The Development and Treatment of Personality Disorders

Online Conference Transcript

What is a personality disorder? How are different personality disorders diagnosed and what does the treatment of personality disorders consist of?

Our guest, Dr. Joni Mihura, a licensed psychologist and an assistant professor of psychology joined us to discuss why they develop, common traits among people who have personality disorders (awful time adjusting, self-esteem, and depressive problems, feeling of rejection and abandonment, unstable sense of themselves, unstable feelings, unstable identity, distorted perceptions of what is happening, feel abandoned, relationships may be poor, acting out behaviors), symptoms of various personality disorders (audience members had a lot of questions about Borderline Personality Disorder, BPD), general treatment guidelines and the big question: When it comes to the treatment of people with personality disorders, what are the chances of significant improvement?

David Roberts is the HealthyPlace.com moderator.

The people in blue are audience members.

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David: Good Evening. I'm David Roberts. I'm the moderator for tonight's conference. I want to welcome everyone to HealthyPlace.com. Our topic tonight is "The Development and Treatment of Personality Disorders." Our guest is Dr. Joni Mihura, a licensed psychologist and an assistant professor at the University of Toledo, where she teaches psychology courses.

Her post-doc training consisted of specializing in women's trauma and psychological assessment. Dr. Mihura's current specialties are psychodynamic therapy and personality assessment. Besides teaching, she has a part-time private practice and she just received an award as a national American Psychoanalytic Association Fellow.

Good evening, Dr. Mihura, and welcome to HealthyPlace.com. We appreciate you being our guest tonight. Just so everyone knows where you are coming from, can you please explain "psychodynamic therapy" to us in layman's terms?

Dr. Mihura: Good evening to you too, David. I'm glad to be here tonight. You could say that psychodynamic therapy addresses the fears and maladaptive coping that people have in response to their needs.

David: Thank you. Now onto our topic. What is a personality disorder?

Dr. Mihura: By the DSM-IV (the diagnostic manual), a personality disorder is an inflexible, persistent pattern of inner experience or behavior that leads to significant distress or dysfunction. The 'significant distress or dysfunction' is what makes it a 'disorder.'

David: When you say "inner experience or behavior," what does that mean?

Dr. Mihura: Basically, thoughts and feelings make up the inner experience. The thoughts can include words or images.

David: So, you're saying these problems really create a problem in allowing the person to function "normally"?

Dr. Mihura: Yes, you're right. In allowing the person to function adaptively and to have good well-being.

David: What causes someone to develop a personality disorder?

Dr. Mihura: There are many ideas on that, but they basically could be summarized as contributions from genetics and environment. There is evidence that personality is somewhat genetically related. And our environment--our interactions with other people, trauma, the general adaptiveness and type of our environment growing up. So it is both genetics and environment.

That is a global answer, the particulars also depend on the disorder. We need an environment, too, that is adaptive for our human needs like safety and attachment to caregivers.

David: - Here are all the different types of personality disorders: Personality Disorders includes: Antisocial Personality Disorder, Avoidant Personality Disorder, Borderline Personality Disorder (BPD), Dependent Personality Disorder, Histrionic Personality Disorder, Narcissistic Personality Disorder, Obsessive-Compulsive Personality Disorder, Paranoid Personality Disorder, Schizoid Personality Disorder, Schizotypal Personality Disorder.

I know that each personality disorder has its own particular traits, but are there common traits among people who have personality disorders?

Dr. Mihura: That's a good question. Mainly, there are commonalities between clusters of personality disorders. The basic commonality they share is the general description that I gave. Concerning the commonalities between groups of personality disorders, for example, schizoid, schizotypal, and paranoid are considered in the 'odd or eccentric' group. They often don't have close relationships, and may not want them.

David: How about when it comes to taking responsibility for their own lives and feelings? Is that another commonality?

Dr. Mihura: Yes, there is something very related to that concerning the way that they see their problems. The types of behaviors they show are usually not what they consider to be the problem. They may, however, take responsibility for their lives in many other ways. Like, the obsessive-compulsive may work a lot and be hyper-concerned with responsibility, but this person's relationships may be poor because they do not take responsibility for the lack of emotional closeness that they may show.

