Personality disorders - general

Just as we have physical features that make us who we are, we also have our own distinct personality features.

Personality refers to the lifelong patterns in the way we see, think about, and relate to ourselves, other people, and the wider world – whether we see ourselves as good or bad, trust or mistrust others, or see the world as a good or bad place.

The term "personality disorder" implies there is something not-quite-right about someone's personality, but that is actually not what is meant by the term. The term "personality disorder" just helps doctors group a set of typical features for people with aspects of their personality that they, and others, may find difficult to deal with. People experiencing a personality disorder are often out of step with others and with their community, so much so that their personal and wider social lives may be considerably disrupted.

People who are diagnosed with a personality disorder experience a lot of problems and can be very distressed by them. The most noticeable and significant feature of personality disorder is the negative effect on relationships. A person with an untreated personality disorder is rarely able to enjoy sustained, meaningful and rewarding relationships with others, and any relationships they do form are often fraught with problems and difficulties.

The common thread that links all personality disorders is difficulties in behaviour and relationships, but there is a lot of variation in these difficulties.

Ten different types of personality disorder have been identified. A diagnosis of personality disorder is only made where the person's problems result in significant difficulty in their day to day activities and relationships, or cause significant distress.

Types of personality disorder include:

Borderline personality disorder is a pattern of having very unstable relationships, self-image and feelings, and behaving recklessly.

Narcissistic personality disorder is a pattern of feeling very self-important, needing admiration from others, and having little feeling for others.

Paranoid personality disorder is a pattern of not trusting and being suspicious of others, and interpreting their motives as damaging or spiteful.

Schizoid personality disorder is a pattern where people avoid social relationships and do not feel or express emotions much. When they do express emotions it is in a very restricted range, especially when communicating with others. These people are often viewed as typical “loners”.

Schizotypal personality disorder is a pattern of being uncomfortable in close relationships, having distortions in thinking or sensation, and behaving oddly. Those experiencing schizotypal personality disorder have great difficulty in establishing and maintaining close relationships with others. Someone with this disorder usually has disturbed thoughts or perceptions as well as eccentricities in their everyday behavior.

The difference between those last two similar sounding forms of personality disorder is that people experiencing schizoid personality disorder don't usually experience the distorted reality, paranoia or extreme ideas typical of schizotypal personality, nor will they experience the psychotic episodes (loss of being in touch with reality) that people with schizophrenia experience. 

Antisocial personality disorder is a pattern of disregarding and violating the rights of others.

Histrionic personality disorder is a pattern of being very emotional and attention-seeking.

Avoidant personality disorder is a pattern of being socially inhibited, feeling inadequate, and being very sensitive to criticism.

Dependent personality disorder is a pattern of having a great need to be cared for by other people, which results in being very submissive and clinging.

Obsessive-compulsive personality disorder is a pattern of needing order, perfection, and control in one's life. This is different from obsessive-compulsive disorder (OCD).

Who gets a personality disorder?

A personality disorder will show up by late adolescence or early adulthood. It remains relatively stable throughout adult life, and can gradually improve with increasing age. This is in contrast to other mental health conditions, which come and go over time, with periods of illness interspersed with periods of wellness.

People who have a diagnosis of personality disorder have a tendency to develop other mental health conditions, particularly if stressed. These include psychotic illnesses, depression and drug and alcohol abuse.

The risk of suicide in people who experience personality disorder is significant. It is important that if you are having any suicidal thoughts you seek help immediately through your doctor, a helpline or by dialing 111.

It’s most important to get diagnosis and treatment as early as possible. Evidence shows that with the best possible treatment over a period of time people with personality disorders can improve considerably.

If you think you have a personality disorder, or you are worried about a loved one, it’s important to talk to your doctor or counsellor, or someone else you can trust, as a first step to getting the important help you or they need.

What causes a personality disorder?

There has been considerable debate in the past regarding whether personality is determined by nature (genes) or nurture (upbringing). There is now good evidence that personality development occurs as a result of both genetic and upbringing influences.

People with a personality disorder often believe they developed it because things have gone wrong in their lives – it could be abandonment, sexual or physical abuse, traumatic experinces, being in an unhappy family/whānau, feeling alienated from people and society or not living up to people's expectations.

Other people with personality disorders cannot so easily find things that have gone wrong in their lives. They may agree with the view that their disorder is genetic in origin. A lot of people with mental health problems believe it is a combination of these things. Sometimes people think their mental health problem is a punishment for their moral, spiritual or cultural failure.

It's important to remember that it is not your fault you experience a mental health problem.

Signs to look for (symptoms)

Each personality disorder has different symptoms, and different people are affected in different ways by their symptoms, so it’s not easy to list precise symptoms. However, personality disorders can be grouped into three “clusters” with each having certain typical behaviours:

Cluster A

• Paranoid personality disorder
• Schizoid personality disorder
• Schizotypal personality disorder

People experiencing these types of personality disorders may be very distrustful of others, including even friends and partners, and are constantly on the lookout for clues or suggestions to confirm his or her fears. They may have no interest in social or sexual relationships, do not appear to care about others or normal social behavior.

They may lack emotional responses; in extreme cases, he or she may appear cold and uncaring. They may also have unusual thought patterns such as odd beliefs, magical thinking, obsessional thoughts, and unusual perceptions of reality.

