The n e w e ng l a n d j o u r na l of m e dic i n e

Review Article

Allan H. Ropper, M.D., Editor

Personality Disorders
Carla Sharp, Ph.D.​​

P
From the Department of Psychology, ersonality refers to a relatively stable set of tendencies in be-
University of Houston, Houston. Dr. Sharp haviors, cognitions, and emotional patterns, which together constitute a
can be contacted at the Department of
Psychology, 126 Heyne Bldg., University person’s unique character. One person may, for instance, be described as
of Houston, Houston, TX 77204. extroverted, flamboyant, and dominant, whereas another may be described
N Engl J Med 2022;387:916-23. as introverted, shy, and submissive. People usually have relatively good insight into
DOI: 10.1056/NEJMra2120164 who they are with respect to these characteristics. They are aware of the effect of
Copyright © 2022 Massachusetts Medical Society. their personalities on others and how the environment shapes who they are. This
awareness helps persons make decisions and manage their relationships. In some
CME
at [Link] persons, however, tendencies in behaviors, cognitions, and emotional patterns are
extreme and maladaptive, indicated by problems in self-regulation and unstable
relationships, with a compromised ability to perform at work or in school. From
a psychiatric point of view, such persons may have a personality disorder.
There are two parallel classification systems for personality disorders in the
fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5).1 Sec-
tion II of the DSM-5, which contains diagnostic criteria and codes for mental
disorders, maintains the tradition of previous editions, viewing personality disor-
ders as discrete, categorical entities. Ten categories of disorders are described:
paranoid, schizoid, schizotypal, antisocial, borderline, histrionic, narcissistic,
avoidant, dependent, and obsessive–compulsive personality disorders. The pre-
dominant features of each personality disorder are summarized in Table 1.
This system has been criticized because of evidence for the continuity between
normal and abnormal personalities, heterogeneity within categories of personality
disorders, a high co-occurrence among personality disorders, a high prevalence of
personality disorder not otherwise specified, arbitrary diagnostic thresholds, and
a restricted clinical ability to predict the efficacy of treatment.2,3 In addition, studies
have called into question the validity of the 10 categories of personality disorders,
leading to a view that personality disorder cannot be considered something that a
person has or does not have but that personality functioning can be described
along a continuum of severity.2-5 Therefore, in Section III of the DSM-5, an alterna-
tive system for diagnosing personality disorders has been endorsed, as summa-
rized in Table 2.
Rather than viewing personality disorders as categorical entities, this system,
called the alternative model for personality disorders, proposes a combination of
categorical and “dimensional” approaches, forming a hybrid diagnostic scheme.
The dimensional approach recognizes individual differences in the manifestation
of personality traits — from mild to moderate to severe — with underlying dimen-
sions (constructs) that account for high levels of overlap between personality dis-
orders. For instance, all 10 categories of personality disorders involve problems in
self-regulation and maintenance of stable relationships, and therefore, it makes
sense to identify a unifying construct that allows for a more parsimonious diag-
nosis.
On the basis of the alternative model for personality disorders, the clinician

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 Personality Disorders

Table 1. Predominant Features of Personality Disorders as Described in the DSM-5, Section II.*

Category Features
Paranoid Distrust and suspiciousness, with a tendency to interpret other people’s motives as malevolent
Schizoid Detachment from social relationships and restricted range of emotional expression
Schizotypal Acute discomfort in close relationships, cognitive or perceptual distortions, and eccentricities
of behavior
Antisocial Disregard for, and violation of, the rights of others
Borderline Instability in interpersonal relationships, self-image, and affects and marked impulsivity
Histrionic Excessive emotionality and attention-seeking
Narcissistic Grandiosity, need for admiration, and lack of empathy
Avoidant Social inhibition, feelings of inadequacy, and hypersensitivity to negative evaluation
Dependent Excessive need to be taken care of, resulting in submissive and clinging behavior
Obsessive–compulsive Preoccupation with orderliness, perfectionism, and control

* DSM-5 denotes fifth edition of the Diagnostic and Statistical Manual of Mental Disorders.

