The contemporary personality disorder approaches found in the Alternative DSM-5 Model and the International Classification of Diseases 11th Edition model of personality disorder are organized along a core axis of personality functioning impairment. Both models represent personality disorder impairment dimensionally. Moreover, the psychological and psychiatric constructs subsumed in this core impairment dimension of personality functioning dovetail with contemporary advances in psychodynamic thinking. Specifically, object relations, attachment/mentalization, intersubjective, and narrative theories are embodied in the personality disorder impairment dimension. This chapter explicates the rich conceptual pluralism of these personality disorder models and identifies implications for measurement, empirical study, and clinical practice.

There are no such things as “personality disorders” distinct from other mental disorders. Distinct personality disorders cannot be identified based on their developmental course or their symptoms. The new ICD and DSM concept of personality disorder as self and interpersonal dysfunction identifies important forms of psychopathology but is not more (or less) related to personality than are other disorders. Rather, personality traits contribute to risk for all forms of mental disorder, and most symptom dimensions are coextensive with dimensions of normal personality, such that persistent symptoms of psychopathology are typically extreme or maladaptive variants of normal personality traits. However, symptoms are merely indicators of risk rather than necessary and sufficient indicators of psychopathology. We draw on our cybernetic dysfunction theory of psychopathology to clarify the role of personality in mental disorder. Psychopathology is defined as “persistent failure to move toward one’s goals, due to failure to generate effective new goals, interpretations, or strategies when existing ones prove unsuccessful.” Personality is exhaustively described by personality traits and characteristic adaptations, the latter being relatively stable goals, interpretations, and strategies that are specified relative to an individual’s particular life circumstances. Psychopathology always involves failure of characteristic adaptations and thus breakdown in personality functioning.

This chapter describes the value of using Contemporary Integrative Interpersonal Theory (CIIT) to understand the self and social impairments that define personality disorders as a group. CIIT’s major tenets are summarized, with a particular emphasis on elaborating how the self and self-functioning are an integral part of interpersonal experience and expression. A generic definition of adaptive interpersonal functioning is provided along with a demonstration of how CIIT can accommodate specific constructs and diagnoses using borderline personality disorder and narcissism as examples.

This chapter brings to light the salience of psychopathy and personality disorders to cult leaders and their followers. Cult leaders present with distinctive personalities that enable them to exert inordinate influence over others and to exhibit highly manipulative and remarkably destructive conduct. Within the literature on cults, narcissistic and antisocial personality disorders are among the most commonly identified character pathologies ascribed to cult leaders. However, psychopathy may be the most fitting yet least explored constellation of traits and behaviors observed in such individuals. This chapter sheds light on the neglected perspective of psychopathic cult leaders while also focusing on the Cluster B personality disorders. The corresponding psychological profile that emerges for cult followers is typified by a noteworthy comorbidity of antisocial, obsessive compulsive, and dependent personality disorders. Suggestive forensic instruments to utilize for the clinical and forensic assessment of cult leaders and their followers include the PCL-R, Rorschach, MMPI-2, and TRAP-18.

CJ experienced mental health problems and trauma during childhood and adolescence. This was treated effectively with psychotherapy. He remembers being exuberant and outgoing. Then, at the age of twenty-one, he developed a severe depressive episode, feeling numb and emotionless, unable to taste anything. Due to the previous history, a diagnosis of personality disorder was suggested, resulting in a delay in starting ECT whilst an inpatient. Relapses followed, the first one in Brazil, where he was quickly offered ECT. Back in the UK, CJ found pervasive barriers to getting treated with ECT, especially maintenance ECT, which he asked for several times, having seen the effect of the acute courses. He had to first try various drug treatments. There was also hesitancy in receiving psychotherapy because it was felt that ECT may affect his ability to engage in therapy. CJ feels that the community team had been inadequately resourced, equipped and educated about ECT to properly support him as an outpatient. CJ finishes the story with a description of his ‘life on maintenance’, which did not stop him from starting studies on a degree and working part-time as a research assistant.

Antisocial personality disorder (ASPD) is a mental condition in which a person exhibits a pattern of repeated disregard for and violation of others’ rights. The Diagnostic and Statistical Manual of Mental Disorders (DSM) provides the framework for diagnosing ASPD. The prevalence rate of ASPD is high in prisons. Genetics, epigenetics, neuroscience, sociology, epidemiology, psychology, and other behavioral science fields have attempted to find a primary etiology. Despite decades of research, the precise etiology of ASPD has not been found, and its pathophysiology remains a complex question. The interaction between genes and the environment appears to be a significant factor in the development of ASPD. Brain imaging in subjects with ASPD has revealed structural brain changes in those with ASPD. Individuals with ASPD are challenging to manage for health care providers because of their complicated clinical presentation, high comorbidity of medical and mental disorders, lack of licensed pharmacotherapies for ASPD, and increased utilization of healthcare resources. ASPD requires tremendous effort from treating clinicians. Clinicians can successfully manage individuals with ASPD if they remain aware of the unique challenges of these patients while thoughtfully applying available research.

