Table Of ContentPERSONALITY-
DISORDERED
PATIENTS
Treatable and Untreatable
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PERSONALITY-
DISORDERED
PATIENTS
Treatable and Untreatable
By
Michael H. Stone, M.D.
Professor of Clinical Psychiatry, Columbia College of
Physicians and Surgeons, New York, New York
Washington, DC
London, England
Note: The author has worked to ensure that all information in this book is accu-
rate at the time of publication and consistent with general psychiatric and medical
standards. As medical research and practice continue to advance, however, thera-
peutic standards may change. Moreover, specific situations may require a specific
therapeutic response not included in this book. For these reasons and because hu-
man and mechanical errors sometimes occur, we recommend that readers follow
the advice of physicians directly involved in their care or the care of a member of
their family.
Books published by American Psychiatric Publishing, Inc., represent the views and
opinions of the individual authors and do not necessarily represent the policies and
opinions of APPI or the American Psychiatric Association.
Copyright © 2006 American Psychiatric Publishing, Inc.
ALL RIGHTS RESERVED
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Library of Congress Cataloging-in-Publication Data
Stone, Michael H., 1933-
Personality-disordered patients : treatable and untreatable / by Michael H. Stone.
-- 1st ed.
p. ; cm.
Includes bibliographical references and index.
ISBN 1-58562-172-2 (pbk. : alk. paper)
1. Personality disorders--Patients--Treatment. 2. Psychotherapy. I. Title.
[DNLM: 1. Personality Disorders--therapy. 2. Psychotherapy.
WM 190 S879p 2005]
RC554.S765 2005
616.85'81--dc22
2005022750
British Library Cataloguing in Publication Data
A CIP record is available from the British Library.
PREFACE - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - vii
1 AMENABILITY TO TREATMENT IN THE REALM OF
PERSONALITY DISORDER - - - - - - - - - - - - - - - - - - - - - - - - - - - 1
2 PERSONALITY DISORDERS MOST AMENABLE TO
PSYCHOTHERAPY: BORDERLINE PERSONALITY DISORDER - - - - 47
3 PERSONALITY DISORDERS MOST AMENABLE TO
PSYCHOTHERAPY: THE ANXIOUS CLUSTER AND
RELATED DISORDERS - - - - - - - - - - - - - - - - - - - - - - - - - - - - 79
4 PERSONALITY DISORDERS OF INTERMEDIATE
AMENABILITY TO PSYCHOTHERAPY:
BORDERLINE PERSONALITY DISORDER - - - - - - - - - - - - - - - - - 99
5 PERSONALITY DISORDERS OF INTERMEDIATE
AMENABILITY TO PSYCHOTHERAPY:
OTHER PERSONALITY DISORDERS - - - - - - - - - - - - - - - - - - - - 117
6 PERSONALITY DISORDERS
OF LOW AMENABILITY TO PSYCHOTHERAPY:
BORDERLINE PERSONALITY DISORDER - - - - - - - - - - - - - - - - 137
7 PERSONALITY DISORDERS OF LOW AMENABILITY TO
PSYCHOTHERAPY: OTHER PERSONALITY DISORDERS - - - - - - 169
8 PERSONALITY TRAITS AT
THE EDGE OF TREATABILITY - - - - - - - - - - - - - - - - - - - - - - - 193
9 UNTREATABLE PERSONALITY DISORDERS - - - - - - - - - - - - - - 213
AFTERWORD - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - 257
INDEX - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - 263
C O N T E N T S
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PREFACE
Of the many tasks Dr. Otto Kernberg has addressed throughout his ca-
reer, one of the most important has been the application of the scientific
method to psychoanalysis and to the psychoanalytically oriented therapy of
patients with borderline personality disorder. All forms of psychotherapy
are mixtures of art and science, but for too long psychoanalytic therapy and
the way in which it worked were subjects surrounded with mystery and
haze. In recent years, the precision Dr. Kernberg has brought to the anal-
ysis of videotaped sessions of transference-focused psychotherapy with bor-
derline patients has lifted much of the haze and removed much of the
mystery. He and his colleagues at the Personality Disorder Institute have
developed a manual for carrying out this form of therapy, and this accom-
plishment has contributed to the refinement of technique in treating pa-
tients with borderline and other severe disorders of personality. Dr.
Kernberg’s influence, when we first met, spurred my own interest in per-
sonality disorders, and borderline personality most especially, to which I
have now devoted half my life.
This book deals with the whole range of personality disorders, from the
mildest and most successfully treated to those of the greatest malignancy,
where successful treatment is only a wish, not a realizable venture. The em-
phasis in this book is not on the “how-to” aspects of treatment but on the
amenability of the various disorders to amelioration by any method of ther-
apy whatsoever. With which kinds of patients is therapy likely to succeed?
With which is failure almost a certainty?
Success with the treatment of personality disorders is at best a long and
painstaking process that effects only modest changes. Symptoms can often
be alleviated dramatically; personality is, as it should be, highly resistant to
change. Personality is the skin that separates us from the outside world.
vii
viii PERSONALITY-DISORDERED PATIENTS
Psychotherapists do not aim to make radical changes in a patient’s person-
ality, but rather to smooth down the rough edges with fine sandpaper—to
make the abrasive person more polite, the impulsive person more re-
strained, and so on.
In my clinical work I have come to realize that a large number of factors
help determine, within the broad domain of personality disorders, which
patients are likely to respond well to psychotherapeutic interventions and
which will prove most resistive. These factors, and relevant clinical exam-
ples, are discussed in the early chapters. Because the main instrument ther-
apists use in this work is their own personality, inevitably there is much
subjectivity in how therapists go about their work and in the range of pa-
tients with whom they have the best results. This is the “art” with which
the science of psychotherapy is necessarily mixed. Illustrations of this phe-
nomenon are offered in the middle sections of the book. The final chapters
are taken up with the most severe aberrations of personality and with the
limitations these conditions impose on therapists’ efficacy. Some may take
this discussion as a counsel of despair, but realism and honesty should com-
pel us to acknowledge these limitations. To this end, I offer in the last chap-
ter some rather extreme examples that I hope make this point clear.
My gratitude goes also to Dr. Glen O. Gabbard, who reviewed the
manuscript as it was unfolding and gave me many helpful recommendations
and suggestions for improving its substance. No less important, the serenity
and calmness of my wife Beth’s personality created an optimal atmosphere
for carrying out the lengthy task of authorship.
1
AMENABIL ITY TO TREATMENT IN
THE REALM OF PERSONALITY
D ISORDER
For the past quarter century, the Diagnostic and Statistical Manual of Mental
Disorders (of which the latest version is the text revision of the fourth edi-
tion, DSM-IV-TR [American Psychiatric Association 2000]), has appor-
tioned the various entities into two broad divisions: one devoted to
symptom disorders (Axis I) and the other to disorders of personality (Axis
II). Some voices have been raised in criticism of this division as too arbitrary
and inelastic. Persons with the symptom of agoraphobia, for example, often
manifest avoidant personality. Provided they confine themselves to the
safety of home, only the latter is apparent. If they are forced to venture out-
side, the related symptom disorder quickly reaches the level at which it is
clinically recognizable. Still, the bipartite division has one special virtue, es-
pecially for our purposes. Symptoms are defined as uncomfortable condi-
tions for which the term ego-dystonic is customarily used. It is unpleasant and
disadvantageous to be depressed, schizophrenic, bulimic; to be unable to
touch a doorknob for fear of germs; or to be “phobic” about entering an
1
C H A P T E R
