Frontiers in Psychiatry is proud to present our Case Reports series. Our case reports aim to highlight unique cases of patients that present with an unexpected/unusual diagnosis, treatment outcome, or clinical course. Case reports provide insight into the differential diagnosis, decision-making, and clinical management of unusual cases and are a valuable educational tool. This Research Topic will only accept Case Reports or Community Case Studies but also relevant Opinions and Perspectives may be considered, all manuscripts must be original with the aim to significantly advance the field to be considered. We welcome contributions that cover all aspects of Personality Disorders.

Dipartimento Salute Mentale e Dipendenze Patologiche, Azienda Unità Sanitaria Locale (AUSL) della Romagna

University of Bologna

Frontiers in Psychiatry

Personality Disorders

Case Reports in Personality Disorders

Data from Waves 1 and 2 of the National Epidemiologic Survey on Alcohol and Related Conditions suggest that, in the United States, approximately 15% of the adult population suffers from at least one personality disorder (PD) (<a href="#B1">1</a>). PDs are pervasive patterns of interior and behavioral experience that stray from cultural and individual expectations, leading to an impairment in self-functioning (identity and self-direction) and interpersonal functioning (empathy and intimacy) (<a href="#B2">2</a>). These patterns manifest themselves in different areas like cognition, affectivity, interpersonal functioning and impulse control. PDs are characterized by the persistence of these traits over time, and in different situations. PDs are of great social impact for their high prevalence (the burden on psychiatric services is approximately 10%) (<a href="#B3">3</a>) and high mortality, often due to suicide (<a href="#B4">4</a>).For these reasons, an improvement in the treatment of PDs is required to reduce their burden. So far, there is no evidence about the effectiveness of pharmacological treatment (which has only shown mild efficacy on impulse control and emotional regulation) (<a href="#B5">5</a>), while it seems that psychological treatment is more efficacious, although there is no agreement in the literature on which treatment should be the first-line choice (<a href="#B6">6</a>, <a href="#B7">7</a>). However, despite the acquisitions of recent decades that attest that personality disorders should be treated with psychotherapeutic interventions, the offering of treatment provided is predominantly anchored to pharmacotherapy alone (<a href="#B8">8</a>).In this Research Topic, we have presented four studies, all focused on treatment strategies for PD.<a href="https://doi.org/10.3389/fpsyt.2023.1283145">Hafkemeijer et&nbsp;al.</a> presented two case reports with a diagnosis of borderline PD (BPD) and not fulfilling the diagnostic criteria for post-traumatic stress disorder (PTSD), to investigate the efficacy of trauma-focused therapy through a 10-session intensive trauma-focused therapy course using eye movement desensitization and reprocessing (EMDR) therapy, considering a bidirectional relation between the two disorders (25–30% of PTSD patients meet the diagnostic criteria for BPD, while 30–70% of BPD patients fulfilled the diagnostic criteria for PTSD in their lifetime). The authors targeted both A-criterion-worthy memories (without intrusive reliving) and non-A-criterion-worthy memories, which are considered responsible for the patients’ most prominent symptoms. Then, they investigated the effects on psychological distress, quality of life, and difficulties in emotion regulation at intake, post-treatment, and at 3, 6-and 12-month follow-up. Both patients showed a strong decline in psychological distress and difficulties in emotion regulation, and reported an improvement in their quality of life, no longer meeting the diagnostic criteria of BPD. The authors concluded that EMDR therapy appears to be a promising treatment approach for patients with BPD.<a href="https://doi.org/10.3389/fpsyt.2023.1186524">Blay et&nbsp;al.