Can you imagine the reaction if one person in ten was affected by a disease that could destroy their life, yet was missing out on treatment — often because they were seen as ‘attention-seeking’ or time-wasting?
That’s what happens to many people with personality disorder.
There is still a lot of stigma around mental health conditions, particularly personality disorder. Few people understand it and consequently many are left to suffer in silence, unaware there is help available.
Those who do seek help often describe being dismissed by health professionals as ‘difficult’ and are treated in a cruel or unsympathetic way.
I’ve seen this myself when patients with borderline (or emotionally unstable) personality disorder have come into A&E after they’ve self-harmed, with staff failing to understand this is a sign they are at rock bottom.
And rather than being shown the understanding they deserve, these patients are often considered annoying and selfish because they’ve ‘done this to themselves’. There are even stories of patients being stitched without adequate anaesthetic to ‘teach them a lesson’.
The tragic truth is that these patients often have a history of trauma and this treatment only contributes to it.
The stigma around personality disorder means we don’t talk about it, but it’s nothing to be ashamed of and certainly not the person’s fault they have it. Part of the problem is that people think personality disorder means ‘dangerous ‘psychopath’, which is wrong and only adds to the stigma.
In fact, there are ten different types and the chances are you have a colleague, friend or even partner affected by one of these without them realising it, yet suffering real distress as a result.
Until quite recently, people with a personality disorder received pretty poor care on the NHS. They were treated in general adult psychiatry services that were often overstretched and not experienced in dealing with their specific needs.
And because it was thought that people with a personality disorder had it for life, it was assumed little could be done. But thanks to advances in brain scanning, we now know our brains can change — to an extraordinary degree — over the course of our lives.
Large studies have shown that personality characteristics change, too. The good news is that with the right treatment, people with personality disorder do get better, and their symptoms can improve.
As I explained last week, lots of people have aspects of a personality disorder. But unless it is causing serious problems, it is often said that they have ‘traits’ of a personality disorder but not the full-blown version where the symptoms are a constant feature that hampers their life.
Sometimes the disorder emerges only later in life, perhaps because they’ve been in a relationship that helped to contain the most difficult aspects. Money problems and stressful situations, or important events, can also trigger it.
ALWAYS NEEDS TO BE ADMIRED
A few years ago, I worked privately for a short while, and among my patients were several former pop stars. One in particular had been quite famous several decades ago, but the spotlight had dimmed and he now exhibited clear narcissistic personality disorder traits.
There are three broad types of personality disorder, known as clusters, based on the type of emotional problem underlying them. Narcissism belongs to the Cluster B group, characterised as dramatic, emotional or erratic. Last week we looked at three of the four types in this group: antisocial (psychopathic), histrionic and borderline (or emotionally unstable).
The fourth type, narcissistic personality disorder, often generates a lot of interest because people believe they can see it in those around them. In fact, we are all a little self-obsessed at times, and this is perfectly normal.
Of course, some of us are more self-obsessed than others but this is different from narcissistic personality disorder, where there is an overriding feeling of self-importance combined with a disregard for others’ feelings and an excessive need for adoration.
The former pop star was crestfallen, then angry when I confessed I hadn’t heard of him. It was clear his success as a pop star was of great importance to him.
He was very grandiose and self-important and spoke bitterly of his contemporaries who were still successful. Interestingly, narcissistic traits are common in celebrities and very successful people: they helped them remain focused on getting what they want from life.
While they are successful and riding high, things are usually relatively stable. They might seem very full of themselves but their ego remains satisfied because, objectively, they are successful and people adore them.
However, when there is a fall from grace — when they lose their jobs, fail to gain promotion or, as in the case of my former pop star patients, when the spotlight dims — things start collapsing and the symptoms of the personality disorder come to the fore and start causing serious problems.
They can become very depressed and even suicidal — the former pop star had come to see me because of problems with alcohol, which is a common way for people to try to numb emotional pain.
Loved by the boss but not colleagues
People with obsessive compulsive personality disorder are often highly valued by their bosses, as they are reliable and their standard of work is high.
But it can be virtually impossible to work with, or under, them; they are also difficult to live with. About 5 per cent of the population has this personality disorder, and it is more common in men. These are the characteristics that can identify them. The people affected…
- Need to keep everything in order and under control.
