What is personality disorder?
The word ‘personality’ refers to the pattern of thoughts, feelings and behaviour that makes each of us the individuals that we are. We don’t always think, feel and behave in exactly the same way. It depends on the situation we are in, the people with us, and many other things. But mostly we do tend to behave in fairly predictable ways, and can be described, accordingly, as shy, selfish, lively, and so on. We each have a set of these patterns, and this set makes up our personality.
Generally speaking, personality doesn’t change very much, but it does develop as we go through different experiences in life, and as our circumstances change. We mature with time, and our thinking, feelings and behaviour all change depending on our circumstances. We are usually flexible enough to learn from past experiences and to change our behaviour to cope with life more effectively.
However, if you have a personality disorder, you are likely to find this more difficult. Your patterns of thinking, feeling and behaving are more difficult to change and you will have a more limited range of emotions, attitudes and behaviours with which to cope with everyday life. This can lead to distress for you or for other people. If you have a personality disorder, you may find that your beliefs and attitudes are different from most other people. They may find your behaviour unusual, unexpected and may find it difficult to spend time with you. This, of course, can make you feel very hurt and insecure; you may end up avoiding the company of others.
The diagnosis applies if you have personality difficulties which affect all aspects of your life, all the time, and make life difficult for you and for those around you. The diagnosis does not include personality changes caused by a life events such as a traumatic incident, or physical injury.
Personality disorders usually become noticeable in adolescence or early adulthood, but sometimes start in childhood. They can make it difficult for you to start and keep friendships or other relationships, and you may find it hard to work effectively with others. You may find other people very scary, and feel very alienated and alone.
However, with the right help you can learn to understand other people better, and cope better with social situations and relationships with other people. Working in groups of people with similar problems can be very helpful too.
What are the different types of personality disorder?
Personality disorder can show itself in different ways. Psychiatrists tend to use a system which identifies 10 different types of personality disorder, which can be grouped into three categories:
| • Suspicious | • Emotional and impulsive | • Anxious |
| paranoid | borderline | avoidant |
| schizoid | histrionic | dependent |
| schizotypal | narcissistic | obsessive compulsive |
| antisocial |
Avoidant and dependent personality disorder are very similar, as are schizoid and schizotypal, and histrionic and narcissistic personality disorders.
One person may meet the criteria for several different disorders, while a wide range of people may fit different criteria for the same disorder, despite having very different personalities.
Paranoid personality disorder
You are likely to feel very wary of others, imagining they have hidden motives, will use you, or take advantage of you if you don’t stay vigilant.
As a result, you will find it very difficult to trust other people. You will be suspicious and always on your guard, even with your friends, and you may feel that it’s not safe to confide in them. You may watch others closely, looking for signs of betrayal or hostility and you will read threats and menace – which others don’t see – into everyday situations. Others may complain that you are far too mistrustful.
Schizoid personality disorder
Having a schizoid personality disorder means that you aren’t really interested in forming close relationships with other people.
You feel that relationships interfere with your freedom and tend to cause problems. You prefer to be solitary and inward looking, and choose to live your life without interference from others. Other people will see you as a loner. Few things in life give you pleasure, and you may have little interest in sex or intimacy.
Schizotypal personality disorder
Making close relationships will be extremely difficult for you. People may describe you as eccentric, and you will find that you think differently to others.
You might believe that you can read minds or that you have special powers and you may feel anxious and tense with others who do not share these beliefs.
Borderline personality disorder (BPD)
BPD may cause a number of problems in different areas of your life. You may feel that you don’t have a strong sense of who you really are, and others may describe you as very changeable. You will suffer from mood swings, switching from one intense emotion to another very quickly, often with angry outbursts, and you may have brief psychotic episodes when you hear voices or see things that others can’t.
You may end up doing things on impulse, which you later regret. You may have episodes of harming yourself, and think about taking your own life. You will probably also have a history of stormy or broken relationships, and you will have a tendency to cling on to very damaging relationships, because you are terrified of being alone.