Table 2. Abbreviated Diagnostic Criteria for Personality Disorder, According to the DSM-5, Section III, and the ICD-11.*

DSM-5, Section III (Alternative Model for Personality Disorders)

Patient has moderate or greater impairment in personality functioning (self-functioning and interpersonal functioning),
rated >2 on a 5-point severity scale (ranging from 0 to 4), indicated by difficulty in at least two of the following four
areas: identity, self-direction, empathy, or intimacy
Patient has maladaptive traits in one or more of the following five trait domains (or trait facets within domains): nega-
tive affectivity, detachment, antagonism, disinhibition, or psychoticism (odd, eccentric, or unusual behaviors or
cognitions)
Personality dysfunction and trait expression are relatively inflexible and pervasive across multiple contexts (i.e., symp-
toms do not occur only at home or during certain times)
Personality dysfunction is stable across time, and onset can be traced back to adolescence or early adulthood
Dysfunction is not better explained by another mental disorder
Dysfunction is not attributable to physiological effects of a substance or another medical condition
Impairments are not better understood as normal for the person’s developmental stage or sociocultural environment
ICD-11
Patient has impairments in aspects of self-functioning and interpersonal functioning, described as mild, moderate, or
severe personality disorder
Personality disorder and personality difficulty can be further described in terms of five trait domain specifiers: negative
affectivity, detachment, dissocial behavior (lack of empathy, callousness, or meanness), disinhibition, or anankastia
(obsessive–compulsive behavior)
Disturbance has persisted over an extended period (e.g., ≥2 yr)
Disorder is manifested in patterns of cognition, emotional experience, emotional expression, and behavior that are mal-
adaptive (e.g., inflexible or poorly regulated)
Disorder is manifested across a range of personal and social situations, although it may be consistently evoked by par-
ticular types of circumstances and not others
Symptoms are not due to direct effects of a medication or substance, including withdrawal effects, and are not better ac-
counted for by another mental disorder, a disease of the nervous system, or another medical disorder
Disorder is associated with substantial distress or marked impairment in personal, family, social, educational, occupa-
tional, or other important areas of functioning
Personality disorder should not be diagnosed if the patterns of behavior characterizing the disturbance are developmen-
tally appropriate or can be explained primarily by social or cultural factors, including sociopolitical conflict

* ICD-11 denotes 11th revision of the International Classification of Diseases.

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 The n e w e ng l a n d j o u r na l of m e dic i n e

first assesses the underlying dimension shared This review, therefore, focuses predominantly
by all personality disorders (criterion A): mal- on BPD, with perspective provided by consider-
adaptive self-functioning (meaning disordered ing the five other categories of disorders that
identity and self-direction) and interpersonal have been retained in the alternative model.
functioning (meaning disordered empathy and
intimacy). Next, the clinician evaluates the se- Epidemiol o gy of BPD
verity of pathologic personality traits across five
maladaptive trait domains (criterion B): negative A meta-analysis has suggested that BPD has a
affectivity, detachment, antagonism, disinhibi- community point prevalence of 0.7 to 2.7%,19
tion, and psychoticism. In a third step, the clini- which is similar to the prevalence of other per-
cian has the option to specify one of six discrete sonality disorders in the general population. A
categories of personality disorders: schizotypal, systematic review has estimated that the mean
antisocial, borderline, narcissistic, avoidant, and prevalence of BPD is 22.4% among patients hos-
obsessive–compulsive personality disorders. The pitalized in psychiatric units and 11.8% among
four other disorders that were in the traditional patients in outpatient psychiatric settings.20 Some
categorization (paranoid, schizoid, histrionic, studies have suggested that the rates for BPD are
and dependent personality disorders) were not higher than the rates for other personality disor-
retained in the alternative model for personality ders. Furthermore, analyses have suggested that
disorders because of insufficient data to validate up to half of psychiatric patients may meet cri-
them as distinct entities.6-8 teria for a personality disorder.21,22 Data on the
Another perspective is provided by the diag- prevalence of personality disorders among ado-
nostic scheme for personality disorder in the 11th lescents are lacking, except for BPD, which has
revision of the International Classification of Diseases been reported to have a prevalence of 11%
(ICD-11),9,10 endorsed by the World Health Orga- among adolescents in outpatient psychiatric set-
nization. This scheme, which is also summa- tings.23 The rate of BPD among adolescents in
rized in Table 2, reflects the alternative model inpatient psychiatric settings is generally higher
for personality disorders in its initial assessment than the rate among adults, with two studies
of criteria of maladaptive self-functioning and showing prevalences of 35.6% and 32.8%.24,25
interpersonal functioning, as well as its use of Less is known about the prevalence of per-
the maladaptive trait domains, but the ICD-11 sonality disorders in primary care because they
discards all the traditional categories of person- are not routinely assessed in this setting. A
ality disorders except borderline personality dis- missed diagnosis of personality disorder in a pri-
order (BPD). This category has been retained as mary care setting can have serious consequences,
a specifier for the purpose of giving mental given the associated risks of suicide (2 to 5%
health services time to adjust their systems to among persons with BPD)26 and impaired social
the dimensional model, after which the BPD functioning20 and the high burden of personal
specifier is expected to be removed. suffering, health care costs, and lost productiv-
Although the transition to an alternative ity.27-29 Prevalence studies of personality disor-
model for diagnosing personality disorders is ders have suggested that the rate among men is
supported by the research and clinical commu- similar to the rate among women in the general
nities,4,11 the literature regarding treatment is population,19 but in clinical psychiatric settings,
still predominantly focused on the categorical the prevalence has been higher among women,
approach. The highest-quality evidence for vari- with little evidence suggesting that this is the
ous treatments concerns BPD, which is the most result of gender bias in assessment.30 Although
frequently diagnosed personality disorder in most prevalence studies have not shown system-
clinical settings12-14 and the most extensively re- atic racial or ethnic differences, a few studies are
searched personality disorder.15,16 There is also addressing this issue.20
support for the notion that BPD represents fea-
tures of personality dysfunction that are shared Cl inic a l Fe at ur e s
across all manifestations of personality disor-
der,17,18 meaning that information on BPD may The diagnostic criteria for personality disorders
be relevant to all other personality disorders. are assessed through an interview by a clinician,

