Personality disorders in adults

Diagnoses such as anxiety and depression manifest themselves by symptoms that you are not used to living with. This may, for example, be sadness or heart palpitations. In contrast to this, personality disorders manifest themselves in the form of certain character traits. If you have a personality disorder, you will therefore often experience your reactions as natural because they have been there for a long time.

One example could be a woman with a personality disorder who experiences that she is an unwanted person. She will act in a quiet and restrained manner and not show very much of herself in social contexts for fear of doing or saying something from which others will distance themselves.

She will not think that her experience is something that can be talked about and nuanced. Instead, she will see it as a truth. In her contact with other people, she will therefore think that she is wrong, embarrassing or unwanted.

For example, if she has experienced several times that others do not approach her and that they overlook her, she will see it as proof of her thoughts about herself. This experience will repeat itself in new situations in which she will be restrained and convinced that others think that she is wrong or embarrassing. She will pay close attention to signs that others are not addressing her or are talking across her as if she were someone with whom you do not want to have contact.

The experience of being overlooked and unwanted will typically make her sad and perhaps also angry, rather than trying to understand it as a pattern in her experiences.

A personality disorder often manifest itself at two extremes: introvert and extrovert.

At one extreme, the person will be introvert and humble in relation to others. It can be seen as an attempt to avoid anxiety and conflicts.

At the other extreme, the person will be extrovert and impulsive. It can be seen as an attempt to dominate the relationship with others.

A person with a personality disorder is most typically dominated by one extreme or the other. However, the extremes may alternate. In some situations, the person will thus appear inhibited, while, in other situations, he or she will be more dominant and explosive.

The two extremes may be expressed as follows:

• Either great dependence on boyfriend or girlfriend, family and friends or repeated conflicts with the same
• Either excessive self-control or lack of self-control
• Difficulty understanding and setting boundaries. A person with personality disorder will either accept that other people overstep his or her boundaries or overstep other people’s boundaries
• Persistent problems at a place of study or workplace. Some avoid relevant work assignments and are quiet and inconspicuous. Others are too controlling, unstable and desire-driven in their work performance.

Seen from the outside, the various types of personality disorders may look very different. But they have many common traits. Most people with personality disorder have:

• Very low self-esteem
• Difficulty adjusting their emotions and impulses. Some over-regulate their emotions and impulses and barely notice them. Others under-regulate their emotions and impulses and notice them way too much
• A tendency to perceive social situations from their own perspective, and difficulty considering other people’s perspectives.

We especially develop our personality during the first 2-3 years of our life. What the child learns during this period about how to handle adversity and deal with his or her own needs as well as those of others is of great importance to the relationship patterns that he or she establishes.

Although the first 2-3 years are of great importance, a person’s personality develops until the age of 10-12. The patterns founded in the early years can be reinforced. This happens if the child’s relationship with others continues along the same track. Conversely, the patterns can be adjusted if interactions with others change.

A fundamentally secure attachment can therefore become less secure. This may occur if there are sudden large changes in the child’s life. Likewise, an insecure attachment can become more secure if the child’s carers become more stable and present.

The overall criteria indicate whether you have a personality disorder. There are also criteria for specific types of personality disorders.

The essence of paranoid personality disorder is anxiety about humiliation and general insecurity about other people. It is often expressed by:

• Generalised suspicion
• You experience other people as malicious and offensive
• You often react with anger

The essence of schizoid personality disorder is that contact with others is perceived as being much too overwhelming. It therefore causes discomfort and anxiety. It is often expressed by:

• A lack of interest in socialising
• Isolation
• A cold attitude towards others

The essence of a dissocial personality disorder is the absence of empathy. You have typically had a childhood with neglect and therefore have no positive expectations of others. A dissocial personality disorder is often expressed by:

• Great impulsivity, often in the form of crime committed without any thought as to whether it affects other people
• Lack of a conscience

The essence of emotionally unstable personality disorder is the fear of being abandoned. This anxiety expresses a feeling of only being something by virtue of others. Therefore, you feels a deep longing to be one with another person. It is often expressed by:

• Fear of abandonment
• Uncertainty about your own identity
• Self-destructive and impulsive behaviour
• Strong emotional fluctuations (all depending on whether the other person is perceived as being with you or against you)
• Internal emptiness
• Black-and-white thinking (either/or).