Histrionic personality disorder
Being ignored is probably very uncomfortable for you, and you feel much more at ease as the ‘life and soul of the party’.
But you may also feel that you have to entertain people and that you are dependent on their approval. You may flirt or behave provocatively to ensure that you remain the centre of attention, or find that other people influence you too easily. You may earn a reputation for being dramatic and overemotional. Because you love excitement and don’t tolerate boredom, you may behave recklessly or impulsively at times.
Narcissistic personality disorder
You may believe that there are special reasons that make you different, better or more deserving than others, but because your self-esteem is rather fragile, you rely on others to recognise your worth and your needs.
However, other people often ignore your special needs and don’t give you what you feel you deserve, so that you then feel upset, and resent other people’s successes. Because of this, you put your own needs above other people’s, and demand they do too. People are likely to see you as selfish and ‘above yourself’.
Antisocial personality disorder (ASPD)
This is closely linked with adult criminal behaviour, so if you are diagnosed with ASPD you are likely to have a criminal record. You may also be a heavy drinker or a drug-user.
You are very easily bored and you may find it difficult to hold down a job for long or stay in a long-term relationship. You will tend to act impulsively and recklessly, often without considering the consequences for yourself or for other people. You may do things – even though they may hurt people – to get what you want, putting your needs above theirs. You believe that only the strongest survive and that you must do whatever it takes to lead a successful life, because if you don’t grab opportunities, others will. You may be regarded as being selfish and hard. You will have had a diagnosis of conduct disorder before the age of 15.
This diagnosis includes ‘psychopathy’. This term is no longer used in the Mental Health Act, but a ‘psychopathy checklist’ questionnaire may be used in your assessment.
Avoidant (or anxious) personality disorder
Feeling inadequate or inferior to other people, and avoiding work or other social activities, is one sign of avoidant personality disorder.
You expect disapproval and criticism, and you worry constantly about being ‘found out’ and rejected. You may be particularly worried about being ridiculed or shamed by others, so you avoid social relationships, friendships and intimacy. However, you feel lonely and isolated, and long to have the very relationships you avoid. It’s hard for others to understand the extent of your worries and not to believe you’re exaggerating your fear of ordinary social situations. They will see you as a loner.
Dependent personality disorder
You are likely to feel needy, weak and unable to make decisions or function properly without help or support. You allow others to assume responsibility for many areas of your life, finding it hard to say when you disagree with them because you fear losing their support.
You could find yourself agreeing to things you feel are wrong, and put up with other people’s unreasonable behaviour to avoid being alone. Your self-confidence will be low, and you see other people as being much more capable than you are. Others may describe you as much too submissive and passive.
Obsessive-compulsive personality disorder (OCPD)
If you are very concerned to keep everything in order and under control this can be a sign of OCPD.
You are likely to set unrealistically high standards for yourself and others, and you generally think yours is the best way of making things happen, so you end up feeling responsible for everything. You worry when you or others make mistakes, and expect catastrophes if things aren’t perfect.
OCPD is separate from obsessive compulsive disorder (OCD), which describes a form of behaviour rather than a type of personality.
What causes a personality disorder?
There is a great deal of research about personality disorders suggesting that a number of different interacting factors are involved.
Genetics and inheritance
Some elements of our personality are inherited. People are born with different temperaments; for example, babies vary in how sociable they are, in the intensity of their reactions, and in the length of their attention span. Some experts believe that inheritance may play a relatively big part in the development of OCPD and ASPD and that there may also be a genetic link between personality disorders and certain other mental health problems; for example, schizophrenia or manic depression.
Trauma
Repeated childhood traumas may lead to personality disorder. This is not to say that everyone who experiences a traumatic situation will develop these problems, just that it might leave someone more vulnerable. It’s been suggested that early and severe trauma, in particular, can cause personality difficulties. However, the way you and others around you reacted and dealt with it, and the support and care you received, will have made a lot of difference.
Family circumstances
There is some evidence to suggest that family circumstances can make you vulnerable to personality disorder. ASPD has been linked to antisocial behaviour in childhood, which could be the result of high levels of stress and family problems. These might include your parents not giving you enough warmth, intimacy, consistency or appropriate discipline and supervision. Your parents having ASPD or abusing drugs or alcohol may also be factors.
