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Understanding personality disorders

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Copyright note: professionals are not permitted to print off copies for distribution to colleagues or clients. For more information see Mind's copyright guidelines.

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‘Other people don’t understand me. I don’t really understand me. I just know I’m not like other people. My life’s been a mess from start to finish. Nothing has ever gone right – I just seem to wreck everything and I don’t know why or how I do it.’

‘I used to get wound up over all kinds of stuff. I’ve learned I don’t have to worry and fight over everything.’

This booklet is for anyone who wants to know about personality disorder, one of the most controversial of all psychiatric diagnoses. It does not include multiple personality disorder, which is a dissociative disorder covered in a separate booklet. (See Understanding dissociative disorders.)

What is personality disorder?

The word ‘personality’ refers to the pattern of thoughts, feelings and behaviour that makes each person the individual that they are. People don’t always think, feel and behave in exactly the same way. It depends on the situation they are in, the people with them, and many other things. But people do tend to behave in fairly predictable ways, and can be described, accordingly, as shy, selfish or lively, and so on. Each person has a set of these patterns, and this set makes up their personality.

Generally speaking, personality doesn’t change very much. Yet it does develop as people go through different experiences in life, and as their circumstances change. A person will mature with time, and their thinking, feelings and behaviour all adapt to fit their circumstances. People are usually flexible enough to learn from past experiences and to change their behaviour to cope with life more effectively. But, if you have a personality disorder, you are likely to find this more difficult. Your patterns of thinking, feeling and behaving are much more stubborn, and you will have a much more limited range of emotions, attitudes and behaviours with which to cope with everyday life.

This can lead, repeatedly, 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’s. They may find your behaviour unusual, unexpected or perhaps offensive.

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 will find it hard to work effectively with others. Not surprisingly, you may feel very alienated and alone. The risk of suicide in someone with a personality disorder is about three times higher than average. See Mind’s booklet How to help someone who is suicidal.)

How much the problems disrupt someone’s life, and how well they can be treated, will vary. You may have other difficulties at the same time, such as depression or phobia. Someone with avoidant personality disorder (APD), for instance, may also suffer from agoraphobia. Even if the phobia is sorted out, stressful events can still trigger problems linked with the personality disorder.

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What are the different types?

Personality disorder can show itself in different ways. The DSM-IV-TR (The American Psychiatric Association’s manual of mental disorders) lists ten types. Each one is linked with a different set of attitudes, emotions, and behaviours. While some people will have only one type, other people may have elements of two or more.

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. 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 be ridiculed for this. You may feel anxious and tense with others.

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. You may end up doing things on impulse, which you later regret. This may include attempts to harm yourself in some way. 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. (See, also, Mind’s booklet, Understanding borderline personality disorder.)

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 frequently overlook your special needs and fail to give you what you feel you deserve, so that you then feel badly done by, and grudging of others’ successes. Because of this, you put your own needs above other people’s, and demand they cater to you. People are likely to see you as selfish, because you miss or ignore what your expectations cost them. They may also describe you as being ‘grand’ or haughty.

Antisocial personality disorder (APD)
This is known as ‘psychopathy’ under the Mental Health Act (MHA) 1983. It is closely linked with adult criminal behaviour, so if you suffer from ASPD you will probably have a criminal record. You may also be a heavy drinker or a drug-user. Boredom is a problem for you 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.

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)
A preoccupation with orderliness and keeping everything under control 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.

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What causes a personality disorder?

There is a great deal of research and writing about personality disorders suggesting that a number of different interacting factors are involved. Researchers know what these factors might be, but not how much influence they may have over the development of different personality disorders. One factor may be much more important than any other in the development of your own disorder. But one factor alone will not inevitably lead to a personality disorder.

Research shows that some elements of our personality are inherited. People are born with different temperaments. For example, babies vary in how sensitive they are to stimulation,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.

Another important factor is the quality and type of attachments people make as they grow up. Some experts believe that how your mother or primary carer met your needs, when you were a child, may have influenced the type and degree of your personality difficulties.

Early traumas might also lead to personality disorder. This is not to say that everyone who experiences a traumatic experience 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, can also make a difference.

There is some evidence to suggest that family circumstances can make you vulnerable to personality disorder. There have been reports that the relatives of people suffering from schizophrenia and manic depression are more prone than other people to having a 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. (See Useful organisations for more information.)

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Why is diagnosis so controversial?

Experts describe personality disorders as being ‘fuzzy at the edges’. One person may qualify for several different disorders, while a wide range of people may fit different criteria for the same disorder, despite having very different personalities. Avoidant and dependent personality disorder are very similar, and so are histrionic and narcissistic personality disorders.

Slotting people into neat categories is almost impossible, because each individual is unique and personality is very complex. It’s a mistake to assume that giving people a diagnostic label means knowing more about them, and it’s too easy to use these terms in a judgemental way. Many of these diagnostic labels have been used in a way that stigmatises people.

Personality disorders can be seen as extreme examples of tendencies that everybody shares. Negative personality traits and extremes of behaviour are often regarded as quite excusable and unremarkable if the individual is gifted, famous or creative. On the other hand, a person who is always irritable or smug may find themselves being rejected far more often than someone diagnosed with a personality disorder who is much more pleasant to be with. Labelling people as ‘masochistic’, ‘dependent’ and ‘inadequate’ can be insulting and hurtful. It could be that medical professionals gave people these labels simply because they were ‘difficult’ in some way.