The essence of histrionic personality disorder is a fear of not having the other person’s attention. This results in an experience of not being anything. It is often expressed by:

• A great need to be the centre of attention
• Rapidly changing, strong and dramatic expressions of emotions
• Flirting and sexualisation of contact with others (without necessarily having sexual intentions).

The essence of obsessive-compulsive personality disorder is the fear of not being perfect. It is often expressed by:

• Preparation of lists, rules and schedules
• Perfectionism
• A great need for control
• Stubbornness

The essence of anxious-evasive personality disorder is the fear of being embarrassing as well as of criticism and rejection. A deep desire for closeness is also seen It is typically expressed by:

• Anxiousness in social situations
• A feeling of inadequacy
• Excessive inhibition of behaviour

The essence of dependent personality structure is a fear of not being able to cope, without help and guidance. It is often expressed by:

• Practical and emotional dependence on others
• Generalised lack of independence

The essence of narcissistic personality disorder is the fear of not being seen and recognised. It is typically expressed by:

• A need for excessive recognition and admiration
• Excessive self-esteem
• Arrogance and self-absorption

This designation is not an expression of any specific type. The person meets the general criteria for a personality disorder, but does not match a specific type.

This designation is used if a person has symptoms that relate to several different personality disorders.

Psychotherapy may be either individual or in a group. In some cases, both types can be combined. The therapy consists of consultations. Relationship patterns, perceptions of social situations and views of yourself and others are examined in these consultations.

The purpose of both the individual therapy and group therapy is to strengthen your ability to handle difficult emotions. In this way, you can help to develop a sense of greater inner security. The more successful this is, the more robust you will become when faced with adversity, and the better your relationships with others will be.

Psychoeducation is an important part of the therapy. Here you learn what it means to have a personality disorder. You review what lies behind a personality disorder, how the disorder manifests itself and how it is treated.

Patterns of attachment or the ability to deal with emotions cannot be treated with medication. Therefore, there are no specific medication for personality disorder. Sometimes, however, it is possible to try to alleviate some of the symptoms. For example, mood stabilisers can be tried in some cases. It may diminish violent emotional fluctuations between anger, sadness and other feelings.

Some people have symptoms of anxiety or depression. In some cases, these symptoms can be treated with antidepressants. Antidepressants can be used against both depression and anxiety. If you experience racing thoughts, difficulty sleeping or perceptions of unreality, you may, in some cases, benefit from very low-dose antipsychotics.

Often, the medication will have little or no effect on the symptoms. This is because the symptoms stem from the underlying personality patterns. If you develop anxiety or depression (independently from your personality disorder), the medication will be more effective against the symptoms.

We are born with an ability to attach ourselves emotionally to others. This ability is known as our attachment system. As newborns, we are helpless and dependent on our father and mother. Our attachment system ensures that we attach ourselves to them. This attachment bond secures us of food, drink and warmth. 

When we feel threatened, the ability also ensures that we seek help and protection from persons who are ‘stronger’ than us. The attachment system thus ensures that we are helped into the complex human world early in life. Here we learn how to behave, what is right and wrong and what others can expect from us.

Attachment patterns

The way we relate to other people stems from our early experiences: What have we learned that we can expect from others? What do others expect from us? And how do they react to us? These experiences are called the attachment style.

If you have a secure attachment style, you naturally expect other people to wish you well. If, on the other hand, you have an insecure attachment style, you distrust others. Therefore, you basically expect other people to be dismissive or hostile. The more secure a person’s attachment style is, the more his or her relationships with those close to him or her will therefore be characterised by trust. The more insecure a person's attachment style, the greater the risk that he or she will feel insecure and rejected in his or her relationships.

