Personality Disorders

Transcription

1 Personality Disorders We all have individual characteristics called personality traits. These will affect the way we think, feel and behave. Someone may be described as having a personality disorder if these characteristics cause regular and long-term problems in the way they cope with life, interact with others or how they respond emotionally. There are a number of different types of personality disorders. In the experience of Rethink Mental Illness, a diagnosis of personality disorder may sometimes be given inappropriately (for example, to someone who does not engage or may be difficult to treat). There is no single cause of personality disorder. It is likely to be a combination of reasons, including genetic and psychological causes. Personality disorder may increase the risk of substance misuse, self-harm or suicide. It is possible to have a personality disorder alongside a mental illness, such as schizophrenia or bipolar disorder. In the past, personality disorder was often viewed by the mental health services as untreatable. However, this is no longer the case with a number of treatments being found to be effective for personality disorder. This factsheet covers: 1. How common is personality disorder? 2. What are the different types of personality disorder? 3. How is a personality disorder diagnosed? 4. What causes personality disorders? 5. What is the connection between personality disorder and substance misuse? 1

2 6. Personality disorder and other mental disorders 7. How is a personality disorder treated? 8. Problems with service provision 9. Risks associated with personality disorder 1. How common is personality disorder? Estimates vary on how common personality disorder is. In the community, around 10-13% of the population are thought to have a personality disorder. 1 Personality disorders are found more in younger age groups (25-44 year age group) and are equally common between males and females (although this may vary for specific personality disorders). Research has found that the number of people with personality disorder is highest in prison, which has a population with 64% of male sentenced prisoners and 50% of female prisoners being found to have a personality disorder What are the different types of personality disorder? A guide to diagnosis, called the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), divides personality disorders into three clusters- Cluster A - Odd/eccentric- paranoid, schizoid, schizotypal Cluster B - Dramatic/emotional/erratic- antisocial, borderline, histrionic, narcissistic Cluster C - Anxious/fearful- dependent, avoidant, obsessive-compulsive In addition there is the controversial label of dangerous severe personality disorder (DSPD). However, this is not recognised in clinical terms. Cluster A Paranoid personality disorder- People with a paranoid personality disorder essentially have an ongoing, unfounded suspicion of others. This suspicion could lead to them feeling that they are being exploited or deceived by other people. This is likely to mean they will feel very wary and find it difficult to trust others, even friends. People with this personality disorder may see signs of hostility or threats in everyday situations, which other people do not see. They may also hold grudges and find it very difficult to forgive insults. They can also be emotionally detached. When this condition is diagnosed, schizophrenia and psychotic features of mood disorders must be ruled out. Schizoid personality disorder- People with schizoid personality disorder have few social relationships, preferring to be alone. They express few emotions (especially those of warmth and tenderness), and appear not to care about the praise or criticism of others. They may appear absent minded and aloof, but are actually very shy. 2

3 Schizotypal personality disorder- Schizotypal personality disorder is characterised by problems with social and interpersonal relationships, as well as thought disorders and paranoia. People with this personality disorder often have magical thinking (e.g. if I think this, I can make that happen ) and other seemingly strange thoughts. They may appear odd or eccentric, for example by talking to themselves or dressing inappropriately. When schizotypal personality disorder is diagnosed, schizophrenia, mood disorder with psychosis, another psychotic disorder or a persistent developmental disorder need to be ruled out. Cluster B Antisocial personality disorder- Antisocial personality disorder (ASPD) is closely linked with criminal behaviour. People with this personality disorder are often impulsive or reckless, without considering the consequences for themselves or others. They may put their needs above those of others, doing things to get what they want even if that means they may hurt people. Others may regard them as selfish, and they can be prone to outbursts of aggression and violence. A diagnosis of ASPD is not usually given to someone under 18 years old. However, its characteristics can be seen in younger people as conduct problems. Conduct problems can include aggressive or defiant behaviour and unlawful behaviour such as stealing. It is more than teenage rebellion. If young people with conduct problems are treated at an early age, this can prevent more serious problems later on. Borderline personality disorder- Borderline personality disorder (BPD) originally referred to the condition being on the borderline between psychosis and neurosis. It is a disorder in which a person has a pattern of unstable personal relationships and poor impulse control in areas such as spending, sexual conduct, driving, eating, and substance abuse. They may not have a strong sense of who they are. Additionally, the person suffering from BPD fears abandonment and will go to any length to prevent this, often feeling chronic emptiness. There may be suicidal threats, gestures or attempts made by the person with BPD. There may also be self-harming behaviour. Their mood may change quickly, often with outbursts of anger. There may also be times when someone with BPD believes in things that aren t real (delusions) or experiences things that aren t really there (hallucinations). BPD is a controversial diagnosis and some psychiatrists do not believe it exists. Histrionic personality disorder- Histrionic personality disorder is characterised by people who like being the centre of attention and who are lively and over dramatic. They easily become bored with normal routines, 3

