Posted by: carolg1849 | September 6, 2009

Royal College of Psychiatrists leaflet on PD

Another inormative leaflet. Most of the information is up to date , however its widely know now that Drug therapy is not the therapy of choice now, medication is best used only as temporary measures to help a person over a particular period and not continously.  

Personality Disorders

About this leaflet

This leaflet is for anyone who has been given a diagnosis of personality disorder – and also for their family and friends.

Introductionpersonality disorders_web

It’s not easy to pin down exactly what we mean by the word ‘personality’.  It seems obvious, but it is hard to put into words.  Part of the reason is that many of the words we use to describe people have wide meanings – and these meanings often overlap.

These words can cover more than one area of experience. ‘Anxiety’ describes the feeling of worrying, ‘nervousness’ describes the behaviour that others might notice if you feel like this. ‘Shyness’ describes the feeling of awkwardness with other people, but also the behaviour of being rather quiet in company.

It is also difficult because the way we appear to other people can be very different in different situations.  If you only know someone from work, you may see quite a different side to them if you meet socially.

However, in mental health, the word ‘personality’ refers to the collection of characteristics or traits that makes each of us an individual. These include the ways that we:

  • think
  • feel
  • behave

By our late teens, or early 20s, most of us have developed our own personality with our own distinctive ways of thinking, feeling and behaving. It remains pretty much the same for the rest of our life. Usually, our personality allows us to get on reasonably well, if not perfectly, with other people.

Personality disorder

However, for some of us, this doesn’t happen. For whatever reason, parts of our personality develop in a way that makes it difficult for us to live with ourselves and/or other people. It can be difficult to learn from experience and to change those traits – the unhelpful ways of thinking, feeling and behaving – that cause the problems. Unlike the changes in personality that can be caused by traumatic events, or an injury to the brain, these traits will usually have been noticeable from childhood or early teens.

You may find it difficult to:

  • make or keep relationships
  • get on with people at work
  • get on with friends and family
  • keep out of trouble
  • control your feelings or behaviour

 

If, as a result, you:

  • are unhappy or distressed

and/or

  • find that you often upset or harm other people

then you may have a personality disorder (see below for descriptions of the different types). Having a personality disorder makes life difficult, so other mental health problems (such as depression, or drug and alcohol problems) are also common.

Talking about personality disorder

There are different ways to describe mental disorders, and to put them into categories. The difficulty in describing any personality clearly, makes this more controversial with personality problems than with mental illnesses, such as depression or schizophrenia. Indeed, many people feel that it is unhelpful to ‘label’ personality difficulties in this way. However, although we are all individuals, certain patterns of personality problems do seem to be shared by fairly large numbers of people. By identifying these patterns, we can then develop ways of helping, and treatments that can be of use to many people, not just an individual. 

Personality disorder – a suitable case for treatment?

There is good evidence that people with the diagnosis of personality disorder have not received the attention they should have from mental health services. These services have focused mainly on mental illnesses, such as schizophrenia, bipolar disorder and depression. There has been some uncertainty about whether they have anything useful to offer people with personality disorders. Research has made it clear that mental health services can, and should, help people with personality disorders.

Different kinds of personality disorders

Research has shown that personality disorders tend to fall into three groups, according to their emotional ‘flavour’:

Cluster A:  ‘Suspicious’

Cluster B:  ‘Emotional and impulsive’

Cluster C:  ‘Anxious’

As you read through the descriptions of each type, you may well recognise some aspects of your own personality. This doesn’t necessarily mean that you have a personality disorder. Some of these characteristics may even be helpful in some areas of your life. However, if you do have a personality disorder, these aspects of your personality will be quite extreme. They may spoil your life, and often the lives of those around you. 

People may display the signs of more than one personality disorder. 

