CAPITULO III: SUSTENTO PEDAGÓGICO
3.6 Evaluación
Areas of development
In the last 2 years there is an increasing belief that personality disorder has crossed the Rubicon; it is now perceived as a treatable condition. We now have a whole raft of developments that support the idea that a range of interventions may be effective in personality disorder.
Even since the time of our last article we have further evidence of effective-ness of psychological therapies, both psychodynamic and cognitive-behav-ioral (Leichsenring and Leibing, 2003;Tyrer et al, 2004), and there are also new encouraging signs that antide-pressants, atypical antipsychotic drugs and mood stabilizers may have a role in treatment (Hollander et al, 2003; Rinne et al, 2002; Zanarini et al, 2004).
Treatment is also more focused on reduction of specific features, like self-mutilating and self-damaging impulsive behaviors (Verheul et al, 2003; Tyrer et al 2004) and on the overall social adjust-ment (Chiesa and Fonagy, 2003). It seems as if therapeutic alliance plays a major role for change more than the specific mode of psychosocial treatment.
However, these successful treatment pro-grams are mostly reported in people with cluster C personality disorders (Svartberg et al, 2004) and borderline personality dis-order (Bateman and Fonagy, 2001).This is a large group in clinical practice but there is evidence of a much larger group who never present for treatment for their per-sonality abnormality. The treatment-resisting personality disorders (Type R) may require a completely different type of treatment approach from those with treatment-seeking personalities (Type S) (Tyrer et al, 2003).
Outcome
Areas of development
Outcome studies in personality disorders are difficult to conduct. The presence of comorbidity, lack of specificity of psy-chotherapies, difficulties in implementing optimal randomized controlled studies, changes of diagnostic criteria and lack of precise outcome measures are the most obvious obstacles to progress and a com-mon approach would be of great value.
By definition personality disorder should be stable and enduring and therefore out-come might not be regarded as a relevant
NEW DEVELOPMENTS IN PERSONALITY DISORDER RESEARCH
concept. However, as we indicated above, several recent papers have shown that treatment is effective in the short term.
Long-term outcome studies have been limited to antisocial and borderline per-sonality disorder. There is a decline of psychopathology and better social func-tioning around the age of 40 in those with borderline pathology but those with other personality disorders may retain long-term social dysfunction (Seivewright et al, 2004). A recent 6-year follow-up study of 290 patients, who met the criteria of bor-derline personality disorder, suggests that borderline psychopathology now may have more rapid improvement and remis-sion than formerly (Zanarini et al, 2003).
About three-quarters of the patients had their symptoms remitted after 6 years.
Impulsivity resolved most quickly, cogni-tive and interpersonal problems were intermediate, whilst the affective symp-toms were most chronic.
Conclusion
The field is slowly moving from a stage of general speculations and clinical observations about etiology and
thera-py to more empirical analyses of the basic questions on concepts, etiology, classification, and outcome. New con-ceptions of personality pathology and new treatment paradigms have led to more tailored integrated therapies designed to address specific personality problems like impulsivity, disconnected, insecure attachment, self-harm, aggres-sion, or mood swings. The good message is that recent well-designed trials have underlined that these treatment pro-grams work for most patients with per-sonality disorders.
The challenge in the future will be to develop a classification system of higher clinical utility. Research on alternative dimensional models in the coming years may pave the way for a new under-standing of etiology, promote better assessment, better coverage of personal-ity pathology and more effective guide-lines for treatment. Longitudinal studies are needed not only to get a better understanding of the interaction between gene and environment, but also to determine the long-term effects of treatment.
PSYCHOPATHOLOGY
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NEW DEVELOPMENTS IN PERSONALITY DISORDER RESEARCH
Eric Simonsen, Amtssygehuset Fjorden, 10-16 Smedegade, Birkehus 2, Roskilde, Denmark DK-4000 E-mail: [email protected], [email protected]
Smoking is a very important topic for the Section on Psychiatry, Medicine and Primary Care as it has been demonstrat-ed that the incidence of smoking among individuals who abuse alcohol, stimu-lants, and opiates is about 90%. Many of those who work with psychiatric patients have observed that cigarette smoking is extremely common among schizophrenic patients. New neurobiological knowledge has explained why patients with psychi-atric disorders smoke. There are nicotine-induced changes in neurotransmitters, and further research is needed to under-stand nicotine’s involvement in the pathophysiology of psychiatric disorders.
Maybe future antipsychotics will not only ameliorate psychiatric symptoms but also decrease nicotine dependence in schizo-phrenic patients.
Major depression is also associated with tobacco use; researchers have found that alcoholism has the highest associa-tion with smoking. Smoking rates among patients with anxiety disorders are at least twice that of people without a psychiatric diagnosis.
Studies of the prevalence and use of tobacco at world level shows a plateau or drop of this phenomenon in devel-oped countries, and an increase in developing countries. Surveys carried out in Argentina to establish the preva-lence of tobacco use show that about a third or more of the population smokes, there is a tendency to increase the inci-dence and prevalence among women, and to extend to younger individuals.
In Argentina, the prevalence of tobacco use is one of the highest in the conti-nent, approximately 39% of the adult population and 33% of the teenagers are smokers. A recent survey carried out in schools in the city of Buenos Aires shows that some children smoke from the age of nine. Age has an important influence on tobacco behavior: the age of initiation determines subsequent use, and therefore an early use of tobacco implies a later daily important use. In developed countries, in the 1990s, approximately 21 million individuals have died due to a tobacco-dependence illness. In Argentina, mortality