About personality disorders
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. These lifelong patterns are shaped by a combination of our individual natures, our genetics, and our life experiences as we develop.
The term “personality disorder” can, unfortunately, be seen to imply that there is something not-quite-right about someone’s personality – that it is disordered, broken or wrong, or that they are somehow a bad person. But that is not what the words are intended to mean. The term “personality disorder” helps clinicians group a set of typical features for people with aspects of their personality that can be debilitating for that person and challenging for those around them. People experiencing a personality disorder often feel isolated from others and can struggle to maintain close relationships.
Because each person experiences a different combination of symptoms, they will all have their own unique experience, as well as sharing common ground with others. Many people who are diagnosed with one personality disorder have overlapping traits with another personality disorder.
The most noticeable and significant feature of personality disorder is the negative effect on relationships. People with a personality disorder often strongly desire connection and strong attachments with others and want to feel loved. Attempts to make and keep long-term friendships and relationships can leave people with a personality disorder feeling frustrated, confused, and alone.
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 and cause significant distress.
Look at these behaviour as on a spectrum of human behaviour. We all have times of some of these features, but for some of us, they end up clustered together, making life more difficult. So much of life is bound up in relationships, and being able to ‘people’ is important to wellbeing.
Types of personality disorder include the following:
Borderline personality disorder is a pattern of being highly sensitive, experiencing intense emotions, and taking longer to get back to feeling okay. People with BPD often find maintaining relationships challenging and make decisions without considering the bigger picture.
Narcissistic personality disorder is a pattern of feeling self-important and grandiose, needing admiration from others to feel okay about yourself, struggling to emotionally connect with others, and focusing on yourself and your own needs ahead of others.
Paranoid personality disorder is a pattern of intense difficulty trusting others, being suspicious of others, and interpreting others’ motives as damaging or spiteful. People with paranoid personality disorder struggle to feel safe in the world and with others.
Antisocial personality disorder is a pattern of difficulty being able to fully put oneself in someone else’s shoes, which can result in behaviour that seems to disregard or violate the rights of others. People with APD can at times struggle to fit into society and can feel isolated, angry and low.
Histrionic personality disorder is a pattern of feeling very emotional and feeling a compulsive need for attention from others to feel validated. People experiencing HPD can use their facial expressions and voices to show very strong emotions, as a way of finding that validation. They can struggle to authentically connect and maintain connection with others and themselves.
Avoidant personality disorder is a pattern of feeling very uncomfortable in social situations, feeling like you are not good enough, and being sensitive to criticism. This can be seen as an extreme version of social anxiety disorder that affects many parts of a person’s life.
Dependent personality disorder is a pattern of feeling incapable on one’s own, feeling unsafe in the world alone and having a great need to be cared for by other people. People experiencing dependent personality disorder may be very submissive and want to stay close to others at all times.
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).
Schizoid personality disorder is a pattern where people avoid social relationships and can feel void of emotions or show emotions differently from what is considered typical in our communities, and therefore struggle to connect with others. When they do express emotions, it is in a very restricted range, especially when communicating with others.
Schizotypal personality disorder is a pattern of being uncomfortable in close relationships and having distortions in thinking, focus or sensation. People with schizotypal personality disorder may be seen by others as eccentric or unusual. They have great difficulty in establishing and maintaining close relationships with others. Someone with this disorder usually has unwanted and intrusive, or “stuck”, thoughts or perceptions as well as unusual ways of behaving.
The difference between those last two similar-sounding forms of personality disorder is that people experiencing schizotypal personality disorder are more likely to perceive reality differently from the people around them, believe that others want to hurt them, hold ideas that seem extreme to others, and experience periods of time where they lose touch with reality.
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 a combination of genetic predisposition, temperament, and the environment. A number of people who develop personality disorders have experienced traumatic events. These can be major isolated events or a series of invalidating experiences that take place consistently during a time of life that is important to a person’s development. These seemingly smaller traumas can have a major effect, like the dripping of a leaky tap.
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 experiences, being in an unhappy family/whānau, or feeling alienated from people and society.
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.
It's important to remember that it is not your fault that you experience a mental health problem.
