has attempted to test the efficacy of the intervention approach advocated by Beck et al. (1990) using a series of single case studies with repeated measures (Nelson-Gray, Johnson, Foyle, Daniel, and Harmon, 1996). The nine subjects for this study were diagnosed with major depressive disorder and one or more co-occurring personality disorders. Each subject was assessed pre-therapy, post-therapy, and at a three-month follow-up for level of depression and for the number of diagnostic criteria present for their primary personality disorder. After receiving 12 weeks of treatment, six of the eight subjects who completed the three-month follow-up manifested a significant decrease in level of depression, two subjects manifested a significant decrease on both measures of personality disorder symptomatology, two failed to show improvement on either measure, and four showed mixed results. As the authors note, 12 weeks of treatment is a much shorter course of treatment than Beck et al. (1990) would expect to be required for most clients with personality disorders.

Much of the theory and research on the treatment of personality disorders has focused on outpatient treatment. However, inpatient treatment has received some attention as well. Springer, Lohr, Buchtel, and Silk (1995) report that a short-term cognitive-behavioral therapy group produced significant improvement in a sample of hospitalized subjects with various personality disorders and that a secondary analysis of a subset of subjects with borderline personality disorder revealed similar findings. They also report that clients evaluated the group as being useful in their life outside the hospital.

At least three personality disorders have been the subject of controlled outcome studies. In a study of the treatment of opiate addicts in a methadone maintenance program, Woody, McLellan, Luborsky, and O'Brien (1985) found that subjects who met DSM-III diagnostic criteria for both major depression and antisocial personality disorder responded well to both Cognitive Therapy and a supportive-expressive psychotherapy systematized by Luborsky (Luborsky, McLellan, Woody, O'Brien, & Auerbach, 1985). The subjects showed statistically significant improvement on 11 of 22 outcome variables used, including psychiatric symptoms, drug use, employment, and illegal activity. Subjects who met criteria for antisocial personality disorder but not major depression showed little response to treatment, improving on only 3 of 22 variables. This pattern of results was maintained at a 7-month follow-up. While subjects not diagnosed as antisocial personality disorder responded to treatment better than the sociopaths did, sociopaths who were initially depressed did only slightly worse than the non-sociopaths while the non-depressed sociopaths did much worse.

Studies of the treatment of avoidant personality disorder have shown that short-term social skills training and social skills training combined with cognitive interventions have been effective in increasing the frequency of social interaction and decreasing social anxiety (Stravynski, Marks, & Yule, 1982). Stravynski, Marks, & Yule (1982) interpreted this finding as demonstrating the "lack of value" of cognitive interventions. However, it should be noted that the two treatments were equally effective, that all treatments were provided by a single therapist (who was also principal investigator), and that only one of many possible cognitive interventions (disputation of irrational beliefs) was used. In a subsequent study, Greenberg and Stravynski (1985) report that the avoidant client's fear of ridicule appears to contribute to premature termination in many cases, and they suggest that interventions which modify relevant aspects of the clients' cognitions might add substantially to the effectiveness of intervention.

The studies, cited previously, by Linehan and her colleagues (Linehan et al., 1991; Linehan, Tutek, & Heard, 1992; Linehan et al., 1993) on the treatment of borderline personality disorder have been widely recognized as providing evidence that cognitive-behavioral interventions can be effective with clients who have severe personality disorders. The finding that one year of cognitive-behavioral treatment can produce significant improvement in subjects who not only met diagnostic criteria for borderline personality disorder but who also were chronically parasuicidal, had histories of multiple psychiatric hospitalizations, and were unable to maintain employment due to their psychiatric symptoms is quite encouraging.

The Effect of Personality Disorders on “Real Life” Clinical Practice

In clinical practice, most therapists do not apply a standardized treatment protocol with a homogeneous sample of individuals who share a common diagnosis. Instead, clinicians face a variety of clients and take an individualized approach to treatment. A recent study of the effectiveness of Cognitive Therapy under such "real world" conditions provides important support for the clinical use of Cognitive Therapy with clients who are diagnosed as having personality disorders. Persons, Burns, and Perloff (1988) conducted an interesting empirical study of clients receiving Cognitive Therapy for depression in private practice settings. The subjects were 70 consecutive individuals seeking treatment from Dr. Burns or Dr. Persons in their own practices. Both therapists are established Cognitive therapists who have taught and published extensively and in this study both therapists conducted Cognitive Therapy as they normally do. This meant that treatment was open-ended, it was individualized rather than standardized, and medication and in-patient treatment were used as needed.

The primary focus of the study was on identifying predictors of dropout and treatment outcome in Cognitive Therapy for depression. However, it is interesting for our purposes to note that 54.3 % of the subjects met DSM-III criteria for a personality disorder diagnosis and that the investigators considered the presence of a personality disorder diagnosis as a potential predictor of both premature termination of therapy and therapy outcome. The investigators found that while patients with personality disorders were significantly more likely to drop out of therapy prematurely than patients without personality disorders, those patients with personality disorder diagnoses who persisted in therapy through the completion of treatment showed substantial improvement and did not differ significantly in degree of improvement from patients without personality disorders. Similar findings were reported by Sanderson, Beck, and McGinn (1994) in a study of Cognitive Therapy for generalized anxiety disorder. Subjects diagnosed with a co-morbid personality disorder were more likely to drop out of treatment , but treatment was effective in reducing both anxiety and depression for those who completed a minimum course of treatment.