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 Personality Disorders

Table 3. Categorically Defined Borderline Personality Disorder, According to the DSM-5, Section II.

Patient has pervasive pattern of instability in interpersonal relationships, self-image, and affects and marked impulsivity,
indicated by at least five of the following nine personality traits:
Frantic efforts to avoid abandonment
Unstable and intense interpersonal relationships
Identity disturbance
Impulsivity in at least two areas (e.g., spending, substance abuse, reckless driving, or binge eating)
Recurrent suicidal or self-mutilating behavior
Affective instability
Chronic feelings of emptiness
Inappropriate, intense anger or difficulty controlling anger
Transient, stress-related paranoid ideation or severe dissociative symptoms
Symptoms are relatively inflexible and pervasive across multiple contexts (i.e., symptoms do not occur only at home or
during certain times)
Symptoms result in significant distress or impairment in functioning
Symptoms or patterns of behavior are stable across time, and their onset can be traced back to adolescence or early
adulthood
Symptoms are not better explained by another mental disorder
Symptoms are not attributable to physiological effects of a substance or another medical condition

which can be supplemented by semistructured mood disorders 82.7%, and substance use disor-
interviews or patient-reported measures. A list of ders 78.2%.14 High rates of post-traumatic stress
measures commonly used to assess patients for disorder (30.2%), attention deficit–hyperactivity
BPD is provided in Table S1 in the Supplemen- disorder (33.7%), bipolar I disorder (21.6%), bi-
tary Appendix, available with the full text of this polar II disorder (37.7%), and somatic disorders
article at [Link]. Several of these measures have also been reported among patients with
can be used to evaluate patients for other per- BPD.32 The overlap of BPD with other psychiatric
sonality disorders, as well. In addition, the Inter- disorders and with other personality disorders
national Consortium for Health Outcomes supports the idea that there are features shared
Measurement has a battery of patient-reported by all these disorders, including features of in-
measures that can be used to assess the out- ternalizing behavior (e.g., depression, anxiety,
comes of personality disorders.31 and stress-related disorders) and externalizing
BPD is characterized by a pervasive pattern of behavior (e.g., substance use and antisocial be-
inadequate emotional regulation, a poor or inco- havior).34
herent sense of self and identity, and disordered
interpersonal relationships.32 The disorder was Onse t a nd C our se
first included in the third edition of the Diagnos-
tic and Statistical Manual of Mental Disorders, pub- For decades, it was thought that personality dis-
lished in 1980.33 According to Section II of the orders could not be diagnosed in adolescence.
DSM-5, the diagnosis of BPD can be established Opponents of early diagnosis argued that per-
when an adult or adolescent meets at least five sonality was not yet stable enough to warrant
of nine diagnostic criteria, listed in Table 3. any diagnosis, and it would be stigmatizing to
The coexistence of personality disorders and diagnose a personality disorder in a young per-
other mental disorders is common. For example, son. However, more recent empirical research on
an analysis of data from the National Epidemio- BPD has altered this view.35 There is evidence
logic Survey on Alcohol and Related Conditions that BPD in adolescents is a coherent syn-
showed that among patients with BPD, the life- drome,36 that valid and reliable measures of this
time prevalence of anxiety disorders is 84.5%, syndrome are available,37,38 that it is separate