Symptoms
Signs to look for (symptoms)
Each personality disorder has different patterns of behaviour or indications, 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”. Reading the descriptions below and finding themes that resonate with your experience may help you find the right support.
Cluster A
- Paranoid personality disorder
- Schizoid personality disorder
- Schizotypal personality disorder
People experiencing these types of personality disorders may be very fearful and distrustful of others, including friends and partners, and can be on the lookout for clues or suggestions to confirm their fears. They may have little interest in social or sexual relationships and find day-to-day social interactions challenging. To an observer, it may appear that they do not care about other people.
They may seem to lack emotional responses. They may also have distinctive thought patterns such as unusual beliefs, magical thinking (believing that their thoughts or feelings can influence events in the world around them), 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 experience intense emotions and can appear dramatic and possibly erratic/impulsive and self-destructive in their behaviour. Self-harm, suicidal ideation, threats and attempts of self-harm are common. Suicide completion is a higher risk for people with these personality disorders. People in the cluster B category often feel overwhelmed.
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.
I needed to know that I didn’t have anything wrong with my personality, that there was not something wrong with my soul. Rather, what I had come to understand about the world and about people was not accurate… I found that I would learn new things, and learn new ways of being in the world.
Treatment options
Once your clinician has an accurate and specific diagnosis of which personality disorder or traits you might be experiencing, they can then help you get the best evidence-based treatment available for that particular condition, tailored to your individual needs and your preferences/choices. 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
DBT and CBT approaches are usually the most effective, and are continued over a significant period of time, often for a year or more. Personality disorders develop over a long period of time, so it is helpful to emotionally invest in a long-term treatment plan.
Some other therapies that may be beneficial include attachment therapy, trauma-focused CBT, mentalisation therapy, schema therapy and narrative therapy, to name a few.
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.
Dialectical Behaviour Therapy (DBT)
DBT is seen to be the gold-standard therapy for treating some personality disorders and co-morbidities. DBT is based on the idea that two seemingly opposite things can both be true: for example, you can accept your feelings and behaviour while also wanting to change some aspects of them. DBT involves four main components: learning distress tolerance, emotional regulation, interpersonal effectiveness and mindfulness strategies. DBT therapy often includes group skills training and individual sessions.
Cognitive Behaviour Therapy (CBT)
CBT largely focuses on recognising and overcoming unhelpful beliefs and learning strategies to develop more helpful beliefs.
Acceptance and Commitment Therapy (ACT)
ACT has the goal of increasing psychological flexibility, to help people to be more in the present moment and to lessen unhelpful thoughts and connect with and live by one’s values.
Counselling
This may include some techniques referred to above, but is mainly based on supportive listening, practical problem solving and information giving.
Looking after yourself
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
- what the process of stopping medication may look like.
If you are pregnant or breastfeeding, talk with your health care provider about any potential benefits or problems.
Other strategies to support recovery
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.
Peer support
Support groups can connect you with others who have similar experiences. Many find they are a key part to their wellbeing.
Physical health
It is also really important to look after your physical wellbeing. Make sure you get an annual check-up with your doctor, and do what you can to reduce stress, get enough sleep, eat a balanced diet and exercise. 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 condition.
What has helped me? Relationships that are honest but warm. That don’t give up. That are transparent. Medication helped as I learn emotional regulation tools. Counselling. Intentional peer support. Conflict resolution skills. Journaling. Reading inspiring stories. Understanding human dynamics. Understanding self-stigma versus stigma. Dealing with shame.
Strategies for family and whānau 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 very personally and can be highly sensitive and reactive to perceived rejection. Keep in mind that messages might get lost in translation, but that someone with a personality disorder is not trying to misinterpret you. Be clear in what you say, and, if misunderstood, clarify your meaning or intention.
- Remember that it takes time for people to change their thinking and behaviour patterns.
- Learn what you can about the condition, what it is like for those experiencing it, its treatment, and what you can do to assist the person.
- If possible, 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, manage challenging situations, 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. Many people who are supporting someone with a personality disorder find having their own therapy helpful.
Thanks to Jenni Beckett, clinical psychologist, and members of the Thriving Madly peer support network in Christchurch for reviewing this content. Date last reviewed: September, 2022.
Thanks also to Sutherland Self-Help Trust for making the 2022 updates possible.