All about Personality Disorders

According to NHS estimates, around 1 in 20 people has a personality disorder. More specifically, the prevalence of more common varieties of personality disorders is between 2% and 8%. This includes personality disorders defined as antisocial, histrionic, borderline, schizotypal and obsessive-compulsive. For the least common personality disorders like avoidant and narcissistic, the prevalence is less than 1%.

In this article, we’ll tell you everything you need to know about personality disorders.

What is a personality disorder?

A personality disorder means a person thinks, behaves and feels differently to typical people. There are lots of different types of personality disorders and they affect people in different ways.

A person’s personality is their collection of feelings, behaviours and thoughts that make them who they are. Not everyone experiences things in the same way in situations and personality disorders are complex and often difficult to diagnose – a lot of the time this is because those who are suffering don’t know about personality disorders.

With a personality disorder, the way a person thinks, feels and behaves causes them significant problems day to day. The problems they have will also affect different parts of their lives and won’t just be limited to friendships, for instance. The emotions that come with a personality disorder are overwhelming, intense and can be frightening. Problems often begin in childhood or adolescence and usually carry on into adulthood.

Types of personality disorders

There are three categories of personality disorders and eleven separate diagnoses within these four types.

The three categories are suspicious, emotional and impulsive, and anxious.

Suspicious personality disorders

Included in this category are paranoid personality disorder, schizoid personality disorder and schizotypal personality disorder.

Paranoid personality disorder

With paranoid personality disorder, a person experiences feelings and thoughts associated with paranoia. This means that they find it hard to trust or confide in people as they believe that other people will use them or take advantage of them. They also struggle to relax and will likely read danger and threats into innocent remarks or looks and see harm in everyday life and situations.

Schizoid personality disorder

With this personality disorder people tend to function well day to day. Unlike with schizoaffective disorder or schizophrenia, they don’t have psychotic episodes or symptoms. However, the feelings and thoughts people do have mean they often find it difficult to form a close relationship with other people. As such, they may choose to live their lives without influence or interference from other people.

Generally speaking, people with schizoid personality disorder will prefer being alone with their own thoughts. They won’t experience pleasure from a lot of activities, including not having an interest in intimacy or sex. This might mean they come across as emotionally cold.

Schizotypal personality disorder

All individuals have differing behaviours but if a person’s way of behaving and thinking make it difficult for them to relate to others, they could have schizotypal personality disorder. With this condition, there is no psychosis so it’s not to be confused with schizophrenia.

They may, however, experience distorted perceptions or thoughts, find it difficult to make close relationships, and express themselves in ways that other people might perceive to be ‘odd’ such as using unusual vocabulary, which makes it difficult for others to relate to them. They might also believe they have an ability to read minds or that they have a ‘sixth sense’. When others don’t share their beliefs, they might feel tense or anxious. They might also feel paranoid or anxious in social settings.

Emotional and impulsive personality disorders

Included in this category are antisocial personality disorder, borderline personality disorder, histrionic personality disorder and narcissistic personality disorder.

Antisocial personality disorder

It’s completely natural to put one’s own needs, personal gain or pleasure before others’. However, if this happens frequently and someone struggles with instability or they act impulsively due to a lack of consideration or because of anger, this might mean they have antisocial personality disorder.

Someone with this condition might:

• Put themselves in risky or dangerous situations without thinking of the consequences for themselves or others.
• Behave dangerously.
• Behave illegally (and have a criminal record).
• Behave unpleasantly.
• Act on impulse or be bored easily. As such, they may struggle to keep a job.
• Behave aggressively.
• Do things despite the action hurting others in order to get what they want. They might not show guilt about this.
• Be diagnosed with ‘conduct disorder’ in childhood.

With this diagnosis, the terms ‘sociopathy’ and ‘psychopathy’ might be referred to. However, these terms no longer form part of the Mental Health Act 1983.

