"The meeting of two personalities is like the contact of two chemical substances; if there is any reaction, both are transformed." - Carl Jung

Know somebody that you just cannot get on with? Does their behaviour irritate and confuse you? Are they generally a massive pain in the distal digestive tract? There is always the possibility that they have a personality disorder. If, however, everybody you know seems like this...maybe you do!

So, what is a personality disorder?

Good question.

The ICD 10 (the Bible of psychiatry favoured in the UK) defines it as: "[a condition that comprises] deeply ingrained and enduring behavioural patterns, manifesting themselves as inflexible responses to a broad range of personal and social situations. They represent either extreme or severe deviations from the way the average individual in a given culture perceives, thinks, feels, and particularly relates to others. Such behaviour patterns tend to be stable and to encompass multiple domains of behaviour and psychological functioning. They are frequently, but not always, associated with various degrees of subjective distress and problems in social functioning and performance."

Sorry. I dozed off then. What did you say?

Yeah, fair enough. It's a bit wordy, isn't it? For the layman - in essence, a personality disorder is when a person has deeply ingrained, pervasive flaws in their personality. It develops from adolescence, and to varying extents, it is there for life. It affects almost all aspects of their lives and relationships. It can lead to repeated problems at work, and turbulent, strained interactions with friends, partners and relatives. The sufferer may lack insight, but the "average individual" (ICD 10's words, not mine) would find severe faults in their character. Usually, people close to the sufferers suffer themselves. They may avoid contact, or may only have difficult, fractious interactions.

So, is it a mental illness?

Absolutely not! Whereas a mental illness is a change in somebody's normal state, personality disorders are ingrained. They dwell in the very fibre of that person's essence. Potentially mental illnesses can be reversed (though rarely cured) with medication, therapy and care. Ideally with a combination. A tablet that can change a person's personality is about is feasible as a tablet that can solve world poverty. Co-morbid anxiety or depression might be relieved by medication, but the personality disorder itself will always be there. Therapy and time might help sufferers mellow out. I'm sure that age has also mellowed out many an anarchistic punk rocker, or a moody sarcastic goth into...your average, tubby, middle-aged bank manager.

Is it really that important?

Is what?

The distinction between mental illness and personality disorder.

Absolutely. Without it, psychiatrists such as myself could be inadvertently medicating, treating, and even more egregiously, detaining somebody for the wrong reasons. Many times in my career, I've seen people incorrectly being treated for depression, anxiety, and even schizophrenia when they had a personality disorder. However, it was not necessarily incompetence that led to misdiagnosis - inevitably symptoms relating to feelings, emotions, reactions, beliefs, thoughts and behaviours, can be extremely difficult to assess, especially if the patient is particularly agitated, pugnacious or deceitful. You'd be surprised at how many people fake symptoms of psychosis for medication or for hospitalisation. It can take months, even years, of observation and assessments to reach the final corollary of a diagnosis of personality disorder.

Treating somebody for a mental illness, when they actually have a personality disorder, not only gives doctor and patient false hopes and unrealistic expectations, but wastes valuable time that could have been used in therapy, teaching the patient how to adapt their behaviour for their own benefit, as well as for the benefit of people close to them.

Sounds like a diagnosis of personality disorder is pretty serious

Yep. Sadly, the label of "personality disorder" can be used by lazy or inexperienced health-care professionals as an alternative moniker for "difficult patient" when communicating with other lazy or inexperienced health-care professionals. This can lead to people assuming that people with personality disorders are demanding, aggressive, malingering, or time wasting. It can lead to patients who are in crisis to be ignored or discharged prematurely.

One could argue that the label is detrimental to the person's health. My view is that it can be, potentially, but not if it is discussed and explained to the patient, the condition is monitored, and treatment is offered. Treatment should never be forced, but always offered - it is morally wrong to insist somebody needs to change who they are. The exception to this would be life-threatening situations, such as a high risk of suicide.

