Pervasive, persistent and problematic
Support and information on personality disorder (PD), including possible causes and how you can access treatment and help.
Why am I as I am? To understand that of any person, his whole life, from birth must be reviewed. All of our experiences fuse into our personality. Everything that ever happened to us is an ingredient.Malcolm X
What is a personality?
Before considering Personality Disorder, it is useful to think about what a personality is. There is no such thing as a ‘good’ personality, as all humans have both positive (adaptive) and negative (dysfunctional) parts to theirs. A personality is a combination varying qualities that form an individual’s distinctive character.
The Big Five
Psychological researchers often define personality in terms of five core traits, known as the ‘Big 5’. This model states that every human has elements of the five characteristics in this diagram, to a lesser or greater extent, and it is the mix of these that lead to our unique personalities.
Personality is the dynamic organisation within the individual of those psychophysical systems that determine his characteristics, behaviour and thought.Allport
What is a personality disorder?
Personality disorder can be categorised by individuals who show extreme character differences from the average person in their given culture. This pattern needs to be seen in two or more of the following areas:
- cognition (thinking and views of the self, others or events)
- affect (the range, intensity and appropriateness of emotional responses)
- interpersonal functioning (being able to develop mutual relationships)
- impulse control
It’s not a personality disorder unless the symptoms are…
- Problematic – unusual and causing distress to self or others
- Persistent – starting in adolescence and continuing into adulthood
- Pervasive – affecting a number of different areas in the person’s life
Personality disorders include a deeply ingrained and enduring behaviour pattern that lead to unhelpful reactions towards self and others. Usually this would be seen over a number of years, across different life situations (work, home, friendships). The person will either suffer from distress and social problems themselves or will cause these for others.
When individuals show these characteristics resulting from disease or damage to the brain, or from another psychiatric disorder, this is called Organic Personality Disorder.
We continue to shape our personality all our life. If we knew ourselves perfectly, we should die.Albert Camus
A controversial diagnosis.
The diagnosis of Personality Disorder has a long history of being controversial and is seen by some individuals as unhelpful. There are a number of reasons for this, and these include:
- Historically, the label of Personality Disorder led individuals to be excluded from mental health services as it was felt that it was untreatable.
- It has led to stigmatisation for people, with certain stereotypes being created – for example that a person is ‘manipulative’; ‘attention seeking’; and ‘are doing it on purpose’.
- The diagnosis only focuses on the negative parts of a person’s character, rather than also looking at their strengths.
- The diagnosis identifies behaviours but does not offer any understanding of where these come from, their function or the experiences of the person that have led to this.
- Often people do not fit exactly in one category of personality disorder, which can lead to further difficulty in finding support.
Services and attitudes do seem to be changing, however people still report that some difficulties remain. One of the key changes over the years has been a move away from the idea that it is ‘untreatable’ to an understanding that a number of therapies can help.
What are the different types of personality disorder?
The diagnostic criteria for personality disorder are set out in the Diagnostic and Statistical Manual of Mental Disorders (DSM–5) in the US. In Europe, the most well known terms used for Personality Disorder come from the International Statistical Classification of Diseases and Related Health Problems (ICD 10). However, a new way of classifying Personality Disorder has been published in the ICD 11. This article uses the ICD 10 criteria as they are still the terms most used in the medical community at the present time.
There are some differences in name of diagnosis between these manuals – for example, Borderline Personality Disorder in the DSM V is the same as Emotionally Unstable PD in the ICD 10. Also notable is that Narcissistic PD only appears in the DSM V.
The three clusters of personality disorder include A: Odd and Eccentric, B: Dramatic and Erratic and C: Anxious and Fearful.
Click on the different types of personality disorder to learn more specific information on each of these.
Cluster A: Odd and Eccentric.
Paranoid Personality Disorder
Mistrust and suspicion of others
Schizoid Personality Disorder
Disinterest in social interactions and limited expression of emotions
Schizotypal Personality Disorder
Unusual beliefs and a pervasive feeling of being different
Cluster B: Dramatic and erratic.
