Rob - thanks for the question. My approach has been to use the presence of the personality variables to adjust my expectations of what I can accomplish with a patient in a set number of sessions. For example, with an average headache patient, I can generally get an 50-80% reduction in headache activity in about 4 sessions. But with say borderline personality spectrum issues cropping up, I will adjust my goals and the patient's expectations to what might be the easiest outcome to achieve, call that a success, and then build on that in subsequent passes through therapy (because they will be through again). I have worked with patients primarily in a primary care setting with the usual HMO restrictions, so I haven't engaged the personality disorder directly a la Linehan or Jeff Young. -John
So as for symptoms, I try to identify the lowest level symptom and use that to gain momentum on attacking the other associated symptoms that are invariably present. I have seen this momentum actually have powerful effects on the underlying pathology.
I pretty much follow your approach as far as the context of treatment is concerned.
In a previous professional life, I was a director for clinical information development in a for profit outpatient medical center. We did a survey on how often personality disorders were being diagnosed in our psychiatry department. What we found out was that personality disorders were being diagnosed at much lower rate than you would expect given the DSMIV literature. And where they were diagnosed, they were not the focus of treatment.
This raised a lot of issues as you might imagine, but what struck me was this: diagnosis is supposed to imply a treatment. What is happening when something is being diagnosed, but nobody professes to be treating it?
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