Understanding

Personality disorder
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Personality disorder is one of the most controversial psychiatric diagnoses. It covers
widely different kinds of behaviour. This booklet gives a brief description of the
various disorders, discusses the possible causes and looks at what sort of help is
available and where to find it.

hat is personality disorder?

The word 'personality' refers to the enduring pattern of thoughts, feelings
and outward behaviour which makes each of us individual. We tend to behave
in relatively predictable ways, yet our personalities also develop and change
in response to changed circumstances. Many people are flexible enough to be
able to learn from past experiences and change their behaviour in order to cope
more effectively.

Personality disorders, on the other hand, are characterised by a long-lasting,

inflexible and limited range of attitudes and behaviours which are expressed in
a wide variety of settings. These attitudes and behaviours also deviate markedly
from the expectations of the person's culture, and cause distress to that person
or to others.

Personality disorders often start or become noticeable during adolescence or

early adulthood, although they sometimes begin during childhood. The narrow
range of experiences, responses and coping strategies displayed by someone
suffering from a personality disorder cause great distress in most circumstances.
It is difficult for sufferers to develop friendships, maintain stable partnerships
and work co-operatively with others. The suicide risk is reckoned to be three
times greater in people suffering from a personality disorder than in the general
population. For more information, see Mind’s booklet How to Help Someone who
is Suicidal (details of this and other Mind booklets may be found on pp. 10-11).

Personality disorders disrupt people's lives (and those of others they come in contact
with) to different degrees. They also vary in their treatability. Often, someone
diagnosed with a disorder of this kind has an emotional problem such as depression
or phobia too. For example, someone suffering from a social phobia or agoraphobia
may also be diagnosed as having an avoidant personality disorder. Even if many of
the problems associated with the phobia have been resolved, stressful events may
trigger an underlying pattern of avoidance and dependency. (See Mind’s booklets,
Understanding Depression and Understanding Phobias, details on p. 10).

There are ten personality disorders according to the DSMIV – The American
Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders. (The
terminology used and the characteristics described in this booklet follow DSM1V and

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The Oxford Textbook of Psychiatry. There are slight differences between this
system and other classifications systems). Information about multiple personality
disorder is not included here since it is classified as a dissociative disorder, not a
personality disorder. The characteristics of the various personality disorders are
as follows:

Paranoid personality disorder

Continual and unwarranted distrust and suspicion of others. People are constantly
vigilant, looking out for attempts by others to harm them.

Schizoid personality disorder

Lack of interest in forming close relationships. People tend to be solitary,
introspective and lacking in empathy.

Schizotypal personality disorder

Social anxiety, inability to make close relationships, cognitive or perceptual
distortions and eccentric behaviour. People may, for example, imagine that external
events relate to them in some significant way or that they can read others' thoughts
and exercise magical control over other people. Some researchers claim that this
personality disorder is related to schizophrenia. (See Mind’s booklet, Understanding
Schizophrenia).

Borderline personality disorder (BPD)

This is characterised by some of the following features: intense unstable
relationships, impulsiveness, major shifts in mood, inappropriate anger, self-
damaging acts, uncertainty about personal identity, chronic feelings of boredom
and emptiness, and fear of being abandoned. Because of confusion about personal
identity and terror of being left alone, people may cling on to very damaging
relationships. Many people who meet the criteria of BDP also meet the criteria for
histrionic, narcissistic or antisocial personality disorder. A support group has been
set up for the relatives and friends of people with this diagnosis (see Useful
Organisations, p. 10).

Histrionic personality disorder

Excessive emotional display, attention-seeking behaviour, dependency on the
support and approval of others and a constant search for novelty and excitement.

Narcissistic personality disorder

A grandiose sense of self-importance, fantasies of unlimited success or
achievement, a constant need for attention and admiration, and a tendency
to exploit others.