Patients with personality disorder, especially borderline personality disorder, are challenging for psychotherapy. Yet there is good evidence that most patients can recover if offered specific forms of specialized therapy that are empirically supported treatments. The majority of research studies in personality disorder have focused on borderline personality disorder, and we have only limited data on other categories. The strongest findings for the efficacy of treatment concern dialectical behavior therapy, but other options may yield similar results. Credible components include teaching emotion regulation skills and a present-oriented focus. Some of the effects of effective therapy could be specific to underlying theory and methods, while others may depend on common factors. A sidebar discusses self-injurious thoughts and behaviors in youth.

Reflection on diagnoses, treatments and comorbidities – anxiety, obsessive-compulsive disorder and substance misuse or addiction. Stigma, and self-stigmatisation are common, and hard to address. The treatments for bipolar disorder can be difficult to tolerate, including weight gain and sedation. Life as a patient informs work as a psychiatrist as a psychiatrist, hopefully for the good. I do have long periods of being on the high side of normal, which is enjoyable, but can end in disaster. The future with bipolar disorder is ultimately unpredictable.

Borderline personality disorder is a complex mental health condition. Those with the condition have unstable moods, a history of difficulty functioning in relationships, and a dysfunctional self-image. Patients have emotional dysregulation that can lead to impulsive behaviors, self-harm, and fear of abandonment and have significant challenges in life that can lead to poor psychosocial outcomes. Interpersonal relationships can often be intense and dysfunctional and demonstrate frequent conflicts. Emotional dysregulation can lead to rapid and intense mood swings. Impulsivity can lead to issues such as reckless spending, risky sexual behaviors, and substance abuse. The treatment of borderline personality disorder is largely through long-term psychological therapy and the gold standard therapy approach is dialectical behavior therapy. This therapy focuses on optimizing emotional regulation, distress tolerance, interpersonal effectiveness, and mindfulness skills.

Personality traits are patterns of thoughts, feelings, and behaviors that remain relatively stable over a person’s life and strongly influence how people interact with and perceive the world. Personality disorders are personality traits that cluster in recognizable patterns and produce dysfunction in multiple areas of life. They do not respond well to pharmacologic interventions but are often accompanied by other psychiatric comorbidities. Recognizing personality disorders can help a provider avoid misdiagnosing psychiatric conditions, anticipate future care challenges, and counsel family and caregivers.

This chapter considers how to care for patients who meet the criteria for a diagnosis of personality disorder. We reflect on the role of the psychiatrist in creating a resilient, honest and caring clinical environment, delivering interventions in a considered and coherent manner. Central to this is the relationship between doctor and patient, which includes not only direct clinical care but also the orchestration of work across the multi-disciplinary team and other agencies through clinical leadership.

We approach personality disorders as a relational problem in which the patient experiences their difficulties through their relationships with themselves and the world around them. These difficulties often, though not exclusively, are a developmental consequence of adverse childhood experiences, brought to life within the therapeutic relationship itself. This inevitably means the work is challenging, but it also means that the way we comport ourselves and lead becomes central to the therapeutic culture.

Much has been written on the challenges of working with people who are diagnosable with personality disorder, but perhaps less acknowledged is how these challenges represent not only the very material fundamental to our primary task but also the reason it is such rewarding work given the right circumstances.

Personality disorder represents a diagnosis very different from others in psychiatry. This is because it describes a long-standing integral part of a person, not just an affliction that has happened. Because of the sensitivity of ascribing a core part of a person’s being to the impersonality of a diagnostic term, the subject has been widely stigmatised. However, the condition is very common and affects one-tenth of the population. In this chapter, the clinical features of personality disorder identified in the new ICD-11 severity classification are described and their value illustrated. A fuller description of the ICD-11 classification can be found in another College publication.

There are five levels of diagnosis of personality disorder, including the sub-syndromal form – personality difficulty – which is by far the most common. The diagnosis of borderline personality disorder is the most used in practice but is a heterogeneous term that overlaps with almost every other disorder in psychiatry. All personality disorders have approximately equal genetic and environmental precursors, and the involvement of childhood adverse experiences and trauma is unfortunately true for this as for all psychiatric disorders.