'Personality disorder' is a relatively new diagnosis in the field of mental health. As its name suggests, it is a disorder linked to personality and, because of this, for a long time, it was not recognised or acknowledged as a mental health diagnosis. For the same reason, personality disorders were considered to be untreatable, as they were not seen as an illness, but rather the result of an unbalanced personality.
Personality disorders are now recognised within the spectrum of mental health diagnoses; they are also considered treatable, as research continues to find more effective means of treatment, and practice bears this out.
Each of us has a unique personality made up of traits that come from both our genetic make-up and our life experiences and is a vital part of what makes us who we are and how we interact with others.
Someone may be diagnosed as having a personality disorder if their pattern of behaviour, mood, social interaction, or impulsiveness causes severe disturbance in the individual’s personal and work life.
In general, individuals with personality disorders may have difficulty sustaining close or intimate relationships. They may experience chronic interpersonal problems, or have difficulties in establishing a coherent sense of self or identity. Others may perceive them to be impulsive, irritable, fearful, demanding, hostile, manipulative, or even violent.
Problem alcohol or drug use, mood disorders, certain anxiety or eating disorders, self-harm, suicidal thoughts or attempts, and sexual problems often accompany personality disorder.
A diagnosis of personality disorder can present difficulties. Mental illness in general can bring with it, both on the part of the affected individual, and others, a sense of somehow being to ‘blame’ for their condition. A mental health diagnosis may also result in individuals feeling they ‘should’, or can take more responsibility than would be expected, for instance, from someone given a diagnosis of a physical health condition. This tendency, and the accompanying distress, resulting from an inability to ‘do’ more, may be even more pronounced with a diagnosis of personality disorder.
While a sense of ‘owning’, accepting and taking responsibility for any illness or condition can bring positive benefits, it needs to be balanced with the recognition that professional help, support and treatment may also be necessary.
The cause or causes of personality disorder are still unclear. However, it is likely to be caused by a combination of factors that may be different from person to person.
It has been found that people with a personality disorder have often experienced physical or sexual abuse in their early years, though recent research suggests that neglect in these early years may be the most significant factor.
Childhood is the time when children learn about relationships, and how to develop their own relationships, for example with parents or carers. They learn how to acquire social skills and build a sense of self. They also learn how to manage their emotions, both enjoyable ones, and those that are more difficult, like anger and sadness. Parents and carers play a key role in helping children to understand these emotions, and how to manage them.
Children who have been abused or neglected can find it difficult to develop in these areas and this can lead to emotional problems later in life. These problems tend to be a common factor in those diagnosed with personality disorder, though there may be other contributing factors as well.
Problem drug or alcohol use may be a complicating feature for instance; this can arise from an individual’s attempt to cope with their own difficulties, and/or result from the impulsive/destructive aspect of personality disorder which finds it hard to recognise or understand the consequences of certain behaviours.
There is a range of different personality disorders. The descriptions below give a basic outline of the different types. Some people may be diagnosed with one type only; others may have traits of more than one disorder.
The symptoms of personality disorder may be familiar to everyone as traits within their own personality.
NB: While it can be tempting to ‘self-diagnose’’ a personality disorder, it is important to remember that a diagnosis can only be made by a psychiatrist, and that the disorder is such that it causes severe disruption and distress in an individual’s life and also affects those around
Antisocial personality disorder (ASPD)
This is characterised by a lack of regard for the rights and feelings of others, and a lack of remorse for actions that may hurt others. People with this diagnosis frequently ignore social norms of acceptable behaviour; they may disregard rules and break the law. Consequently, if you have this diagnosis you may also have a criminal record; you may also have problem drug or alcohol use. Sadly, this kind of behaviour is also likely to result in difficulties in relationships, with rejection (given or received) a major feature.
Avoidant (anxious) personality disorder
Typically, a person with this diagnosis fears being judged negatively by others, leading to feelings of discomfort in group or social settings. You may come across as being socially withdrawn, a ‘loner’. Fear and anxiety may mean that you have difficulty in holding down a job, as well as experiencing difficulties in relationships.
This can be very painful for you as you can feel lonely and isolated, while at the same time, fearful of those relationships and situations that might make you feel more included and engaged with a community or circle of family or friends.
Borderline personality disorder (BPD)
This is the most commonly diagnosed personality disorder. The term borderline originally referred to symptoms being on the borderline between psychosis and neurosis. Typically, with a diagnosis of BPD, you are likely to have a poor self-image and unstable personal relationships, which are likely to result from mood swings that may involve angry outbursts, which tend to drive people away. Conversely, you may find it difficult to break away from damaging relationships as you are frightened of being alone.
