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WPA/ISSPD Educational Program on Personality Disorders

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WPA/ISSPD Educational Program on Personality Disorders Editors Erik Simonsen, M.D., chair Elsa Ronningstam, Ph.D. Theodore Millon, Ph.D., D.Sc. December 2006 International Advisory panel John Gunderson, USA Roger Montenegro, Argentina Charles Pull, Luxembourg Norman Sartorius, Switzerland Allan Tasman, USA Peter Tyrer, UK 2 Authors Module I Authors Module II Renato D. Alarcon, USA Anthony W. Bateman, UK Judith Beck, USA Robert F. Bornstein, USA G.E. Berrios, UK Vicente Caballo, Spain Vicente Caballo, Spain David J. Cooke, UK Allen Frances, USA Peter Fonagy, UK Glen O. Gabbard, USA Stephen D. Hart, Canada Seth Grossmann, USA Elisabeth Iskander, USA W. John Livesley, Canada Yutaka Ono, Japan Juan J. Lopez-Ibor, Spain J. Christopher Perry, Canada Theodore Millon, USA Bruce Pfohl, USA Joel Paris, Canada Elsa Ronningstam, USA Robert Reugg, USA Henning Sass, Germany Michael Rutter, UK Reinhild Schwarte, Germany Erik Simonsen, Denmark Larry J. Siever, USA Peter Tyrer, UK Michael H. Stone, USA Irving Weiner, USA Svenn Torgersen, Norway Drew Westen, USA Reviewer Module I Reviewers Module II Melvin Sabshin, USA/UK David Bernstein, USA Sigmund Karterud, Norway Cesare Maffei, Italy John Oldham, USA James Reich, USA 3 Authors Module III Reviewers Module III R.E. Abraham, The Netherlands Anthony Bateman, UK Claudia Astorga, Argentina Robert Bornstein, USA Marco Aurélio Baggio, Brazil Vicente Caballo, Spain Yvonne Bergmans, Canada Glen O. Gabbard, USA Mirrat Gul Butt, Pakistan Yutaka Ono, Japan H.R. Chaudhry, Pakistan Elsa Ronningstam, USA Dirk Corstens, The Netherlands Henning Sass, Germany Kate Davidson, UK Erik Simonsen, Denmark Mircea Dehelean, Romania Allan Tasman, USA Andrea Fossati, Italy E. Gómez Gazol, Spain Dishanter Goel, India H. Groen, The Netherlands Sabine C. Herpertz, Germany T.M.J. Huyen, The Netherlands Merete Johansen, Scandinavia Sigmund Karterud, Scandinavia Morten Kjølbye, Denmark Nestor Koldobsky, Argentina D. Lecic-Tosevski, Serbia and Montenegro Paul Links, Canada Cesare Maffei, Italy J.M. Mburu, Kenya Aurel Nirestean, Romania Joel Paris, Canada Gabriele Partscht, Germany A. Pérez Úrdaniz, Spain James Reich, USA Danilo Rolando, Uruguay Janine Stevenson, Australia M.M. Thunnissen, The Netherlands Jitindra Kumar Trivedi, India Øyvind Urnes, Scandinavia Sergio Valdivieso Fernández, Chile 4 Editorial introduction In 2002 at the World Congress in Yokohama, the World Psychiatric Association, under the guidance of the International Society for the Study of Personality Disorders (ISSPD), established a new division on personality disorders as an official branch of the world organization. In accordance with this decision, the new division, entitled WPA Section on Personality Disorders, has been given the opportunity to develop a formal WPA educational program on personality disorders to be published on the website. An editorial steering committee (Erik Simonsen, Theodore Millon, and Elsa Ronningstam) was created to formulate, organize, and coordinate the development of the program. The program was designed to provide useful information about characteristics of personality disorders as conceived in the ICD and DSM. An outline of topics was developed and a set of authors was selected. The ISSPD Board and the Board of the WPA Section on Personality Disorders approved the proposal. Members of the ISSPD and WPA Section on Personality Disorders were then encouraged to take part in the development of the program. The project has been financially supported both by the ISSPD and WPA. The program represents the contributions and collaborations of researchers and clinicians from around the world. The response of our colleagues has been both generous and outstanding in quality. The target audience for the program is planned to be broad, ranging from medical and psychology students, psychiatric nurses and social workers, primary care clinicians, psychologists, psychiatrists, and the staff in academic institutions. The structure of the program is comparable to other WPA Educational programs. The first module provides information on history, concepts and methodological issues. The second module describes detailed diagnostic and clinical descriptions of each disorder, prevalence, age and gender issues, etiology and pathogenesis, course and prognosis, and comorbidity and treatment. The third module presents a series of clinical vignettes that illustrate their features in concrete and realistic forms. After each section you will find curriculum suggestions for classroom teaching and workshops. The program was written by several authors who are acknowledged at the following pages. The program has been approved by the WPA Educational Committee under the vigorous leadership of Allan