4 and crave new situations and excitement. In relationships, they form bonds quickly, but the relationships are often shallow, with the person demanding increasing amounts of attention. Narcissistic personality disorder -Narcissistic personality disorder involves a sense of inflated self-importance, preoccupation with fantasies about unlimited success and a driven desire for attention and admiration. They are often referred to as being conceited and can act selfishly, with a sense of entitlement over others. They generally have a low self esteem. Cluster C Dependent personality- Dependent personality disorder involves passively allowing others to assume responsibility for major areas of ones life, often with a lack of self-confidence or lack of ability to function independently. This leads to the person making their own needs secondary to the needs of others, and then becoming dependent on other people. While everyone is dependent on others in some parts of their lives, those with dependent personality disorder are dependent in almost all major areas of their lives and view themselves only through an extension of others. Avoidant personality disorder- Avoidant personality disorder is where a person has an extreme fear of being judged negatively by other people and suffers from a high level of social discomfort as a result. They tend only to enter into relationships where uncritical acceptance is almost guaranteed. They are often socially withdrawn and suffer low self-esteem. They may have a great desire for affection and acceptance. However, the fear of rejection can overwhelm this desire. Obsessive-compulsive personality disorder- Obsessive-compulsive personality disorder is characterised by a person who has a decreased ability to show warm and tender emotions and a perfectionism that decreases the ability to see the bigger picture. Essentially, everything must be just right, and nothing can be left to chance. It is difficult to do things in any way but their own. Obsessive-compulsive personality disorder is different from obsessive-compulsive disorder which must be ruled out before a diagnosis is made. Dangerous severe personality disorder (not in above clusters) The government first introduced the term dangerous severe personality disorder in a consultation paper 'Managing Dangerous People with Severe Personality Disorder' in 1999, which was intended to lead to reform of the mental health legislation. Some specialist services have been set up to deal with these people, most of whom are thought to be serious violent and sexual offenders. The term DSPD has no legal or medical basis and many doctors regard it as a political intervention. Around 450 people have been admitted to the DSPD programme to date. The effectiveness of the programme has still not been fully evaluated. 4

5 It is important to remember that most people diagnosed with a personality disorder are not dangerous. 3. How is a personality disorder diagnosed? The features of all personality disorders are long-lasting if not permanent, and play a major role in most or all aspects of the person's life. They do not fluctuate in the way that symptoms of mental illness fluctuate. This is said to be because of the ingrained nature of personality disorders. As is the case with mental illnesses, there are no direct medical tests (such as a blood sample) to check whether someone has a personality disorder. Psychiatrists have to look for signs and characteristics and will use classification systems like ICD10 or DSM IV (also called diagnostic schedules) to help them identify the groups of traits which make up particular disorders. In making a diagnosis, doctors need to find out a great deal about the person concerned by talking to them, their family and perhaps others who know them. Specific personality disorders will have specific criteria attached to them. A psychiatrist will look to identify combinations of features that indicate a particular personality disorder. A psychiatrist considering a diagnosis of personality disorder will also look for the following general criteria- 3 a) Inner experience and behaviour that has been present for an extended period of time and is inflexible. The experience and behaviour are significantly different to that expected by the person s culture. (They are not a result of alcohol or drugs or another psychiatric disorder). b) This enduring pattern of inner experience and behaviour is seen in at least two of the following areas- Thoughts - ways of looking at the world, thinking about self or others, and interacting Emotions - appropriateness, intensity, and range of emotional functioning Interpersonal functioning - relationships and interpersonal skills Impulse Control impulsivity and recklessness c) The pattern has caused and continues to cause significant distress or negative consequences in different aspects of the person's life. The above criteria come from the diagnostic schedule DSM-IV. 5

