Social and therapeutic environments such as day hospitals, halfway houses, and self-help communities utilize peer “pressure” to modify the self-destructive behavior. The patient with a personality disorder often has failed to profit from experience, and difficulties with authority can impair the learning experience. The use of peer relationships and the repetition possible in a structured setting of a helpful community enhance the behavioral treatment opportunities and increase learning. When problems are detected early, both the school and the home can serve as foci of intensified social pressure to change the behavior, particularly with the use of behavioral techniques.
The behavioral techniques used are principally operant conditioning and aversive conditioning. The former simply emphasizes the recognition of acceptable behavior and its reinforcement with praise or other tangible rewards. Aversive responses usually mean punishment, although this can range from a mild rebuke to some specific punitive responses such as deprivation of privileges. Extinction plays a role in that an attempt is made not to respond to inappropriate behavior, and the lack of response eventually causes the person to abandon that type of behavior. Pouting and tantrums, for example, diminish quickly when such behavior elicits no reaction. These traits are less likely to develop in children at risk for development of antisocial tendencies due to a genetic predisposition when they are given positive reinforcement for positive behaviors. Dialectical behavioral therapy is a program of individual and group therapy specifically designed for patients with chronic suicidality and borderline personality disorder. It blends mindfulness and a cognitive-behavioral model to address self-awareness, interpersonal functioning, affective lability, and reactions to stress. Psychodynamic psychotherapy can also be an effective treatment.
Psychological interventions can be conducted in group and individual settings. Group therapy is helpful when specific interpersonal behavior needs to be improved. This mode of treatment also has a place with so-called “acting-out” patients, ie, those who frequently act in an impulsive and inappropriate way. The peer pressure in the group tends to impose restraints on rash behavior. The group also quickly identifies the patient’s types of behavior and helps improve the validity of the patient’s self-assessment, so that the antecedents of the unacceptable behavior can be effectively handled, thus decreasing its frequency. Individual therapy should initially be supportive, ie, helping the patient to restabilize and mobilize coping mechanisms. If the individual has the ability to observe his or her own behavior, a longer-term and more introspective therapy may be warranted. The therapist must be able to handle countertransference feelings (which are frequently negative), maintain appropriate boundaries in the relationship, and refrain from premature confrontations and interpretations.
Hospitalization is indicated in the case of serious suicidal or homicidal danger. In most cases, treatment can be accomplished in the day treatment center or self-help community. Pharmacotherapy can be directed to specific symptom clusters, but there is limited evidence for its efficacy in personality disorders. Antidepressants have improved anxiety, depression, and sensitivity to rejection in some patients with borderline personality disorder. SSRIs also have a role in reducing aggressive behavior in impulsive aggressive patients (eg, fluoxetine 20–60 mg orally daily or sertraline 50–200 mg orally daily). Antipsychotics may be helpful in targeting hostility, agitation, and as adjuncts to antidepressant therapy (eg, olanzapine [2.5–10 mg/day orally], risperidone [0.5–2 mg/day orally], or haloperidol [0.5–2 mg/day orally, split into two doses]). In some cases, these medications are required only for several days and can be discontinued after the patient has regained a previously established level of adjustment; they can also provide ongoing support. Anticonvulsants, including carbamazepine, 400–800 mg orally daily in divided doses, lamotrigine, 50–200 mg/day and valproate 500–2000 mg/day, have been shown to decrease the severity of behavioral dyscontrol in some personality disorder patients. Patients with a schizotypal personality often improve with antipsychotics, while those with avoidant personality may benefit from strategies that reduce anxiety, including the use of SSRIs and benzodiazepines. Intermittent explosive disorder is characterized by episodes of unwarranted anger and sometime violence. Antipsychotics and anticonvulsants have been helpful for some patients with intermittent explosive disorder. In addition, there is some initial evidence that the combination of dextromethorphan and quinidine, which is currently approved for treating pseudobulbar affect, may have a role in the treatment of intermittent explosive disorder. Studies are in progress as of early 2020.