Others may find it difficult to relate to you, as your response tends to be unpredictable, or people may be afraid of your anger. While seeking contact and support with others, you may also be quite rejecting of this, which makes it hard for people to engage with, or relate to you.
While in some ways inviting rejection, you also find it hard to be rejected and may act impulsively in reaction to this, sometimes threatening, or carrying out self-destructive behaviour such as self harm or suicide attempts.
Life can be very difficult and painful, both for you, and for those who care about you. You may have feelings of emptiness and fear abandonment by friends or partners.
Dependent personality disorder
With this diagnosis you are likely to take a passive position with regard to your own life, allowing others to assume responsibility for many areas of your life. You are likely to lack selfconfidence, assuming that the needs of others take precedence to yours. You may find it very
hard to even recognise that you have rights and needs.
This can leave you in a very vulnerable position as you are reliant on others looking out for your needs and not abusing the position you take within relationships. Other people are more likely to identify this vulnerability as they recgonise your passivity and submissiveness .
Histrionic personality disorder
This disorder is characterised by extreme or over-dramatic behaviour, with a need to be the centre of attention. If you have this diagnosis, you may form relationships quickly, but be demanding and attention-seeking. You may also flirt or behave provocatively in order to ensure you attract or retain the attention of others.
To others you may appear to be self-centred, with shallow emotions. While you crave attention, this may also be difficult as you may feel you have to entertain others, be the life and soul of the party and that you are dependent on the approval of other people.
Narcissistic personality disorder
People with this diagnosis usually have an exaggerated sense of their own importance. They are frequently self-centred and intolerant of other people. The condition is typified by grandiose plans and ideas and cravings for attention and admiration.
Obsessive-compulsive personality disorder
A person with this disorder tends to have difficulties in expressing warm or tender emotions to others. They are frequently perfectionists, things must be done in their own way. They often lack clarity in seeing other perspectives or ways of doing things, and their rigid attention to detail may prevent them from completing tasks.
Paranoid personality disorder
People with this diagnosis are often emotionally detached and suspicious of other people and their motives. They may hold longstanding grudges, and believe that other people are not trustworthy, are deceiving, threatening, or making plans against them.
Schizoid personality disorder
People diagnosed with schizoid personality disorder tend to have difficulties in expressing emotions, particularly around warmth or tenderness. They often feel shy in company, but may come across as aloof or remote, and have difficulty in developing or maintaining social relationships.
Schizotypal personality disorder
A person with this disorder typically has problems around developing interpersonal relationships. The condition is characterised by thought disorders and paranoia. To others they may appear odd or eccentric; they may dress or behave inappropriately, for example talking to themselves in public.
The behaviour patterns associated with personality disorders are usually deeply entrenched, having become the individual’s way of coping with and reacting to life and relationships. Because of this, it was long thought that these disorders were untreatable, with some clinicians questioning the diagnosis itself.
However, the latest research is very positive: neuroscientists are doing exciting research and therapeutic treatments are being developed and used with very positive results in the treatment of people diagnosed with personality disorder.
Talking treatments such as schema therapy, dialectic behavioural therapy (DBT), mentalisation, and cognitive analytical therapy (CAT) can be helpful for people living with a personality disorder.
Schema therapy is an integrative approach that focuses on cognitive development, ie how we learn to think and respond to our thoughts. It explores how early experiences may have led to particular ways of thinking, and helps individuals to make a connection between these early experiences and present responses, finding new and more helpful ways of responding and reacting to thoughts.
Dialectical behaviour therapy (DBT) is proving to be particularly helpful for those with a diagnosis of BPD. It incorporates both individual and group work; the group work helping people to understand how they respond to others, and the individual work helping individuals
understand their thinking processes.
Mentalisation is also a relatively new approach to helping those with personality disorders. It works on the basis of trying to help individuals understand their own thinking and also to understand the assumptions they may make about other people’s thinking and responses. The greater level of awareness and understanding that can arise from this helps people to manage themselves and their relationships better.
Cognitive analytical therapy (CAT) uses a combination of cognitive behavioural therapy and psychodynamic psychotherapy. Like the other therapies described here, it helps individuals understand how their past experience has influenced their present behavior and helps them find tools and techniques to manage the less helpful aspects of their behaviour.
Therapeutic communities can provide intensive psychological treatment in a group-living environment. This can be particularly helpful for those who experience significant difficulties in interacting with others and/or having a clear and stable sense of self. Engaging with others and finding out more about what makes relationships function in a healthy way can be helpful in developing skills that can be used in every aspect of life.
