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The Royal College of Psychiatrists Improving the lives of people with mental illness

Personality Disorder

 

About this leaflet

This leaflet is for anyone who has been given a diagnosis of personality disorder and forPersonality Disorder their family and friends.

 

Introduction

It's not easy to pin down exactly what we mean by the word ‘personality’. It seems obvious, but it can be hard to put into words. This can be because the words we use to describe people tend to have wide meanings – and these meanings often overlap. These words can also cover more than one kind of experience. For example, ‘shyness’ describes the feeling of awkwardness with other people, but also how we behave by being rather quiet in company.

It is also difficult because the way we behave - and appear to other people - can be very different in different situations. You can know a person well at work, but find that they behave quite differently in their private life.

In mental health, the word ‘personality’ refers to the collection of characteristics or traits that we have developed as we have grown up and which make each of us an individual. These include the ways that we:

  • think
  • feel
  • behave

By our late teens, or early 20s, most of us have developed our own personality. We have our own ways of thinking, feeling and behaving. These stay pretty much the same for the rest of our life. Usually, our personality allows us to get on reasonably well with other people.

 

Personality disorder

However, for some of us, this doesn't happen. For whatever reason, parts of your personality can develop in ways that make it difficult for you to live with yourself and/or with other people. You don't seem to be able to learn from the things that happen to you. You find that you can't change the bits of your personality (traits) that cause the problems. These traits, although they are part of who you are, just go on making life difficult for you - and often for other people as well.

 

Other people will often have noticed these traits from your childhood and early teens. For example, you may find it difficult to:

  • make or keep close relationships
  • get on with people at work
  • get on with friends and family
  • keep out of trouble
  • control your feelings or behaviour
  • listen to other people

If this makes you

  • unhappy or distressed

and/or

  • often upset or harm other people

then you may have a personality disorder (see below for descriptions of the different types). Life is more difficult if you have a personality disorder, so you are more likely to have other mental health problems such as depression, or drug and alcohol problems.

 

Personality disorder – treatable or untreatable?

People with a diagnosis of personality disorder have not, in the past, had enough help from mental health services. These services have been more focussed on mental illnesses like schizophrenia, bipolar disorder and depression. There have been arguments about whether mental health services can offer anything useful to people with personality disorders. Recent research makes it clear that mental health services can, and should, help people with personality disorders.

 

Different kinds of personality disorders

There are different ways to describe mental disorders, and to put them into categories. The first step is to see if there are patterns, or collections, of personality traits that are shared by a number of people. Once these patterns have been identified, we can start to find effective ways of helping.

 

Research suggests that personality disorders tend to fall into three groups, according to their emotional 'flavour':

 

Cluster A: 'Odd or Eccentric

Cluster B: 'Dramatic, Emotional, or Erratic'

Cluster C: 'Anxious and Fearful'

 

As you read through the descriptions of each type, you may well recognise some aspects of your own personality. This doesn't necessarily mean that you have a personality disorder. Some of these characteristics may even be helpful in some areas of your life. If you do have a personality disorder, some of these traits will be spoiling your life - and often the lives of those around you.

 

A person can have the characteristics of more than one personality disorder.

 

Cluster A: 'Odd and Eccentric'

Paranoid

  • suspicious
  • feel that other people are being nasty to you (even when evidence shows this isn’t true)
  • feel easily rejected
  • tend to hold grudges

Schizoid

  • emotionally 'cold'
  • don't like contact with other people, prefer your own company
  • have a rich fantasy world

Schizotypal

  • eccentric behaviour
  • odd ideas
  • difficulties with thinking
  • lack of emotion, or inappropriate emotional reactions
  • see or hear strange things
  • sometimes related to schizophrenia, the mental illness

Cluster B: 'Dramatic, Emotional and Erratic'

Antisocial, or Dissocial

  • don't care much about the feelings of others
  • easily get frustrated
  • tend to be aggressive
  • commit crimes
  • find it difficult to make close relationships
  • impulsive - do things on the spur of the moment without thinking about them
  • don’t feel guilty about things you've done
  • don’t learn from unpleasant experiences

