Front Matter

Anthony W. Bateman, M.A., FRCPsych—Honoraria: trainings in mentalization-based treatment; Royalties: various books on mentalizing

Donna S. Bender, Ph.D., FIPA—Royalties: American Psychiatric Association Publishing; Wolters Kluwer (UpToDate)

Donald W. Black, M.D.—Consultant: Otsuka

Nancee S. Blum, M.S.W.—Royalties: American Psychiatric Association Publishing (SIDP)

Peter Fonagy, Ph.D.—Honoraria: trainings in mentalization-based treatment; Royalties: various books on mentalizing

Carlos M. Grilo, Ph.D.—Consultant: Sunovion; Weight Watchers; Honoraria: lectures, CME activities, and presentations at scientific conferences and universities; Royalties: Guilford Press; Taylor & Francis

Patrick Luyten, Ph.D.—The author has been involved in the training, evaluation, and dissemination of mentalization-based therapy

Katharine J. Nelson, M.D.—Grant support: American Board of Psychiatry and Neurology; Royalties: Wolters Kluwer (UpToDate); Oxford University Press

John M. Oldham, M.D., M.S.—Joint Editor: Journal of Personality Disorders (Guilford); Joint Editor-in-Chief: Borderline Personality Disorders and Emotion Dysregulation, BioMed Central; Co-owner: Npsp25.com, LLC

Andrew E. Skodol, M.D.—Royalties: Merck (Merck Manual); Wolters Kluwer (UpToDate)

David M. Benedek, M.D., Col, M.C., U.S.A.

Philippe Boursiquot, M.D., FRCPC

Beth S. Brodsky, Ph.D.

Chloe Campbell, Ph.D.

Andrew M. Chanen, M.B.B.S., Ph.D., FRANZCP

Lois W. Choi-Kain, M.D., M.Ed.

John F. Clarkin, Ph.D.

Jennifer C. Elliott, Ph.D.

J. Christopher Fowler, Ph.D.

Sharely Fred Torres, M.D.

Lauren R. Gorfinkel, M.P.H.

Ilana Gratch, B.A.

Thomas G. Gutheil, M.D.

John M. Hart, Ph.D.

Deborah S. Hasin, Ph.D.

Sabine C. Herpertz, M.D.

Richard Hersh, M.D.

Christian Hicks, M.D.

David Kealy, Ph.D.

Amy R. Kegley, Ph.D.

Sophie Kerr, B.A.

Harold W. Koenigsberg, M.D.

Jay L. Lebow, Ph.D.

Kenneth N. Levy, Ph.D.

Madison Links, M.D.

Paul S. Links, M.D., FRCPC

Nicolas Lorenzini, Ph.D.

Ricky D. Malone, M.D., Col (Ret.) M.C., U.S.A.

Jacquelyn L. Meyers, Ph.D.

Leslie C. Morey, Ph.D.

Philip R. Muskin, M.D., M.A.

Sara Siris Nash, M.D., FACLP, FAPA

Antonia S. New, M.D.

John S. Ogrodniczuk, Ph.D.

William H. Orme, Ph.D.

Seth J. Prins, Ph.D., M.P.H.

Daniel R. Rosell, M.D., Ph.D.

Abigail B. Schlesinger, M.D.

Christian Schmahl, M.D.

Carla Sharp, Ph.D.

Jennifer Sotsky, M.D.

Barbara Stanley, Ph.D.

Svenn Torgersen, Ph.D.

Sherab Tsheringla, M.D.

Amanda A. Uliaszek, Ph.D.

Drew Westen, Ph.D.

Victoria Winkeller, M.D.

Frank E. Yeomans, M.D.