</a> described an adaptation of Good Psychiatric Management (GPM), a generalist clinical management approach for borderline PD (BPD) that incorporates common ingredients of good standard care for any psychiatric diagnosis with what works from prevailing specialist psychotherapies, to allow generalist clinicians to have simple-to-use dimensional tools that may help them distinguish, in the different categorical PD diagnoses, the most relevant issues for the patient. They administered it to one case of BPD with core detachment, negative affectivity, dissociality and other three comorbid personality disorders, and another case of BPD with core anankastia in a patient also diagnosed with obsessive-compulsive PD, assuming that BPD criteria may be the strongest markers of general personality functioning. The authors hypothesized that the disorder’s symptoms arise from a dynamic model called interpersonal hypersensitivity (IHS), which provides a framework for understanding the fluctuating self- and interpersonal issue patterns prototypical of BPD. They concluded that specialist psychotherapies should therefore meet the demands of public health needs to treat personality dysfunction, and the incorporation of new dimensional models of diagnosis is needed for treatments that can provide a minimum standard of care for providers and patients.<a href="https://doi.org/10.3389/fpsyt.2022.899847">Mu et&nbsp;al.</a> described the case of a 24-year-old young woman suffering from Paranoid Personality Disorder (PPD) with clinical manifestations of feeling targeted, cheated, tracked, misunderstood, and repeating actions. Since the prescribed pharmacotherapy was not effective for her delusions, the patient underwent Modified electric convulsive treatment (MECT). After MECT, the psychopathology improved, but the patient’s body temperature increased, and leukocytosis was found. After excluding infection and other possibilities, intravenous 1000 ml of physiological saline was administered to the patient. The white blood cell (WBC) count normalized shortly. The authors concluded that MECT treatment should be considered for drug-resistant psychotic symptoms in PPD, but it is necessary to screen blood cytology.A study by <a href="https://doi.org/10.3389/fpsyt.2018.00275">Webster et&nbsp;al.</a> highlighted the validity of the Post Traumatic Model (PTM) in a female patient who suffered severe and prolonged physical, psychological, and sexual abuse from two years old through adulthood, with the development of a Dissociative Identity Disorder (DID) (four full identity “alters” in her head). Later, the patient was also diagnosed with Major Depressive Disorder (MDD), PTSD, and associated features such as passive or active suicidal ideations and psychomotor retardation, which she had not been able to cope with in almost 10 years of therapy and psychiatric medications. After a hospitalization, the patient was referred by the inpatient psychiatrist for Electroconvulsive Therapy (ECT) and after two years, she reported having “lost the others”. With the integration of these alters she was able to restore the memories and pain that the alters had protected her from. This case highlights the importance of the PTM as an etiological description for DID and the importance of mental health providers further studying and researching the effects of ECT on patients with chronic MDD, PTSD, and suicidality, especially if these are comorbid with DID.The case reports in this Research Topic underline the scientific community&#x2019;s efforts to detect efficacious treatments for PDs. They highlight the importance of collecting a detailed psychiatric history, and investigating physical and sexual trauma histories. Moreover, it is important to consider the dimensional aspects of personality instead of focusing on the categorical approach, to find the most important aspect to cope with during the psychotherapy sessions. ECT can provide some improvement in drug-resistant patients, but (even rare) side effects should be taken into consideration. Moreover it is very important to treat them through the interaction between biological and psychosocial aspects of mental illness and the complexities of this biopsychosocial model. MB: Conceptualization, Writing &#x2013; original draft, Writing &#x2013; review &amp; editing. MS: Writing &#x2013; review &amp; editing.MB collaborated on a Lundbeck and an Angelini project.The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.