Cluster B

• Antisocial personality disorder
• Borderline personality disorder
• Histrionic personality disorder
• Narcissistic personality disorder

People with any one of these disorders are dramatic and possibly erratic in their behaviour. Suicidal threats and acts of self-harm are common, and situations are often over-dramatised in order to attract attention or seek support. 

People experiencing these disorders tend to act impulsively, lack guilt over their actions and ignore social rules and obligations. They can be extremely charming and easily find relationships, yet these are often fiery, turbulent and short-lived. They can exploit others to achieve their goals and respond very negatively if they feel they are being looked down upon.

Cluster C

• Avoidant personality disorder
• Dependent personality disorder
• Obsessive-compulsive personality disorder

This group is more nervous and cautious than the other two. They feel inadequate and often helpless. They believe they are socially unappealing, or inferior, and avoid meeting people unless they are certain they will be being liked.

They are typically doubting and cautious, rigid and controlling, and often without a sense of humour. They may go to incredible lengths to stay in a relationship as they do not think they can otherwise cope.

How the doctor determines if you have a personality disorder (diagnosis)

People with personality disorders, in general, do not often seek out treatment until the disorder starts to significantly interfere with or otherwise impact on their life.
Therefore, as difficult as it may be, it is important to make that first step and talk to your doctor.

Once you have spent some time talking to your GP, they will refer you to a mental health professional qualified to diagnose and treat people with this condition. A diagnosis for personality disorder is made after talking with you about what you have been experiencing, especially around your level of personal functioning and personality traits that may suggest a particular personality disorder.

For this reason, it’s important the mental health professional gets a full, honest picture of the difficulties you have had, both from you and your family/whānau or others who know you well.

To be diagnosed as having a personality disorder, your pattern of behavior will be causing you significant distress or difficulty in personal, social, spiritual, cultural and/or work situations.

Treatment options

Treatment of personality disorders can involve a number of aspects, each of which will be tailored to meet your individual needs. Psychological therapies are generally seen as the treatment of choice for personality disorders. They may include individual, couple, family/whānau and/or group therapy.

Therapy, such as talking therapies

These therapies involve a trained professional who uses clinically researched techniques to assess and help people to make positive changes in their lives. They may involve the use of specific therapies such as Dialectical Behaviour Therapy (DBT ) which has shown good results for people; or types of cognitive behavioural therapy (CBT), which largely focuses on overcoming unhelpful beliefs and learning helpful strategies. 

Counselling may include some techniques referred to above, but is mainly based on supportive listening, practical problem solving and information giving.

DBT and CBT approaches are the most effective, but are usually continued over a significant period of time, often for a year or more.

Problem solving/skill training

This is often part of an overall approach, but can also be learnt in skills training groups. They aim to help you learn more effective ways of dealing with problem situations.

All types of therapy/counselling should be provided to you and your family/whānau in a manner that is respectful of you, and with which you feel comfortable and free to ask questions. It should be consistent with and incorporate your cultural beliefs and practices.

Medication

Medication, as a general rule, is not a long-term option for treatment of personality disorders. It can have a place in treatment, but the priority should be an effective psychotherapy/counselling programme.

Medication is generally used for treating any other mental health condition that you may be experiencing, e.g. depression. It may also be useful as a short-term strategy to help with coping in times of extreme stress or distress.

If you are prescribed medication you are entitled to know:

• the names of the medicines
• what symptoms they are supposed to treat
• how long it will be before they take effect
• how long you will have to take them for and what their side effects (short and long-term) are.

If you are breast feeding no medication is entirely safe. Before making any decisions about taking medication at this time you should talk with your doctor about the potential benefits and problems.

Complementary therapies

The term complementary therapy is generally used to indicate therapies and treatments that differ from conventional western medicine and that may be used to complement and support it.

Certain complementary therapies may enhance your life and help you to maintain wellbeing. In general, mindfulness, hypnotherapy, yoga, exercise, relaxation, massage, mirimiri and aromatherapy have all been shown to have some effect in alleviating mental distress.

Physical health

It is also really important to look after your physical wellbeing. Make sure you get an annual checkup with your doctor. Being in good physical health will also help your mental health.

Other strategies to help yourself

• Talk to your doctor about treatment options and stick with treatment
• Try to maintain a stable schedule of meals and sleep times
• Engage in mild activity or exercise to help reduce stress
• Set realistic goals for yourself
• Break up large tasks into small ones, set some priorities, and do what you can, as you can
• Try to spend time with other people and confide in a trusted friend or family member
• Tell others about events or situations that may trigger symptoms
• Expect your symptoms to improve gradually, not immediately
• Identify and seek out comforting situations, places, and people
• Continue to educate yourself about this disorder.

Important strategies to support recovery

Family, whānau and friends of someone with a personality disorder have found the following strategies important and useful. Remember that people with these conditions tend to easily take words and actions the wrong way. It’s important to be clear in what you say, and to be willing to clarify your meaning or intention if you get a bad reaction. It’s also important not to take these reactions personally, but see them as a result of the person misinterpreting you. 

Ways to support:

• Learn what you can about the condition, its treatment, and what you can do to assist the person.
• Take the opportunity, if possible, to contact a family or whānau support, advocacy group or culturally appropriate organisation. For many, this is one of the best ways to learn about how to support the person, deal with difficulties, and access services when needed.
• Encourage the person to continue treatment and to avoid alcohol and drug abuse.
• Find ways of getting time out for yourself and feeling okay about this. It’s important to maintain your own wellbeing.

Thanks to Janet Peters, registered psychologist for reviewing this content. Date last reviewed: October, 2014.