Personality disorder often appears as a vague and nebulous construct to many people. But first the author thanks two bright student nurses ‘L’ and ‘T’ for stimulating this post which was already on the way.  I consider an entire range of things related to personality disorder. This article was followed up by A Closer Look at Personality Disorders on 10/05/2024, which built on concepts here.

As I am not limited by a word count, this post will be very long.

Table of Contents

• Introductory remarks
  • Diagnostic Considerations
  • Specific personality disorders
• What is (not) personality disorder?
  • Misunderstandings
  • Difficulties in the concept
• Treating PD
  • Complexity
  • Bias or Parity
    • Symptom improvement or relief
    • Fluctuating course – digging deeper
    • Treatment parity
  • Medication
• Stigma and labelling
• Risk Management
  • Risk precipitation
  • Risk control
• Teamwork
  • Education & Reflection
• Key points
• Supplemental References

Introductory remarks

All of this post is based on individual professional knowledge and experience over 20 years. The contents may vary in parts, significantly from what is in standard textbooks and teachings – as well as the contents may cohere well with what is in books, teachings, and psychiatric literature. If you are in training or a course, give only the answers that are required in your assessments (assignments or exams). At the end of this post will be a list of supplemental articles.

Personality disorder is a broad category of diagnoses. It covers specific personality disorders, non-specific, and acquired types.

I reluctantly abbreviate ‘personality disorder’ to PD in this post. The reasons for my hesitance have relevant historical foundations:

1. PD used to mean ‘psychopathic disorder’ (abbreviated here as PsyPD) which was a legal diagnosis in the MHA 1983, before it was amended in 2007.
2. But pre-1983 PD, was still taken to mean personality disorder though it was often conflated with ideas about PsyPD.
3. PsyPD – was truly a legal diagnosis in the way it was defined in law.
4. The term borrowed from some social and clinical concepts of psychopathy, which itself is not a clinical diagnosis.
5. Psychopathy is still, even today, a social construct that has been ‘medicalised’ in part into clinical diagnoses of antisocial personality disorder (or dissocial personality disorder).
6. Pre-1983 PsyPD was held to be untreatable in England & Wales.
7. But then the government created Dangerous Severe PD (DSPD) – which again was a ‘politically’ driven diagnosis. Millions were wasted developing DSPD services. Those were eventually shelved years later, and nobody heard anything more about it.
8. Attitudes about PsyPD contaminated the clinical treatment of PD. This persists today.
9. PD was always known in the sciences to be treatable.
10. But pre-1983 and even today the big unseen issue is ‘mental illness or PD?‘ even when the law does not make that distinction anymore.

What is (not) personality disorder?

People often come to a topic based on what they picked up – from some lecture or expert, and the mysterious ‘they’. What ‘they say’ is so important for many things but particularly important in mental health circles. ‘They’ often mislead lay persons and professionals.

Misunderstandings

Not everybody has a personality disorder. I have heard on several occasions non-psychiatrist professionals saying, ‘everybody is personality disordered‘. That is 100% wrong. Why? Because the scientific literature says that roughly 10% of people have PD – and 2 to 4% have antisocial PD. To put that in context, the prevalence of schizophrenia is only about 1%.

There is a general sense coming from what ‘they say’, that people with mental disorders are dangerous. There are tons of media headlines which catch attention about individuals suffering with mental disorders, who committed serious crimes (like murder).  The general public is not too interested in diagnosis; only that they get ‘locked away’. Headlines about people with PD committing heinous crimes have also become more common. The effect of that is to magnify perceptions about the size of the risk. A majority of the lay public and mental health professionals do not know that most serious crime is caused by alcohol and substance misuse. And the general public often thinks that all alcohol and drug problems are ‘mental disorders’. Some are and some are not.

Difficulties in the concept

The concept of PD is very large and not easy to keep in memory. There must be evidence for patterns of disturbance in a set of domains that impact in several other domains. Finding all that – if they fit the criteria – is not an easy job. This is not as simple as diagnosing schizophrenia. In PD diagnosis there is a need to satisfy some 50 descriptors. There is no medication to give that can just clear up all the patterns.