6 Reaching the correct diagnosis can be difficult, because- People being assessed by a psychiatrist may conceal information about themselves or mask the degree of their symptoms (which is why it can be important for doctors to talk to others close to the person). Symptoms like anxiety or paranoia might indicate a personality disorder but could be associated with a mental illness. Symptoms of personality disorder may be masked by the use of street drugs or alcohol (sometimes referred to as self-medicating). It is possible for someone to have both a mental illness and personality disorder. In practice, it is very important that doctors recognise any symptoms present which will respond to treatment, especially because personality disorders carry an increased risk of self-harm and suicide 4. It is also important that if any other psychiatric condition is identified (e.g. schizophrenia, depression), this is treated appropriately. In the experience of Rethink Mental Illness, a diagnosis of personality disorder is sometimes given inappropriately to people who- are 'non-compliant' or difficult to engage in treatment do not respond to most treatments are difficult to 'manage' in settings like a hospital ward are difficult to diagnose 4. What causes personality disorders? Like other mental illnesses, it is thought that personality disorders are caused by a number of factors. These include upbringing in childhood and social development as well as genetic and biological factors. Genetic causes Research has looked at the inheritance of normal personality traits. This has suggested that some personality traits are more likely to be inherited (e.g. narcissism), while some (e.g. submissiveness) are less so. It has also been identified that individuals with certain personality disorders tend to have relatives with certain mental illnesses. 5 For example, people with schizoid, paranoid and schizotypal personality disorders tended to have relatives with schizophrenia or schizophrenia-related conditions. People with dependent, avoidant and obsessive compulsive personality disorders tended to have relatives with an anxiety disorder. Psychological causes A separate body of research shows that many people with personality disorders have experienced trauma such as physical or sexual abuse. One piece of research found that up to 87% of those with borderline personality disorder have suffered some sort of childhood trauma. 6 Abuse can be physical or sexual or involve neglect. Childhood is the time to learn 6

7 to cope with and manage intense emotional changes and form healthy attachments and relationships. Children who are abused or neglected often do not learn these lessons, so they may be more likely to have difficulty regulating their emotions as adults. This does not mean that all people who experience trauma will develop personality disorders, but they may become vulnerable. 5. What is the connection between personality disorder and substance misuse? Although estimates vary widely, research finds a strong association between personality disorder and substance misuse (misuse of drugs or alcohol). The rate of personality disorder (particularly antisocial and borderline personality disorders) is higher in people with substance misuse than in the general population. 7 There are many reasons why people with personality disorders and other mental health problems turn to drugs and or alcohol. They may feel anxious or wish to block out symptoms or side-effects of various medications. They may feel bored and isolated, lonely, marginalised and depressed. They may have sleeping difficulties or hope to boost their selfconfidence and feel normal. Rethink Mental Illness believes it s important that the mental health services and drug and alcohol agencies come together to treat the individual. Unfortunately, this kind of service is not often available, and individuals are more likely to be referred to a substance misuse service than a mental health service. Sometimes, people may fall between the cracks of mental health and drug/alcohol services entirely. Please see our factsheet on Dual Diagnosis for more detailed information about mental health and substance misuse. A copy can be obtained by contacting the Rethink Advice & Information Service (contact details in further information) or a copy can be downloaded for free from 6. Personality disorder and other mental disorders People with personality disorders are more likely to have other mental health problems during their lifetime. 8 When personality disorders exist alongside a mental illness, this sometimes causes conflict around diagnoses. It can also confuse issues around best treatment. A second opinion may be useful in some cases. For further information on second opinions, please see the factsheet Second Opinions. A copy can be obtained by contacting the Rethink Advice & Information Service (contact details in further information) or a copy can be downloaded for free at 7

