Personality disorders: Psychosocial treatment
Many kinds of psychotherapy exist for people with personality disorders. The main issue for primary care providers is often whether they have the time, interest or training to do psychotherapy. Trying to change personality in individuals with long-standing character structure is a challenging task and many primary care providers may want to refer patients to someone who specializes in treating personality disorders.
Dialectical behavioural therapy
Dialectical behavioural therapy (DBT) is the most researched psychotherapy for people with BPD. This form of cognitive-behavioural therapy emphasizes validation and acceptance, while focusing on change. DBT views people with BPD as having temperamental irregularities that combined with an invalidating environment result in affective dysregulation (Linehan, 1992).
The goal of DBT is to learn strategies for modulating the reactivity, intensity and duration of reactions to stress. The focus is on validating the "kernel of truth." In reviewing when a patient has a characteristic meltdown, the clinician searches for the trigger and motivation for the response, which might be expressed as "you wanted to escape the pain."
The primary care provider role
Busy primary care clinicians may not have the training or interest in using DBT or other therapeutic modalities that psychotherapists use to treat BPD. However, they are uniquely situated to contribute to the care of these patients.
Primary care providers can help patients with personality disorders learn how to develop an "owner's manual" so they can better understand their personality. Patients need to find ways to manage their core vulnerabilities.
Primary care providers can help patients to understand and manage their reactivity. They can also help patients to understand various issues related to their personality disorder. The mnemonic TAACO summarizes these issues:
the Triggers that cause the emotional overreactivity
the Antecedents that make those things the triggers (e.g., why did the boss's criticism trigger such a reaction and what might that reflect from earlier in life?)
how the triggering situation could have been Anticipated so that it could have been better managed
the Consequences of the overreaction
the Option that could have been used to avoid the reaction and the negative consequences
Borderline personality disorder: recognition and management (NICE guideline CG78, 2009)
Antisocial personality disorder: prevention and management (NICE guideline CG77], 2008)
Clinical Practice Guideline for the Management of Borderline Personality Disorder (National Health and Medical Research Council, 2012)
Treatment guidelines for personality disorders (Project Air, 2015)