A few months ago, I was giving evidence as a professional witness at a Tribunal for one of my patients. The Medical Member kept on asking me about symptoms of personality disorder. I became distressed because I could not believe what I was being asked about. I am meant to be polite at these legal proceedings so I did not point out the doctor’s lack of understanding and knowledge of the concept of personality disorder.  Now with experience, if that happens again, I will declare, “Personality disorder has nothing to do with symptoms because ICD-10 and ICD-11 says so. I cannot answer the question as asked.” [BTW all doctors are taught that a symptom is a feature of the condition observable by the patient, and a sign is what is noticed by an observer. A symptom can be a sign only when patient and observer notice the feature. Elevated blood pressure among most people is not a symptom – it is a sign. People cannot feel 140/90 or differentiate that from 150/100. Why? That is a measure by an observer – someone taking the blood pressure.

The point in the above paragraph is that few individuals with a personality disorder will find a psychiatrist and complain about features of PD that they experience. Most of PD is therefore ‘signs’ i.e. patterns observable by a trained diagnostician.

Lack of education affects recognition, diagnosis, and treatment attempts. Staff in many services have been heard over the years saying almost these exact words, “She’s not mentally ill. It is behavioural!” When one looks at the definition or description, it is predominantly behavioural. It is the patterns of thinking, emotional expressions and behaviours that define the concept.

On two occasions I recall staff saying, “He’s not PD. He’s pure evil!” The general public will be unaware of the things said behind closed doors.

Because the nature of the concept is so complex:

1. PD is widely misdiagnosed or poorly diagnosed.
2. The main reason for the above is that ‘people’ do not apply the diagnostic criteria properly.
3. Most PD in everyday practice of psychiatry is about the ‘specific types’ (e.g. borderline, narcissistic etc)
4. There are ‘non-specific’ types in ICD-10 that are often not considered but are equally or more debilitating.
5. No one can be properly diagnosed with a specific type of PD without meeting the General Criteria for PD. ICD-10 says so. ICD-11 keeps the same high standard.

Treating PD

In this part I am talking mostly about inpatient treatment of PD. Outpatient treatment is normally for the milder cases. Inpatient treatment usually requires more than about 2 years.

There is not one ‘treatment for PD’. There is no sound evidence that medication works for the range of specific personality disorders or the non-specific mixed PD. See CG78 NICE guidance https://bit.ly/NICE-CG78-treating-borderline-pd. Patient’s with PD are often ‘drugged up’ (aka polypharmacy) on the grounds of symptomatic treatment (which is unlicenced treatment). From the full guidance, NICE states, “No psychotropic drug has specific marketing authorisation in the UK for the treatment of borderline personality disorder, although some are licensed for the management of individual symptoms or symptom clusters. This means that recommendations for specific pharmacological interventions would be for off-licence indications.“

Para 94 of GMC Prescribing Standards apply: “When you review a patient’s medicines, you should reassess their need for any unlicensed medicines (see paragraph 103 to 106) they may be taking, for example antipsychotics used for the treatment of behavioural and psychological symptoms in dementia.“

It is great to know that a range of psychological treatments can be used e.g. psychoeducation, CBT, DBT, RET, CAT, SCM, Schema Therapy, Mindfulness, Trauma focused therapies, and a whole bunch more. This is like the dozens of antipsychotics that can be used to treat schizophrenia. The problem is the same though – finding the right therapy to match the individual patient. But the ‘pill’ – by analogy in PD (meaning therapy) – and the person handing out the ‘pill’, are the therapist or therapeutic group. Basically ‘the pill’ and the therapist are one. The quality of the ‘pill’ and its delivery become very important factors. Assessing the quality and efficacy of ‘the pill’ in treating psychosis is pretty easy business. Assessing the ‘pill’ (therapy) in treating PD is not easy. It takes a long time, and one cannot chop and change like with pills for schizophrenia.

Therapists tend to become ‘judge and jury’ after being the ‘pill and pill-giver’, for the efficacy of the treatment they supply. I know of a situation it the last 3 years where a group of psychologists delivered a violence reduction treatment that was well established in research literature, as good. The efficacy of the treatment delivered was questioned because several patients coming out of the programme showed no improvement and continued with violence as if they never had the treatment. I cannot go into details here but trust me there was good evidence for lack of efficacy. Recognition of lack of efficacy took about 2 years and cost probably over £200,000. More importantly, where did that leave the patients? No further forward. The psychologists believed they did a respectable job of delivering the treatments, but the problem was the evidence said otherwise. By analogy, it is no good psychiatrists saying, “We gave the right pill – it is in the research.”, but the pill does not do the job. The latter is not an overgeneralisation from a single example.