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 The n e w e ng l a n d j o u r na l of m e dic i n e

from other disorders in course and outcome,39,40 positions and environmental factors.48,49 In line
and that it is similar to BPD in adults with re- with these models, children who are born with
spect to prevalence,41 stability,42 and risk fac- a sensitive temperament and who are raised in
tors.43 There is also preliminary support for the families in which the caregivers struggle to meet
efficacy of treatment for BPD in adolescents, al- the children’s emotional needs are at increased
though more studies are needed.44 Adolescence risk for the development of personality disor-
is a risk period for the onset of personality dis- ders,46,50-55 and prospective studies have shown
orders, and advocacy groups have made gains in that harsh or insensitive parenting, emotional
destigmatizing these disorders in adults and neglect, physical or sexual maltreatment, and
adolescents, as well as promoting prevention victimization by bullying are associated with the
and early intervention.45 Given that the stability development of personality disorders.43 The
of personality increases with age, it may make specificity of these risk factors and the role of
sense to intervene early, when personality is more the child’s temperament in evoking parenting
malleable, but this has not been established em- behaviors are not clear.
pirically. Data on physiological factors associated with
Prospective cohort studies have shown differ- personality disorders are lacking for most condi-
ent rates of the stability of the diagnosis of BPD tions. However, cross-sectional studies suggest
(i.e., the consistent presence of BPD) from ado- that there are correlates of BPD in three do-
lescence through adulthood, with the stability mains. First, a meta-analysis showed that, as
rate depending on how the disorder is mea- compared with healthy or depressed persons,
sured.32 The stability rates for the categorical persons with BPD have pronounced amygdala
diagnosis range from 14 to 40%. Naturalistic hyperreactivity in response to negative emo-
follow-up studies have shown that the severity of tional stimuli that have been associated with
BPD diminishes over time, with a mean remis- emotional dysregulation. However, persons with
sion rate of 60%.26 In contrast, when BPD traits post-traumatic stress disorder have even more
are counted dimensionally rather than categori- pronounced amygdala hyperreactivity than those
cally, the average stability of the diagnosis over with BPD,56 which indicates that these findings
time is higher, with estimates of 39 to 59%. may not be specific. This meta-analysis also
When a person’s ranking in terms of the level showed that patients with BPD have enhanced
of BPD traits is compared with the ranking of activation of the medial cingulate gyrus during
other persons of the same age, the stability of processing of negative emotional stimuli.
BPD has reportedly been even higher (53 to 73%). Second, a meta-analysis showed that, as com-
The low stability rates for the categorical diag- pared with healthy controls and persons with
nosis, along with treatment outcomes, have other personality disorders, persons with BPD
challenged the notion that BPD is an intractable have abnormalities in stress responses, indicat-
and untreatable disorder. However, even when a ed by continuous cortisol output and blunted
patient no longer meets the clinical threshold cortisol response to stress. Although these stud-
(i.e., five of nine criteria) for BPD and the disor- ies have generally been of low quality, they point
der is considered to be in remission, functional to directions for research on hypothalamic–pitu-
impairment persists. itary–adrenal axis functioning and BPD.57
Third, persons with BPD have abnormal func-
tional neuroimaging findings in brain areas as-
C ause s a nd Pathoph ysiol o gic a l
C or r el ate s sociated with social cognition, self-functioning,
and identity functioning. Such areas include re-
Studies in twins have suggested that BPD is ap- gions of the orbitofrontal, medial prefrontal,
proximately 55% heritable.46 Although data on and anterior cingulate cortexes; regions of the
other personality disorders are scarce, some re- precuneus and posterior cingulate cortex; corti-
ports have suggested moderate heritability.47 cal and subcortical regions of the temporal
Theoretical models of the development of per- lobes, including the amygdala; and the somato-
sonality disorders are based on the view that sensory cortexes.58 These findings may not be
there are interactions between biologic predis- specific to BPD and require replication.