David: How do you evaluate a person for a personality disorder?

Dr. Mihura: Evaluating a person for a personality disorder is often more difficult than other disorders, like depression, and this is very related to the fact that they do not usually see their behaviors as being the problem, so they may not report the behaviors a psychologist considers to be part of their personality disorder to be 'the problem.'

Largely, a clinician will use the criteria in the DSM-IV manual, as they would for any other disorder, but often you will have to ask them more directly about these things. And you may need to observe over time or get information from other respondents. For example, someone with an antisocial personality is not that likely to want to tell you about their criminal activity.

David: That I can understand :) On the subject of diagnosis, here's an audience question, Dr. Mihura:

moonNstars: Is this a disorder that can be diagnosed with a single visit to a doctor?

Dr. Mihura: Sometimes, yes, it can be. Often, clinicians will have enough information to diagnose on the first visit, but not always. I'm sorry to give the 'it depends' answer, but I wanted to say that it can be diagnosed in one visit. Just not always.

David: What about treatment of personality disorders? I have heard that most people with personality disorders of any type have a poor prognosis; a poor chance of getting significantly better, even with therapy. Is that true?

Dr. Mihura: That is a good question, and you are right about the difficulty with treatment, but the amount of difficulty also does depend on the disorder. For example, many people with borderline personality disorder can get much better with treatment, but it takes a long time. The good news is that it can get better, which has been shown by research.

David: In general, what types of treatments are available?

Dr. Mihura: People often use an eclectic approach to treatment, which means several different methods are used. For example, cognitive-behavioral components can help people monitor their thoughts and notice when they are starting to get very angry. Social skills training can be used for those people who have significant interpersonal problems, and is used for problems like borderline or avoidant personality disorder. Often, people will use what is called a 'psychodynamically informed' approach, where you try to understand why the person might be feeling and acting as they are now, and what to do about it. Often, a person will have a difficult time with dynamic therapy initially if they have a personality disorder, but it can inform treatment throughout.

David: And when you say "a long time" to get better with treatment, are you saying 3-6 months or years of constant, intensive therapy?

Dr. Mihura: I am saying that it may be as long as two years. However, this depends on what your goal is. If it is to significantly change the personality, it is that long or longer. To address crises or for supportive therapy, it can be much shorter until the person stabilizes. For example, a person with narcissistic personality disorder may suffer a loss and have an awful time adjusting, with self-esteem and depressive problems. Therapy can be focused on supporting the person through their loss in an empathic manner that will help the person's self-esteem recover, and help them grieve their loss without major depressive problems.

David: We have many audience questions, let's get to them:

ladyofthelake: Why is it that different members of the same family living with similar genetics and heredity develop different disorders?

Dr. Mihura: It is the same reason that people with the same genetics also don't look exactly like each other. There are many combinations of genes that can result. Also, there are environmental factors, like how the person is raised and the events that happen in their lives.

lostsoul2: The feeling of rejection and abandonment is really hurting me and I can't get over those negative feelings. Can you tell me how I can "stop" this or if it can be stopped?

Dr. Mihura: Often people can use a cognitive behavioral approach for this, which asks you what are the underlying beliefs and what evidence do you have for them. For example, sometimes people believe that they are not lovable or not loving people, and this is what makes them feel so bad and like it will last forever. But, if that is your belief, you need to challenge it.

ladyw5horses: My 16 year old daughter has been diagnosed as BPD (borderline personality disorder). I am not sure of how to handle her. We talk, she tells me how she feels... I'm not sure about what BPD means.

