Treatment of severe personality disorders
Primary aim is control of impulsivity and aggression.Medication is used to deal with incapacitating symptoms, such as anxiety, rage, depression, and somatic complaints. SSRIs (selective serotonin reuptake inhibitors) and lithium carbonate may be beneficial in regulating serotonergic function which is often underlying impulsive behaviour and aggression. Antiepileptic drugs, such as carbamazepine and clonazepam could be used for aggressive outbursts. Classical benzodiazepines are contraindicated since they might cause behavioural disinhibition and aggressive outbursts. Non-compliance is a common problem, as well as drug abuse. Therefore drugs should be used judiciously.
Mental health professionals often consider personality disorders with therapeutic nihilism and as unable to remit. However, few offenders who commit homicidal violence are professional criminals. Their own violence and its effects can be profoundly shocking to them and cause posttraumatic stress disorder.
The first modest aim of treatment is to prevent incarceration making individuals with severe personality disorders more disturbed and potentially more dangerous. Skilled mental health professionals and medical doctors can, and should provide assistance to such individuals. They should be encouraged to find alternative ways of coping with intense emotions than aggressive acts, and protected from their self-defeating behaviour. It can be achieved slowly by enabling the acquisition of new social and interpersonal skills, and the abandoning of disturbed ways of behaving and coping.
Realistic conditions should be created, with setting limits, and eliminating all tertiary gains of treatment, like escape from the sanctions [7]. These changes can be achieved only in the supportive relationships with health professionals and peers. They like to be leaders and it should not be taken away from them in the doctor-patient relationship, by competing for control, which is a frequent mistake of ambivalent therapists.
They might feel intense fear when not in control. It may help both doctor and patient if this becomes a theme. Slowly alternative ways of seeing things may develop. The channel for action is behaviour, and patients can learn from the constant, unchanging and accepting behaviour of the doctor who shows understanding "in spite of everything". It should be emphasized that doctors should not judge the behaviour but try to understand it. Below the mask of a personality disorder, and below the overwhelming anger, there is pain and anxiety.
[7] Mullen, P.E., Lindquist, P. (2000). Treatment and care in forensic mental health. In New Oxford Textbook of Psychiatry (eds. M.G. Gelder, M.G., J.J. López-Ibor Jr., and N.C. Andreasen), pp. 2109-2121. Oxford University Press. Oxford, New York.