Editorial: Case reports in personality disorders

BackgroundExposure to adverse childhood events plays an important role in the development of borderline personality disorder (BPD). Emerging evidence suggests that trauma-focused therapy using eye movement desensitization and reprocessing (EMDR) can be beneficial for patients with BPD symptoms. To date, the effects of brief, intensive EMDR treatment for this target group have not been investigated in this population.</sec>ObjectiveThis study aimed to evaluate the effects of a brief and intensive trauma-focused therapy course using EMDR therapy in two patients diagnosed with BPD who did not fulfill the diagnostic criteria for post-traumatic stress disorder (PTSD). It was hypothesized that this approach would be associated with a decline in the core symptoms of BPD, and that this would have an enduring long-term effect on patients’ diagnostic status.</sec>MethodTen sessions of EMDR therapy were carried out across four consecutive treatment days, with the aim of processing patients’ core adverse childhood experiences. Both A-criterion-worthy memories (without intrusive reliving) and non-A-criterion-worthy memories that were considered responsible for the patients’ most prominent symptoms were targeted. The effects of EMDR therapy on trauma symptom severity and BPD diagnostic status (as established by the Structured Clinical Interview DSM-5) were determined. Additionally, the effects on psychological distress, quality of life, and difficulties in emotion regulation were determined at intake, post-treatment, and at 3-, 6-, and 12-months follow-up.</sec>ResultsBoth patients showed a strong decline in psychological distress and difficulties in emotion regulation, and reported an improvement in their quality of life. At post-treatment, and at 3-, 6-, and 12-months follow-up they no longer met the DSM-5 criteria for BPD.</sec>ConclusionThe findings of this small case study are in line with mounting evidence that a brief track of intensive trauma-focused therapy can result in long-term remission in patients with BPD. EMDR therapy seems to be a promising treatment approach for patients with BPD; however, the results need to be replicated in clinical trials.</sec>

Background: Exposure to adverse childhood events plays an important role in the development of borderline personality disorder (BPD). Emerging evidence suggests that trauma-focused therapy using eye movement desensitization and reprocessing (EMDR) can be beneficial for patients with BPD symptoms. To date, the effects of brief, intensive EMDR treatment for this target group have not been investigated in this population.Objective: This study aimed to evaluate the effects of a brief and intensive trauma-focused therapy course using EMDR therapy in two patients diagnosed with BPD who did not fulfill the diagnostic criteria for post-traumatic stress disorder (PTSD). It was hypothesized that this approach would be associated with a decline in the core symptoms of BPD, and that this would have an enduring long-term effect on patients’ diagnostic status.Method: Ten sessions of EMDR therapy were carried out across four consecutive treatment days, with the aim of processing patients’ core adverse childhood experiences. Both A-criterion-worthy memories (without intrusive reliving) and non-A-criterion-worthy memories that were considered responsible for the patients’ most prominent symptoms were targeted. The effects of EMDR therapy on trauma symptom severity and BPD diagnostic status (as established by the Structured Clinical Interview DSM-5) were determined. Additionally, the effects on psychological distress, quality of life, and difficulties in emotion regulation were determined at intake, post-treatment, and at 3-, 6-, and 12-months follow-up.Results: Both patients showed a strong decline in psychological distress and difficulties in emotion regulation, and reported an improvement in their quality of life. At post-treatment, and at 3-, 6-, and 12-months follow-up they no longer met the DSM-5 criteria for BPD.Conclusion: The findings of this small case study are in line with mounting evidence that a brief track of intensive trauma-focused therapy can result in long-term remission in patients with BPD. EMDR therapy seems to be a promising treatment approach for patients with BPD; however, the results need to be replicated in clinical trials.

Case report: Brief, intensive EMDR therapy for borderline personality disorder: results of two case studies with one year follow-up

Good Psychiatric Management (GPM) is a generalist clinical management approach for borderline personality disorder that incorporates common ingredients of good standard care for any psychiatric diagnosis with what works from prevailing specialist psychotherapies. Similar to all validated therapies for BPD, it relies on a specified formulation of the disorder' symptoms as arising from interpersonal hypersensitivity, to dynamically describe typical patterns of daily self- and interpersonal issues that drive the instability that defines the general personality dysfunction characteristic of the disorder. Recent adaptations of GPM have been proposed for narcissistic personality disorder and obsessive-compulsive personality disorder, with development of similar dynamic models for both (intrapsychic coherence model and model of overcontrol). New dimensional models of personality disorder diagnosis have been developed to address limitations of categorical approach, but the incorporation of these models into usage in the delivery of clinical services (where categorical approach remains the most used) is limited. This paper describes an adaptation of GPM to two cases of personality disorder that illustrate the usefulness of GPM models for dynamic representation of complex daily fluctuations in internal psychic coherence and interpersonal functioning. Specialist psychotherapies will never meet the demands of public health needs to treat personality dysfunction, and incorporation of new dimensional models of diagnosis are needed for treatments that can provide a minimal standard of care for providers and patients.