Antisocial/ Dissocial Personality Disorder
Rule breaking, anger, contemptuous
Borderline/ Emotionally Unstable Personality Disorder
Emotional, impulsive, unstable relating patterns
Histrionic Personality Disorder
Excessive emotionality and attention-seeking
Narcissistic Personality Disorder
Grandiosity, lack of empathy and hypersensitivity to the evaluation of others.
Cluster C: Anxious and Fearful
Avoidant Personality Disorder
Social discomfort, fear of negative evaluation and shyness
Dependent Personality Disorder
Persistent dependant and submissive behaviour
Obsessive-Compulsive | Anankastic Personality Disorder
Indecisiveness, excessive caution and rigidity
The chart below offers a useful way of considering the different Personality Disorders using Aaron Beck’s cognitive behavioural model. This focuses on the core beliefs that may sustain personality problems:
Why do people get Personality Disorder?
There are a number of different models that look at how personality disorder is formed. Most theories identify that it is a mixture of biological influences and early childhood social environment.
Biological: This includes the natural temperament that we are born with (introvert/ extrovert; emotionally sensitive; impulsive) as well as other factors such as gender, physical health and IQ.
Psychological: A person’s attitudes, emotional coping style, expectations and beliefs about self/ others and social skills. Likely to be heavily impacted by social environment and biology, however, once these areas have been developed they can lead to repeated unhelpful patterns of behaviour.
Social Environment: Early childhood experiences can shape attachment and coping mechanisms that are used throughout life. Abuse, neglect, invalidation and inconsistency in parenting may lead to dysfunctional management of emotions and behaviour.
Over the last few years, there has been debate as to whether the name Personality Disorder should be changed to a complex trauma reaction or complex PTSD. This is because there is growing research that some Personality Disorders, in particular Borderline PD, have strong correlations with childhood abuse and trauma.
I have worked with people who do not like the label of Personality Disorder and have had negative experiences from others because of this. For others, having the diagnosis has helped them to understand themselves better.
I always use a formulation approach during therapy. This means that the first few sessions will involve us developing your understanding of your current difficulties. If you have a diagnosis of a Personality Disorder, or think you have one, I am always happy to talk these through with you, and what they mean. However, my role is to help you understand why you show certain behaviours and react in the ways you do and how your childhood experiences, current situation, thinking and feelings all play a part.
With schema therapy, we will focus on understanding the different parts to your personality, including your vulnerable emotional part, your self-critical and demanding parts and the coping parts that you have developed to manage these.
With DBT informed therapy we will identify the current behaviours which are causing you distress, and develop an understanding of why you react in these ways.
I will also take into account and help you understand all three of the areas discussed above – how your biology, social environment and psychological needs have led to the development of your personality traits.
There are a number of therapies that have a growing evidence base in the treatment of Personality Disorder. These include:
Designed specifically for individuals with Borderline PD, DBT has a focus on teaching skills to manage crisis behaviours, emotions and relationship dynamics.
Full DBT involves both individual and group sessions over approximately 18 months. It has a strong evidence base for effectiveness.
This is a fairly new therapy in the UK and looks to work with individuals who are over controlled – so it may help individuals who have Avoidant, Dependant and Obsessive-Compulsive personality traits. The skills in this therapy look at helping people to connect with their emotions and learn to express these more.
This therapy explores the dysfunctional patterns of thinking, feelings and behaviour that individuals have developed over their life (schemas). It focuses on both the here and now and making links to past childhood experiences. It can be used for individuals with any of the Personality Disorders above, although research has focused on Emotionally Unstable, Dissocial and Narcissistic PD.
This therapy focuses on ‘thinking about thinking’. It helps individuals to understand their own and others mental states, and how these impacts on behaviour.
Often run in a group, treatment is recommended for 18 – 24 months. It has been found to be effective with Dissocial Personality types, as well as potentially helpful for other Personality Disorders as well.