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 Personality Disorders

T r e atmen t regulation by discussing and building emotional-

regulation skills. The aim of mentalization-based
There have been few randomized disorder- therapy is to help patients view problems and
specific trials of treatment for schizotypal, anti- their interpretations of interactions from multi-
social, narcissistic, avoidant, and obsessive–com- ple perspectives, with the goal of improving self-
pulsive personality disorders. However, treatment regulation and the quality of interpersonal rela-
protocols have been developed for BPD, and tionships. Other treatment approaches, with
several randomized, controlled trials have been fewer trials, include good psychiatric manage-
conducted to evaluate them. Although psycho- ment for BPD,64,65 schema-focused therapy,66
tropic medications such as mood stabilizers, transference-focused psychotherapy,67 and Systems
antidepressant agents, and antipsychotic medi- Training for Emotional Predictability and Prob-
cations are routinely prescribed for persons with lem Solving (STEPPS),68 all of which have adher-
BPD, no medications have been approved by ents but are not as widely accepted as dialectical
regulatory agencies for the treatment of BPD, behavior therapy and mentalization-based therapy.
and the effect of medications is uncertain. Phar-
macotherapy has been used to alleviate symp- C onclusions a nd F u t ur e
toms of coexisting disorders, such as depres- Dir ec t ions
sion, anxiety, impulsivity, and psychosis, with
little evidence that they address the specific Inexpensive treatments that require fewer and
symptoms of BPD.32 shorter psychotherapy sessions delivered by less
A Cochrane review59 and national treatment specialized mental health professionals are
guidelines60,61 suggest that psychotherapy may needed, since current approaches require consid-
be an effective approach to treatment for BPD. erable resources and patient involvement. Although
The Cochrane review included randomized, con- the benefits of prevention and early intervention
trolled trials of psychotherapy that enrolled a are generally accepted, few high-quality ran-
total of 4507 patients, predominantly female pa- domized, controlled trials have focused on per-
tients 15 to 46 years of age in outpatient settings, sonality disorders in adolescents. The field is in
with treatment lasting only up to 36 months. As transition and continues to grapple with the
compared with treatment as usual, psychotherapy question of whether a categorical system of di-
had moderate but clinically relevant effects on agnosing personality disorders or a dimensional
symptom severity, self-harm, suicidality, and im- model is more beneficial to patients. The lack of
paired psychosocial functioning (listed in approxi- data on treatment outcomes for many of the
mately declining order of effectiveness). Although personality disorders, as well as data on the al-
approximately 16 different kinds of psychother- ternative model for personality disorders, has
apy have been evaluated for the treatment of made it difficult to draw conclusions about the
BPD, one third of trials have used dialectical value of various treatments. Our understanding
behavior therapy,62 followed in frequency by trials of personality disorders continues to evolve.
of mentalization-based therapy.63 Dialectical be- Disclosure forms provided by the author are available with the
havior therapy aims to reduce emotional dys- full text of this article at [Link].

References
1. Diagnostic and statistical manual of Progress in achieving quantitative classi- diagnosis for DSM-5 part II: clinical ap-
mental disorders, 5th ed: DSM-5. Wash- fication of psychopathology. World Psy- plication. Personal Disord 2011;​2:​23-40.
ington, DC:​American Psychiatric Associ- chiatry 2018;​17:​282-93. 8. Skodol AE, Clark LA, Bender DS, et al.
ation, 2013. 5. Sharp C. Current trends in BPD re- Proposed changes in personality and per-
2. Clark LA. Assessment and diagnosis search as indicative of a broader sea- sonality disorder assessment and diagno-
of personality disorder: perennial issues change in psychiatric nosology. Personal sis for DSM-5 part I: description and ra-
and an emerging reconceptualization. Disord 2016;​7:​334-43. tionale. Personal Disord 2011;​2:​4-22.
Annu Rev Psychol 2007;​58:​227-57. 6. Skodol AE, Bender DS, Morey LC, et al. 9. Tyrer P, Mulder R, Kim YR, Crawford
3. Widiger TA, Trull TJ. Plate tectonics Personality disorder types proposed for MJ. The development of the ICD-11 clas-
in the classification of personality disor- DSM-5. J Pers Disord 2011;​25:​136-69. sification of personality disorders: an
der: shifting to a dimensional model. Am 7. Skodol AE, Bender DS, Oldham JM, amalgam of science, pragmatism, and
Psychol 2007;​62:​71-83. et al. Proposed changes in personality politics. Annu Rev Clin Psychol 2019;​15:​
4. Krueger RF, Kotov R, Watson D, et al. and personality disorder assessment and 481-502.