Borderline, or Emotionally Unstable

  • impulsive - do things on the spur of the moment
  • find it hard to control your emotions
  • feel bad about yourself
  • often self-harm, e.g. cutting yourself or making suicide attempts
  • feel 'empty’
  • make relationships quickly, but easily lose them
  • can feel paranoid or depressed
  • when stressed, may hear noises or voices

Histrionic

  • over-dramatise events
  • self-centered
  • have strong emotions which change quickly and don't last long
  • can be suggestible
  • worry a lot about your appearance
  • crave new things and excitement
  • can be seductive

Narcissistic

  • have a strong sense of your own self-importance
  • dream of unlimited success, power and intellectual brilliance
  • crave attention from other people, but show few warm feelings in return
  • take advantage of other people
  • ask for favours that you do not then return

Cluster C: 'Anxious and Fearful'

Obsessive-Compulsive (aka Anankastic)

  • worry and doubt a lot
  • perfectionist - always check things
  • rigid in what you do, stick to routines
  • cautious, preoccupied with detail
  • worry about doing the wrong thing
  • find it hard to adapt to new situations
  • often have high moral standards
  • judgemental
  • sensitive to criticism
  • can have obsessional thoughts and images (although these are not as bad as those in obsessive-compulsive disorder)

Avoidant (aka Anxious/Avoidant)

  • very anxious and tense
  • worry a lot
  • feel insecure and inferior
  • have to be liked and accepted
  • extremely sensitive to criticism

Dependent

  • passive
  • rely on others to make their own decisions
  • do what other people want you to do
  • find it hard to cope with daily chores
  • feel hopeless and incompetent
  • easily feel abandoned by others

But I don't fit any of these ...

The symptoms and difficulties may not fit exactly into any one of these categories. You may see aspects of yourself in more than one category. Professionals, too, may find it hard to give you a single diagnosis. This is not unusual. It is pretty hard to describe any personality clearly, and so it can be difficult to make a clear diagnosis of personality disorder. It may be more helpful to think of these diagnoses, not as clear categories, but as exaggerations of normal, overlapping personality types.

What causes personality disorder?

The answer is not clear, but it seems that like other mental disorders, genes, brain problems and upbringing can play a part.

 

Upbringing

Sometimes, but not always, people with personality disorder have experienced

  • physical or sexual abuse in childhood
  • violence in the family
  • parents who drink too much

If children are taken out of this sort of difficult environment, they are less likely to develop a personality disorder.

 

Early problems

Severe aggression, disobedience, and repeated temper tantrums in childhood.

 

Brain problems

Some people with antisocial personality disorder have very slight differences in the structure of their brains, and in the way some chemicals work in their brains. However, there is no brain scan or blood test for a personality disorder.

 

Triggers

  • using a lot of drugs or alcohol

  • problems getting on with your family or partner

  • money problems

  • anxiety, depression or other mental health problems

  • important events

  • stressful situations

Help

With help, many people with personality disorder can start to lead a normal and fulfilling life. Most can, at least, cope more effectively with their difficulties.

 

Treatment for people with personality disorders can be psychological (talking therapies) and/or physical (medication).

The type of therapy or treatments offered depends on:

  • what you want or prefer
  • the type of difficulties you have
  • what is available locally

1. Psychological: talking treatments or therapies

A number of psychotherapies seem to work well, particularly for cluster B personality disorders ('Dramatic, Emotional and Erratic'). They all have a clear structure and idea of how they work which must be explained to the patient.

Longer-term therapy can last for years, and may have to be more than once a week. They all involve different ways of talking with a therapist, but are all different from each other. Some have a clear structure to them, others are more flexible. They include:

