From the Guest Editor

Only a few years ago, I was preparing a presentation about the impact of personality disorders on the treatment of depression for an industry-sponsored symposium at the annual meeting of the American Psychiatric Association. As I went through my slides at a rehearsal a month before the meeting, the symposium chair interrupted me and asked, “Aren’t you going to show a slide that lists the 10 personality disorders in DSM-IV?” I replied that I didn’t think that was necessary since everyone in the audience already knew what they were. My colleague shook his head and said, “I’m afraid that’s not true. Most psychiatrists ignore axis II pathology.”

I was a bit taken aback, but I knew there was some truth in what he was trying to convey to me. Personality disorders are often relegated to diagnostic oblivion because they are deemed unfathomable or untreatable by psychiatrists and third-party payers alike. Many insurance companies and managed care organizations will shamelessly assert that they do not cover treatment for axis II conditions. If there is no reimbursement for the treatment, clinicians are less likely to make the diagnosis and think about treatment. Yet these conditions are ubiquitous in psychiatric practice and must be taken into account if optimal outcomes are desired. Moreover, there is now substantial evidence that personality disorders can be effectively treated.

This issue of FOCUS, devoted to personality disorders, is an attempt to bring readers the latest information emerging from the study of these axis II conditions. In his comprehensive review of the field of personality disorders, John Oldham traces the history of the diagnosis up to the current controversy surrounding the dilemma of categorical versus dimensional classifications. He points out that the current diagnostic system presents a host of problems, including the fact that there is extensive overlap in diagnostic criteria, leading to the common observation that one patient can meet criteria for several personality disorders. He also reviews the impressive breakthroughs in neurobiological research on personality disorders using imaging techniques. This growing body of empirical work establishes unequivocally that personality disorders are biopsychosocial entities requiring a comprehensive approach to diagnostic understanding and treatment. Finally, he succinctly reviews the data from randomized controlled trials suggesting that specific psychotherapeutic interventions are highly efficacious in treating borderline and cluster C personality disorders, at times in combination with a target-symptom approach to pharmacotherapy.

In my own clinical synthesis article, I present a systematic psychodynamic approach to personality disorders that helps the clinician use transference and countertransference data to understand and treat the patient. A primary sign of disturbance in personality is problematic interpersonal relationships. The clinical setting is akin to a laboratory where the clinician can observe these problems in vivo as they emerge in the therapeutic relationship. Personality disorders are the exemplar of the fundamental psychodynamic principle that patients recapitulate their world of internal object relations in the treatment setting. By studying the transference-countertransference dimensions of the therapeutic relationship, one has a privileged view of the typical problems that occur in relationships outside the clinical setting.

The management of chronic suicide risk is a major component of the treatment of severe personality disorders. Even the most experienced clinician is challenged to the utmost by the patient who thinks about suicide every day and is vexed by characterological impulsivity. In this issue Harrison Levine and Ronald Albucher present a detailed patient management exercise involving a suicidal patient with borderline personality disorder. They take the reader by the hand and offer a step-by-step consideration of managing suicide risk and other features one is likely to encounter in treating such patients.

Other contributions to this issue include an Ask the Expert column in which Deborah Cabaniss provides a thoughtful response to a clinical challenge. We have also selected a representative sample of recent research papers in the area of personality disorders. These articles cover such issues as the fate of personality disorder traits over time, the biological components of emotion regulation, and the impact of psychotherapy on defense mechanisms.

I have no doubt that readers will find a great deal of clinical value in the pages of this issue. At the same time, there is a broader message that can be read between the lines. The field of psychiatry is moving beyond the days when patients with axis II pathology were pejoratively referred to as “character disorders” and regarded with contempt because of the difficulties they presented in treatment. People with personality disorders need humane and sophisticated treatment, like all other persons with psychiatric illnesses. We now have the tools to help this group of patients, and we owe it to them and their families to educate ourselves on what we know and what we don’t know so we can offer them the assistance they need.