Borderline personality disorder (BPD)

This condition is also referred to as EUPD – emotionally unstable personality disorder. All people experience problems in their relationships or with their emotions and self-image at times. However, if a person feels consistently intense or unstable and has daily problems with this, they could have borderline personality disorder.

With this condition, people might:

• Fear abandonment by those they love and care about, which means they do things to try and stop this from happening or they push them away.
• Experience intense emotions that change quickly.
• Not know what they want in life or who they are. Their ideas might change depending on who they are with.
• Find friendships difficult to make and maintain.
• Act on impulse and do things that might harm them like driving dangerously, using drugs or binge eating.
• Experience thoughts of suicide.
• Self-harm.
• Feel lonely or empty a lot of the time.
• Struggle with trusting others.
• Experience other conditions like depression, PTSD, anxiety and eating problems.

If a person with BPD feels very stressed, they might feel paranoid, feel numb and experience dissociation, or have psychotic experiences.

This is the most frequently diagnosed personality disorder.

Histrionic personality disorder

A person with histrionic personality disorder will depend heavily on seeking approval and being noticed. This will affect their day-to-day living. They might feel extremely uncomfortable if they’re not the centre of attention and might always feel a need to be an entertainer.

As such, they tend to make rash decisions and might get a reputation for being overemotional and dramatic. Due to constantly being dependent on the approval of others, they might behave or dress provocatively and be seen as a flirt. They’re also easily influenced.

Narcissistic personality disorder

It’s natural to be aware of one’s needs and feel a need to express them but in narcissistic personality disorder, the thoughts and behaviours are so extreme as to cause problems with other people.

A person with this condition might:

• Believe that they are more deserving or better than others.
• Have extremely poor self-esteem to a point where they rely on other people to recognise their needs and their worth.
• Feel down if they are ignored or not given the attention they feel they deserve.
• Resent the successes of others.
• Put their own needs before other people’s needs and demand others do the same.
• Be seen as unaware or dismissive of others’ needs and come across as selfish.

Anxious personality disorders

This category includes avoidant personality disorder, dependent personality disorder and obsessive compulsive personality disorder.

Avoidant personality disorder

People with avoidant personality disorder will have things that cause them so much anxiety that they struggle to function in day-to-day life. They might avoid social activities or work that means they have to be with other people. They often expect criticism and disapproval and will be sensitive to this.

What’s more, they frequently experience ‘imposter syndrome’ and worry about being rejected and ‘discovered’. As such, they worry about being shamed or ridiculed and might avoid relationships, intimacy or friendships due to their fear of rejection. They might feel isolated, lonely and inferior. Finally, they are often reluctant to try out anything new in case they embarrass themselves.

Dependent personality disorder

This type of personality disorder is characterised by an overwhelming need to rely on other people. People with this condition might feel ‘weak’ and unable to function or make decisions without support from someone else. They might need other people to assume responsibility for areas of their lives and can often agree to things they don’t want to do for fear of losing the support of a person.

Essentially, with dependent personality disorder, a person is afraid of being left alone to fend for themselves. They have extremely low confidence and see others as much more capable.

Obsessive-compulsive personality disorder

Often shortened to OCPD, this is separate from OCD (obsessive-compulsive disorder) as this describes a personality type rather than a specific form of behaviour. However, the two conditions share similarities in that they centre on problems to do with perfectionism, being inflexible and needing to be in control.

A person who has this condition might need to keep things in order, set unrealistically high standards, think their way of doing things is the best, worry about making mistakes and feel extremely anxious if things are not perfect.

Personality disorder not otherwise specified (PD-NOS)

If a person doesn’t fit in with one of the specified personality disorders, they might receive a diagnosis of personality disorder not otherwise specified, or PD-NOS. This could also be referred to as PD-TS, which stands for personality disorder trait specified, which means that the person’s traits don’t fit one particular diagnosis.

Symptoms of a personality disorder

Each type of personality disorder has unique and specific symptoms.