Antisocial personality disorder (APD)

This has been known as 'psychopathy' (a term which is employed by the Mental
Health Act 1983) and is the disorder most closely linked with adult criminal
behaviour. People with APD consistently disregard and violate other people's

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rights. They may appear to be superficially charming, but are callous and self-serving
and lacking in empathy. They are often incapable of consistent employment and
maintaining a long-term relationship. People with APD behave impulsively without
considering the consequences. Impulsive behaviour is often linked with criminal
offences, particularly violent offences. Studies indicate a higher rate of alcoholism
and substance abuse among people with APD than the rest of the population.
Behaviour is made more extreme by the effects of alcohol or drugs. A central feature
of this disorder is complete lack of guilt about criminal or exploitative behaviour.

Avoidant personality disorder

This is characterised by avoidance of social situations because of feelings of inadequacy
and fear of disapproval, criticism or rejection. It is similar to social phobia but people
with avoidant personality disorder are more likely to fear social relationships and
intimacy rather than social circumstances.

Dependent personality disorder

This is characterised by clinging and submissive behaviour towards others. People are
driven by a great fear of separation and an overwhelming need to be taken care of.

Obsessive-compulsive personality disorder (OCPD)

This is characterised by a preoccupation with orderliness, perfectionism and keeping
everything under control. People have unrealistically high standards for themselves
and others. OCPD is not necessarily linked with obsessional disorders, although some

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people may be diagnosed with both. The day-to-day functioning of people with
obsessive-compulsive disorder is likely to be much more impaired. People with OCPD
may also suffer from depression or social phobia. (See Mind’s booklet Understanding
Obessessive Compulsive Disorder, p. 10).

hat are the problems in

diagnosing personality disorder?
Experts have described personality disorders as syndromes that are 'fuzzy at the
edges'. There are strong similarities between the criteria for different personality
disorders, for example, avoidant and dependent personality disorder or histrionic
and narcissistic personality disorder. A person may qualify for a number of
diagnoses across the categories. A wide range of people fit different criteria for
each disorder – people who would appear to have very different personalities. Each
individual is unique and personality is so complex that slotting people into neat
psychiatric categories is an almost impossible task.

The Oxford Textbook of Psychiatry warns against 'pseudo-insight through

terminology' – the assumption that assigning a client to one of these categories

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automatically means that more is known about the person. Mind also recognises
that many of these terms have been used in a stigmatizing, derogatory way.

Eccentric or 'abnormal'?
Personality disorders can be seen as extreme examples of tendencies which are
observable in everyone. Negative personality traits and extremes of behaviour tend
to be regarded as excusable and unremarkable in the socially dominant or creatively
gifted. Some people may have one or two particularly offensive traits such as being
smug or long-winded or perpetually irritable, which cause them to experience more
rejection and distress than someone suffering from a personality disorder whose
overall personality is more pleasant.

Misdiagnosis
Labels such as 'masochistic', 'dependent', 'inadequate' may be used in an insulting,
punitive and pointless way and applied to people who are perceived as being in some
way 'difficult'. Victims of domestic violence or child abuse may be more likely to be
diagnosed as suffering from a personality disorder. Because post-traumatic symptoms

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are so persistent and wide-ranging, they may be mistaken for enduring characteristics
of the victim's personality. Many survivors may be misdiagnosed as having a
dependent or avoidant personality disorder. (See Understanding Post-traumatic Stress
Disorder, on p.11).

hat causes a personality disorder?

Although a great deal of research has concentrated on the causes of antisocial
personality disorder (see p. 6), the causes of other personality disorders have
received little in-depth investigation.

It has been reported that there is a strong genetic basis to obsessive-compulsive

personality disorder and also that there may be a genetic connection between
personality disorders and particular mental health problems. There have been
reports of an increase in personality disorders among relatives of people suffering
from schizophrenia and manic depression.