Good Psychiatric Management (GPM) is a generalist clinical management approach for borderline personality disorder that incorporates common ingredients of good standard care for any psychiatric diagnosis with what works from prevailing specialist psychotherapies. Similar to all validated therapies for BPD, it relies on a specified formulation of the disorder' symptoms as arising from interpersonal hypersensitivity, to dynamically describe typical patterns of daily self- and interpersonal issues that drive the instability that defines the general personality dysfunction characteristic of the disorder. Recent adaptations of GPM have been proposed for narcissistic personality disorder and obsessive-compulsive personality disorder, with development of similar dynamic models for both (intrapsychic coherence model and model of overcontrol). New dimensional models of personality disorder diagnosis have been developed to address limitations of categorical approach, but the incorporation of these models into usage in the delivery of clinical services (where categorical approach remains the most used) is limited. This paper describes an adaptation of GPM to two cases of personality disorder that illustrate the usefulness of GPM models for dynamic representation of complex daily fluctuations in internal psychic coherence and interpersonal functioning. Specialist psychotherapies will never meet the demands of public health needs to treat personality dysfunction, and incorporation of new dimensional models of diagnosis are needed for treatments that can provide a minimal standard of care for providers and patients.

Case reports: Using Good Psychiatric Management (GPM) conceptualizations in the dimensional assessment and treatment of personality disorders

IntroductionModified electroconvulsive therapy (MECT) is a viable therapeutic option for patients with mood disorders and schizophrenia. We found that there is a relationship between MECT and leukocytosis. To the best of our knowledge, this is the first case of this problem. There are no relevant guidelines recommending the risk of leukocytosis caused by MECT, nor the method to reduce the risk. We hope to share this case to provide a reference for the prevention and treatment of similar patients with leukocytosis during or after MECT and remind psychiatrists to pay attention to this risk of leukocytosis before making the decision of MECT while knowing how to deal with it.</sec>Case presentationWe describe a case of a 24-year-old woman diagnosed with Paranoid personality disorder (PPD) whose symptoms began at 19 years old. Her main clinical manifestations are feeling targeted, cheated, tracked, misunderstood, and repeating action. Since antipsychotic treatment was ineffective, we considered MECT. After MECT, the patient’s body temperature increased, and leukocytosis was found. After excluding infection and other possibilities, we added 1,000 ml physiological saline to the patient through the vein. The white blood cell (WBC) count returned to normal in a short time.</sec>ConclusionBefore MECT, it is necessary to screen blood cytology. During and after MECT, we should be alert to leukocytosis that may be related to MECT and deal with it correctly in time.</sec>

Introduction: Modified electroconvulsive therapy (MECT) is a viable therapeutic option for patients with mood disorders and schizophrenia. We found that there is a relationship between MECT and leukocytosis. To the best of our knowledge, this is the first case of this problem. There are no relevant guidelines recommending the risk of leukocytosis caused by MECT, nor the method to reduce the risk. We hope to share this case to provide a reference for the prevention and treatment of similar patients with leukocytosis during or after MECT and remind psychiatrists to pay attention to this risk of leukocytosis before making the decision of MECT while knowing how to deal with it.Case presentation: We describe a case of a 24-year-old woman diagnosed with Paranoid personality disorder (PPD) whose symptoms began at 19 years old. Her main clinical manifestations are feeling targeted, cheated, tracked, misunderstood, and repeating action. Since antipsychotic treatment was ineffective, we considered MECT. After MECT, the patient’s body temperature increased, and leukocytosis was found. After excluding infection and other possibilities, we added 1,000 ml physiological saline to the patient through the vein. The white blood cell (WBC) count returned to normal in a short time.Conclusion: Before MECT, it is necessary to screen blood cytology. During and after MECT, we should be alert to leukocytosis that may be related to MECT and deal with it correctly in time.