In most psychological treatments delivered for PD, objective rating scales are rarely used to gauge what parts of disturbed functioning are actually improving. In research centres these are used. In clinical practice improvement usually means more settled behaviour or less extreme patterns of expression across the main domains in the diagnostic criteria. There are real problems and confounding factors with this. Read on.

Complexity

PD is almost never pure PD. Look left. It is not easy to spot NPD/DisPD in that picture.

Inpatients often suffer with one or more comorbid conditions such as substance misuse/dependence disorders, anxiety disorders, depression, psychoses, ADHD, PTSD and even autism. Many PD patients often suffer with one or more co-morbid physical conditions e.g. diabetes, lung problems, back problems, scarring from years of self-harm or longstanding physical disability from broken/disfigured limb(s) following failed suicide attempts. PD cannot be treated in isolation. So – it is like having a patient with chronic fatigue syndrome (CFE), morbid obesity, heart failure, and COPD. You cannot just say ‘Right we’ll treat the CFE and that’s that.’

ADHD co-existing with PD is problematic. Practical experience has informed me that those with ADHD tend not to process well what is to be learned from psychological therapies. Some patients with ADHD will not accept treatment for that condition. In those cases, psychological treatment will be expected to have low traction and low gain.

Bias or Parity

Symptom improvement or relief

Does improvement based on clinical observations mean improvement of the condition? Some will say a resounding ‘Yes’. I will say a resounding ‘No!’ Again I must return to analogies in treating other medical conditions – and PD is a medical condition,  make no mistake. Think ‘personality disorder’ in looking at the following.

Starting off with headaches – whilst these may be seen as a medical condition they are not diagnoses. Most headaches are uncomplicated; without an underlying medical condition. Even a headache caused by a hangover, is not something you would pitch up in A&E about. A few home remedies and some painkillers will sort that out. Symptom relief is not treating a medical condition – it is treating the symptom. If however, a person has headaches that are due to DTs (delirium tremens); now that’s serious. Pain killers may dull the headache a bit, but it they’re not going to treat the underlying condition. Migrainous headaches are a medical condition that can be caused by several underlying disorders.

So let us take another example – and this sort of example happens every day. [If I say ‘you’, I do not mean you who reads this]. You suffer an attack of severe chest pain and breathlessness. You do not collapse. You are admitted to hospital because the doctors are worried. After a few tests, a consultant doctor tells you that you have a severe attack of variant angina. A couple of injections and an hour’s worth of oxygen and you feel better. After 3 hours you thank the doctor and say “Hey doc! That’s great treatment. I feel like new again. I need to get home now. Thanks for an excellent job!” The doctor advises 24 hours more observation in hospital and a few more tests. He also recommends some new pills which you should start while in hospital, whilst having the tests. You go, “No doc. I’m good. I’ll come back to outpatients for follow up.” Against medical advice you sign out and depart on your feet at a reasonable pace. Two days later, in getting ready to go to the outpatient appointment you collapse in serious chest pain. Someone is there to call an ambulance. After some first aid they rush you to hospital with blue lights on. You then have a cardiac arrest in A&E, and they pump your chest for 30 mins. They brought you back. You awake in ITU feeling like a real plonker.

What happened there is that you believed that rapid symptom reduction was good treatment. You do not know what’s what and you were hasty to get home instead of listening to medical advice. The doctor knew of the seriousness of your condition, although it is your body. The temporary reduction in symptoms was not the full treatment and investigation. Some will say the above is a bad example for an analogy. Of course it is. There are no good examples in ‘physical medicine’ that closely matches personality disorder for an analogy.

Settled behaviour based on mere clinical observations over a few months could be the result of a lot of support from very good staff. A familiar environment and a set of routines may have contributed. So, it should be no surprise that the patient with PD would settle. But take away the scaffolds of all that care – how will the patient react?