Cluster A: ‘Suspicious’

Paranoid

  • suspicious
  • feel that other people are being nasty to you (even when evidence shows this isn’t true) 
  • sensitive to rejection
  • tend to hold grudges

Schizoid

  • emotionally ‘cold’
  • don’t like contact with other people, prefer your own company
  • have a rich fantasy world

 

Schizotypal

  • eccentric behaviour
  • odd ideas
  • difficulties with thinking
  • lack of emotion, or inappropriate emotional reactions
  • can see or hear strange things
  • related to schizophrenia, the mental illness

 

Cluster B:  ‘Emotional and impulsive’

Antisocial, or Dissocial

  • don’t care about the feelings of others
  • are easily frustrated
  • tend to be aggressive
  • commit crimes
  • find it difficult to make intimate relationships
  • impulsive – do things on the spur of the moment without thinking about them
  • don’t feel guilty
  • don’t learn from unpleasant experiences

Borderline, or Emotionally Unstable

  • impulsive
  • find it hard to control emotions
  • feel bad about yourself
  • often self-harm, e.g. cutting yourself or making suicide attempts
  • feel ’empty’
  • make relationships quickly, but easily lose them
  • can feel paranoid or depressed
  • when stressed, may hear noises or voices

Histrionic

  • over-dramatise events
  • self-centered
  • show strong emotions, but which change quickly and don’t last long
  • can be suggestible
  • worry a lot about your appearance
  • crave new things and excitement
  • can be seductive

Narcissistic

  • have a strong sense of your own self-importance
  • dream of unlimited success, power and intellectual brilliance
  • crave attention from other people, but show few warm feelings in return
  • exploit others
  • ask for favours that you do not then return

 

Cluster C:  ‘Anxious’

Obsessive-Compulsive (aka Anankastic)

  • worry and doubt a lot
  • perfectionist – always check things
  • rigid in what you do
  • cautious, preoccupied with detail
  • worry about doing the wrong thing
  • find it hard to adapt to new situations
  • often have high moral standards
  • judgemental
  • sensitive to criticism 
  • can have obsessional thoughts and images (although these are not as bad as those in obsessive-compulsive disorder)

 

Avoidant (aka Anxious/Avoidant)

  • very anxious and tense
  • worry a lot
  • feel insecure and inferior
  • have to be liked and accepted
  • extremely sensitive to criticism

 

Dependent

  • passive
  • rely on others to make their own decisions
  • do what other people want you to do
  • find it hard to cope with daily chores
  • feel hopeless and incompetent
  • easily feel abandoned by others

What causes personality disorder?

The answer is not clear, but it seems that like other mental disorders, genes, brain problems and upbringing can play a part. There is evidence for the importance of:

 

Upbringing

  • physical or sexual abuse in childhood
  • violence in the family
  • parents who drink too much

If children are taken out of this sort of difficult environment, they are less likely to develop a personality disorder.

 

Early problems

Behaviour problems in childhood, such as severe aggression, disobedience, and repeated temper tantrums. 

 

Brain problems

Some people with antisocial personality disorder have very slight differences in the structure of their brains, and in the way some chemicals work in their brains. However, there is no brain scan or blood test for a personality disorder.

 

Things that make it worse

  • using a lot of drugs or alcohol
  • problems getting on with your family or partner
  • money problems
  • anxiety, depression or other mental health problems

Help

Treatment for people with personality disorders can be psychological (talking therapies) and/or physical (medication).

 

1. Psychological: talking treatments or therapies

 

  • Counselling – talking and listening.  This depends on a trusting relationship between the counsellor and the person counselled.
  • Dynamic psychotherapy – looks at how past experiences affect present behaviour. 
  • Cognitive therapy – a way to change unhelpful patterns of thinking.
  • Cognitive analytical therapy – a way to recognise and change unhelpful patterns in relationships and behaviour.
  • Dialectical behaviour therapy – this uses a combination of cognitive and behavioural therapies, with some techniques from Zen Buddhism.  It involves individual therapy and group therapy. 
  • Treatment in a therapeutic community – this is a place where people with long-standing emotional problems can go to (or sometimes stay) for several weeks or months. Most of the work is done in groups. You learn from getting on – or not getting on – with other residents. It differs from ‘real life’ in that any disagreements or upsets happen in a safe place. The staff and other residents help you to get through such problems and learn from them. Users/residents often have a lot of say over how the place runs, but have to be prepared to stay and work through difficult periods.

