Personality Disorders: A Once and Future (Nonbinary) King/Queen

The ancient founders of medicine developed humorism, a scientific framework that identified four different chemical systems, mechanistically determining physiology, basic elements within and outside individuals, and human behavior. These basic humors had roots in different developmental phases and origins, seasons of the year, and temperaments. Although rendered obsolete with the advent of germ theory, humorism’s influence remains potent in understanding how people tick. Fast forward 2,500 years and the domain of personality disorder still retains the basic idea that having too many or too few specific personality traits can determine both management of oneself and how one relates to others. All of these elements therefore converge as determinants of mental and physical health, as well as human functioning, broadly.

Despite the obvious fundamental role that personality has in determining how our lives unfold, it has suffered a marginalized position in psychiatry and psychology. Over the last 50 years, most work done by our domain’s forefathers was to legitimize personality disorders as a significant category of psychiatric illness. It is an understatement to say that times have since changed. The radical transformations and enlightenments brought about by the COVID-19 pandemic era have forced a reorganization of the world as we know it. Within the field of personality disorder theorizing, research, and treatment, we are doing the same, critically and honestly questioning long-held beliefs and systems of understanding people. The reviews and articles in this special issue of Focus on borderline and other personality disorders represent this movement.

The readers of this journal—our workforce of mental health care practitioners during these turbulent times—are exactly those we want to update with all we have investigated and discussed in our intellectual silo. Choi-Kain and colleagues begin this issue with “Borderline Personality Disorder: Updates in a Post-Pandemic World,” which highlights advances in understanding and treating borderline personality disorder, possibly the paradigmatic and most clinically urgent personality diagnosis. The authors provide updates on the review published nearly a decade ago in Focus’s last special issue on personality disorders (1). To complement this review, Hersh’s “Review of Contemporary Risk Management Challenges in the Treatment of Patients With Borderline Personality Disorder” provides a high-yield guide to risk management challenges regarding the treatment of borderline personality disorder in an era of evidence-based treatment. Freed and colleague’s article, “Borderline Personality Disorder and Psychosis: A Case Managed by Transference-Focused Psychotherapy,” is a clinical illustration of comorbid borderline personality disorder and delusional disorder that presents a case from the perspectives of a transference-focused psychiatrist, the patient, and a psychotic disorders expert, and illustrates the contemporary challenges of managing the complex comorbid conditions patients face with personality pathology. This clinical report demonstrates that binary thinking about diagnoses as either-or can be harmful to patients in achieving optimal recovery. However, still, the tools developed to treat borderline personality disorder, such as mentalizing, hold utility as a window into understanding all patients psychologically, regardless of diagnosis. These contributions to borderline personality disorder treatments help all clinicians be better psychiatric professionals, as explained by Bazargan-Hejazi et al. in their 21st-Century Psychiatrist feature, “Addressing Patient-Centered Care Through Mindful Listening and Mentalization in Psychiatry.”

Now that borderline personality disorder is accepted by most clinicians trained in the modern era as a serious mental illness, we are better defining other clinically prevalent personality problems implicated in the care of many, including narcissistic personality disorder (NPD) and obsessive-compulsive personality disorder (OCPD). Weinberg and Ronningstam, as an update to Focus’s Spring 2013 issue, provide an overview of progress in understanding and treating NPD in their review, “Narcissistic Personality Disorder: Progress in Understanding and Treatment.” In addition, a pragmatic cognitive-behavioral framework for treating NPD is described in Nook and colleagues’ review, “A Cognitive-Behavioral Formulation of Narcissistic Self-Esteem Dysregulation,” which can be applied in general clinical settings without specialist or intensive intervention. OCPD, the most prevalent personality disorder, affects as many as one in 10 people, yet tailored interventions are understudied. Pinto et al.’s “Obsessive-Compulsive Personality Disorder: A Review of Symptomatology, Impact on Functioning, and Treatment” provides an expert and practical overview of OCPD, research regarding its core features, and existing treatments to guide practitioners on how to understand and approach rigid perfectionism and its related dysfunctions.

This issue also reports on areas of innovation and new directions in personality disorder assessment and treatment. Chanen and colleagues, who are leading experts on personality disorder development, contribute “Early Intervention for Personality Disorder,” a novel synthesis that emphasizes the emerging understanding of personality dysfunction’s role in psychiatric vulnerability among young people, as well as the utility of dimensional models in diagnosing personality disorders when, developmentally, personality is normatively undergoing dynamic transformation. Further, Dr. Jenna Traynor and collaborators provide a thought-provoking and cogent argument on “MDMA-Assisted Psychotherapy for Borderline Personality Disorder.” We know that no medications are proven to work for the treatment of personality disorders, and new directions of inquiry are needed to break ground on finding solutions for our patients and their families. Also in this issue, John Oldham returns for the Ask the Expert column as one of the Alternative Model for Personality Disorder’s (AMPD) chief architects, and poses the question: “How Will Clinicians Utilize the Alternative DSM-5-TR Section III Model for Personality Disorders in Their Clinical Work?” In the column, Oldham grounds the AMPD into everyday clinical practice by providing an explanation as to how the AMPD works.

The preparation for this issue truly represents a labor of work and love, which, as Freud taught us, is the cornerstone of humanity. Colleagues—who have inspired me most in my thinking and work, remained robust, relentless partners in revolutionizing the field, and deeply supported me as friends—have joined forces to deliver this issue to you. Their passion, vision, and courage to keep going, despite the usual hurdles of research, prevailing misinformation about these disorders, and current strains on the mental health care delivery system universally, provide reassurances that during the radical, daily upheavals we face globally, positive change is happening. The editorial team lead by Mark Rapaport, M.D., Michael Roy, and Peyton Fultz has been a dreamy collaboration of efficiency, pragmatism, and innovation. I am confident their four essential humors are in optimal balance. Last, I dedicate this issue to my dear mentor John Gunderson, M.D., who showed his confidence in me by encouraging a difference of opinion, an ability to stand up for myself, and ultimately, separation from him as a self-reliant individual with a supportive network of friends, which includes most of the authors and editors of this issue. As John would say, I hope this is useful.