n engl j med 387;10 [Link] September 8, 2022 921

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 The n e w e ng l a n d j o u r na l of m e dic i n e

10. Reed GM. Progress in developing a in hospitalized adolescents with border- adulthood: findings from a genetically
classification of personality disorders for line personality disorder. J Clin Psychiatry sensitive longitudinal cohort study. J Am
ICD-11. World Psychiatry 2018;​17:​227-9. 2014;​75(5):​e457-e464. Acad Child Adolesc Psychiatry 2020;​
11. Sharp C, Miller JD. Ten-year retro- 26. Álvarez-Tomás I, Ruiz J, Guilera G, 59(10):​1165-1177.e2.
spective on the DSM-5 alternative model Bados A. Long-term clinical and func- 40. Winsper C, Wolke D, Scott J, Sharp C,
of personality disorder: seeing the forest tional course of borderline personality Thompson A, Marwaha S. Psychopatho-
for the trees. Personal Disord 2022;​ 13:​ disorder: a meta-analysis of prospective logical outcomes of adolescent borderline
301-4. studies. Eur Psychiatry 2019;​56:​75-83. personality disorder symptoms. Aust N Z J
12. Pedersen L, Simonsen E. Incidence 27. Soeteman DI, Hakkaart-van Roijen L, Psychiatry 2020;​54:​308-17.
and prevalence rates of personality disor- Verheul R, Busschbach JJ. The economic 41. Zanarini MC, Horwood J, Wolke D,
ders in Denmark — a register study. Nord burden of personality disorders in mental Waylen A, Fitzmaurice G, Grant BF. Preva-
J Psychiatry 2014;​68:​543-8. health care. J Clin Psychiatry 2008;​ 69:​ lence of DSM-IV borderline personality
13. Newton-Howes G, Cunningham R, 259-65. disorder in two community samples:
Atkinson J. Personality disorder preva- 28. Hastrup LH, Jennum P, Ibsen R, Kjell- 6,330 English 11-year-olds and 34,653
lence and correlates in a whole of nation berg J, Simonsen E. Societal costs of bor- American adults. J Pers Disord 2011;​25:​
dataset. Soc Psychiatry Psychiatr Epide- derline personality disorders: a matched- 607-19.
miol 2021;​56:​679-85. controlled nationwide study of patients 42. Ferguson CJ. A meta-analysis of nor-
14. Tomko RL, Trull TJ, Wood PK, Sher and spouses. Acta Psychiatr Scand 2019;​ mal and disordered personality across the
KJ. Characteristics of borderline person- 140:​458-67. life span. J Pers Soc Psychol 2010;​98:​659-
ality disorder in a community sample: 29. Sansone RA, Farukhi S, Wiederman 67.
comorbidity, treatment utilization, and MW. Utilization of primary care physi- 43. Stepp SD, Lazarus SA, Byrd AL. A sys-
general functioning. J Pers Disord 2014;​ cians in borderline personality. Gen Hosp tematic review of risk factors prospec-
28:​734-50. Psychiatry 2011;​33:​343-6. tively associated with borderline person-
15. Blashfield RK, Intoccia V. Growth of 30. Sharp C, Michonski J, Steinberg L, ality disorder: taking stock and moving
the literature on the topic of personality Fowler JC, Frueh BC, Oldham JM. An in- forward. Personal Disord 2016;​7:​316-23.
disorders. Am J Psychiatry 2000;​157:​472-3. vestigation of differential item function- 44. Jørgensen MS, Storebø OJ, Stoffers-
16. Boschen MJ, Warner JC. Publication ing across gender of BPD criteria. J Ab- Winterling JM, Faltinsen E, Todorovac A,
trends in individual DSM personality dis- norm Psychol 2014;​123:​231-6. Simonsen E. Psychological therapies for
orders: 1971–2015. Aust Psychol 2009;​44:​ 31. Prevolnik Rupel V, Jagger B, Fialho adolescents with borderline personality
136-42. LS, et al. Standard set of patient-reported disorder (BPD) or BPD features — a sys-
17. Clark LA, Nuzum H, Ro E. Manifesta- outcomes for personality disorder. Qual tematic review of randomized clinical
tions of personality impairment severity: Life Res 2021;​30:​3485-500. trials with meta-analysis and trial sequen-
comorbidity, course/prognosis, psychoso- 32. Bohus M, Stoffers-Winterling J, Sharp tial analysis. PLoS One 2021;​ 16(1):​
cial dysfunction, and ‘borderline’ person- C, Krause-Utz A, Schmahl C, Lieb K. Bor- e0245331.