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.

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Are personality disorders treatable?

It’s true that personality disorders are difficult to treat because they involve such deeply rooted patterns of thoughts, feelings and ways of relating. The type of treatment, and its success, may well depend on where you are (at home, in hospital or in prison) and on what is available. Sadly, when treatments aren't successful, it's patients who are sometimes seen as failing rather than the treatments being seen as not suiting their needs. Having said that, however, many people are able to change the way they think and behave, to control their emotions and eventually lead more fulfilling lives.

There is quite a lot of evidence that treatment can help people with BPD or the milder problems, such as OCPD, APD and dependent personality disorder. New research shows people with the more severe personality disorders may also change, although this may take a number of years.

It’s clear that psychological treatments can be helpful, especially for less severe personality disorders. There are certain keys to its success. 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.

Talking treatments
The usual talking therapies aren’t always as useful for people with a personality disorder as they are for others. But a number of therapies designed specifically for the purpose have shown promise. Most of this research, so far, has focused on treatment for BPD and milder forms of personality disorder.

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 social skills and assertiveness training, offering opportunities to practise new skills and do things differently. If you tend to form intense, ‘special’, one-to-one relationships, a group lets you try out different relationships and broaden your range of attachments to other people.

Dialectical behaviour therapy (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) 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. 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 dislodge the idea that you must not, under any circumstances, make any mistakes.

Psychodynamic therapy, which focuses on the relationship between client and therapist, has also proven useful with BPD, in particular. It can help you manage your relationship with other people and improve the way you feel about yourself.

Therapeutic communities
Living in a therapeutic community for a number of months can be very helpful for more severe personality disorders. The NHS runs some therapeutic communities specially for them. 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 a group discussion. This inevitably means having to face up to the impact your attitudes and behaviour have on others.

Although communities vary, there’s often no individual therapy and no medication involved. Therapy takes place, informally, through the day-to-day process of community living and through group psychotherapy, community meetings and other types of group activities. There are similar therapeutic communities within the prison system.

Medication
Drugs can't cure a personality disorder, but doctors sometimes prescribe them to treat particular symptoms. For example, antidepressants can be used for irritability or depression. It can take some time to find a drug that works and often medication may be most effective when combined with a talking treatment.

What can other people do to help?

If your friend or relative has a 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 BPD doesn’t stop people being likeable, intelligent, highly motivated or creative.

Good information is crucial. Medical professionals shouldn’t talk about someone being ‘narcissistic’ or ‘dependent’ without explaining what this means. It’s also important they discuss with the person what treatment approaches might be useful, and how they can best help themselves. For instance, alcohol, drugs or abusive relationships can only add to problems. People need the encouragement of friends, family and professionals to change their behaviour. Being judgemental or calling someone ‘immature’ or ‘inadequate’, is counterproductive. Everybody behaves immaturely or inadequately at times.

Try to identify situations that bring out the best or worst in your friend or relative, and follow up on this. For example, even if they are fearful of intimacy and ill at ease with people, they may forget about all this and lose their inhibitions when they are discussing a subject that really interests them. So joining a particular society, club or further education class may be a way of learning to enjoy company.

Advocacy
There are concerns about people diagnosed with a personality disorder (compared to those diagnosed with a mental illness) not being eligible to receive support services. If a person can’t get the help they need, finding someone to speak for them can be very useful. There are a number of organisations that can offer advice about this. (See Useful organisations and The Mind guide to advocacy.)

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 be a danger to yourself than to others, and more at risk of self-harming or committing suicide than them. You need help, not stigmatisation.

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Useful organisations

Association of Therapeutic Communities
T: 01242 620 077
w: www.therapeuticcommunities.org
The forum for debate, information, training and support for professionals working in therapeutic communities

British Association for Behavioural and Cognitive Psychotherapies (BABCP)
T: 01254 875 277
w: www.babcp.com
Promotes the development of the theory and practice of behavioural and cognitive psychotherapies. Can provide details of accredited therapists. Full directory of psychotherapists available online

British Association for Counselling and Psychotherapy (BACP)
T: 0870 443 5252
w: www.bacp.co.uk
Provides online search facility for accredited counsellors and psychotherapists in the UK

The Cassel Hospital
1 Ham Common, Richmond, Surrey TW10 7JF
T: 020 8940 8181
w: www.thecasselhospital.org
Therapeutic community for those with less severe personality disorders

First Steps to Freedom
T: 0845 120 2916
w: www.first-steps.org
Supports those with BPD, their friends and relatives

The Henderson Hospital
2 Homeland Drive, Sutton, Surrey SM2 5LT
T: 020 8661 1611
Therapeutic communities for those with severe personality disorders

NAPAC
helpline: 0800 085 3330
w: www.napac.org.uk
For people abused in childhood

The Prison Reform Trust
T: 020 7251 5070
w: www.prisonreformtrust.org.uk
Advice and information for prisoners and their families

Useful websites

www.borderlineuk.co.uk
National user-led network of people with BPD

www.mentalhealth.org.uk
The Mental Health Foundation

www.nice.org.uk
Provides guidance on various mental disorders and their treatments

www.personalitydisorder.org.uk

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Useful organisations

Further reading