Personality Disorders

New Symptom-Focused Drug Therapy

S. Joseph

• Publisher: Routledge
• Year: 2019
• ISBN:
  9780429639913
• Edition: 1
• Topic: Psychology
• Subtopic: Abnormal Psychology
• Index: Psychology

Originally published in 1997, using 50 pharmacological case studies, this title illustrates how chronic and difficult psychiatric disorders ranging from paranoid to obsessive-compulsive personality disorder can be responsive to treatment. Readers are first taught to translate DSM-IV diagnostic criteria to identifiable and treatable symptom correlates which are then targeted for treatment using rationally chosen medications or combinations of medication along with psychotherapy. Since medications rapidly control dysfunctional symptoms, psychotherapy becomes much more effective, enabling psychotherapists and patients to focus on underlying psychosocial issues and conflicts. Personality Disorders can help you acquire an understanding of general diagnostic and treatment concepts, the ability to identify target symptoms, and the knowledge to select medications to address each symptom identified. As a result, psychotherapy will become less time-consuming and costly and therapeutic results will be felt more quickly--desirable goals in this managed care environment.This guidebook prepares you for effective treatment of personality disorders by exploring:

• symptom correlates of all personality disorders

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• medication groups with dosage guidelines

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• clinically relevant explanations for choice of symptoms and medications

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• clinical profiles of new antidepressants and antipsychotics

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• intelligent use of modern rational polypharmacy

Clinicians seeking to modernize and refine their approaches to treating personality disorders will learn effective drug therapy treatments that produce rapid results. Personality Disorders helps psychiatrists, primary care physicians, psychologists, psychiatric residents, counselors, social workers, and nurses who manage personality disorders to understand that patients' dysfunctional thoughts, perceptions, and behaviors are symptoms mediated by the brain. Medical students and clinical psychology students learn to approach personality disorders in the same clinically precise manner they would use when learning to treat nonpsychiatric illness. Personality Disorders is an important resource for dispelling the myth that personality disorders are permanent and un-responsive to treatment as it walks readers through successful intervention strategies step by step and disorder by disorder.

Part I:
Personality Disorders and Case Studies

Chapter 1

Personality Disorders: General Clinical Concepts

It is a popular belief among today’s mental health community that personality disorders are unbeatable except with long-term psychotherapy, and that psychoanalysis, psychoanalytically oriented psychotherapy, and intensive, long-term behavioral restructuring/retraining are the preferred treatment techniques for most personality disorders. With the advent of a variety of new psychopharmacological agents and judicious use of medication combinations, it is the author’s belief, based on vast clinical experience, that most of what we now call personality disorders are treatable to varying degrees of success if their component symptoms are deciphered. Once the symptom configuration is understood, the combination of medications that will address specific symptoms can be identified.

Personality disorders are diagnosed under Axis II disorders according to DSM-IV and are typically confusing to other medical professionals. There is an implication that personality disorders are permanent or chronic and that anything other than a structural personality change by means of psychoanalytically oriented psychotherapy or psychoanalysis will not be effective. Such a hopeless attitude toward personality disorders was probably justified several years ago, prior to the advent of new classes of psychiatric medications, such as the SSRIs (selective serotonin reuptake inhibitors), atypical antipsychotics, clomipramine, and others yet to be introduced. The prevalent misinformation in the nonpsychiatric community related to personality disorders is facilitated by the relegation of such disorders to Axis II status. No longer valid is the widely held belief that personality disorders for the most part are unbeatable; much of what were thought to be immutable personality characteristics and traits are now modifiable with a variety of medications or combinations of medications.

Psychiatric training must now, to a greater degree, be geared toward understanding our patients’ dysfunctional thoughts, feelings, perceptions, and behaviors in terms of symptoms mediated by the brain, rather than as syndromes that exist independently of brain chemistry. Human traits and functions such as character, attitudes, conscience, thinking, perception, and emotions are mediated by the brain. This does not invalidate concepts such as soul, spirit, heart, and mind, which have applicability in the world, but serve only to obscure when goals are medical or psychiatric and not philosophical, religious, poetic, or figurative. Clinicians will attest to the commonness of personality changes that are seen after brain injury. This indicates that changes in anatomic brain structure have an impact on personality; thus, it seems a fair extrapolation to conclude that people with no brain injury are dependent on functional brain characteristics that are alterable with medications which act on the different neurotransmitter systems.