Tasman, who has been very supportive throughout the process. On behalf of the editors, I would like to thank all the contributors for their steadfast efforts in making this possible. The material is easily accessible on the internet. Hopefully, the material will be used worldwide to advance the understanding of diagnosis and management of personality disorders. We would appreciate a feedback from those who used the program. Our plan is to make an update every 3 rd year. Erik Simonsen M.D. Editor, Committee chair Chairman, WPA Section on Personality Disorders [email protected] 5 Foreword Few problems in the field of psychiatry are more complex to address than personality disorders. The dilemma starts, in fact, with trying to decide what is the personality, and how we understand the influences that determine the mature personality? Contemporary views assume a complex interaction between genetic factors, with a present emphasis on temperament, and life experiences. While most believe that what will become the mature personality is, for most people, essentially determined by late adolescence, we know that a variety of adult life influences can exert modifying effects throughout the life cycle. Thus, the conceptualization that personality reflects a matrix of qualities of character and patterns of reactivity has become generally accepted, though still difficult to quantify. Moving from a general framework of understanding to a definition of specific aspects of personality has, therefore, been more difficult. This leads to the greater difficulty for our field, which is the differentiation of normal from abnormal personality. It is within this area of inquiry that the definition of personality disorders lies. Complicating this definition is the fact that not only genetic heritage and life experiences exert influences on personality development and structuralization, but also a wide range of cultural and ethnic variables also play a substantial, though thus far also not quantifiable, effect. If, given all of the dilemmas enumerated above, we can arrive at a consensus about what is a personality disorder, this leads to the next dilemma of how we can best assess personality disorders. There is little agreement in this area, best conceptualized through the ongoing debate about whether diagnosis of personality disorders should occur within a dimensional or categorical approach. A further complication arises due to the fact that advocates for either categorical or dimensional approaches have thus far not reached a consensus on the optimal approach even within their own domain of study. Finally, how to treat something defined as a disorder, but which is embedded in the person of the individual seeking treatment, and thus not easily amenable to modification, remains one of the most complex clinical problems in the field of psychiatry. The conceptual and diagnostic dilemmas have made research in the area of personality disorders’ treatment quite difficult, as comparisons across studies are difficult to make. An additional level of complexity occurs because we well know that personality disorders and other psychiatric disorders often co-exist, but unfortunately not in ways which lead us to easy construction of frameworks for treatment planning. Molecular genetics holds out the promise that if we identify genetic predispositions for a variety of psychiatric illnesses, that we can use this knowledge to develop more effective treatments for them. Few would suggest a similar likely outcome in the area of personality disorders. Our psychological task, then, is to provide state-of-the-art information which can be used by clinicians at any stage of training in understanding personality disorders and developing a treatment plan. This monumental task has been handled with aplomb by the workgroup responsible for the preparation of the work you are reading. Calling upon an outstanding group of experts in all aspects of personality studies around the globe, Eric Simonsen, M.D., and colleagues have produced a work that is comprehensive, yet organized in a way that makes access to the material easy for individuals at any stage of their professional career. Their work is an excellent illustration of ways in which the WPA can productively collaborate with other international organizations, in this case the International Society on the Study of Personality Disorders (ISSPD). The work is designed in three modules. Module 1, Conceptual and Methodological Foundations, reviews the scholarly contributions to our understanding of personality and how we might classify personality and personality disorders and reviews a variety of therapeutic management approaches. Module 2 addresses each personality disorder and reviews diagnostic criteria, etiology, epidemiology, comorbidity, and treatment. Module 3 presents
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