The first section of this textbook might be thought of as the foundation for the parts that follow. First, in Chapter 1 (“Personality Disorders: Recent History and New Directions”), Oldham presents a brief overview of the recent history of the personality disorders, along with a summary look at the evolution of the personality disorders component in successive editions of DSM, including the shift toward more dimensional representations of personality pathology. In Chapter 2 (“Theories of Personality and Personality Disorders”), Westen and Kegley review major theories that have influenced thinking about the nature of personality and personality disorders, including psychodynamic, cognitive-social, trait, and integrative theories. The next chapter (Chapter 3, “Articulating a Core Dimension of Personality Pathology”), by Morey and Bender, follows naturally from the previous one, emphasizing the fundamental roles of self and interpersonal functioning as core components of personality and as defining features of impairment in personality disorders. These concepts are central components of the Alternative DSM-5 Model for Personality Disorders (AMPD), described in more detail in Chapters 4 and 5. In Chapter 4, Skodol, Bender, and Oldham summarize current controversies about and present a detailed chronicle of the evidence supporting the AMPD, and the complex process of its development. In Chapter 5, Skodol reviews the defining features of DSM-5 Section II and Section III personality disorder assessment models, discusses complementary approaches to the clinical assessment of a patient with possible personality psychopathology, provides guidance on general problems encountered in the routine clinical evaluation, and outlines processes of diagnosis and guidelines for differential diagnosis according to the AMPD. Throughout, Skodol provides expert guidance to introduce readers to the new model, clarifying the differences in the application of this innovative dimensional-categorical hybrid system compared with the traditional DSM-IV (and now DSM-5 Section II) categorical approach.

Part II begins with data on prevalence, sociodemographics, and levels of functional impairment associated with personality disorders, described by Torgersen in Chapter 6 (“Prevalence, Sociodemographics, and Functional Impairment”). Although there are relatively few well-designed population-based studies, Torgersen reviews important contributions, including his own Norwegian study, and he tabulates prevalence ranges and averages for individual DSM-defined personality disorders as well as for all personality disorders taken together. Fonagy and colleagues, in Chapter 7 (Development, Attachment, and Childhood Experiences: A Mentalizing Perspective”), then present a developmental perspective, stressing the importance of healthy attachment experiences as building blocks for effective adult personality functioning. Disruptions in attachment, conversely, set the stage for future impairment, and they correlate strongly with the development of the neurobiological dysregulation that is present in many patients with personality disorders, described in Chapter 8 (“Genetics and Neurobiology”) by Fred Torres and colleagues. In Chapter 9 (“Longitudinal Course and Outcomes”), Grilo and Skodol provide an overview of the clinical course and symptomatic and functional outcomes of personality disorders, synthesizing the empirical literature on the long-term course of personality disorder psychopathology, including the importance of comorbidity and continuity of psychopathology over time in understanding personality stability and change.

Chapters 10–19 offer a range of treatment options and clinical considerations that cut across therapeutic modalities. In a new, cutting-edge chapter for the third edition of this textbook, Sharp and colleagues, in Chapter 10 (“Early Identification and Prevention of Personality Pathology: An AMPD-Informed Model of Clinical Staging”), argue for the early identification of borderline psychopathology in children and young adolescents, in an effort to prevent the development of the full-blown disorder later in life. The authors describe how the DSM-5 AMPD provides a framework for understanding why the transition from childhood to adulthood appears to be a sensitive period for the development of personality pathology, and a developmentally sensitive clinical staging approach to prevention of and early intervention for personality pathology. The treatment section continues with Chapter 11 (“Therapeutic Alliance”), in which Bender underscores the necessity of explicitly considering aspects of alliance building with various styles of personality psychopathology across all treatment modalities. Yeomans and colleagues, in Chapter 12 (“Psychodynamic Psychotherapies”), summarize the salient features of psychodynamic psychotherapies—both traditional and eclectic therapies—including discussions of mechanisms of change and of empirical validation, as applied to patients with personality pathology. In Chapter 13 (“Dialectical Behavioral Therapy”), Stanley and colleagues review the essentials of dialectical behavior therapy (DBT). In Chapter 14 (“Cognitive-Behavioral Therapy”), Fowler and colleagues summarize several specific cognitive-behavioral therapy strategies, including traditional cognitive-behavioral therapy itself, schema-focused therapy, and DBT, as applied in working with patients with personality disorders. In another new chapter for this edition, Chapter 15 (“Good Psychiatric Management: Generalist Treatments and Stepped Care for Borderline Personality Disorder”), Choi-Kain and Hersch detail the essentials of “Good Psychiatric Management,” a treatment that can be used successfully by “generalists” in various mental health settings and in primary care, thus addressing a critical public health need caused by the shortage of therapists trained in “brand name,” evidence-based treatments, such as DBT.

