John M. Oldham, MD: A History of Personality Disorder Pathology

The first evidence-based practice guideline for personality disorders was published in the American Journal of Psychiatry in 2001. The guideline entailed recommendations based on the randomized, controlled, clinical trial evidence accrued for 2 different treatments—dialectical behavior therapy (DBT) and metallization based therapy (MBT)—and provides a broad approach to uniquely identifying and managing borderline personality disorder, one of the most prominent forms of the condition.

Though historic for its time, the recommendations are due for an update—one it will get later this year, to the excitement of original guideline’s chair.

In an interview with HCPLive during the American Psychiatric Association (APA) 2024 Annual Meeting in New York, NY, last week, John M. Oldham, MD, MS, distinguished emeritus professor at the Menninger Department of Psychiatry and Behavioral Sciences at Baylor College of Medicine, discussed the work the work in personality disorder that’s progressed strategy from his workgroup’s guideline in 2001, to the anticipated new recommendations set to publish in September this year.

“It's time for an update, and it's been time for an update for quite a while,” Oldham said.

A primary component of the guideline updates, Oldham said, hinge around the altered perception of personality pathology as a more dimensional prospect than previously considered. As a member of the work group that developed the personality disorder system definition for the DSM-5, Oldham and colleagues advocated for a move away from the medically-based categorical labels; though it did not reach the final publication, it has been respected as an “alternative” model for disease mapping and monitoring by specialists. In the anticipated guideline updates, the dimensional pathology model is influential.

“The alternative model really talks about the definition of a personality disorder which is moderate or greater impairment and functioning in 2 areas: a sense of self and your interpersonal relationships,” Oldham said. “And the sense of self is unpacked a bit into a sense of identity and self-direction. And the interpersonal relationships is unpacked into a capacity for empathy and a capacity for intimacy—not meant in a romantic way so much as a mutually gratifying capacity to have long-term relationships.”

Oldham described 4 different capacities for functioning, phrased as reflective questions, that when impaired would imply likelihood of personality disorder:

• Do I know who I am?
• Do I know where I’m going?
• Am I able to understand other people?
• Can I have lasting, mutually rewarding, healthy relationships?

In considering the validity of the 10 categories of personality disorders labeled in DSM-5, Oldham and colleagues retained only 5 label, while returning a previous addition, in its latest iteration of pathology understanding. Among those retained were borderline, narcissistic, antisocial, and schizotypal.

“And those are what we thought as a way to move forward but at the same time, not get too far in the unfamiliar weeds, and help people really move to a new place, but not be too disoriented and not get into too unfamiliar territory,” Oldham explained.

In anticipating a September publication of the new personality disorder guideline, Oldham expressed hope the reliable framework set by he and colleagues a quarter-century ago is supplemented by a more refined, dimensional perspective of how these conditions manifest and persist in patients.

“Our recommendation is that we move to a more just systemic definition of personality disorders—moving away from the individual labels, and defining the disorder in a very personalized way,” Oldham said. “So, if there is moderate or greater impairment, then the pathological personality traits characterize your particular patient, or help you fill in the colors of your particular patient.”