Psychological causes have been suggested for most personality disorders. Most
psychological explanations speculate that people with personality disorders have
experienced poor parenting, rejection, lack of love or abuse when young. Negative
childhood experiences seem to be particularly important in borderline personality
disorder. Many people with this diagnosis report having been neglected, or
physically or sexually abused as children.

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w hat are the causes of
antisocial personality disorder?
Antisocial behaviour in childhood seems to be linked with antisocial behaviour in
adults. Research has established that high levels of stress and family problems are
important causes of behaviour problems in childhood. The significant factors in
developing behaviour problems or delinquency seem to be:

• the absence of a warm, intimate and continuous relationship with parents

• inconsistent discipline and supervision
• parents who have an antisocial personality disorder or abuse drugs or alcohol.
Studies suggest that children who experience divorce are at greater risk of
delinquency, but it is the level of discord in the home which causes the behaviour.
Parents who stay together but who are neglectful and quarrelsome are more likely
to produce delinquent children than more stable single-parent homes. Some experts
consider that upbringing is an important cause of antisocial personality disorder in
adults. Others point out that most people who have had painful childhoods do not
go on to develop APD as adults.

Childhood behaviour problems and APD

Most adults with APD showed this behaviour as children. However, the reverse is
not true: most children with behaviour problems will not grow up to have APD.
Children with an early and long history of antisocial behaviour are the most likely to
develop into antisocial adults. Significant signs are: truancy, running away from home,
initiation of fights using weapons, sexual abuse of other children, cruelty to animals or
people, vandalism, fire-setting, lying or stealing. Difficulty in concentrating and paying
attention make it difficult for children to learn. Studies have found a link between
hyperactivity and behaviour problems and juvenile convictions. Poor language skills
and home environment are more likely to produce aggressive behaviour.

Genetic causes
Studies of identical twins and the adopted children of antisocial parents have
attempted to show that there is a genetic factor in the development of this disorder.
In pairs of identical twins in which one of the pair had committed a criminal offence
it was more likely that the co-twin had also offended. Research suggests that
antisocial behaviour is higher in adopted children of antisocial biological parents.

Serotonin and aggression

Low levels of a chemical messenger in the brain called serotonin mean less control over
our impulses. This can lead to increased irritability and impulsive aggression. Research
has found low levels of serotonin in people with antisocial or borderline personality
disorder who had committed impulsive acts of violence. Biological and environmental
factors are linked since levels of serotonin can be affected by social factors. Stress
caused by social isolation or deprivation can also cause lower levels of serotonin.

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Brain damage/abnormalities in brain function
Tests have demonstrated brain damage and abnormalities in brain function in
habitually aggressive men convicted of violent offences. Such abnormalities would
make it more difficult for people to reflect, to judge the consequences of their
actions, to learn from experience and to feel fear or remorse. Studies have found
that people with antisocial personality disorder respond less to expectations of

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stress. Because of this relative lack of anxiety, people may not learn to avoid
threatening situations and, instead, may actively seek out danger in order to feel
stimulated and alive.

re personality disorders treatable?

All personality disorders are difficult to treat because they involve long-term
pervasive patterns of thoughts, feelings and ways of relating to other people. But
many people with personality disorders are able to change their thinking and
behaviour and eventually lead more fulfilling lives. More positive outcomes tend to
be associated with the milder personality disorders – avoidant, dependent and
obsessive-compulsive. But research focusing on more severe personality disorders
also suggests that over a period of years some people are capable of modifying and
changing their outlook.

There seems to be considerable evidence that psychological treatments

are beneficial, particularly for less severe personality disorders. Certain key
characteristics seem to matter. Positive qualities are: motivation; introspection;
honesty; willingness to acknowledge imperfections; an ability to accept
responsibility for one's problems. People who lay all the blame on others and
external circumstances are unlikely to benefit from therapy.

Some practical changes may be brought about quite quickly through therapy, but
for many people progress is likely to be slow and difficult.