Fluctuating course – digging deeper

There are several physical conditions with that can present with a fluctuating course, which lead to people being admitted to hospital e.g. complication of diabetes, respiratory system, cardiac disease, kidney problems etc. The fluctuating course itself means the body is struggling to correct itself, and it is probably losing. But with mental disorders people do not seem to recognise that the fluctuations mean something serious. Delirium is a serious physical and mental condition. It is a diagnosis but the underlying causes in any one case are to be discovered and treated.

Doctors treating serious physical problems often aim to get the central pathology treated. If it was a cancer, you do not just want the lump being removed. You want every bit of spread – say into lymph nodes – being targeted. Likewise with personality disorder the treatment(s) should get to the source of the pathology. Where and when did that start? It started earlier on in life, usually in adolescence. Brain circuits regulating emotions and reactions to stress may have been laid down. We cannot see those, but they are there in the microstructure and chemistry of the brain. When I say ‘circuits’, people will probably have images in he mind of bundles of electrical wires, or bundles of fibres in the brain. Whilst the brain has those bundles, ‘circuits’ in the brain do not just mean fibres. The brain forms chemical microcircuits. This can be understood from Long Term Synaptic Potentiation. LTSP is not just a model. It is real and explains emotional, cognitive and behavioural patterns (akin to memory) of responses. At this point one should recall that the latter three are majorly disturbed in personality disorders.

Emotions lay down pathways and potentiations for the future in the brain (which is the seat of the mind). Those potentiations in turn will shape how the individual learns, pays attention and reacts. See The Influences of Emotion on Learning and Memory – which is just skimming the surface.

So what does any of the above have to do with fluctuations? Emotions fluctuate – that’s basic. And where there are pathways that are primed for dysfunctional reactions we can expect more extreme fluctuations. What are emotions? Read it in the article again.

Emotions are the psycohoneural processes that are influential in controlling the vigor and patterning of actions in the dynamic flow of intense behavioural interchanges between animals as well as with certain objects that are important for survival. Hence, each emotion has a characteristic “feeling tone” that is especially important in encoding the intrinsic values of these interactions, depending on their likelihood of either promoting or hindering survival (both in the immediate “personal” and long-term “reproductive” sense). Subjective experiential-feelings arise from the interactions of various emotional systems with the fundamental brain substrates of “the self,” that is important in encoding new information as well as retrieving information on subsequent events and allowing individuals efficiently to generalise new events and make decisions.

Deep in the microstructure of chemical pathways we can ‘find’ the priming for responses. Those responses were originally laid down early on, to adapt to particular environments and circumstances. When the PD affected individual comes into perceived similar circumstances the pathways become activated. Often times they are overactivated. That may cause emotional and behavioural reactions that are extreme e.g. self-inflicted harm – like cutting or head banging. The individual is supported/counselled by hospital staff and that settles in a reasonable time. In other words the pathways flare up and overreact, then ‘environmental’ changes come in to sooth. But the current stressors that precipitated reactions, were not the similar degree to when they were laid down. The individual can recognise that in a proportion of cases. They too can exert some degree of control – whilst being assisted by trained staff. All that accounts for the fluctuation. There are of course other things – I’m only able to give a few ideas here.

Settling of a patch of disturbance could mean that the deeply etched pathways of responses are calmed down. This could last days or even weeks. But what about those pathways and potentiations? Those still remain. That is where the real pathology lies. So how do ‘we’ fix those pathways?  Can we fix them at all? Those should be the real questions. What I mean is that symptom improvement in fluctuations should not simply be seen as improvement in the core pathology of personality disorder.

Treatment parity

Treatment with psychological therapies therefore must go very deep to re-adjust the responses that led to expressions of patterns in the diagnostic criteria. That is no easy job. It is possible that pathological pathways in the microchemistry of the brain can never be repaired. We can’t see them anyway. So what’s next?

Returning to physical conditions for analogies – the body reacts and adapts to things that can’t be fixed. It can develop callouses. It can form scar tissue to wall off and strengthen certain structures and intrusions. Likewise in the psyche of the individual, if we can’t fix the pathways that led to flare-ups, we can still assist them to find ways to make helpful counter responses i.e. helpful controlling responses.