Engaging with psychological therapies: As with all therapies, these approaches work best when individuals engage with them on a voluntary basis, taking responsibility for their behaviours and actions, and being willing to learn from the experience. This may be very
challenging and difficult, particularly for those with personality disorders. However, such therapies can also be very helpful and provide learning, tools and techniques that can continue to be used outside the therapeutic relationship or context.
Availability of psychological therapies: Unfortunately, these therapies may not be widely or easily available, and may be dependent on geographical location and local policies.
Medication alone cannot ‘cure’ personality disorders; however, a range of medication may be used to help address certain symptoms that may accompany these disorders in some individuals. Medication is likely to be most effective when used in combination with talking treatments. As with any medication, it may take time to find the right one, or combination of medications for each individual.
Anti-depressants can be used to treat symptoms of depression when this is a feature of personality disorder.
Mood stabilisers can help relieve mood swings; they can also help reduce impulsiveness and aggression. This kind of medication may be helpful in stabilising and individual so they are more able to make use of talking therapies.
Anti-psychotic medication can help where psychotic symptoms are a feature of a personality disorder. Such symptoms can be distressing both for the individual and their family and friends, and relieving them can be helpful for everyone, and enable individuals to take more informed decisions about other forms of treatment that may be appropriate for them.
Hospital treatment may also be an option for those with personality disorder. This may be particularly the case before a clear diagnosis has been made, where an individual’s behaviour, e.g. self harm, suicide attempts, violence and/or use of alcohol and drugs has interfered with their life to such an extent that hospital admission seems the most appropriate treatment. This allows time for assessment and diagnosis and the development of a care plan, and may provide a foundation for future treatment and support. As with all hospital admissions, it is done preferably on a voluntary basis, but on occasion a person may be admitted under a section of the Mental Health Act if they are not well enough to make this decision for themselves.
There are many ways in which you can help yourself cope with a personality disorder. Understanding the nature of the disorder and its symptoms can be really helpful, as you may feel more in control of your life, and more able to take an active part in support and treatment.
Giving and receiving support
Having a diagnosis of personality disorder can feel challenging and distressing. It is a diagnosis that affects not just you, but may also affect the people and relationships in your life. You may have to live with it on a long term basis, with an uncertainty about how it may affect you over time.
It is a situation you may be angry about, or feel it’s unfair, particularly before you have had a diagnosis, or in the early stages of coming to terms with a diagnosis.
You may also feel, or come to feel, that your condition gives you an insight into life or a way of being that has positive aspects to it. You may feel it has given you a level of awareness, understanding and empathy that you might otherwise not have had.
While you may have support and understanding from family and friends, it can be difficult for those who have not had direct experience of the condition to fully understand it. You may also not be in a position to share your experience with family or friends.
Whatever your situation, you may find it helpful to meet with or make contact with other people in a similar position. If there is a self-help group close to you, you may be able to do so in person. Alternatively, you may find that making contact through a medium such as an internet forum provides you with the contact you need.
Group or internet contact allows you to give support, based on your own experience, and also to receive encouragement and support from those who have an experience similar to yours. If you have felt that your condition has placed you in a position where you need to be ‘helped’ or ‘supported’, it can be very beneficial to realise that you too can provide support to others, who may be at a different stage of living with the condition.
You can find out more about support options in your area from SANE Services (including the SANE Support Forum).
As with any mental health condition, one of the ways in which you can help yourself is to try to ensure that you attend to your general wellbeing. This may be hard at times of crisis or when you are very unwell. However, it is helpful to have a basic routine in place that can support you when you are well enough to be able to attend to it.
This can include ensuring that you get enough sleep and that you eat as well as you can. Your family and friends can help you devise a system that works for you, with regard to eating well and having a regular sleeping pattern.
Being physically active can also be very therapeutic and supportive. This doesn’t mean that you need to join a gym, or participate in a particular sport unless this is something that you enjoy or is part of your regular routine. It can be as simple as trying to get out in the open air for a walk, going to and from work, or as part of your normal daily routine.
Getting support from friends and family
Although your personality disorder may create difficulties in your relationship with other people, it can be helpful to let your family and friends know as much about your condition as possible – perhaps by sharing factsheets such as this with them.
This may enable them to provide you with help and support, perhaps particularly at times when you’re not feeling very well. If self-harm, suicidal thoughts or attempts, or are a feature of your disorder, friends and family may also be able to provide you with understanding and support. They may also be able to help you recognise when your condition may be deteriorating and help you get extra support at times when you may need it.
SANE provides emotional support to anyone affected by mental health problems, including families, friends and carers.