Dr. Mihura: It does sound like you will need outside assistance with a professional. It can be very difficult. It sounds like you are trying. People with BPD have a very unstable sense of themselves, unstable feelings, unstable identity. Often their emotions overwhelm their ability to take perspective, and they feel caught up in any one moment. They may have distorted perceptions of what is happening and may easily feel abandoned, like they are being attacked, and/or being cruelly rejected. It is a painful experience. At any one time, it is difficult for them to see the whole person, the whole situation, especially in close emotional relationships. But this disorder has been shown to be responsive to treatment. It can take some time, (so can finding a professional she can make a good alliance with) but it can be helped by treatment.

ladyw5horses: Some of my daughter's problems are similar but are compounded by problems in school, relationships with peers, etc. How can I help my daughter? A psychiatrist told me that I could not affect her, just offer suggestions when she asked me my opinion.

Dr. Mihura: I don't know if you 'could not affect her,' but perhaps she or he was saying that you cannot completely change the situation. You just need to be there, open for her emotionally, letting her know you aren't intruding but are there as a strong emotional source.

David: ladyw5horses, we have an excellent site on Borderline Personality Disorder in the HealthyPlace.com Personality Disorders Community. It's called "Life at the Border."

If you haven't been on the main HealthyPlace.com site yet, I invite you to take a look. There's over 9000 pages of content.

Here's the link to the HealthyPlace.com Personality Disorders Community. You can click on this link and sign up for the mail list at the side of the page, so you can keep up with events like this.

Here's the next question:

SuzyR: Is it at all possible for a person with a personality disorder to 'just decide' to get better?

Dr. Mihura: I'm not completely sure of your question. If you are asking if one can 'just decide' to get better and everything will markedly change, that is not likely. But 'just deciding to get better,' could be rephrased by saying that one could decide 'to change.' And then one can make progress towards that change by identifying the problems and the methods and ways to address them.

terriej: How much success have you had with treatment of PPD (Paranoid Personality Disorder)? If they are suspicious of everything and will not accept blame or dismiss the idea of having the slightest problem, it seems that the efforts would be in vain

Dr. Mihura: You are very right in the sense that PPD is a very difficult problem to treat. Part of the initial problem is that the person is not likely to be present for therapy on their own accord, because they have such a lack of trust and expect malevolent intent and actions from others. And therapists are 'others.' I have treated PPD in an inpatient setting, but not in an outpatient basis. You are right, it is very difficult. In treating PPD, it takes a long time to build trust and address the anger.

mj679: Do you find that behavioral methods or medications are more successful in treating personality disorders, or is some combination of both best?

Dr. Mihura: Those methods have been effective with certain disorders and symptoms of the disorder. For example, people with Schizotypal Personality Disorder can sometimes be helped with a low-dose anti-psychotic. For people with borderline personality disorder, sometimes different combinations of medications are used to address the problematic symptoms, like labile mood or transient psychotic symptoms. The issue is that the personality disorders are treated by different methods depending on the disorder, and also, that some people within personality disorders may use some therapies better or have different types of predominant symptoms to address.

David: Here's the next audience question:

C.U.: Is it rare for me to see my acting out behaviors as a problem for others but not for myself?

Dr. Mihura: To not see one's acting out behaviors as a problem for themselves is common. I'm not sure whether you mean 'a problem for others' as in 'that is their problem' or you are concerned that it might be a problem for others. That is a complicated question, either way because sometimes people who have acting out problems may see it not as a problem for others at the time, but at other times, they can see that it was a problem for others. Often people with acting out problems may think that it is someone else's problem, not theirs, as they can't see the problems that arise from their behavior, yet someone is telling them that there are problems. So it must be 'their problem.'

seeking peace: Please advise me on where to go for help. My therapist and several clinics have refused to help. I am bipolar with psychosis. I had therapy for years and was recently diagnosed with BPD and have no more services.

Dr. Mihura: It depends on the specifics of why they refuse to help. I am certainly not familiar with that happening. If it is because of financial problems, community mental health centers should be able to help because they will treat those people with severe disorders, and bipolar with psychosis would fit this category.

ladyofthelake: How difficult is it to get a person with a personality disorder to realize they have a disorder and that they may need help?