 

2.  Physical

 

Medication can help in some personality disorders. 

 

Antipsychotic drugs (usually at a low dose)

  • Can reduce the suspiciousness of the three cluster A personality disorders (paranoid, schizoid and schizotypal).
  • Can help with borderline personality disorder if people feel paranoid, or are hearing noises or voices. 

 

Antidepressants

  • Can help with the mood and emotional difficulties that people with cluster B personality disorders (antisocial or dissocial, borderline or emotionally unstable, histrionic, and narcissistic) have.
  • Some of the selective serotonin reuptake inhibitor antidepressants (SSRIs) can help people to be less impulsive and aggressive in borderline and antisocial personality disorders.
  • Can reduce anxiety in cluster C personality disorders (obsessive-compulsive, avoidant and dependent).

 

Mood stabilisers

Medication such as lithium, carbamazepine, and sodium valproate can also reduce impulsiveness and aggression. 

 

These medications and treatments also help if someone with a personality disorder develops depression or schizophrenia.

 

The type of therapy offered depends on:

  • individual preference (of the patient/service user);
  • the type of personality disorder;
  • the availability of the treatment in that geographical area.

 

If you have a personality disorder, you may not need treatment at all – but you might find medication or talking treatments helpful, and sometimes both.  Admission to hospital usually happens only as a last resort (e.g. when a person with borderline personality disorder is harming themselves badly) and for a short time. A lot of the help that was once only offered in hospital wards is now available in day centres or clinics.

How common are personality disorders?

  • About 40-70% of people on a psychiatric ward will have a personality disorder.
  • 30-40% of psychiatric patients being treated in the community by a psychiatric service will have a personality disorder.
  • Around 10-30% of patients who see their general practitioner (GP) will have a personality disorder.

Do personality disorders change with time?

Yes. There is evidence that they tend to improve slowly with age. Antisocial behaviour and impulsiveness, in particular, seem to reduce in your 30s and 40s.

It can, however, sometimes work in the opposite direction. For example, schizotypal personality disorder can develop into the mental illness schizophrenia.

Do interventions/treatments work?

There is evidence for both psychotherapies and medication, but it is weak because:

  • the interventions are usually quite complicated, so it is difficult to know what part (or parts) of the intervention are actually having an effect;
  • the number of participants is usually small;
  • the ways of measuring improvement are poor;
  • the studies into interventions and treatments have mostly been quite short.

Living with personality disorder

People with a personality disorder, just like anyone who has mental health difficulties, can be stigmatised because of their diagnosis. They can attract fear, anger and disapproval rather than compassion, support and understanding. This is both unfair and unhelpful. Personality disorder is a real problem that demands real help. We can all help by extending our friendship, support and understanding, rather than our judgement and discrimination, to people with a personality disorder.

Self-help

  • Try to unwind when stressed – have a hot bath or go for a walk.  You may find yoga, massage or aromatherapy useful.
  • Make sure you get a good night’s sleep – but don’t get too upset if you can’t sleep.
  • Look after your physical health and what you eat.  You’ll feel better on a balanced diet, with lots of fruit and vegetables.
  • Avoid drinking too much alcohol or using street drugs.
  • Take some regular exercise.  This doesn’t have to be extreme.  Even getting off the bus one stop early, and walking the rest of the way can make a difference.
  • Give yourself a treat (although not drugs or alcohol!) when things are difficult or you have coped at a stressful time.
  • Take up an interest or hobby. This is a good way to meet others and take your mind off the day to day stresses that we all face.
  • Talk to someone about how you are feeling. This could be a friend or relative or, if preferred, a therapist or counsellor.  If you don’t have access to a counsellor or therapist, then try your general practitioner (GP). 
  • Looking for information on the internet is a good resource (see further information).
  • If things get really tough, try phoning the Samaritans (see further information).