8 7. How is personality disorder treated? In the past personality disorders were considered to be largely untreatable. This way of thinking has been challenged and in 2003 the National Institute for Mental Health in England (NIMHE) published a report 'Personality Disorder, no longer a diagnosis of exclusion'. This laid out effective ways in which people with personality disorders can be treated. These include psychological and drug therapies. In order to decide which treatment will be suitable for you, you should ask your GP or psychiatrist for an assessment. Psychological treatments- Dynamic psychotherapy (also known as psychoanalytic psychotherapy)- Dynamic psychotherapy works on the basis that problems and behaviour in the present may be a result of past experience. The focus is the relationship between the therapist and client so that as problems arise, they can be dealt with in the hope that new strategies will be applied to other relationships. This treatment is generally long term. Cognitive Analytical Therapy (CAT)- CAT involves a therapist and a client working together by looking at what has hindered changes in the past in order to understand better how to move forward in the present. Questions like 'why do I always end up like this?' become more answerable. The focus is on recognising how coping strategies started and how they can be adapted and improved. By activating the client s own strengths, resources and tools, plans are developed to bring about change. In this way clients gain skills to help them manage their lives more successfully and to continue. The work is active and shared between the client and the therapist. Cognitive Behavioural Therapy (CBT)- CBT combines two very effective kinds of therapies - cognitive therapy and behavioural therapy. It works on the basis that how you think affects how you feel and what you do. It works to try and change unhelpful thoughts and behaviours and break vicious cycles. Dialectic Behavioural Therapy (DBT)- This is a special adaptation of CBT originally designed specifically for people with borderline personality disorder. It focuses on enhancing someone s skills in regulating their emotions and behaviour. It aims to look at and change behaviour patterns by finding a balance. It can help someone to gain control over behaviour such as self-harm. Therapeutic community treatments- Therapeutic communities provide intensive psychosocial treatment which may include a variety of therapies. However, it is the therapeutic environment itself that is seen as the main agent of change. They include democratic and concept types, the former including members of the community as decision makers. External control 8

9 is kept to a minimum. Members of the community take a significant role in decision making and the everyday running of the unit. Drug therapies 9 Antipsychotic drugs- These have been shown to have variable results in controlled trials. It is claimed they may cause a reduction in hostility and impulsivity. 'Schizotypal features are helped the most and atypical (new generation) antipsychotics may offer advantages over the older drugs. Antidepressant drugs- Both tricyclics and SSRI s have been recommended in the treatment of borderline personality disorder. Improvement in borderline patients may be linked to helping relieve depressive symptoms rather than personality based improvements. Impulsiveness is particularly improved and SSRI s may offer advantages in this respect. Mood stabilisers- Lithium, carbamazepine and sodium valproate have all been used to treat symptoms of mood disorder in those with personality disorder. There is weak support for the idea that cluster B (antisocial, borderline, histrionic, and impulsive) personality disorders may be helped by mood stabilisers. The Rethink Advice & Information Service has produced information on medication. There are factsheets on antipsychotic medication, antidepressants and mood stabilisers. It has also produced a medication guide called Only the Best about antipsychotic and mood stabilising medication. For a copy of any of these, contact the Rethink Advice & Information Service (details in further information) or download them for free at 8. Problems with service provision The Rethink Advice & Information Service has learned from clients experience that most general mental health services have difficulty providing services for people with personality disorders. They have generally been treated at the margins, relying on Accident and Emergency units, inappropriate hospital admissions and support in the community from staff who lack the specific skills needed to engage with personality disorder. Following the report, Personality Disorder, no longer a diagnosis of exclusion, 11 pilot services were set up, which were examined in a further report produced in A summary of the report was also produced. 11 The research found that the pilot services set up for people with personality disorder offered flexibility and a variety of services. People involved (including service users, service providers and academics) seemed to agree that this approach was important. Service users provided positive feedback on the services. The pilot services reported among other aspects, reduced use of inpatient beds and accident and emergency departments. 9

