The most recent version of the Diagnostic Manual of Mental Disorders (5th ed.; DSM-5; American Psychiatric Association [APA], 2013) characterizes personality disorders (PDs) as developing through a complex interaction of environmental influences (including family, peer, societal, and cultural influences) and inherited characteristics. PDs involve a way of thinking, feeling, and behaving that differs from cultural expectations, impairs functioning, and largely endures over time. Although there is still much to be learned about how these processes unfold, our evolving knowledge is crucial for future advancements in understanding, defining, assessing, and treating PDs.
PDs represent a significant challenge for those who suffer from these disorders and for society more broadly. PDs also present a wide array of challenges for researchers and treatment professionals who work in this area. The willingness to take on these challenges has led to a proliferation in recent decades of research examining both PDs and personality processes across a continuum from normal to pathological functioning. Research across multiple disciplines has played an important role in this regard, spurring advances in our understanding of basic mechanisms underlying personality pathology, as well as the development of novel assessment, prevention, and treatment strategies. With the elimination of the multiaxial classification system in DSM-5, PDs are no longer relegated to Axis II and distinguished from other disorders that had previously occupied Axis I. Rather, the classification of PDs alongside other disorders has clarified their clinical relevance and highlighted the importance of further research in this area.
This considerable progress has also led to difficult and sometimes highly charged questions that are now shaping the future of research and clinical endeavors in the PDs. These questions include the relative contribution of biological and environmental factors to the development of personality pathology, the stability of PD diagnoses and personality pathology over time, the meaning and implications of heterogeneity across PDs and even within individual PDs, and the most effective treatments for PDs. However, the most widely recognized and debated controversy in the field came to the forefront during the lead-up to the DSM-5. This controversy focused on the conceptualization of PDs and the question of whether the longstanding categorical approach to the diagnosis of PDs should be replaced by a dimensional approach or a hybrid of the two approaches. After considerable (and sometimes contentious) debate, the decision was made to keep the main body of the diagnostic system categorical and add a hybrid dimensional-categorical approach to a separate section of the DSM-5 (with the idea that this hybrid approach could play a more significant role in the primary diagnostic system in future iterations). Now more than five years since the publication of the DSM-5, there are important questions regarding how best to navigate the growing disparity between the large amount of emerging research on dimensional approaches to personality pathology and the largely exclusive focus on categorical diagnoses in the DSM-5.
In considering how best to advance research on the etiology, underlying mechanisms, assessment, and treatment of PDs and personality pathology more broadly, this is an ideal time to take stock of current research in this area and review both recent progress and needed future directions for advancing our understanding of the pathogenesis and treatment of PDs. This perspective serves as the impetus for this handbook and the selection of chapters that provide coverage of more basic and foundational principles and processes at the core of personality pathology, in addition to cutting-edge research on the diagnostic categories that currently make up the PDs. We also have endeavored to pay equal attention to the basic and applied developments in the field, with the goal of informing both research and treatment.
Part I: Etiology includes chapters covering neurobiology, genetics, environmental/sociocultural factors, and developmental considerations. Part II: Models includes chapters covering the controversies surrounding classification and diagnosis with specific chapters from categorical, dimensional, and interpersonal perspectives. Part III: Individual Disorders and Clusters includes chapters covering each cluster along with specific chapters on borderline PD and psychopathy/antisocial PD for which a larger body of specific theory and research is available. Part IV: Assessment includes chapters covering categorical and dimensional assessment approaches as well as the use of assessment to target underlying mechanisms. Finally, Part V: Treatment includes chapters covering pharmacological therapies, as well as cognitive behavioral, psychodynamic/psychoanalytic, trait-based, and brief therapeutic approaches. Together, these chapters provide a comprehensive picture of personality pathology that acknowledges the contributions and missteps of the past, identifies the thorny and crucial questions of the present, and sets a course for the future.
One positive outcome of the controversy surrounding the conceptualization of PDs that emerged in the years leading up to the publication of DSM-5 is the recognition of the importance of multiple voices in shaping and sharing what we know about PDs. With that in mind, an innovative feature of this handbook is that each chapter forms the basis of a set of scientific documents that introduce multiple perspectives and greater nuance than afforded by a single chapter alone. Specifically, each chapter is accompanied by two commentaries from leading experts in the field, as well a final rejoinder from the original chapter authors. The goal of this approach was to recognize and facilitate the importance of multiple perspectives in a manner that provides a deeper connection to the material for readers. This approach mirrors a signature feature of the American Psychological Association journal, Personality Disorders: Theory, Research, and Treatment (PDTRT), one that has been adopted for several recent special issues by the Journal of Personality Disorders. This approach has been invaluable to the PD field over the past ten highly impactful years and we believe it has translated well to this handbook.
To further increase the impact of this novel approach, we have also strategically sought to provide diversity of thought in our selection of authors for the chapters/rejoinders and commentaries. In addition to ensuring wide representation of different perspectives and areas of expertise, we were cognizant of the importance of featuring fresh perspectives. Thus, although our handbook includes many of the more senior names in the field, we have also intentionally sought out mid-career and early-career scholars whose work is clearly driving the future of the field.
As we reflect on the complicated, rich, and impactful history of the study and treatment of PDs, we endeavored to pull together a series of manuscripts that both acknowledge that history and begin to point us in the new directions that will mark the future of PDs. We believe that these contributions will clarify the ongoing controversies in this field and provide a comprehensive framework for resolving debate, guiding future research, and developing clinical innovations as the field of PDs moves forward.
Carl W. Lejuez, PhD
Interim Provost
Professor, Department of Psychology
University of Kansas
Kim L. Gratz, PhD
Professor and Chair, Department of Psychology
University of Toledo