Apart from the realm of individual treatments, there are other venues for therapeutic interventions. In Chapter 16 (“Group, Family, and Couples Therapies”), Ogrodniczuk and colleagues demonstrate the application of group, family, and couples therapies to personality disorders, emphasizing the unique aspects of each type of therapy that can facilitate treatment of personality pathology. Nelson and Tsheringla then take up the issue, in Chapter 17 (“Pharmacological Management”), of pharmacotherapy, because many patients with personality disorders may benefit from complementing their psychosocial treatments with evidence-based, symptom-targeted adjunctive medications. Winkeller and Schlesinger, in Chapter 18 (“Collaborative Treatment”), provide recommendations about the best ways of negotiating collaborative treatments, because many patients with personality disorders are engaged in several treatment modalities with several clinicians at the same time. In the final chapter in this section (Chapter 19, “Boundary Issues”), Gutheil sagely cautions practitioners about dynamics that can lead to boundary violations when working with certain patients with personality disorders.

In recognition of the fact that patients with personality disorders can be particularly challenging, we have included five chapters devoted to special issues and populations. Of prime importance is the risk for suicide. In Chapter 20 (“Assessing and Managing Suicide Risk”), Links and colleagues provide evidence on the association of suicidal behavior and personality disorders, examine modifiable risk factors, and discuss clinical approaches to the assessment and management of suicide risk. In Chapter 21 (“Co-occurring Substance Use Disorders”), Gorfinkel and colleagues focus on pathways to co-occurring substance abuse in patients with personality disorders, and they discuss issues of differential diagnosis and treatment. Substance use and abuse is common in many patients with personality disorders, perhaps particularly in patients with antisocial personality disorder. Black and Blum, in Chapter 22 (“Antisocial Personality Disorder and Other Antisocial Behavior”), present the latest findings regarding antisocial behavior. Of the personality disorders, antisocial personality disorder is one of the costliest to society, and it can be associated with serious personal consequences. Unfortunately, far too little is available to offer at this point in terms of effective treatment, and many of these individuals end up in correctional and forensic settings.

In Chapter 23 (“Personality Disorders in the Medical Setting”), Nash and colleagues provide a new take on presentations of personality pathology in general medical settings, and how to manage them, since physical conditions frequently coexist with and are complicated by personality pathology and patients with personality disorders often seek treatment from primary care or family medicine practitioners. In the final chapter in this section, Chapter 24 (“Personality Disorders in the Military Operational Environment”), Malone and Benedek focus on an important population that often gets overlooked: soldiers on active duty in the U.S. military. In military settings, personality disorders can be masked or unrecognized but can eventually lead to significant impairment in functioning. The armed services are increasingly alert to the accurate recognition of personality disorders within their ranks, and to the not uncommon co-occurrence of PTSD, traumatic brain injury, major depression, and suicide risk.

In the final chapter of this textbook (Chapter 25, “Translational Research in Borderline Personality Disorder”), Schmahl and Herpertz focus on the increasing usefulness of translational research to deepen understanding of the biopsychosocial nature of the personality disorders, particularly borderline personality disorder. They discuss recent research on dysfunctions of social interaction and the role of oxytocin, and on perceptual alterations, including pain processing and dissociation, believed to be central to borderline pathology.

 

We are grateful to all of the chapter authors for their careful and thoughtful contributions, and we hope that we have succeeded in providing a current, definitive review of the field.