Dr. Mihura: It often takes a meaningful event in their lives to bring them to therapy. And the 'distress or dysfunction' part of the disorder is key here. Often, it is something negative that happened that is very meaningful in their lives, like a relationship or their job, and either it was a highly significant thing, and/or it has happened over and over again. The events must hold significance to the person, and/or the distress has gotten to where the person feels they have tried everything possible and nothing has helped.

I am speaking, by the way, about someone who is having difficulty acknowledging a problem and seeking treatment. Some people more easily will seek therapy, but for most people, it is still a difficult decision. Sometimes people will seek treatment to relieve distress, and often that will bring them to therapy, but for those who have trouble trusting, that is a challenge.

moonNstars: When you have two disorders that are somewhat similar, for example Bipolar and BPD, which one is treated first, or can they be treated together?

Dr. Mihura: They can be treated together, but are treated with different methods (although one may also help the other). For bipolar disorder, it is the general consensus and based on research, that this needs to be treated with bipolar medications, and the person needs to stay on that medication so they will not relapse. The BPD can be helped with medication, but it is recommended the person seek psychotherapy also. Additionally, treating bipolar disorder will help the BPD symptoms not be as unstable (mood swings, for example).

Any approach that helps the person address their stress/anxiety points, whether internal or external sources, can help reduce the occurrence of the symptoms of a disorder. So, the psychotherapy could also help the person learn how to notice when their mood is shifting and how to modulate it, and when to increase their meds, but the bipolar part does need the medication. So, yes, they can be treated at the same time in one's life.

David: For those in the audience, you can read more about Bipolar Disorder and Borderline Personality Disorder, as well as all psychological disorders, here.

cathygo: Dr. Mihura, I have a very close friend who I know has BPD, but his Dr's will not recognize it. He uses prescription drugs, is a cutter, and he has a little boy who is being exposed to this behavior and a wife who thinks he's just a drug addict. What can I do to help him?

Dr. Mihura: That sounds like a very tough situation for you to be in. I am not sure exactly what you mean by his doctor will not recognize it. If your friend recognizes the problems, he can tell his doctor what the problems are. He will need to tell his doctor what his symptoms are, the ones you refer to as BPD. If the doctor still will not address them, then he should seek out the help of someone else. I would be sure that it is the doctor that is not recognizing them first and that your friend has talked about these problems.

It sounds like you care very much about your friend. As a note, I can only give feedback based on little information here, but I would try not to feel too much responsibility. Sometimes, one can feel very caught up in a person's life and problems when they have borderline features. Sometimes a spouse, for example, can describe these behaviors to a doctor but it is up to the patient what they want to do. Good luck in whatever you do, and to your friend and his family.

David: I have one question. Can personality disorders be diagnosed in young children and adolescents?

Dr. Mihura: Yes, they can, although this is less common. The patterns of behavior and problems need to be problematic and enduring, however. For example, sometimes adolescents may have what look like borderline features, in problems with identity and some anger control, but it may change over time with maturation. Sometimes, as in adults too, the symptoms may be more confined to an 'Axis I' disorder, like emerging bipolar in an adolescent that looks like the anger, depression, liability of a borderline personality, but it is due to an 'episodic' disorder, not a long-lasting pattern as in a personality disorder.

David: Thank you, Dr. Mihura, for being our guest tonight and for sharing this information with us. And to those in the audience, thank you for coming and participating. I hope you found it helpful. We have a very large and active community here at HealthyPlace.com. You will always find people in the chatrooms and interacting with various sites. Also, if you found our site beneficial, I hope you'll pass our URL around to your friends, mail list buddies, and others. http://www.healthyplace.com/

Thank you again, Dr. Mihura, for coming tonight and for staying late to answer everyone's questions. You were an excellent guest and we appreciate your coming here.

Dr. Mihura: You're very welcome, David. And thank you for having me here. I enjoyed talking to the participants, and I wish all of them luck in the problems they posted, and also for those who didn't post.

David: Good night everyone and I hope you have a pleasant weekend.

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Disclaimer: We are not recommending or endorsing any of the suggestions of our guest. In fact, we strongly encourage you to talk over any therapies, remedies or suggestions with your doctor BEFORE you implement them or make any changes in your treatment.