Despite this, to my surprise I found out that the diagnosis of personality disorder can actually be enlightening and useful for some people. I remember seeing a young woman as an outpatient when I worked in Australia. She had a very chaotic and turbulent lifestyle, and frequent explosive altercations with family members. She would drink excessively, and cut herself. Over several hours, she described her life story, previous stressors, and current problems. She became quite animated and angry when discussing certain topics, including her intense dissatisfaction with the medical profession for repeatedly fobbing her off.

I must admit, at times I was scared. Fascinated, but scared. At the end of the consultation, after undertaking a thorough assessment using a personality measurement tool, I gave her my tentative diagnosis - reiterating of course, that I couldn't confirm my conjecture in one meeting, and that it would have to be reassessed over a long period of time.

I timorously told her that I thought she had Borderline Personality Disorder (whose features include impulsivity, fear of abandonment, chronically low mood, a feeling of emptiness, unclear identity and unstable relationships). She was a...feisty person (when I say feisty, I actually mean intimidating), but surprisingly, she seemed grateful for the diagnosis and explanation. She was relieved. Firstly that she had a recognised disorder, and that she was "not the only one". Secondly, that she did not have schizophrenia, which had ruined the life of her cousin.

"I have an unfortunate personality" - Orson Welles

You ain't the only one, Orson. It is estimated that 10% of the population has a personality disorder (usually younger people, and more often male than female), though the truth is, many more people may never be diagnosed. There are several defined types (nine or 10, depending on which classification system you use), that all have very different characteristics. Aggression and confrontational attitudes are present in very few, though these are the ones that tend to come to the attention of psychiatric services e.g. Borderline Personality Disorder. This is because sufferers are more likely to have symptoms and behaviours that are relevant to mental health interventions - i.e. self harm, an explosive temper and a low mood.

In comparison, people with Narcissistic Personality Disorder (whose features include a grandiosity, and lack of empathy, as well as the need for admiration) are far less likely to want or need help.

Antisocial Personality Disorder (whose features include a callous lack of concern for others, irresponsibility, aggression, and a disregard for others' rights) is very common in the prison population (about 10 times higher than the rest of society), and in my line of work - Forensic Psychiatry.

The different types of personality disorder are beyond the scope of this blog entry, but I may write another one about them if people are interested.

Is it the person's fault?

Now that is a tricky question, which I cannot answer with confidence, or without awkwardness.

Sorry.

That's okay. I don't think there's a straight answer. A person with a personality disorder is in full control of their actions and behaviours, just like the rest of us. Of course they are - their personality disorder is them. Somebody with a mental illness may not have full responsibility of their actions, if they are particularly unwell at the time. For example, somebody with schizophrenia may be out of touch with reality, or somebody with severe depression might lose their motivation or their judgement.

However, people do not choose to have a personality disorder, and they cannot simply just "snap out of it". So I guess they cannot control the way they are, but they can control what they do.

This guy at work is really obnoxious and argumentative. I bet he's got a personality disorder.

Now hold your horses. I appreciate your zealous absorption of this information. But let's be clear.

The majority of people who are unpopular, fractious, irritating and impulsive do not have a personality disorder. This diagnosis is especially unlikely if they get on with others, without rubbing them up the wrong way. It is also rarely compatible with a high level of functioning. Although there are tools (personality inventories) and other indications in somebody's background (e.g. a childhood of emotional privation) it's very easy to misdiagnose.

Psychologists and psychiatrists should only make such a diagnosis after a thorough assessment. This isn't because we like to feel intellectually superior, and utilise our jargon. Okay, maybe it is a tiny bit.

But mainly, it's down to experience. Even a person who veraciously reads textbooks (or perhaps an informative, well written, concise blog) cannot acquire the nuances of sensing how a personality disordered person makes them feel (known as "transference").
So, all you Armchair Psychiatrists; beware. Only by seeing and assessing hundreds of normal people, and dozens of people with a personality disorder, can a professional recognise the latter with confidence.

Help does exist, and people do improve.

So, you never know, with encouragement and guidance, that person you loathe could potentially become your best friend...