Schema Therapy(ST) digs deep and provides individuals with alternative ways of managing deeply etched response-pathways. But that doesn’t mean you just stick someone into ST and expect improvement. A word of caution: for any therapy what matters a whole lot is the quality of delivery. That depends on the skill and experience of the therapist or therapeutic group. Improvements have to be carefully and objectively monitored and assessed, to avoid therapists becoming their own ‘judge and jury’; afflicted by various biases.

Medication

The most polypharmacy I see is among PD patients – even though NICE has warned about medicating PD patients. How is this ‘allowed’? Big questions to think about.

I have seen more patients made unwell by polypharmacy in the treatment of PD than those who have benefitted from medication.

From my observations this happens because of the following:

1. Lack of understanding of PD.
2. Poor training.
3. Symptomatic treatment i.e. throwing in a bit of mood stabilisers when affective dyscontrol is seen as a partial mood disorder, or throwing in some antipsychotics when there is the appearance of psychotic or quasi-psychotic symptoms.

Medications for the treatment of mental disorders, are not licenced for treatment of symptoms. Many of my psychiatrist colleagues will argue differently.

There are three cases I can recall which I inherited from other doctors, on polypharmacy. In each of them, my plan to reduced the cocktail and stop it, led to improvement.

In many other cases I have not been able to reduce the polypharmacy. The reasons for that are complex. Both staff and patients become terribly anxious about reducing medication for fear of breakout of ‘symptoms’ as they would see it.

Medications can be used to manage comorbid conditions such as schizophrenia.

Depression can similarly be treated. However, separating depression from PD is no easy task.

Stigma and labelling

All mental disorders carry some degree of stigma. This varies on a spectrum. Though stigmatising diagnoses such as Autistic Spectrum Disorder and ADHD are in some degree of demand. What I mean by that, is that there is a rush of self-referrals and professional referrals for assessments. This may not be seen in inpatient services, but it is there. PD and schizophrenia are in low demand. Very few want to have those diagnoses. Both of them are associated with the proverbial ‘axe-wielding’ types often seen in tabloid headlines. That’s how those diagnoses become stigmatised. I do not wish to go much further than that, as the scope of this publication is not mainly about stigma.

The big problem with PD (and schizophrenia) is insight and self-awareness. Most people with PD do not know they ‘have it’. Recall that the prevalence of PD is around 10% compared to 1% for schizophrenia. Most PD is not ‘picked up’. PD usually comes to attention after risk to self or others becomes pretty serious. You do not have people voluntarily queuing up for PD assessments. I’ve never seen that, in the UK.

Self-awareness and insight are hard to come by, because the criteria are about patterns (not symptoms) over a broad time frame in several domains.

PD diagnoses are ‘sticky’. Once it is properly diagnosed you do not have PD today and not have it 2 years later. Antisocial, borderline and narcissistic PD are particularly sticky. So these appear to be labels, or be taken as labels. The labelling issue I think arises from the ‘antipsychiatry movement’ with its subtle influences working on professionals.

The worst kind of stigma is that coming from staff who are poorly trained. This is mentioned above e.g. “He’s not PD. He’s pure evil!” or “She’s not mentally ill. It is behavioural!“

Risk Management

The big picture is that about 80 to 90% of suicides will be committed by people with mental disorders in high-income countries such as the UK.

One can never escape risk when treating PD inpatients. Suicide occurs in about 10% of borderline PD cases.

It is difficult to say much about risk to others here because that is a huge PhD thesis in itself.

Forensic history and patterns of risk to others in particular circumstances are relevant.

Risk precipitation

I’m borrowing from weather and climate studies in this part. One need not be a meteorologist to grasp some of this. In winter there is a greater chance of precipitation of rain, sleet, hail and snow compared to other seasons. Everybody knows that. History has shown us these weather patterns, and what the probabilities are.

Similarly for all patients including PD patients, the patterns in their forensic history sets the ‘climate’. You do not know when risk will precipitate on any day or week. You’re not a fortune teller, in this business. It is not your job.

And like with the weather on particularly cold days with lots of cloud cover you can expect precipitation. Similarly on ‘cold and dark days’ persisting in the mood of a patient, expect trouble if suicide or violence were big parts of their history. What do you do? You do something to avoid precipitation.

