Personality Disorder
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About this leaflet
This leaflet is for anyone who has been given
a diagnosis of personality disorder - and also for 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 is partly because many of the words we use to
describe people have wide meanings – and these meanings often
overlap. These words can also cover more than one area 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 rather differently in their private life.
In mental health, the word ‘personality’
refers to the collection of characteristics or traits that makes
each of us an individual. These include the ways that we:
By our late teens, or early 20s, most of us
have developed our own personality. We have our own
distinctive 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 experience. You can't change the
unhelpful ways of thinking, feeling and behaving 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 relationships
- get on with people at work
- get on with friends and family
- keep out of trouble
- control your feelings or behaviour
- and listening
If, as a result, you:
- are unhappy or distressed
and/or
- find that you often upset or harm other people
then you may have a
personality disorder (see below for descriptions of the different
types). If you have a personality disorder, life is
more difficult, so you are more likely to have other
mental health problems, as well as depression, or drug
and alcohol problems.
Personality disorder – a suitable
case for treatment?
People with the diagnosis of
personality disorder have not in the past had enough help
from mental health services. These services have focused
on mental illnesses like schizophrenia, bipolar disorder and
depression. There have been arguments about whether
mental health services have anything useful to offer people
with personality disorders. Recent research has made 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 put them into categories. The first step is to see
if there are patterns, or collections, of personality traits that
are shared by people. Once these patterns have
been identified, work can begin 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 intimate relationships
- impulsive - do things on the spur of the moment without
thinking about them
- don’t feel guilty
- don’t learn from unpleasant experiences
Borderline, or Emotionally Unstable
- impulsive
- 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
- exploit others
- 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
- 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 is more
difficult to be confident about a 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 can be a sign 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 can start to lead
a normal and fulfilling life, and 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 and aims to help you better understand yourself
and others - being aware of what’s going on in your own head
and in the minds of others. It is effective 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.
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 only 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
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.
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 Recovery Forum
© Illustration by Lo Cole. www.locole.co.uk/
This leaflet reflects the best available evidence available at
the time of writing.
© Updated: June 2011; Due for review:
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