Information about autism and personality disorder
Summary
Trigger warning: this section contains references to trauma.
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Personality disorder means having some personality traits that cause longstanding, extensive and serious difficulties in a person's life, affecting how a person thinks and feels about themselves and how they relate to other people.
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The most commonly diagnosed type of personality disorder is borderline personality disorder.
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Borderline personality disorder is characterised by experiencing frequent and intense emotional distress, and reacting very strongly to feeling let down or uncared for by other people. This can lead to conflict and difficulties in sustaining relationships. People with this diagnosis may manage feelings of intense distress by self harming or other coping mechanisms like disordered eating or substance misuse. A person with this diagnosis may also feel unsure about who they are as a person, and may experience intense feelings of disconnection from reality (“dissociation”).
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The internal experiences, distress and behaviours of people diagnosed with a personality disorder – particularly borderline personality disorder – can often make sense when we understand how they have been shaped by early experiences of trauma, abuse and neglect.
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You can read some of the controversies about the diagnosis of personality disorder here.
In-depth information
Personality traits are characteristic patterns of thoughts, feelings and behaviours that are relatively consistent over time, like being shy, kind, considerate, conscientious, sociable, stubborn, confident, or being prone to anxiety. Our personalities also include what we like and dislike, our sense of humour, and our talents and passions. Our personalities are shaped by our genes and by our experiences, especially our experiences as a child and teenager. People can express different aspects of their personalities in different situations, and people's personalities can change as they get older and enter different phases of their lives. Everybody has a mix of personality traits. Most people find they have some personality traits that they like and that help them relate to other people and succeed in work or other aspects of life, alongside other personality traits that sometimes make life more challenging for them, like being very shy or being a perfectionist.
ICD-11, which is the diagnostic system used in the UK and Europe, defines a personality disorder as having some personality traits that lead to longstanding and extensive difficulties in how a person thinks and feels about themselves and others, which impact their behaviour and relationships with other people [1, 2]. To be defined as a personality disorder, these difficulties need to be persistent (lasting a number of years), pervasive (affecting all areas of a person’s life) and problematic (causing significant distress and difficulties with coping with important aspects of life like education, work and relationships with other people.)
Of course, a person who has some personality traits that cause them difficulties is very likely to also have many personality traits that can be thought of as strengths, like being kind, being passionate about their interests or about important issues, and caring deeply about other people.
The ICD-11 diagnostic system gives some examples of personality traits that can make life more challenging for people, which include a tendency to experience a broad range of extreme negative emotions, or to avoid social interactions and avoid getting emotionally close to other people, or to avoid experiencing and showing emotions, or to be self-centred and lacking in empathy, or to be impulsive and irresponsible, or to be rigid and perfectionistic [2]. Everyone struggles with these areas sometimes to a greater or lesser extent, but to be defined as a "disorder" these personality traits have to be persistent, pervasive and cause serious difficulties in a person's life. These particular examples of personality difficulties are not often diagnosed yet, as they have been relatively recently introduced into the diagnostic system.
The most commonly diagnosed type of personality disorder has historically been “borderline personality disorder” or BPD (as it is called in the American diagnostic system, the DSM-5) [3]. It’s a bit more complicated in ICD-11 so we’ll stick to DSM-5 for now (see the section on Controversies about diagnosing personality disorder for information on BPD in ICD-11). DSM-5 defines borderline personality disorder as “(1) a pervasive pattern of instability of interpersonal relationships, self-image, and affects, and (2) marked impulsivity” [4]. This means a person can be quite changeable and swing between different extremes in how they feel about themselves and their relationships with other people, and their moods and emotions ("affects") can be very changeable and swing between extremes too. They may also find ways of coping through self-harm and/or do other things impulsively which damage their health. DSM-5 go on to say that these difficulties should have begun by early adulthood and should be present in a variety of contexts.
They say that to be given the diagnosis, someone should experience at least 5 of the following 9 difficulties:
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Frantic efforts to stop other people leaving or abandoning you.
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A pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization (thinking someone is perfect) and devaluation (thinking someone is awful).
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Markedly and persistently unstable self-image or sense of self e.g. frequent big changes in your beliefs, opinions, lifestyle, ambitions or career, or feeling like who you are as a person changes a lot, or you don’t know who you are.
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Impulsive behaviour in at least two areas that are potentially self-damaging (eg, spending, sex, substance abuse, reckless driving, binge eating) (this does not include self-harm).
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Repeated feelings of suicidality, or self-harm.
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Moods and emotions changing easily and swinging from one intense emotion to another.
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Profound feelings of emptiness.
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Intense anger or difficulty controlling anger.
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Temporarily feeling paranoid or feeling dissociated (like your consciousness is disconnected from your body or from reality), or seeing and hearing things that are not there, particularly when stressed.
Again, many of these are things that most people struggle with sometimes to differing extents, but to be defined as a "disorder" these need to be persistent and pervasive experiences/ behaviours that cause serious difficulties in a person's life. Viewed through a trauma lens, the set of difficulties described above can be understood as necessary coping mechanisms, survival strategies and/or consequences of surviving trauma [5]. For example, if past experiences have taught you that even people who seem caring cannot be trusted and may be dangerous, to protect yourself it makes sense to react with anger and to quickly end relationships if you notice signs that a person may be untrustworthy or uncaring [6].
You can read some more on the controversies about the diagnosis of personality disorder here.
There has been quite a lot of research on psychological treatments to help people with a diagnosis of BPD. Specialist psychological therapies for BPD include dialectical behaviour therapy and mentalization based therapy and, whilst not everyone benefits, for many people with a diagnosis of BPD they have been shown to help with self-harm and improving mental health [7].
Any personality traits that cause people difficulties in their lives only reflect a small aspect of who that person is. All of us have unique personalities that are rich and complex and make us who we are. It is always important to consider someone's personality strengths alongside any difficulties, such as kindness, generosity, passion, humour, talents and empathy for others. For example, research has shown that people with a BPD diagnosis often have enhanced emotional empathy for other people, which means they can have a tendency to feel other people's emotions as if they are experiencing them themselves and to be deeply affected by caring about other people's distress or sharing in their joys [8]. If you want to find out more about your personality strengths, you can take the free VIA personality strengths test here.
3. References
[1] Wood, H., Bolton, W., Lovell, K., & Morgan, L. (2014). Meeting the challenge, making a difference: Working effectively to support people with personality disorder in the community.
[2] World Health Organization (WHO) (2019). International Classification of Diseases, Eleventh Revision (ICD-11), https://icd.who.int/browse11.
[3] Tyrer, P. (2018). Accurate recording of personality disorder in clinical practice. British Journal of Psychiatry Bulletin, 42, 135-136.
[4] American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author.
[5] Brickel, R.E. (2019). A Compassionate Look at “Borderline Personality Disorder” From a Trauma-Informed Lens. https://brickelandassociates.com/borderline-personality-disorder-trauma-informed-lens
[6] Shaw, C., & Proctor, G. (2005). I. Women at the margins: A critique of the diagnosis of borderline personality disorder. Feminism & Psychology, 15, 483–490.
[7]. [19]. Cristea, I. A., Gentili, C., Cotet, C. D., Palomba, D., Barbui, C., & Cuijpers, P. (2017). Efficacy of psychotherapies for borderline personality disorder: a systematic review and meta-analysis. Jama psychiatry, 74(4), 319-328.
[8]. Harari, H., Shamay-Tsoory, S. G., Ravid, M., & Levkovitz, Y. (2010). Double dissociation between cognitive and affective empathy in borderline personality disorder. Psychiatry research, 175(3), 277-279.
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