10 More personality disorder services still need to be developed, particularly in some areas where very few exist. However, it is the case that more services now exist since the 2003 report was produced. It is possible to find details of personality disorder services at the National Personality Disorder website However, there is still no uniform approach to personality disorder in mental health services and some clinicians still do not even accept the concept of personality disorder. 9. Risks associated with personality disorder Personality disorders are associated with suicidal behaviour, although this varies considerably between the diagnoses. 12 People diagnosed as borderline or antisocial personality disorder may be at higher risk of suicide than other types of personality disorders. 13 There is also an association between personality disorders and deliberate self harm. 14 Because some personality-disordered people engage in impulsive and dangerous behaviour they have an increased mortality rate. Antisocial personality disorder is associated with a significant increase in unnatural causes of death (largely suicide, accidents and homicides). 15 Research consistently finds a strong association between personality disorders and substance misuse. Estimates vary widely as to the proportion of people with substance misuse problems who also have a personality disorder (and vice versa). Antisocial personality disorder and borderline personality disorder appear to have the strongest association with substance misuse. 16 There are many online support groups and plenty of information for people with a diagnosis of some personality disorders (particularly borderline) and for their carers but almost nothing for other personality disorders. Support and information comes in different forms and you may have the opportunity to chat online with other people with a diagnosis of personality disorder or who are caring for someone with personality disorder or leave messages on bulletin boards. You should always read the website instructions carefully as some messages could be distressing. National Personality Disorder Website provides information and resources relating to personality disorders, and supports the development of the National PD Programme. There is also a discussion forum. Web- Yahoo Health Groups has a number of online support groups, forums and information for different mental health conditions, including personality disorders - Wellness/ 10

11 Emergence is an organisation concerned with personality disorder. It is the result of a merge between Borderline UK and Personality Plus. The website still hosts information from both of these organisations. It also has information on how to join online groups (through Yahoo). Web- BPD World is committed to raising awareness and reducing the stigma of mental health with a focus on Borderline PD. It provides online information, advice and support and has an online forum. Web- Schizoid Personality Disorder yahoo group is a group for the safe support for people who suffer from the many "schizoid" disorders de Girolamo G. & Dotto, P. (2000) Epidemiology of personality disorders- in New Oxford Textbook of Psychiatry, vol. 1 M. G. Gelder, J. J. Lopez-Ibor, & N. C. Andreasen, eds., Oxford University Press, New York, pp Singleton N., Meltzer H., & Gatward R. (1998) Psychiatric morbidity among prisoners in England and Wales. Stationary Office, London. 3 Web- North East London Foundation Trust- Personality Disorder. As accessed at [Accessed August 2010] 4 Moran, P. (2002) The Epidemiology of Personality Disorders. Psychiatry. 1(1), Paris, J. (1996). Social factors in personality disorder- A biopsychosocial approach to etiology and treatment. Cambridge- Cambridge University Press 6 Perry, J. C. & Herman, J. L. (1993) Trauma and defence in the etiology of borderline personality disorder. In Borderline Personality Disorder- Etiology and Treatment (ed. J. Paris). Washington, DC- American Psychiatric Press. 7 Welch, S. (2007) Substance use and personality disorders. Psychiatry. 6(1), Moran, P. (2002) The Epidemiology of Personality Disorders. Psychiatry. 1(1), National Institute for Mental Health for England (2003) Personality Disorder- no Longer a Diagnosis of Exclusion. Policy Implementation Guidance for the Development of Services for People with Personality Disorder, Gateway Reference London- NIMH(E). 10 Crawford M., Rutter D., Price K., Weaver T., Josson M., Tyrer P., Gibson S., Faulkner A., Ryrie I., Dhillon K., Bateman A., Fonagy P., Taylor B. & Moran P. Learning the Lessons- A Multi-method evaluation of Dedicated Community-based Services for People with Personality Disorder. National Co-ordinating Centre for NHS Service Delivery and Organisation, Available at- http-// 11 Research Summary- Evaluating services for people diagnosed with personality disorder. National Co-ordinating Centre of NHS Service Delivery and Organisation. (November 2008) Available at Moran, P. (2002) The Epidemiology of Personality Disorders. Psychiatry. 1(1), Lesage, A. D., Boyer, R., Grunberg, F., et al (1994) Suicide and mental disorders- a case-control study of young men. American Journal of Psychiatry, 1 American Journal of Psychiatry 151 (7), Haw, C., Hawton, K., Houston, K., et al (2001) Psychiatric and personality disorders in deliberate self-harm patients. British Journal of Psychiatry, 178, Martin, R. L., Cloninger, C. R., Guze, S. B et al (1985) Mortality in a follow-up of 500 psychiatric outpatients. II. Cause- specific mortality. Archives of General Psychiatry, 42 (1), Welch, S. (2007) Substance use and personality disorders. Psychiatry. 6(1),

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