- Obsessively check their work, worrying it’s not good enough.
- Set unfeasibly high standards for themselves and others.
- Behave judgmentally towards other people.
- Think their way is the best way of making things happen.
- Struggle to adapt or change.
- Worry that they, or others, might make mistakes.
- Expect catastrophes if things aren’t perfect.
- Find taking criticism very difficult.
- Find it difficult to spend money on themselves or others.
- Have a tendency to hang on to items with no obvious value.
These people are perfectionists to an extreme degree, getting very upset if things aren’t done in exactly the right way, often insisting on things being done again and again.
They are rarely late, usually arriving excessively early.
They are often workaholics and sacrifice relationships. They struggle to relax even at home, with rigid, inflexible routines —they can be preoccupied with cleanliness and symmetry — and can be difficult to live with. They dislike unpredictable things or any sense of loss of control.
ARROGANT AND HYPER-CRITICAL
To have personality disorder diagnosed, someone needs to demonstrate three or four of the characteristics. The following is a checklist for narcissistic personality disorder. Does the person:
- Believe there are special reasons making them different, better or more deserving than others?
- Have fragile self-esteem, relying on others to recognise their worth and needs?
- Feel upset if others ignore them and don’t give them what they feel they deserve?
- Resent the successes of others?
- Put their own needs above those of others, and demand that those others do the same?
- Take advantage of others?
Narcissists can be very difficult to be around, not least because they often don’t think they have a problem. They have a strong sense of superiority and seem arrogant.
The flip side is they need constant admiration to feel fulfilled. Despite their apparent arrogance, they often have very fragile egos.
To feel better about themselves they will often belittle or criticise those around them. If challenged on this, they may be dismissive or suggest the other person is being weak. In the extreme, they can be controlling, blaming and self-absorbed. It’s not just cockiness: they typically believe they are more important, more worthy and their needs should take priority, regardless of their actual status.
About 1 per cent of the population has this personality disorder at some point.
LONELY BUT LONGS FOR COMPANY
Nervy and anxious people can often be misdiagnosed with an anxiety disorder when in fact their anxiety is part of a bigger issue to do with a personality disorder.
The group of personality disorders characterised by anxiety and fearfulness can be very debilitating and isolating. And there can be a real sadness — for instance, one of the disorders in this group, avoidant personality disorder, is strongly associated with neglect or rejection in childhood: those affected sometimes describe being disliked by one parent. The following are characteristics of this disorder:
- Avoid work or social activities which involve being with others?
- Expect disapproval and criticism and are very sensitive to it?
- Worry constantly about being ‘found out’ and rejected?
- Feel insecure or inferior?
- Worry about being ridiculed or shamed by others?
- Avoid relationships, friendships and intimacy because they fear rejection?
- Feel lonely and isolated?
- Avoid trying new activities in case they embarrass themselves?
- Feel a desperate need to be liked and accepted?
People like this will often be bowed down with feelings of inferiority, and their main coping strategy is avoidance. They also struggle in social situations.
Yet, despite this, they will feel lonely and long for company. They are self-critical and have a strong fear of being rejected, embarrassed or humiliated in social settings.
As a result, they often choose jobs where they can work alone.
Treatments that can help ease the torment of personality disorders
There is no quick cure for a personality disorder but lots of treatments can make life easier, and some people improve so much they no longer have a personality disorder.
It’s important to get a formal diagnosis by a psychiatrist or psychologist. Most mental health trusts have specialist teams who assess, diagnose and treat those affected.
The main treatment is psychotherapy, with different types useful for different symptoms: some people may need several types over several years. Where the main symptoms are difficulties in managing emotions, for example, Dialectical Behavioural Therapy, which has elements of cognitive behavioural therapy, can help get people to identify and change unhelpful thoughts and behaviours.
Some treatments are in groups; others are individual. Some psychiatric hospitals also offer therapeutic communities, where people with personality disorders choose to live for a period of time. Personality disorders can’t be cured by medication, however, many psychiatrists prescribe tablets to help with specific symptoms.
