Further developments

It is unlikely that many studies will ever be carried that satisfy the four requirements of minimum evidence of efficacy described at the beginning of this chapter. This is because such explanatory trials would be so far removed from usual psychiatric practice that their results will be difficult to translate into such practice. There is also continuing uncertainty about the best ways of classifying personality disorder and widespread dissatisfaction with the current categorical system. (79 The arguments in favour of a dimensional system of classification extending from normal personality through to higher levels of personality disorder (H> are becoming more powerful. The problem of comorbidity between personality disorders is accentuated by evidence that the more severe personality disorders are associated with greater comorbidity/72) It may be better to regard comorbidity as a measure of severity, thereby combining the advantages of categorical and dimensional systems. (73> It seems increasingly likely that it is severity of personality disturbance rather than a specific categorical label that will be more important in selecting patients for treatment studies.

The problem of adherence to treatment will be more difficult to overcome. Because personality disorders are usually ingrained egosyntonic, it is highly unlikely that patients will continue treatment effectively either with regular medication or with frequent sessions of psychological treatment. However, it may be less difficult to improve compliance with psychological treatment than with drug treatment. Combined drug and psychological treatments may be of value as there is no reason to believe that these would be antagonistic in the treatment of personality disorder. The collaborative approach of cognitive therapy seems well suited to the treatment of personality disorder and could improve adherence to all modes of treatment.

It would be very useful if there was a better theoretical basis for the treatment of personality disorder. Apart from schema theory, there is little rationale for any current treatment of personality disorder. Despite these somewhat gloomy and sceptical views it is important to note that for the first time in the history of personality disorder people the condition is no longer regarded as untreatable. We expect that effective treatments will be found in the course of the next 30 years and, if this happens, it will help greatly in removing the pejorative views that are currently attached to these conditions.

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