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Implications for Clinical Practice
As was noted previously, the past fifteen years have seen advances in theory and practice outstrip the empirical research (Dobson & Pusch, 1993). While this provides grounds for legitimate concern, it would hardly be feasible to suspend theoretical and clinical work until more empirical research is available. The practicing clinician faces a difficult situation in that one can hardly refuse to provide treatment for a class of disorders which may be present in as many as 50% of clients seen in many outpatient settings. However, the available treatment approaches are less fully developed and less well validated than is the case with many of the Axis I disorders. Fortunately, there is an increasing body of evidence that cognitive-behavioral treatment can be quite effective for clients with personality disorders...

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Conclusions

While the number of published studies is quite limited and some studies suffer from methodological problems, several general conclusions are suggested by the available research. First, many reports indicate that standard cognitive-behavioral treatments for Axis I disorders may not prove effective for individuals with co-morbid Axis II disorders even if the treatments are quite effective with subjects who do not have Axis II disorders. Second, the available findings suggest that for some individuals with an Axis I disorder and a concurrent Axis II disorder, behavioral or cognitive-behavioral treatment for the Axis I disorder not only can be effective as a treatment for the Axis I disorder but also can result in overall improvement in the Axis II disorder as well. Third, clinical reports assert that cognitive-behavioral therapy can provide an effective treatment approach for most of the personality disorders. We do not yet have adequate empirical data to support this enthusiasm but a growing body of evidence shows that cognitive-behavioral treatment can be effective for some individuals with personality disorders. Finally, we have little evidence to provide grounds for comparing cognitive-behavioral therapy with alternative approaches to treating personality disorders.

A decade ago, Turkat and Levin (1984) concluded that "in most of the personality disorder literature, there are so few data that conclusions cannot even be attempted." (p. 519). In a similar vein, Kellner (1986) concluded that there were too few adequately controlled studies of behavioral treatment approaches with subjects clearly diagnosed as having personality disorders to provide an empirical basis for recommending specific interventions for clients with personality disorders. In the few years since these two reviews were conducted, the situation has improved slowly but steadily. In particular, the findings reported by Persons, Burns, and Perloff (1988) are quite encouraging. They suggest that while the presence of a personality disorder increases the likelihood of cognitive-behavioral therapy's proving ineffective (if the client discontinues therapy prematurely), when it is possible to induce the client to persist in treatment, cognitive-behavioral therapy can prove quite useful.

It should be noted that the subjects in Persons et al's study received treatment in the period of time before the recent advances in the treatment of personality disorders were widely published. As treatment approaches specifically designed to address the needs of individuals with personality disorders (Beck et al., 1990; Linehan, 1993) are tested, we can hope to learn much more about the strengths and weaknesses of our current approaches to understanding and treating clients with personality disorders.

REFERENCES

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Dreesen, L., Arntz, A. Luttels, C. & Sallaerts, S. (1994). Personality disorders do not influence the results of cognitive behavior therapies for anxiety disorders. Comprehensive Psychiatry, 35, 265-274.

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Stravynski, A., Marks, I., & Yule, W. (1982). Social skills problems in neurotic outpatients: Social skills training with and without cognitive modification. Archives of General Psychiatry, 39, 1378-1385.

Turkat, I.D. & Maisto, S.A. (1985). Personality disorders: Application of the experimental method to the formulation and modification of personality disorders. In D.H. Barlow (Ed.) Clinical handbook of psychological disorders: A step by step treatment manual. New York: Guilford Press.

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Turkat, I.D. & Levin, R.A. (1984). Formulation of personality disorders. In H.E. Adams & P.B. Sutker (Eds.) Comprehensive handbook of psychopathology. New York: Plenum.

Tyrer, P., Seivewright, N. Ferguson, B.. Murphy, S., et al. (1993). The Nottingham Study of Neurotic Disorder: Effect of personality status on response to drug treatment, cognitive therapy and self-help over two years. British Journal of Psychiatry, 162, 219-226.

Woody, G.E., McLellan, A.T., Luborsky, L., & O'Brien, C.P. (1985) Sociopathy and psychotherapy outcome. Archives of General Psychiatry, 42, 1081-1086.

Replies:

Dysfunctional Beliefs Differentiate among Personality Disorders, by Jim Pretzer, 02/23/02 Re:Is there empirical support for CT and CBT with personality disorders?, by Linda Nauth, 03/02/02 Re: Empirical support for CT with personality disorders and Schema Therapy, by Jim Pretzer, 03/02/02 A case study supporting Schema Therapy, by Jim Pretzer, 04/05/02 Can CT cure borderline personality disorder?, by Jim Pretzer, 01/13/04 CT also produces similar "cure" with Avoidant and Compulsive personality disorders, by Jim Pretzer, 01/13/04 Re:CT also produces similar , by mike08302001@yahoo.com, 05/05/04

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