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Concurrent with the idea within psychoanalysis that the personality embodies the resistances to conflict resolution and symptom reduction were efforts within descriptive psychiatry, most notably by Kurt Schneider, to define the overriding construct of personality disorders as stable maladaptive traits that were resistant to change from life experience and likely resistant also to any therapeutic interventions. Against this background of therapeutic pessimism, a series of pioneering clinicians suggested that specific forms of intervention could be effective. Reich presented a theory of therapy advocating persistent and repetitious interpretations of characterological defenses directed at making them more dystonic and eventually weaker. Maxwell Jones developed a model of sociotherapy that involved peer confrontation about maladaptive behaviors in the context of a milieu from which the person with a personality disorder could not easily avoid self-examination.

Nonetheless, until the late 1960s, the prevailing wisdom was that although "character neuroses" were treatable, more severe personality disorders were, at best, manageable. At that time, Kernberg (1967, 1968) popularized the concept of "borderline personality organization" (a construct encompassing most forms of major personality disorder) and suggested that patients with this personality organization were understandable and modifiable by long-term psychoanalytic psychotherapy. The resulting wave of ambitious psychodynamic, residential, family, and individual therapeutic efforts gave expression to a new and widespread interest in the therapeutic possibilities for such patients.

Changes in how a person feels and distorted beliefs about other people can lead to odd behaviour, which can be distressing and may upset others.

Common features include:

• being overwhelmed by negative feelings such as distress, anxiety, worthlessness or anger
• avoiding other people and feeling empty and emotionally disconnected
• difficulty managing negative feelings without self-harming (for example, abusing drugs and alcohol, or taking overdoses) or, in rare cases, threatening other people
• odd behaviour
• difficulty maintaining stable and close relationships, especially with partners, children and professional carers
• sometimes, periods of losing contact with reality

Recent Trends in the Treatment of Personality Disorders
Because the literature on personality disorders largely grew out of psychoanalytic contributions, the treatments recommended for these conditions have traditionally been psychoanalysis and extended psychodynamic psychotherapy. These treatments are still useful and effective for many of the personality disorders. However, these updated chapters reflect the fact that behavior therapies and cognitive therapies also have been used for personality disorders in recent years and that a growing literature supports their use. Pharmacotherapy has been used with increasing sophistication as an adjunct to psychotherapy, particularly in borderline personality disorder, schizotypal personality disorder, and avoidant personality disorder. With the knowledge that personality reflects a genetically based biological temperament as well as a constellation of internalized object relations, defenses, and self-constructs based on experiences with the environment, a rationale can be made for a more sophisticated combination of treatments. Certain aspects of personality disorder can be targeted by specific psychopharmacological agents, whereas other dimensions are the focus of psychotherapy. For many years, only long-term treatments were recommended for personality disorders, but we now know that at least with some conditions, such as avoidant personality disorder, brief behavior therapies may be useful in altering certain symptoms.

The long-term stability of personality disorders has been a protracted point of controversy. A recent investigation examined 250 subjects from a nonclinical university population for personality disorder features at three different time points with well-established instruments. Over a 4-year period, the features of personality disorder, viewed from a dimensional perspective, appeared to be relatively stable. Nevertheless, some follow-up research suggests that significant life events also may influence the course of some personality disorders.

Even though research has expanded considerably since the last edition of this text, only in a few instances can a specific treatment be considered a well-established modality that results in dramatic changes. Nevertheless, the available interventions do suggest that distress caused by personality disorders can be ameliorated to some extent, and there is reason for optimism in prescribing a treatment plan. Moreover, we now know that at least some personality disorders are extraordinarily costly in terms of their effect on society. Weekly psychotherapy extended over 12 months or more may be a relatively expensive and labor-intensive treatment, but in the long run, such interventions may be highly cost-effective. Long-term psychotherapy based on psychodynamic or dialectical behavior therapy principles has been shown to decrease the use of hospitalization substantially and therefore saved money in the case of borderline personality disorder when compared with samples of patients who did not receive such psychotherapy. Hence, in an era of quick-fix managed care approaches, extended psychotherapy may be the preferred treatment for personality disorders in many cases from the standpoint of both effectiveness and cost-effectiveness.

The chapters in this section vary in terms of the amount of recent literature devoted to them. A study that searched MEDLINE for articles on personality disorders found that more than one-half of the individual personality disorders had either a very small amount of literature or literature with negative growth rates. Borderline, antisocial, and schizotypal personality disorders were the only disorders with modestly growing literatures. Indeed, research on Axis II conditions is unbalanced, and readers will note the imbalance as they read through the chapters in this section. The fact that some disorders are not stimulating a great deal of research or clinical interest raises the possibility that the current classification needs to be reconsidered.