  • Mentalisation - combines group and individual therapy. It aims to help you better understand yourself and others by being more aware of what’s going on in your own head and in the minds of others. It is helpful in borderline personality disorder.
  • Dialectical Behaviour Therapy – this uses a combination of cognitive and behavioural therapies, with some techniques from Zen Buddhism. It involves individual therapy and group therapy, and is helpful in borderline personality disorder.
  • Cognitive Therapy - a way to change unhelpful patterns of thinking.
  • Schema Focused Therapy - a cognitive therapy that explores and changes collections of deep unhelpful beliefs. Again, it seems to be effective in borderline personality disorder.
  • Transference Focused Therapy - a structured treatment in which the therapist explores and changes unconscious processes. It seems to be effective in borderline personality disorder.
  • Dynamic Psychotherapy - looks at how past experiences affect present behaviour. It is similar to Transference Focused Therapy, but less structured.
  • Cognitive Analytical Therapy - a way to recognise and change unhelpful patterns in relationships and behaviour.
  • Treatment in a therapeutic community – this is a place where people with long-standing emotional problems can go to (or sometimes stay) for several weeks or months. Most of the work is done in groups. People learn from getting on – or not getting on - with other people in the treatment group. It differs from 'real life' in that any disagreements or upsets happen in a safe place. People in treatment often have a lot of say over how the community runs. In the UK, it is more common now for this intensive treatment to be offered as a day programme, 5 days a week.

2. Physical: medication

Antipsychotic drugs (usually at a low dose)

  • Can reduce the suspiciousness of the three cluster A personality disorders (paranoid, schizoid and schizotypal).
  • Can help with borderline personality disorder if people feel paranoid, or are hearing noises or voices.

Antidepressants

  • Can help with the mood and emotional difficulties that people with cluster B personality disorders (antisocial or dissocial, borderline or emotionally unstable, histrionic, and narcissistic) have.
  • Some of the selective serotonin reuptake inhibitor antidepressants (SSRIs) can help people to be less impulsive and aggressive in borderline and antisocial personality disorders.
  • Can reduce anxiety in cluster C personality disorders (obsessive-compulsive, avoidant and dependent).

Mood stabilisers

Medication such as lithium, carbamazepine, and sodium valproate can also reduce impulsiveness and aggression.

 

These medications and treatments also help if someone with a personality disorder develops depression or schizophrenia.

 

Support

Many people with personality disorder can lead full lives with support. This can be emotional - somebody to talk to - or practical - help with sorting bills out or arranging things. The support can be given by friends and families, self-help groups and networks, as well as your GP or mental health team.

You might need such support occasionally, when things get particularly difficult, or you may need it regularly.

If you have a personality disorder, you may not need treatment at all - but you might find medication or talking treatments helpful, and sometimes both. Admission to hospital usually happens only as a last resort (e.g. when a person with borderline personality disorder is harming themselves badly) and for a short time. A lot of help that was once only offered on hospital wards is now available in day centres and clinics.

 

How common are personality disorders?

The difficulties in clearly defining personality disorders have meant that previous research studies have suggested that up to 1 in 5 people might have a personality disorder. However, a larger and more rigorous UK study in 2006 suggested that, at any given time, about 1 in 20 people will have personality disorder.

Do personality disorders change with time?

Yes. There is evidence that they tend to improve slowly with age. Antisocial behaviour and impulsiveness, in particular, seem to reduce in your 30s and 40s.

 

It can, however, sometimes work in the opposite direction. For example, schizotypal personality disorder can develop into the mental illness 'schizophrenia'.

 

Living with personality disorder

People with a personality disorder, just like anyone who has mental health difficulties, can be stigmatised because of their diagnosis. They can attract fear, anger and disapproval rather than compassion, support and understanding. This is both unfair and unhelpful. Personality disorder is a real problem that demands real help. We can all help by being friendly, supportive and understanding, rather than being judgemental.

 

Self-help

  • Try to unwind when stressed - have a hot bath or go for a walk. You may find yoga, massage or aromatherapy useful.
  • Make sure you get a good night’s sleep - but don’t get too upset if you can’t sleep.
  • Look after your physical health and what you eat. You'll feel better on a balanced diet, with lots of fruit and vegetables.
  • Avoid drinking too much alcohol or using street drugs.
  • Take some regular exercise. This doesn’t have to be extreme. Even getting off the bus one stop early, and walking the rest of the way can make a difference.
  • Give yourself a treat (although not drugs or alcohol!) when things are difficult or you have coped at a stressful time.
  • Take up an interest or hobby. This is a good way to meet others and take your mind off the day-to-day stresses that we all face.
  • Talk to someone about how you are feeling. This could be a friend or relative or, if preferred, a therapist or counsellor. If you don’t have access to a counsellor or therapist, then try your GP.
  • The internet is a good resource of information.
  • If things get really tough, try phoning the Samaritans (see further information).