A Case Report of Leukocytosis During Modified Electroconvulsive Therapy of Paranoid Personality Disorder

The legitimacy and etiology of Dissociative Identity Disorder (DID) remains a controversial topic within Psychiatry. The two schools of thought are the Post-Traumatic Model (PTM) and the Socio-Cognitive Model (SCM). This case highlights the validity of PTM in an individual who suffered severe and prolonged physical, psychological, and sexual abuse from 2 years old through adulthood. The reported abuse was corroborated and proven on two separate occasions via medical professionals/rape kit and the police. This resulted in the incarceration of one of her abusers. The only way for the patient to cope with the trauma she suffered was to dissociate, which resulted in the development of four full identity alters. In addition to being diagnosed with DID, the patient has been diagnosed with Major Depressive Disorder (MDD), Post-Traumatic Stress Disorder (PTSD), and chronic suicidality. Unable to manage the suicidal ideations and MDD after nearly 10 years of therapy and psychiatric medications, the patient was referred for Electroconvulsive Therapy (ECT). Upon receiving ECT weekly for 2 years, the patient reported having “lost the others.” As ECT progressed she went from having four alters to no alters and at the time of this report only being able to vaguely hear alter #4. With the integration of these alters she had access to the memories and pain that the alters had protected her from. Prior to losing the alters, her long-term memory was impaired by dissociative processes. Her long-term memory was also impaired because when one of the alters was in control of consciousness only that alter remembered what had happened during that time, unless that alter shared what had happened with one or more of the others. It is unclear if frequent ECT was the catalyst that lead to the integration of her alters however, integration finally began following prolonged ECT. This case highlights the importance of the PTM as an etiological description for DID and the importance of mental health providers further studying and researching the effects of ECT on patients with chronic MDD, PTSD, and suicidal intent, especially if these are comorbid with DID.

The legitimacy and etiology of Dissociative Identity Disorder (DID) remains a controversial topic within Psychiatry. The two schools of thought are the Post-Traumatic Model (PTM) and the Socio-Cognitive Model (SCM). This case highlights the validity of PTM in an individual who suffered severe and prolonged physical, psychological, and sexual abuse from 2 years old through adulthood. The reported abuse was corroborated and proven on two separate occasions via medical professionals/rape kit and the police. This resulted in the incarceration of one of her abusers. The only way for the patient to cope with the trauma she suffered was to dissociate, which resulted in the development of four full identity alters. In addition to being diagnosed with DID, the patient has been diagnosed with Major Depressive Disorder (MDD), Post-Traumatic Stress Disorder (PTSD), and chronic suicidality. Unable to manage the suicidal ideations and MDD after nearly 10 years of therapy and psychiatric medications, the patient was referred for Electroconvulsive Therapy (ECT). Upon receiving ECT weekly for 2 years, the patient reported having &#x201c;lost the others.&#x201d; As ECT progressed she went from having four alters to no alters and at the time of this report only being able to vaguely hear alter #4. With the integration of these alters she had access to the memories and pain that the alters had protected her from. Prior to losing the alters, her long-term memory was impaired by dissociative processes. Her long-term memory was also impaired because when one of the alters was in control of consciousness only that alter remembered what had happened during that time, unless that alter shared what had happened with one or more of the others. It is unclear if frequent ECT was the catalyst that lead to the integration of her alters however, integration finally began following prolonged ECT. This case highlights the importance of the PTM as an etiological description for DID and the importance of mental health providers further studying and researching the effects of ECT on patients with chronic MDD, PTSD, and suicidal intent, especially if these are comorbid with DID.

Multimodal Treatment With ECT for Identity Integration in a Patient With Dissociative Identity Disorder, Complex Post-traumatic Stress Disorder, and Major Depressive Disorder: A Rare Case Report