In our rejoinder to the excellent commentaries provided by Macfie, Noose, and Gorrondona (This Volume) and Davies and Thompson (This Volume), we discuss three key directions for research and clinical work that emerge from our chapter on environmental and sociocultural influences on personality disorders. First, it is critical to recognize the importance of early caregiving environments and family processes in the etiology of personality pathology. Second, identifying transactional models that integrate biological, psychological and sociocultural influences may move the field towards a more holistic and multifaceted understanding of the underpinnings of personality pathology. Third and finally, expanding the use of dimensional models of personality pathology may contextualize these transactional relationships and facilitate more rapid advances in our understanding and conceptualizations of (mal)adaptive expressions of personality traits. Dimensional models may further facilitate consideration of socioeconomic, cultural and geopolitical influences in evaluating and defining the maladaptiveness of specific traits and behaviors. Increasing our focus on contextual, environmental, and sociocultural influences in research design, assessment, and case conceptualization will improve personality research and clinical care.

The authors offer their appreciation of the astute commentaries by Scott and Pilkonis and Niedtfeld, Paret, and Schmahl regarding their chapter on borderline personality disorder. Scott and Pilkonis address some very important big picture themes regarding the conceptualization, etiology, and treatment of BPD, and Niedtfeld et al. more specifically comment on innovative research highlighting the interplay of neuroscience and psychotherapy. In this rejoinder, the authors comment on these and other issues and suggest that a developmental psychopathology framework for theory and research has promise for illuminating the nature and etiology of BPD and highlighting important directions for prevention and treatment.

Characterized by a combination of interpersonal, emotional, behavioral, and cognitive instability, borderline personality disorder (BPD) is a serious and often misunderstood condition. The prevalence of BPD is approximately 1.4 to 6%, with substantially higher estimates among psychiatric outpatients and inpatients. Beyond the personal costs of BPD in terms of suffering, BPD is strongly associated with functional impairment and high societal costs for mental healthcare. Clinical descriptions of BPD first appeared before the mid-twentieth century and have evolved to the present conceptualization of an overarching BPD construct represented by the key domains of emotion dysregulation, impulsivity, and interpersonal disturbance. BPD has a varying course, with many individuals achieving remission or recovery, but emotional and interpersonal vulnerabilities and functional impairments often persist for many years, even after structured treatment. The success of treatment for BPD over the past few decades, however, has countered common clinical lore that BPD patients are recalcitrant. Further, novel developments in research on the putative core vulnerabilities underlying BPD, as well as evidence that these vulnerabilities can be addressed in treatment, illuminate important future directions and hope for patients and loved ones affected by this disorder.

In addition to identifying important biological and psychosocial correlates of personality disorders, recent research has illuminated environmental and sociocultural factors that influence the development, expression, and maintenance of personality disorders. In particular, cross-national and cross-cultural comparisons indicate that the expression, meaning, and impact of specific personality traits and behaviors differ across gender roles, historical periods, and cultural and socioeconomic groups. Moreover, whereas interpersonal and attachment theories have historically underscored the importance of parent-child relationships, emotional attunement, and early childhood adversity in the formation and continuation of personality pathology, recent behavioral genetic studies suggest that unique, non-shared environmental influences account for as much or more variance in personality disorders as shared influences among family members. Additional sources of sociocultural and environmental influence on personality disorders include peer and romantic relationships. Increasingly, integrative theories highlight the importance of considering interactions and transactions across biological, psychological, and sociocultural systems in understanding the etiology of personality disorders. These theoretical and empirical advances have important implications for personality disorder research and clinical practice, and point to the potential utility of considering cross-cultural diagnostic validity when evaluating dimensional or categorical diagnostic models.