Living with someone who has a personality disorder

You may worry about the effects the personality disorder is having on them, and perhaps on your life too. How would they react if you talked to them about it?

 

If he or she is happy to talk about it, get some more information. Even if they don’t see a problem at the present time, they may do in the future.

 

Day-to-day living with someone who has a personality disorder can be difficult - but it isn’t always difficult. Giving people their own space, listening to and acknowledging their concerns, and involving others (friends, relatives and, at times, mental health professionals – nurses, therapists or doctors) can all be useful. It is also important to look after your own physical and mental health.

 

Further Information

Emergence

Emergence is a service user-led organisation supporting all people affected by a diagnosis of personality disorder, whether you are a service user, carer (which is a family member or friend of a service user) or a professional in the field.

Mind

Mind is a leading mental health charity in England and Wales and has extensive information on personality and personality disorder.

Personality disorder: no longer a diagnosis of exclusion

This provides information, resources and learning opportunities for those with a personality disorder and their carers.

Scottish Personality Disorder Network

Contains information about the network set up by the Mental Health division, and provides information about the services available for those with personality disorders in Scotland.

 

Samaritans

Helpline: 08457 90 90 90, R.O.I: 1850 60 90 90; email: jo@samaritans.org

Samaritans is available 24 hours a day to provide confidential emotional support for people who are experiencing feelings of distress or despair, including those which may lead to suicide. The website has helpful information about stress and self-harm.

 

Rethink Mental Illness

Rethink is a leading national mental health membership charity and works to help everyone affected by severe mental illness recover a better quality of life. Has information on personality and personality disorder.

Aware

Assists and supports those suffering from depression (which can occur in those diagnosed with a personality disorder) and their families in Ireland. A helpline is available as well as support groups, lectures, and current research on depression.

References

  • National Institute for Health and Clinical Excellence: 2009: Borderline personality disorder: treatment and management (CG78) and Antisocial Personality Disorder (CG77).
  • Department of Health (2009): Recognising complexity: commissioning guidance for Personality Disorder.
  • Bateman, A. and Tyrer, P. (2004) Psychological treatment for personality disorders. Advances in Psychiatric Treatment, 10 (5), 378-388.
  • Bateman, A. and Tyrer, P. (2004) Services for personality disorder: organisation for inclusion. Advances in Psychiatric Treatment, 10 (6): 425-433.
  • Coid, J. et al. (2006) Prevalence and correlates of personality disorder in Great Britain. British Journal of Psychiatry, 188, 423-431.
  • Evershed S. (2011) Treatment of personality disorder: skills-based therapies. Advances in Psychiatric Treatment, 17: 206-213.
  • Kendell, R. (2002) The distinction between personality disorder and mental illness. British Journal of Psychiatry, 180, 110-115.
  • NICE guidelines: Personality Disorder programme
  • Tyrer, P. (ed.) (2002) Personality Disorders, Psychiatry, Volume 1:1 March 2002, The Medicine Publishing Company Ltd.
  • Tyrer, P. and Bateman, A. (2004) Drug treatment for personality disorders. Advances in Psychiatric Treatment, 10 (5): 389-398.
  • Tyrer, P. et al. (2007) Critical developments in the assessment of personality disorder. British Journal of Psychiatry, 190 (suppl. 49), s51-s59.

Produced by the Royal College of Psychiatrists’ Public Education Editorial Board.

  • Series Editor: Dr Phillip Timms
  • Original Author: Dr James Stoddart
  • Expert Review: Dr Stephen Miller
  • User and Carer Input: members of the RCPsych Service User Forum

© Illustration by Lo Cole. www.locole.co.uk/

This leaflet reflects the best available evidence available at the time of writing.


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© Updated: September 2013; Due for review: September 2015. Royal College of Psychiatrists. This leaflet may be downloaded, printed, photocopied and distributed free of charge as long as the Royal College of Psychiatrists is properly credited and no profit gained from its use. Permission to reproduce it in any other way must be obtained from permissions@rcpsych.ac.uk. The College does not allow reposting of its leaflets on other sites, but allows them to be linked directly.

 

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