Experiences like these can make you vulnerable to personality disorder. In particular, many people diagnosed with BPD report having been neglected, or physically or sexually abused as children.
Why is the diagnosis so controversial?
You can feel labelled and insulted
The term ‘personality disorder’ can sound very judgemental. Your personality is the core of yourself, and to be told it is ‘disordered’ is very upsetting and undermining. Many of these diagnostic labels have been used in a way that stigmatises people. Labelling people as ‘dependent’ and ‘inadequate’ can be insulting and hurtful.
It can be mistakenly diagnosed
Many survivors of domestic violence or child abuse have been mistakenly diagnosed with a personality disorder because they developed persistent and wide-ranging post-traumatic symptoms, which were misread as part of their basic personality.
It is sometimes associated with crime
It is suggested that about 10 per cent of the general population have a personality disorder, and most of these people have not committed any crime. However, at least 50 per cent of criminals have a diagnosis of personality disorder, with a high proportion of those having ASPD. This is explained by the fact that criminal behaviour is one of the criteria for the diagnosis of ASPD.
Are people with a personality disorder dangerous?
Despite the negative stories that often appear in the press, most people diagnosed with a personality disorder are not violent. If violence does occur, it tends to involve people diagnosed with ASPD. If you have a personality disorder, especially a borderline or paranoid personality disorder, you are much more likely to harm yourself than others.
People who have a diagnosis of a personality disorder and are also considered to pose a serious risk of harm to others or have committed a violent crime may be described as having ‘dangerous and severe personality disorder’. This is not a clinical diagnosis, but a term introduced by a government consultation paper in 1999. Such people were identified as needing to be detained for treatment under the Mental Health Act 1983 (as amended in 2007), in spite of the fact that no successful treatment for dangerousness existed. Various treatment programmes have been put in place, and more are being developed.
What treatments are available?
For a long time it has been widely thought that personality disorders are difficult to treat because they involve such deeply rooted patterns of thoughts, feelings and ways of relating to others. The type of treatment you are offered, and its success, may depend on where you are (at home, in hospital or in prison) and on what is available locally.
However, since 2003, the Government has put in place programmes to improve services for people with personality disorders, and there is now a new national training programme for staff working with people with all types of personality disorders – the Knowledge and Understanding Framework (KUF).
Personality disorders often improve as you get older, suggesting that as you gain life experience and mature you learn better ways of relating to others, gain better understanding of your responses and reactions to people and events, and learn to manage things better. Successful treatments aim to help you to make this happen by focussing on the way you think and behave, how to control your emotions, developing successful relationships and getting more out of life.
Treatment plans need to include group and individual therapies; encouragement for you to continue with the programme; education; and planning for crisis. You may receive treatment as an out-patient in a hospital or a day centre, or as an in-patient.
The most important factor in treatment is the relationship you form with the professionals who are helping you, whether they are a social worker, psychiatric nurse, therapist or psychiatrist. Having someone you trust, who will give you time, listen to you and believe in you, is crucial for your progress.
Therapeutic communities
Whichever personality disorder you are diagnosed with, you are likely to have difficulties with relationships with other people. Living in a therapeutic community for a number of months can be very helpful, and can be seen as a continuous form of group therapy.
The emphasis is on working together, democratically, so that staff and residents share responsibility for tasks and decisions. People are encouraged to express their feelings about one another’s behaviour in group discussions. This inevitably means having to face up to the impact your attitudes and behaviour have on others.
Although traditionally therapeutic communities have been residential, non-residential communities have been developed in recent years. This may involve a service-user-led network which uses web-based messaging as well as face-to-face meetings. There are also some therapeutic communities within the prison system.
Communities vary, and while in some there may be no individual therapy, in others there may be a mixture of whole group meetings, small groups and one-to-one sessions with a member of staff. There is often no medication involved. You will benefit most if you are able to accept your own contribution to your problems and your ability to change. See the Association of Therapeutic Communities below.