Generally speaking, however, personality disorders are characterised by problems around:

• Sense of self and identity: People who have a personality disorder will generally have a poor understanding of their sense of self. How a person sees himself/herself will tend to change depending on who they are with and the situation they’re in. They might, for instance, have unrealistically low or high self-esteem.
• Relationships: People who have a personality disorder tend to struggle to have stable and close relationships due to their behaviours and beliefs. They often lack respect or empathy for other people and might be overly needy or emotionally detached.

Another symptom of a personality disorder is that the person will have little or no self-awareness or insight into how their behaviours or thoughts are problematic.

Who do personality disorders affect?

Anyone can be diagnosed with a personality disorder, but different disorders will affect people in different ways.

Most people start showing signs of a personality disorder in adolescence when their personality is maturing and developing. As such, almost all those with a personality disorder diagnosis are adults.

The only exception is antisocial personality disorder because 8/10 people with this condition begin to show symptoms of it before they reach 11 years of age. This specific personality disorder is most likely to affect males. Conversely, people who experience dependent, histrionic or borderline personality disorders are most likely to be female.

Why do personality disorders occur?

In the same way that everyone’s personality disorder is unique, so are their causes. There is no one clear reason for people developing behaviours and feelings that are associated with personality disorders. Most research indicates that it’s down to a mix of different factors that increase a person’s risk as well as triggers that cause the disorders to develop.

Things that influence a personality disorder occurring include:

• Social circumstances and environmental factors.
• Experiences in early childhood.
• Genetic influences.

Social circumstances and environmental factors

Our social circumstances and the environment in which we develop as well as the quality of care that we receive can impact our personality.

People who develop personality disorders have often experienced some of the following:

• A chaotic or unstable family life. This might include things like living with a person who has an unstable mental health problem or who is an alcoholic.
• No or little support from their caregivers – this might be more evident for people who have experienced traumatic events or difficult situations.
• Bad experiences at school or a lack of support at school, including exclusion and bullying.
• Discrimination or poverty.
• Dislocation such as moving home.

Cultural factors are also thought to play a part in personality disorders. This is shown by the diagnoses in different countries. For example, in Japan, China and Taiwan, there are low incidences of antisocial personality disorders but there are more incidences of avoidant personality disorders, dependent personality disorders and obsessive-compulsive personality disorders.

Experiences in early childhood

The things we experience growing up affect our personalities into adulthood. People who have experienced a difficult childhood might develop certain beliefs around how relationships work or how people act and think. This can mean they develop coping strategies that aren’t helpful in adulthood.

People who have been diagnosed with a personality disorder are more likely to have experienced trauma or difficulties as they were growing up.

This might include:

• Childhood bereavement.
• Neglect.
• Sexual, emotional or physical abuse.
• Accidents or major incidents.
• Feelings of invalidation, upset or fear.

It’s worth noting that not every child who experiences these things will have problems in adulthood. Their individual reactions as well as the support (and the consistency of it) make a difference. In a similar way, not all people who have personality disorders have experienced these things.

Genetic influences

Our personalities are complex and it’s not yet fully understood how much our genetics play a role. Some parts of our personalities are likely to have genetic influences but more research is needed to make concrete conclusions.

What to do if you suspect a personality disorder

If you suspect you have a personality disorder, the first port of call is your GP. They will be able to refer you to the appropriate specialist.

If you know someone with a personality disorder or suspect they have one, their feelings, thoughts and behaviours might mean it is difficult for them to have a good relationship with you. It can often be difficult to know how to help or what to say but there are things you can do to help them.

 This includes:

• Trying to be patient. If the person is struggling emotionally, it is not a good idea to involve yourself in arguments. It will be better to wait until things calm down.
• Talking to them calmly and compassionately. If the person is experiencing difficulties with their thoughts and feelings, they might demonstrate upsetting or unexpected behaviour that makes you feel unsettled. In these cases, it’s important to try and understand what it is they’re experiencing and what is affecting their feelings, thoughts and behaviour.
• Never judge. Be a listening ear and validate their feelings without trying to say how they should feel or act.
• Try to remind them of their positive characteristics. Just because they have a personality disorder, it doesn’t mean they’re not likeable, creative, kind, funny or intelligent, for example.
• Try to have clear expectations and boundaries with them. This can help both people in the relationship.
• Try to learn what triggers them and learn how to support them in those situations.
• Learn about their condition and challenge stigma and misconceptions.