Risk control

Again I return to analogies in the physical world. If you’re driving a car in winter on a winding road and the temperature outside is around 4°C or less, you ought to know to take it easy on the pedal. If you’re crossing a busy road, cross at a working pedestrian crossing, and if there is none then take adequate precautions to look and listen etc. That is the basics of risk control. You need to get your timing right.

And like swinging a racket at a tennis ball, you risk missing the ball if you swing too early or too late. You discover how early or late after you miss the ball.

But with personality disorders, teams often cannot see the nebulous ‘balls of risks’ emerging and if they do, they often struggle to react in time. Some workers are scared to overreact, or to be ‘seen to be overreacting’.

A problem to avoid is becoming too specific about risk. What do I mean? If a PD patient has a history of using weapons does it matter that they have never used a dinner fork on anyone? It matters not. Focusing on the use of a dinner fork is too specific.  I say that in a particular upheaval of disturbance (not necessarily reaching violence), the ‘risk control racket’ has to be wider, to catch the ‘risk ball’ that may be small but carrying serious potential consequences (like a fork in the eye). That sort of approach no doubt raises concerns about offending the so-called ‘least restrictive principle’. It does not, if protective controlling measures are carefully reasoned and proportionate. I did not say that everybody who has a history of using weapons should be given plastic cutlery.

If there are early warning signs about affective instability and there is a history of suicide, be vigilant. If it is getting worse, do something. Waiting for an event to happen means missing the ‘risk ball’.

Substance misuse in PD cases is a ‘red flag’. Many substances – legal or illegal – tend to destabilise PD and disinhibit those patients. But recalling that most PD is not pure PD, substances can ‘upset’ any fragile stability achieved in co-morbid mental disorders. So watch out! Do something.

It is no good just knowing the risks. Risk management in PD cases should be about risk control.

Teamwork

I am not going to explore what is good or bad components of teamwork. What I will say is that good teamwork is absolutely essential for making a difference for personality disordered patients.

Teams are at risk of poor communication and consistency of therapeutic working together.

Team and individual burnout are ever present risk factors.

Teams can become divided on issues such as readiness for discharge or transfer. Some members of a team may be considering short term improvements. Others may be considering hard evidence of enduring change in aspects of personality disorder that point to risk reduction.

All teams treating PD patients are at risk of divisions, splitting, polarisations, deviations and so on.

Sound team management, oversight and insight are essential. Team managers cannot wait for teams to develop dysfunctions.

Education & Reflection

Education and knowledge about PD in teams may be quite different. In psychiatry doctors can specialise is forensic psychiatry. Most nurses and psychologists are not so specialised. The knowledge gap between forensic psychiatrists and others in a team can be significant. Where there are such gaps, differences in ways of working and perspectives can significant. That can lead to all sorts of divisions.

Teams need to be on the same page in terms of knowledge base. Skill and experience will always differ.

Reflection is an important part of learning and education. Individuals and teams can learn from mistakes. They need a lot of support to do that.

In-house led reflective practice is seen as good. I do not see it as good because it sets the stage for development of groupthink. Teams are almost never aware of the extent of their own groupthink.

The best reflective practice I have been involved in was led by an external facilitator.

Key points

1. An understanding of personality is important to understanding personality disorder.
2. The application of diagnostic criteria for personality disorder should be a scientific evidence-based exercise, carried out by clinicians with sound knowledge, skill and experience.
3. Personality disorder can change in its manifestations over time. It is expression can fluctuate over hours, days, weeks or months.
4. Short term periods of improvement should not be taken as improvement of personality disorder.
5. Personality disorder often sits alongside other mental disorders in the same individual. It should not be treated in isolation.
6. Medications for PD should be avoided.
7. Risk management should be about risk control.
8. Sound teamwork is essential to treating most inpatients with PD.

Supplemental References

1. ICD-10 DCR – green book.
2. ICD-11 Personality Disorders: Utility and Implications of the New Model
3. ICD-11 CDDR.
4. A good read that includes the history of borderline personality disorder A Life Span Perspective on Borderline Personality Disorder
5. Serious Mental Illness and Homicide
6. Homicide and major mental disorder: what are the social, clinical, and forensic differences between murderers with a major mental disorder and murderers without any mental disorder?
7. Psychiatric Illness And Criminality