ality features. Curr Opin Psychol 2018;​21:​ derline personality disorder. Lancet 2021;​ 45. Chanen A, Sharp C, Hoffman P;​Global
117-21. 398:​1528-40. Alliance for Prevention and Early Inter-
18. Sharp C, Wright AGC, Fowler JC, et al. 33. Diagnostic and statistical manual of vention for Borderline Personality Disor-
The structure of personality pathology: mental disorders, 3rd ed.: DSM-III. Wash- der. Prevention and early intervention for
both general (‘g’) and specific (‘s’) fac- ington, DC:​American Psychiatric Associ- borderline personality disorder: a novel
tors? J Abnorm Psychol 2015;​124:​387-98. ation, 1980. public health priority. World Psychiatry
19. Eaton NR, Greene AL. Personality 34. Kotov R, Krueger RF, Watson D, et al. 2017;​16:​215-6.
disorders: community prevalence and The Hierarchical Taxonomy of Psychopa- 46. Reichborn-Kjennerud T, Ystrom E,
socio-demographic correlates. Curr Opin thology (HiTOP): a quantitative nosology Neale MC, et al. Structure of genetic and
Psychol 2018;​21:​28-32. based on consensus of evidence. Annu environmental risk factors for symptoms
20. Ellison WD, Rosenstein LK, Morgan Rev Clin Psychol 2021;​17:​83-108. of DSM-IV borderline personality disor-
TA, Zimmerman M. Community and clin- 35. Sharp C. Bridging the gap: the assess- der. JAMA Psychiatry 2013;​70:​1206-14.
ical epidemiology of borderline personal- ment and treatment of adolescent person- 47. Ma G, Fan H, Shen C, Wang W. Ge-
ity disorder. Psychiatr Clin North Am ality disorder in routine clinical care. netic and neuroimaging features of per-
2018;​41:​561-73. Arch Dis Child 2017;​102:​103-8. sonality disorders: state of the art. Neuro-
21. Zimmerman M, Chelminski I, Young 36. Michonski JD, Sharp C, Steinberg L, sci Bull 2016;​32:​286-306.
D. The frequency of personality disorders Zanarini MC. An item response theory 48. Crowell SE, Beauchaine TP, Linehan
in psychiatric patients. Psychiatr Clin analysis of the DSM-IV borderline person- MM. A biosocial developmental model of
North Am 2008;​31:​405-20. ality disorder criteria in a population- borderline personality: elaborating and
22. Zimmerman M, Rothschild L, based sample of 11- to 12-year-old chil- extending Linehan’s theory. Psychol Bull
Chelminski I. The prevalence of DSM-IV dren. Personal Disord 2013;​4:​15-22. 2009;​135:​495-510.
personality disorders in psychiatric out- 37. Sharp C, Ha C, Michonski J, Venta A, 49. Fonagy P, Luyten P. A developmental,
patients. Am J Psychiatry 2005;​162:​1911-8. Carbone C. Borderline personality disor- mentalization-based approach to the un-
23. Chanen AM, Jackson HJ, McGorry PD, der in adolescents: evidence in support of derstanding and treatment of borderline
Allot KA, Clarkson V, Yuen HP. Two-year the Childhood Interview for DSM-IV Bor- personality disorder. Dev Psychopathol
stability of personality disorder in older derline Personality Disorder in a sample 2009;​21:​1355-81.
adolescent outpatients. J Pers Disord of adolescent inpatients. Compr Psychia- 50. Winsper C, Hall J, Strauss VY, Wolke
2004;​18:​526-41. try 2012;​53:​765-74. D. Aetiological pathways to borderline
24. Kaess M, von Ceumern-Lindenstjerna 38. Sharp C, Steinberg L, Temple J, New- personality disorder symptoms in early
IA, Parzer P, et al. Axis I and II comorbid- lin E. An 11-item measure to assess bor- adolescence: childhood dysregulated be-
ity and psychosocial functioning in fe- derline traits in adolescents: refinement haviour, maladaptive parenting and bully
male adolescents with borderline person- of the BPFSC using IRT. Personal Disord victimisation. Borderline Personal Disord
ality disorder. Psychopathology 2013;​46:​ 2014;​5:​70-8. Emot Dysregul 2017;​4:​10.
55-62. 39. Wertz J, Caspi A, Ambler A, et al. Bor- 51. Hallquist MN, Hipwell AE, Stepp SD.
25. Ha C, Balderas JC, Zanarini MC, Old- derline symptoms at age 12 signal risk for Poor self-control and harsh punishment
ham J, Sharp C. Psychiatric comorbidity poor outcomes during the transition to in childhood prospectively predict bor-

