About Personality Disorders

These are defined as long standing features of a person's personality that do not come and go as most episodic mental illnesses do and have typically been presented since at least teenage years. We all have personality traits, but these are more than traits - things we do and patterns we display that affect all we do and keep on making the same old mistakes.

Classifying the different types of personality disorder is difficult as there are no easy divisions to make. The UK/International system called ICD-10 just gives a list and descriptions of different types. The American system called DSM-IV is (on this occasion), better with more robust descriptions and suggesting three main types:

• cluster A: “odd or eccentric” (paranoid, schizoid, schizotypal)
• cluster B: “dramatic emotional or erratic” (histrionic, narcissistic, antisocial, borderline)
• cluster C: “anxious and fearful” (obsessive-compulsive, avoidant and dependent)

In my work as a psychiatrist, and where I am guessing most of you are coming from, another way of thinking might also be useful. Most personality disorders, even the more severe ones, never come to the attention of mental health services because they do not cause the person psychological distress (they just distress those around them!). They are called 'ego-syntonic', meaning they fit with the person's ego. An odd person does not typically see themselves as odd. A psychopath thinks everyone else is weak. By contrast, the type most commonly seen in the NHS is Borderline Personality Disorder where the person is deeply distressed (ego-dystonic) - usually to the point of self harming and attending A&E.

You can read more general information about personality disorders here.

• http://www.personalitydisorder.org.uk/
• http://en.wikipedia.org/wiki/Personality_disorders
• http://www.mind.org.uk/help/diagnoses_and_conditions/personality_disorders
• http://www.rcpsych.ac.uk/expertadvice/problems/personalitydisorders/personalitydisorder.aspx

Borderline Personality Disorder

The textbook descriptions go something like this: you are impulsive, find it hard to control your 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. However this list of problems does not really describe the expereince, so let me share a slighly wacky model called the 'Fresian Cow'.
 
These are the black and white cows that give us most of our milk. We all have our black bits and white bits - bad bits and good bits. It is just that most people can see the whole cow. In Borderline PD, it is like the person has their nose right up against the cow so all they can see is either totally black or totally white. When they get up each morning, it is as though sheer luck determines if it is going to be a black day or a white day. A sudden jolt during the day - even a small one - and the colour can change just like that. The back bits seem like they go on for ever and there is no hope. The white bits are idealised and they want all days to be like that...

The problem is that it is not a black cow - the black days are not representative of the whole. It is not as bad as it seems. Neither is it a white cow - the white days are as fragile and as much a fantasy as the black ones. People seem to know this at some level and so try to walk the line - the 'border' between black and white - but this is like a tightrope and you fall off - usually with an arguement, a mistake and sometimes self-harm.

The trick is to back away slowly from the cow and get the whole perspective. But black and white will still bo too simplistic and too horriffic/attractive, so there is a trick to learn - make the cow grey! When a dialogue is established between the black bit and the white bits the resulting grey is more stable. This is about remembering when all seems black that actually grey is the goal. And likewise when all seems to be white and wonderful that grey is the goal. Once the cow is grey (and this is where the analogy gets a bit stretched) you can begin to paint on the colours of the lost personality, the abandoned hopes and the real and achievable dreams.
 
If by this point you think I am completely mad (seeing rainbow cows and all that) then let's leave the cow for a bit and talk about why people develop Borderline PD. The short answer is that there are a number of reasons and psychiatrists debate the various theories. However, three things are clinically important.

• The first is that there is more and more evidence that there is a strong genetic component to personality disorders. This does not mean that it is permenant and can't be treated, but it does mean that it is not the person's fault and that even when symptoms lessen they are always likely to have some of the traits. These lesser traits can even be advantageous - a sensitivity to change, an ability to keep some emotion at a distance. You can help your personality about as much as you can help your hair colour - dyeing it is not a permenant solution and the true colour will out.
• The second thing is that this does NOT mean the person was abused as a child. Borderline PD does usually come about as a combination of genetic vulnerability and childhood trauma - but trauma is a very subjective thing. There may have been sexual abuse, there may have been other types of abuse, or there may merely have been a lack of (or inability to provide) warmth which was perceived as trauma, or maybe just resulted in a lack of stable attachments forming. These insecure attachments are the root of the emptiness and depression.
• Yet childhood sexual abuse does occupy a special place because these types of very destructive trauma seem to cause the more severe patterns of self harm. One theory says that as a defence against the abuse, the person shuts away part of their body and mind as if it belonged to another person. This was actually a good thing to do at the time because it helped them survive, but (often now that the threat has passed) this fragmentation begins to crack, to cause flashbacks and fragility. These things are so like the early trauma again that they can only be managed by blunt instruments of defence today - dissociation, drugs, self-harm. Denial is the only effective option.

Helping Borderline Personality Disorder

• Stage 0: you will not find this in the manuals. It is a term I use to describe the stage where people have yet to realise that Borderline PD is the problem. They may be seeking relief from antidepressants, or presenting to A&E and not seeking structured help. The main aim here is to try and positivley sell the idea of Borderline PD as the main problem they have and something that can be helped. The difficulty is getting hold of people to tell them this. I sometimes explain it ias MORE servere that depression (which is why antidepressants don't help much) and give a good descritpion (such as the Fresian Cow) so they know I know a bit about what they are going through and not trying to fob them off. It is not a diagnosis of exclusion, but a positive identification of a problem we are getting to know more and more about.
• Stage 1: this is what most people call DBT and has two parts. The D is for diatectic - think dialogue. It is about getting the black and white bits talking to each other to aim for a gray cow. The B is for behavioural skills - usually taught peer-to-peer in a group - giving you just enough stability to begin backing away from the cow to see the whole picture. Stage 1 takes a year or two of hard work but is needed before stage 2.
• Stage 2: this is more like traditional psychotherapy and is a combination of cognitive behavioural and psychodynamic techniques to help process the trauma and move beyond defece mechanisms - to heal the spilt and the fragmentation that happenned within. If you do stage 2 without the stability (dialogue and behavioural skills) of stage 1, you will make the self harm worse - maybe even to the point of the person killing themselves.

You can see more about Borderline Personality Disorder and DBT at these links. I have also not covered the role of some low dose modern antipsychotics and mood stabilisers in helping with symptom control - especially during stage 0 and stage 1 DBT.

• http://www.borderlineuk.co.uk
• http://www.dbtselfhelp.com

Personality Disorder and the Church