Antidepressants can help with mood or emotional difficulties and feelings of impulsiveness or anxiety. Antipsychotics are also sometimes used in low doses to take the edge off of agitation.
Some people don’t need regular treatment, just advice and support at times when they are struggling. In general, admission to a psychiatric hospital is avoided if possible because research has found that it tends not to benefit people with personality disorder and can be counterproductive, as it stops them developing coping strategies. Hospitals have ‘Crisis Teams’ to support patients in the community if they are having a difficult time.
If your partner, colleague or friend has a personality disorder, it’s important that you look after yourself, too. Set clear rules and expectations around their behaviour and walk away, distance yourself or give ‘time out’ when the boundary has been overstepped — but emphasise that it is a temporary measure and doesn’t mean you don’t love or care about them.
NEEDY AND CAN’T MAKE DECISIONS
The medical term for this personality disorder is dependent — those affected are very reliant on others and struggle to attain independence: they have a need to be taken care of and for others to make decisions for them. They are sometimes described as ‘clingy’.
They often have a strong sense of self-doubt and will often refer to themselves as stupid or inept and belittle their own abilities.
They tend to seek relationships with dominant or overprotective partners and avoid positions of responsibility; their social life also tends to be limited to this person or a small group of people on whom they are dependent.
This personality disorder is associated with separation and chronic physical illness when growing up.
Signs to look for — do they:
- Feel needy, weak and unable to make decisions or function properly without help or support?
- Allow others to assume responsibility for many areas of their lives?
- Feel afraid of being left to fend for themselves?
- Have low self-confidence?
- Feel easily abandoned or deserted by people?
- Feel hopeless and incompetent, and see others as being much more capable than they are?
- Appear to others to be much too submissive and passive?
ENRAGED BY OTHER DRIVERS
Odd, eccentric, loner — these are the words typically used to describe the third group of personality disorders.
Typically, these people are also the hardest to treat because they are suspicious and wary, or struggle to express their emotions so they don’t seek help; this is often left to family to do instead. Perhaps one of the better known types in this group is paranoid personality disorder.
This involves much more than the cliche of thinking ‘everyone is out to get them’. To be diagnosed with a personality disorder involves having three or four of the characteristics; these are a constant feature that hampers their life.
Signs to look for — do they:
- Find it hard to confide in people, even friends, and very difficult to trust other people?
- Often suspect that others will use or take advantage of them?
- Watch others closely, looking for signs of betrayal or hostility?
- Bear grudges?
- Read threats and danger that others don’t see into everyday situations?
- Find it difficult to brush off things that others say or do, and dwell on them and get angry?
These people are often very suspicious of others and take offence easily — they are often involved in legal disputes and write lots of complaint letters.
They can be very hard to work with because they assume that the usual mistakes everyone makes are deliberately directed at them. They fall out with lots of people and tend to hold grudges: they often get over-angry if, for example, someone occupies their car parking space or unintentionally cuts them up while driving.
They often have frequent suspicions about a partner’s fidelity. About 2 per cent of the population have this disorder.
HAS NO REAL INTEREST IN SEX
People with schizoid personality disorder often come across as aloof or uninterested in others. They don’t pay much attention to social norms, so their behaviour may seem strange. They are not really interested in forming relationships and are often loners.
Signs to look for — do they:
- Appear emotionally ‘cold’?
- Not like mixing with others and prefer their own company?
- Have a very detailed fantasy life they often retreat into, spending a lot of time daydreaming?
- Have no real interest in sex — intimacy is an encroachment into their personal space?
- Not get angry or hostile, even when provoked?
- Find it hard to express feelings?
BELIEVES THEY MAY BE PSYCHIC
People with schizotypal personality disorder are the odd, eccentric types you might come across around your neighbourhood. But although they may seem alarming at first, over time you realise they are harmless — their behaviour is just who they are. This personality disorder occurs in approximately 3 per cent of the population and is more common in men.
Signs to look for — do they:
- Find making close relationships incredibly difficult?
- Behave in an eccentric way?
- Believe they have special powers, are psychic or have a sixth sense?
- Get anxious and paranoid in social situations?
- Sometimes hear voices or talk to themselves?
- Use odd or unusual words or phrases?
- Struggle to experience normal emotions.