922 n engl j med 387;10 [Link] September 8, 2022

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 Personality Disorders

derline personality symptoms in adoles- ing in borderline personality disorder, 63. Bateman AW, Fonagy P. Mentaliza-
cent girls. J Abnorm Psychol 2015;​124:​ major depressive disorder, and posttrau- tion-based treatment of borderline per-
549-64. matic stress disorder. Biol Psychiatry Cogn sonality disorder. New York:​Oxford Uni-
52. Reinelt E, Stopsack M, Aldinger M, Neurosci Neuroimaging 2019;​4:​220-32. versity Press, 2012.
Ulrich I, Grabe HJ, Barnow S. Longitudi- 57. Drews E, Fertuck EA, Koenig J, Kaess 64. Gunderson JG, Links P. Handbook of
nal transmission pathways of borderline M, Arntz A. Hypothalamic-pituitary-adre- good psychiatric management for border-
personality disorder symptoms: from nal axis functioning in borderline person- line personality disorder. Washington,
mother to child? Psychopathology 2014;​ ality disorder: a meta-analysis. Neurosci DC:​American Psychiatric Publishing,
47:​10-6. Biobehav Rev 2019;​96:​316-34. 2014.
53. Stepp SD, Whalen DJ, Scott LN, Za- 58. Herpertz SC, Bertsch K, Jeung H. 65. Choi-Kain LW. Handbook of good
lewski M, Loeber R, Hipwell AE. Recipro- Neurobiology of Criterion A: self and in- psychiatric management for adolescents
cal effects of parenting and borderline terpersonal personality functioning. Curr with borderline personality disorder.
personality disorder symptoms in adoles- Opin Psychol 2018;​21:​23-7. Washington, DC:​American Psychiatric
cent girls. Dev Psychopathol 2014;​26:​361-78. 59. Storebø OJ, Stoffers-Winterling JM, Publishing, 2022.
54. Belsky DW, Caspi A, Arseneault L, et al. Völlm BA, et al. Psychological therapies 66. Young JE, Klosko JS, Weishaar ME.
Etiological features of borderline person- for people with borderline personality Schema therapy: a practitioner’s guide.
ality related characteristics in a birth co- disorder. Cochrane Database Syst Rev New York:​Guilford Press, 2006.
hort of 12-year-old children. Dev Psycho- 2020;​5:​CD012955. 67. Caligor E, Kernberg OF, Clarkin JF,
pathol 2012;​24:​251-65. 60. Borderline personality disorder: rec- Yeomans FE. Psychodynamic therapy for
55. Sharp C, Kerr S, Barkauskiene R. The ognition and management. London:​Na- personal pathology: treating self and in-
incremental utility of maladaptive self tional Institute for Health and Care Excel- terpersonal functioning. Washington, DC:​
and identity functioning over general lence, 2009. American Psychiatric Publishing, 2018.
functioning for borderline personality 61. NHMRC clinical practice guideline 68. Blum N, St John D, Pfohl B, et al. Sys-
disorder features in adolescents. Personal for the management of borderline per- tems Training for Emotional Predictabil-
Disord 2022 February 24 (Epub ahead of sonality disorder. Canberra, Australia:​ ity and Problem Solving (STEPPS) for
print). National Health and Medical Research outpatients with borderline personality
56. Schulze L, Schulze A, Renneberg B, Council, 2013. disorder: a randomized controlled trial
Schmahl C, Niedtfeld I. Neural correlates 62. Linehan MM. Cognitive-behavioral and 1-year follow-up. Am J Psychiatry
of affective disturbances: a comparative treatment of borderline personality disor- 2008;​165:​468-78.
meta-analysis of negative affect process- der. New York:​Guildford Press, 1993. Copyright © 2022 Massachusetts Medical Society.

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