How are personality disorders diagnosed?

It can be difficult to diagnose personality disorders since most people who have one don’t realise or believe that there is a problem with their way of thinking or behaviour. For this reason, they’re unlikely to seek a diagnosis or treatment. Instead, they’re usually referred by a social agency or their loved ones when their behaviour causes problems for other people.

When people do seek diagnosis, it’s often because they are experiencing things like depression or anxiety due to their personality disorder rather than because of the personality disorder itself.

Healthcare providers will often base their diagnosis on criteria listed in diagnostic manuals. When a personality disorder is suspected, the psychiatrist or psychologist will often ask general questions so that they don’t create a hostile environment or defensive response.

They might ask about the following:

• Relationships.
• Past history, including work history.
• Impulse control.

Due to the way personality disorders work, a person who is suspected of having one might not have insight into their behaviours and so the professionals might work with their friends, family and other professionals involved in their care to gain knowledge about their history and behaviours.

Personality disorders are typically underdiagnosed because of this and also because healthcare providers tend to focus on depression and anxiety symptoms as these are more common.

Treatment for a personality disorder

Personality disorders aren’t easy to treat. This is mainly due to the fact that often people who have a personality disorder don’t see their behaviour as problematic and so won’t think to seek treatment. Added to this is the fact that there are no medicines approved to treat personality disorders. That said, treatments are available to help people manage their symptoms of depression and anxiety which are frequently present in people who have personality disorders.

Psychotherapy (talking therapies) can help people to manage their personality disorders. There are varying types, which aim to identify and change thoughts, emotions and behaviours.

The main goal is to reduce immediate distress like depression and anxiety, help the patient to understand that their problems aren’t caused by situations or other people, decrease socially undesirable or unhealthy behaviours and to try to modify the traits of a person’s personality that are causing problems.

Types of psychotherapy

NICE (the National Institute for Health and Care Excellence) suggests the following therapies for people with personality disorders.

• Dialectical behaviour therapy – DBT
  This is a treatment that was specifically designed to help people with borderline personality disorder. It makes use of both individual and group therapies to help people learn skills and manage their emotions.
• Mentalisation-based therapy – MBT
  This is a talking therapy that is a long-term treatment aiming to improve a person’s ability to understand and recognise their own mental state as well as those of other people. It helps them to examine thoughts about themselves and other people to recognise if they are valid.
• Cognitive behavioural therapy – CBT
  This therapy helps people to understand how their beliefs and thoughts can affect their behaviour and feelings.
• Cognitive analytic therapy – CAT
  This combines the practical methods of CBT while focusing on helping to build trusting relationships and finding healthier ways of coping with problems.
• Therapeutic communities
  There are programmes that are group therapies with a facilitator. Most of the time, these are residential therapies that require patients to stay for a few days or a week. There are different activities including social activities, group therapy and individual therapy.

Support available

The UK charity Mind has lots of useful information and support about personality disorders. This includes their helplines, face-to-face services called Local Minds and Side by Side, which is an online community.

Therapeutic Communities can be accessed via an online directory called the Consortium for Therapeutic Communities.

The outlook for people with personality disorders

Because most people with a personality disorder won’t seek medical attention, the outlook tends to be poor.

Untreated, a personality disorder can result in:

• Impaired social functioning.
• Difficulties at work.
• Poor relationships.

Research suggests that personality disorders are linked to higher rates of unemployment, domestic abuse, divorce, substance misuse, crime and homelessness.

What’s more, people who have a personality disorder are much more likely to visit A&E, experience accidents and trauma or die by suicide.

Though this outlook seems dire, with collaborative management, outcomes can dramatically improve provided that the person is committed to treatment.