Talking treatments
Group therapy can be particularly beneficial for some people. For people who avoid
social situations or tend to become excessively dependent on one person, a group
provides a useful practice ground. People diagnosed with borderline personality
disorder tend to form intense 'special' relationships, so again a group gives them the
chance of forming a range of attachments to people.

Counselling may be helpful when it takes a problem-solving approach focusing on

practical issues and analysing current relationship difficulties. Other approaches such
as social skills training and assertiveness training may also provide useful practice
(see Useful Organisations on p. 9 for further information).

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Cognitive therapy can analyse a person's characteristic pattern of thoughts and
attitudes. It attempts to challenge and change misperceptions. With a client who is
very dependent, for instance, therapy might focus on challenging the idea that they
are helpless and incompetent. With someone who has a diagnosis of obsessive-
compulsive personality disorder, therapy might attempt to change the belief that
mistakes must be avoided and challenge their concentration on duties and work.

Individual therapy is not universally beneficial for people with personality disorders.
An intense one-to-one relationship may increase an already-too-great dependency
or encourage manipulative, exploitative behaviour in people who are antisocial or
narcissistic. However, it can be helpful if people are well-motivated and can be
honest with themselves and come to trust another person. (For information on
various talking treatments see Further Reading p. 10).

Therapeutic communities
Research shows that some people with more severe personality disorders may
be helped by the experience of living for a number of months in a therapeutic
community. The NHS runs in-patient therapeutic communities which specialise in
treating clients with personality disorders (see Useful Organisations p.10).

The emphasis is on a collaborative, democratic approach so that the staff and

residents share responsibility for tasks and decisions. People are encouraged to
express their feelings about one another's behaviour in group discussions. This
inevitably involves residents having to face up to the effects of their attitudes and
behaviour on others. People have to be very well-motivated, able to talk about
their problems and open to change.

There is no individual therapy and drugs are not used. Therapy takes place

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informally through the day-to-day process of community living and through group
psychotherapy, community meetings and other types of group activities. There are
similar therapeutic communities within the prison system (see Further Reading and
Useful Organisations).

hat else can be done to help?

It is important to emphasise the positive aspects of someone's personality and to
encourage each individual to make the most of their strengths and abilities.
Someone may have a diagnosis of borderline personality disorder and be likeable,
intelligent, highly-motivated or creative.

There is little point in telling someone that they are narcissistic or dependent unless
this is accompanied by an explanation of what these terms mean, what treatment

8
approaches might be helpful and how people can best help themselves. People
should be encouraged to avoid adding to their problems by abusing alcohol or drugs
or entering into abusive relationships. Blanket judgemental terms such as 'immature'
or 'inadequate' should never be used. We may all display immature or inadequate
responses in particular situations.

u
It is important to identify situations which bring out the best or worst in people. For
example, someone who is fearful of intimacy and ill at ease with people may lose
their inhibitions when discussing a subject which really interests them, so joining a
relevant society or club or further education class may be a way of learning to enjoy
the company of others.

seful organisations
Association of Therapeutic Communities
Pine Street Day Centre, 13-15 Pine Street, London EC1R 0JH, tel. 020 8950 9557
e-mail: therap.comm@btinternet.com, website: www.pettarchiv.org.uk/atc.htm
Produces a directory of therapeutic communities which includes some for those
diagnosed with personality disorders.

Alcoholics Anonymous
PO Box 1, Stonebow House, Stonebow, York YO1 7NJ, tel. 01904 644026,
helpline (London): 020 7833 0022, website: www.alcoholics-anonymous.org.uk

British Association for Behavioural and Cognitive Psychotherapies (BABCP)

PO Box 9, Accrington BB5 2GD, tel. 01254 875277, e-mail: info@babcp.org.uk,
website: www.babcp.org.uk
Full directory of psychotherapists available for £2.60, payable to BABCP.

British Association for Counselling

1 Regent Place, Rugby CV21 2PJ, tel. 01788 550599, fax: 01788 562189,
minicom: 01788 572838, e-mail:bac@bac.co.uk, website: www.counselling.co.uk
Send an SAE for details of practitioners in your area.

