The Association for Research in Nervous and Mental Disease held its 86th annual meeting in New York City on December 8, 2006. The topic, unusual for the organization, was Personality Disorders. The organizers of the program included two psychoanalysts—John Oldham and Otto Kernberg.
There were six papers on biologic and natural scientific approaches to these conditions. Svenn Torgersen from Oslo reviewed epidemiologic studies. The overall prevalence is about 10 percent. Antisocial is more common in males, dependent more common in females. Most of those afflicted are less educated, however obsessive-compulsive correlates with higher socioeconomic status. Ted Reichborn-Kjennerud, also from Oslo, then discussed genetic factors drawing on data from twin studies. He emphasized the importance of environmental-genetic interactions and estimated that, on the whole, about 50 percent of the etiology can be attributed to genetic factors. Larry Siever, from Mount Sinai in New York City, presented a wide range of neurobiologic research, and anticipated a theme of the meeting by introducing the concept of “endophenotype,” an underlying dimension or clinical characteristic that is related to the disorder and that can be linked to a susceptibility gene. David Silbersweig of Cornell University presented fascinating findings from his functional brain imaging studies of patients with borderline personality disorder, showing abnormal fronto-limbic emotional and behavioral inhibitory function. Their brains suggest deficient control of impulses—a core clinical feature of the disorder. Patricia Cohen of Columbia University offered a developmental perspective. She suggested that many personality disorders are not as stable in the transition from adolescence through young and middle adulthood as our traditional notions assume, and that, in general, core psychological characteristics (possibly temperamental or endophenotypes) are more stable than symptoms or symptom clusters. This came up several times during the day, and relates to the contrast between reliability (e.g., surface phenomenology, symptoms) and validity (e.g., core characteristics) in the definition and diagnosis of these disorders. The final basic science paper was The Thomas William Salmon Lecture presented by Jonathan Cohen, the Higgins Professor of Psychology at Princeton. Cohen, a psychiatrist and cognitive psychologist, studied functional magnetic resonance images of the brain during complex mental tasks, the type in which psychoanalysts might be interested. He described studies in which subjects made decisions (some “moral,” selecting between alternatives that involved responsibility for life and death; others “economic,” making choices that involved selecting alternative financial rewards). He was particularly interested in irrational or suboptimal decisions—How did their brains function when individuals were governed by emotions rather than rationality? He demonstrated that different brain regions were involved in emotional as compared to rational decisions, and conjectured regarding the evolutionary significance of the two systems and their possible maladaptive consequences in our contemporary world.
Our attention is shifting from symptoms and diagnoses to patterns of psychosocial functioning and mechanisms, from surface to depth, from whether treatment works to how it works, and for whom.
The afternoon was devoted to five more clinically immediate papers. Drew Westen of Emory compared psychodynamic, cognitive-behavioral, trait and integrative models, along with therapeutic strategies appropriate to each. Otto Kernberg of Cornell described his transference-focused psychotherapy, and presented the results of a randomized clinical trial comparing it with dialectical behavior therapy and supportive therapy. He found many similarities but also interesting differences. Transference-focused psychotherapy was most successful at the combined goal of maintaining patients in treatment and facilitating their improvement. Paul Links, of Toronto, reviewed the effectiveness of dialectical behavioral therapy, and finally Aaron Beck of the University of Pennsylvania did the same for cognitive-behavioral therapy. These three therapy-focused presentations made clear that systematic clinical research on the efficacy and effectiveness of these treatments with difficult borderline patients is possible and can be fruitful. The era of anecdote and belief is being supplanted by an era of evidence and knowledge. The final clinical presentation was by Mary Zanarini of Harvard and McLean who described a 10-year prospective follow-up of 362 patients with borderline personality disorder. Four out of five attained good psychosocial functioning and, repeating a theme that reverberated through the day, the more dramatic symptoms resolved most quickly while the core psychological characteristics were slower to change.
Robert Michels, M.D., is Walsh McDermott University Professor of Medicine and Psychiatry at Cornell University. He is training and supervising analyst at the Columbia University Center for Psychoanalytic Training and Research.
The day was bracketed by two comprehensive overviews, one by Joel Paris of McGill and the other by Andy Skodol of Columbia (but en route to Arizona). Paris discussed the under-recognition of these disorders by clinicians, while Skodol, who is leading the DSMV efforts on Axis II, discussed the contrast between evidence suggesting improvement over time and the traditional notion of long-term stability. He offered a model of manifest symptom clusters that come and go against a background of more stable traits, together with a possible diagnostic system of mixed categories and dimensions.
The most important thing about the meeting is probably that it occurred under the aegis of a major neuroscience organization. It is not surprising that personality disorders are complex and multifaceted, that they have important genetic and biologic determinants, that they are associated with specific patterns of brain functioning, that they can be treated, and that the type of treatment employed makes a difference. Yet each of these propositions has been disputed. The accumulation of a significant and consistent body of evidence on these and related points means that the field will attract a growing pool of resources—money, of course, but more importantly, talent and intellectual creativity. Our attention is shifting from symptoms and diagnoses to patterns of psychosocial functioning and mechanisms, from surface to depth, from whether treatment works to how it works, and for whom. Personality disorders, along with their treatment—psychoanalytic and otherwise—are finally receiving the attention they have long deserved.