Arts therapies
Art, music and dance therapies may help you to express how you are feeling, especially if you are having difficulty putting things into words. If you are someone who finds social situations very difficult, meeting for a session of art or music, where you can express yourself without words, in a group, can be an excellent way to begin to get used to trusting others and sharing experiences. Drama therapy may help you to say things that are normally difficult to express.
Talking treatments
Therapies designed specifically for personality disorders have been shown to be helpful, though much of the research, so far, has focused on treatment for borderline personality disorder (BPD) and milder forms of personality disorder. A recent paper showed evidence for the success of out-patient and day hospital psychotherapy for the ‘emotional and impulsive’ group of personality disorders.
There are certain keys to the success of talking treatments. If you place the responsibility for your difficulties on others and on outside circumstances, you are unlikely to benefit. You are more likely to benefit from treatment if you can:
· think about and monitor your own thoughts, feelings and behaviour
· be honest about yourself, your problems and imperfections
· accept responsibility for solving your problems, even if you did not cause them
· be open to change and stay motivated.
Dialectical behaviour therapy (DBT)
DBT offers group therapy alongside individual treatment and can be very effective, especially with BPD. DBT teaches new skills to help you manage emotions, such as distress, and improve the way you interact with others. It helps change the behaviour that causes you most problems so you can deal better with day-to-day crises.
Cognitive behaviour therapy (CBT)
CBT has been especially helpful for people with dependent and avoidant personality disorders. It can help you examine your usual pattern of thoughts and attitudes and allow you to challenge ideas and beliefs that cause you problems. For example, if you are too dependent, therapy could focus on your belief that you are so helpless and incompetent you need someone else to rely on. If you have OCPD, therapy might help you explore your feeling that you must not, under any circumstances, make any mistakes.
Psychodynamic therapy
This focuses on the relationship between client and therapist, and can be useful with BPD, in particular. It can help you manage your relationships with other people and improve the way you feel about yourself.
Group therapy
Group therapy can be helpful for anyone who prefers to avoid social situations, or who usually depends too much on another person. The groups may have very practical aims, with the emphasis on practising social skills and assertiveness training. If you tend to form intense, ‘special’, one-to-one relationships, a group can let you try out different relationships and broaden your range of attachments to other people.
Group therapy may include social problem-solving therapy which aims specifically to boost your social confidence and help you to reduce impulsive behaviour by teaching you to stop and think and plan your actions.
Medication
There are no drugs specifically for personality disorder, but doctors may prescribe them to treat additional problems, such as irritability or depression. It may take some time to find a drug that works for you, and often medication may be most effective when combined with a talking treatment.
Advocacy
In the past, people diagnosed with a personality disorder were sometimes not offered support services, and you may still find it difficult to get the help you need. Finding an advocate – someone who can speak for you – can be very useful. There are a number of organisations that can offer advice about this.
How can friends and family help?
If your friend or relative has a diagnosis of personality disorder, it’s important to emphasise the positive aspects of their personality, and to make the most of their strengths and abilities. A diagnosis of personality disorder doesn’t stop someone being likeable, intelligent, highly motivated or creative.
Good information is crucial. If your friend or relative would find it helpful, you could be involved in discussions with mental health professionals, when they are explaining diagnoses and treatment approaches to them. You could act as their advocate and speak up and support them, ensuring they are getting the answers they need from professional services.
They may need your encouragement to change their behaviour. For instance, alcohol, drugs or abusive relationships can only add to problems. Don’t be judgemental or tell them they are ‘immature’ or ‘inadequate’, or ‘attention-seeking’ or ‘making bad choices’: everybody behaves immaturely or inadequately at times, and we all make mistakes.
You can try to help identify situations that bring out the best or worst in, them and follow up on this. For example, even if they are uncomfortable with being close to people and ill at ease in company, they may be much more relaxed and lose their inhibitions when they are discussing a subject that really interests them. So helping or encouraging them to joining a particular society, club or further education class may be a way they can learn to enjoy company.