Everyman Project
40 Stockwell Road, Stockwell, London SW9 9ES, helpline: 0207 737 6747
Counselling for men who want to stop their violent or abusive behaviour.

Families Anonymous
tel. 020 7498 4680
Self-help groups in the UK for families and friends of those with a drug problem.

9
First Steps to Freedom
7 Avon Court, School Lane, Kenilworth, Warwickshire CV8 2GX,
helpline: 01926 851608 , fax: 01926 864473, e-mail: info@firststeps.demon.co.uk,
website: www.firststeps.demon.co.uk
Supports friends and relatives of those with borderline personality disorder.

National Drugs Helpline

tel. 0800 77 66 00
Free 24 hour helpline for information and advice about drug use.

The Cassel Hospital

1 Ham Common, Richmond, Surrey TW10 7JF, tel. 020 8940 8181, fax: 020 8237 2996
In-patient therapeutic community for people with less severe personality disorder.

The Henderson Hospital

2 Homeland Drive, Sutton, Surrey SM2 5LT , tel. 020 8661 1611
Three therapeutic communities for people with severe personality disorder.

The Prison Reform Trust

15 Northburgh Street, London EC1V 0RJ, tel. 020 7251 5070, fax: 020 7251 5076,
e-mail: prt@prisonreform.demon.co.uk

United Kingdom Council for Psychotherapy (UKCP)

167-169 Great Portland Street, London W1N 5FB, tel. 020 7436 3002
Provides access to information about properly accredited psychotherapists.

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YoungMinds
102-108 Clerkenwell Road, London EC1M 5SA, tel. 020 7336 8445,
fax: 020 7336 8446, parents information service: 0800 018 2138
e-mail: enquiries@youngminds.org.uk, website: www.youngminds.org.uk
Information for anyone concerned about the mental health of a child or adolescent.

urther reading

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Qty
A-Z of Your Rights under the NHS and Community Care Legislation (Mind 1993) £3
Cognitive Analytic Therapy and Borderline Personality Disorder A. Ryle et al.

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(John Wiley 1997) £17.99
Factsheet: Cognitive Behaviour Therapy (Mind 1999) 35p

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Factsheet: Counselling (Mind 1999) 35p
Factsheet: Psychosis (Mind 1998) 50p

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oo Getting the Best from your Counsellor or Psychotherapist (Mind 1995) £1
Hostage of the Mind – Living with obsessive-compulsive disorder from the

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point of view of a sufferer A. Lowe (A. Lowe 1998) £11.99
How to Help Someone who is Suicidal (Mind 2000) £1

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How to Look After Yourself (Mind 1999) £1
Making us Crazy – DSM: The psychiatric bible and the creation of mental

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disorders H. Kitchings and S. Kirk (Constable 1999) £14.99
Managing Anger G. Lindenfield (Thorsons 1993) £6.99

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Obsessive-compulsive Disorder: The facts (Oxford University Press 1998) £9.99
Overcoming Social Anxiety and Shyness G. Butler (Robinson 1999) £7.99

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Stop Walking on Eggshells P. T. Mason, R. Kreiger (New Harbinger 1998) £11.99
Risks and Rights – Mentally disturbed offenders and public protection (NACRO

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1998) £10
Understanding Obsessive-compulsive Disorder (Mind 2000) £1

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Understanding Paranoia (Mind 1999) £1
Understanding Post-traumatic Stress Disorder (Mind 2000) £1

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Understanding the Psychological Effects of Street Drugs (Mind 1998) £1
Understanding Schizophrenia (Mind 2000) £1

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Understanding Self-harm (Mind 2000) £1
Understanding Talking Treatments (Mind 2000) £1

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This booklet was written by Janet Gorman

ISBN1 874690 66 9. First published by Mind 1997. Revised edition © Mind 2000
No reproduction without permission
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