It usually takes years of therapeutic work (and considerable expense) for psychoanalysis to have any chance of success, making the process inefficient, given the human life span as well as the competitive psychotherapy marketplace. The careful use of combinations of medications can make an individual personality less symptomatic, the ultimate goal of psychotherapy. The cost and time associated with pharmacotherapy are also expected to be much less when compared to the psychotherapeutic approach, making the pharmacologic approach much more efficient and thereby more immediately beneficial to the patient in resolving symptoms and saving time. However, as I alluded to in the preface, more than symptoms need to be addressed in providing effective care to patients. Psychological conflicts, lack of insight, poor judgment, relationship issues, social deficiencies, and various other psychosocial issues do not respond to medications, but require psychotherapy for optimal intervention. Therefore, the ideal approach in treating psychiatric disorders-including personality disorders-is primary reliance on the use of medications for the treatment of symptoms and the use of psychotherapy for work related to psychosocial issues and conflicts that can cause symptoms or can be caused by symptoms. Treatment using either approach alone is likely to be incomplete and less successful.

If a symptom is ingrained by being present since childhood or early adolescence it is described as a trait, and thereby considered a personality characteristic that is fairly resistant to change. Examples are emotional instability, moodiness, obsessiveness, social withdrawal, grandiosity, dependency, exaggerated emotions, suspiciousness, emotional sensitivity, and impulsivity. Every characteristic or symptom probably has its correlate in the brain, with the complexity of the control mechanisms varying depending upon the symptoms. Much of these control mechanisms are not precisely understood at the present time and might be sufficiently complex that they will defy complete characterization.

When disinhibition disrupts the tenuous control due to the effects of alcohol, the results are dramatic and mediated by primary process thinking. For example, consider antisocial personality disorder, generally considered the most untreatable of all personality disorders. Individuals with antisocial personalities are said to have a deficient conscience, impaired morality, and an inability to learn from the negative consequences of their behaviors. Currently, it is believed that concepts such as conscience and morality, which are broad and difficult to define, are primarily cortical functions that are more advanced in humans compared to other animals; one can employ the operational concepts such as internal controls and inhibitions to represent the more abstract concepts of conscience and morality, and thereby make the broader concept less vague and more amenable to interventions. Impairment in learning from experience or consequences, another facet of antisocial personality disorder that probably is a result of yet-unknown functional impairment in the brain, leads to deficiencies in internal controls and in inhibitions. Functional deficiencies in the brain must ultimately have their correlates in the structure composed of billions of neurons and their neurochemical and electrophysiological properties. Functions such as perception, learning, thinking, reasoning, inhibitions, conscience, morality, internal control, identity, affect, and judgment are all controlled by the integrative processes in the brain. Optimal balance of inhibitory and excitatory effects might improve the above functions. In antisocial persons, in whom the inhibitory effects are already weak, a disinhibitory drug such as alcohol or a sedative lifts the inhibitions to an extent that previously inhibited behaviors then find their full expression. Many heinous crimes are actually carried out under the disinhibiting effects of alcohol or drugs in susceptible individuals. Highly inhibited people find alcohol helpful in relieving some of the inhibitions; alcohol is used either deliberately or unintentionally for this purpose. Alcohol can have disinhibiting effects resulting in behavioral correlates, providing strong logic in support of the potential to develop drugs having the opposite or inhibitory effect, which promote secondary-process thinking. Other commonly abused drugs that have more complex effects on the brain (most of them undesirable) exist, for example, marijuana, cocaine, LSD, and various narcotics. (In this context, it is interesting to note that nicotine, which is probably one of the most addictive and the most commonly used drugs, has, for the most part, beneficial effects on the central nervous system but is considered unhealthy primarily because of its hazardous effects on other organ systems, especially the respiratory system.)

Because this work is not a treatise on the neurochemical, neuro-physiological, and behavioral effects of alcohol and other centrally acting drugs, the purpose of this discussion is intended to provide a brief illustration of the gross effects of centrally acting drugs on behavior. Obviously, the relationship between alcohol and behavior mediated by the br...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Personality Disorders: New Symptom-Focused Drug Therapy
• Original Title Page
• Table of Contents
• Contributor
• Foreword
• Preface
• Acknowledgments
• Part I Personality Disorders and Case Studies
• Part II Personality Disorders and Case Studies
• Appendix A. Alphabetical Listing of Drugs by Generic Names, with U.S. Brand Names
• Appendix B. Alphabetical Listing of Drugs by U.S. Brand Names, with Generic Names
• Appendix C. Alphabetical Listing of Abbreviations
• Bibliography
• Index