Living with someone who has a personality disorder

You may worry about the effects the personality disorder is having on them, and maybe on your life too. How would they react if you talked to them about it?

 

If they take your worries seriously, find out some more information, perhaps from the sources at the end of this leaflet. Even if they don’t see a problem at the present time, they may do in the future. 

 

Day to day living with someone who has a personality disorder can be difficult – but it isn’t always difficult.  Giving people their own space, listening to and acknowledging their concerns, and involving others (friends, relatives and, at times, mental health professionals – nurses, therapists or doctors) can all be useful. It is also important to look after your own physical and mental health.

 

Further Information

Mind

Mind is a leading mental health charity in England and Wales and has extensive information on personality and personality disorder.

 

National Personality Disorder Website

This provides information, resources and learning opportunities for those with a personality disorder and their carers.

 

Borderline UK

This is a national user-led network of people within the United Kingdom who meet the criteria, or who have been diagnosed with borderline personality disorder.

 

Scottish Personality Disorder Network

Contains information about the network set up by the Mental Health Divison, and provides information about the services available for those with personality disorders in Scotland.

 

The BBC’s Health Website

Contains articles on personality, personality difficulties and personality disorder.

Samaritans

Helpline: 08457 90 90 90, R.O.I: 1850 60 90 90; email: jo@samaritans.org

Samaritans is available 24 hours a day to provide confidential emotional support for people who are experiencing feelings of distress or despair, including those which may lead to suicide. The website has helpful information about stress and self-harm.

 

Rethink

Rethink is a leading national mental health membership charity and works to help everyone affected by severe mental illness recover a better quality of life.  Has information on personality and personality disorder.

 

The ‘Mental Health Shop’

This is an online resource for mental health publications, leaflets, booklets, videos and DVDs.  Has information on personality and personality disorder.

 

Aware

Assists and supports those suffering from depression (which can occur in those diagnosed with a personality disorder) and their families in Ireland. A helpline is available as well as support groups, lectures, and current research on depression.

 

Personality disorder: No longer a diagnosis of exclusion” (published by the National Institute for Mental Health in England). Free to download at:www.personalitydisorder.org.uk/assets/Resources/56.pdf

This gives detailed information on personality disorder, current available treatments and services, and future plans. It also discusses the minority of those with a personality disorder who have committed a crime, and services available for them.

 

References

American Psychiatric Association (1994) Diagnostic and Statistical Manual of Mental Disorders (4th edn.) (DSM-IV). Washington, DC: APA.

Bateman, A. and Fonagy, P. (1999) The effectiveness of partial hospitalisation in the treatment of borderline personality disorder – a randomised controlled trial. American Journal of Psychiatry, 156, 1563-1569.

Bateman, A. and Tyrer, P. (2004) Psychological treatment for personality disorders. Advances in Psychiatric Treatment, 10 (5), 378-388.

Bateman, A. and Tyrer, P. (2004) Services for personality disorder: organisation for inclusion. Advances in Psychiatric Treatment, 10 (6): 425-433.

Coid, J. (2003) Epidemiology, public health and the problem of personality disorder. British Journal of Psychiatry, 182 (suppl. 44) s3-s10.

Coid, J. et al. (2006) Prevalence and correlates of personality disorder in Great Britain.  British Journal of Psychiatry, 188, 423-431.

Hill, J. (2003) Early identification of individuals at risk for antisocial personality disorder. British Journal of Psychiatry, 182 (suppl. 44) s11-s14.

Kendell, R. (2002) The distinction between personality disorder and mental illness. British Journal of Psychiatry, 180, 110-115.

 

Tyrer, P. (ed.) (2002) Personality Disorders, Psychiatry, Volume 1:1 March 2002, The Medicine Publishing Company Ltd.

 

Tyrer, P. and Bateman, A. (2004) Drug treatment for personality disorders. Advances in Psychiatric Treatment, 10 (5): 389-398.

 

Tyrer, P. et al. (2007) Critical developments in the assessment of personality disorder.  British Journal of Psychiatry, 190 (suppl. 49), s51-s59.

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