An expectation of rejection will, for example, affect a person’s behaviour towards others. One example may be a male personality disorder sufferer’s relationship with his girlfriend. All depending on whether he tends to submit or dominate, he will react in a clinging or domineering manner. It may, for example, by wanting to know everything about what his girlfriend is doing. Conversely, it may also be that he will try to avoid her because he does not believe that she can give him the reassurance he seeks.

Socialising with others

For many, socialising with others is a nice thing. If you have a personality disorder, however, socialising with others may cause inner turmoil and insecurity. The feelings may be enhanced due to the insecure attachment, which may lead you to expect that others do not wish you well.

For example, you may respond by shutting yourself off from others and becoming dismissive. You may also react with unexpected emotional outbursts, excessive consumption of alcohol or uninhibited behaviour. All these ways of reacting stem from the attachment style founded in your childhood.

Your personality expresses your understanding of who you are and what you expect from others. The attachment style plays a key role in this understanding, which can be more or less conscious on your part. This will be expressed in your way of being together with others.

If you have a secure attachment, you will often have a fairly realistic assessment of a situation. You can see how you contribute to it. You are also able to see the situation from other people’s point of view. If, instead, you have a personality disorder, you will be affected by whether the insecure attachment is activated. It will make you feel insecure in a given situation. For example, you may feel rejected, let down or abandoned.

If your attachment system is activated, your perception will be coloured by your inner sense of insecurity. In this situation, you will therefore often have trouble seeing the situation from other perspectives than your own.

Example

One example could be a boyfriend who is a bit grumpy in the morning. A person with a secure attachment will be able to consider whether he has slept badly, or may be stressed. She may even ask outright if there is something wrong. 

A person with an emotionally unstable personality structure, will instead become insecure about their relationship. She might think: “Why is he in a bad mood? Doesn’t he like me any more?  In fact, I’m worthless!” She will modify her behaviour as a result of these thoughts. Perhaps by starting a big argument. Or she might withdraw and ignore him. Afterwards, she will find it difficult to see her own contribution to the emotional chilliness that will ensue.

Emotional reactions

If you have a personality disorder, your relationships with others will often be associated with some degree of insecurity. Therefore, your attachment system will often be activated when you are with others. It will govern how you react.

Typically, persons with a personality disorder will have greater fluctuations in their emotions in social contexts than other persons. Some easily get angry and verbally abuse others, perhaps they throw things.  In others, the emotional reaction is less visible because it takes place in the person’s thoughts and feelings. Small social signals that others would not register at all, for example a sigh or a wrinkling of the nose, can be perceived as rejection or scorn.

You may also tend to perceive it as a rejection when other people express views that differ from your own. This may cause you to react with coldness. It may also be that you feel inferior in the company of others. To maintain relationships with others, some therefore allow others to do the talking and set the direction of the social interaction.

Research indicates that the temperament traits with which you are born influence your personality development. However, the research also shows that congenital traits are always shaped in interaction with the environment in which you grow up. Your temperament says something about how you will react to different physical or emotional impacts. Some get annoyed easily and feel upset, while it takes a lot to upset others.

When you have a personality disorder, all areas are affected. This means that a person with a personality disorder gets stressed out more easily. In addition, he or she will find it difficult to return to a stable mood. Often, persons with a personality disorder will find it difficult to calm down, and they will remain stressed for longer than others. It can make an experience more emotional than it would be for others.

If you have a personality disorder, you may react in a number of ways. The reactions range from non-reaction to exaggerated reactions in the form of crying and anger. This means that a person with a personality disorder often has problems relative to other people.

Temperament manifests itself in different areas:

• How long and how intensely you are affected by an experience
• How inhibited or fast you react in social contexts
• How realistic and attentive you are in relation to your surroundings 

All people experience having unpleasant feelings like anxiety, anger and shame. If you have a secure attachment, these emotions only rarely exceed the limits for what you can contain. This means that, despite these feelings, you will still be able to be attentive, plan and perform tasks.  You can calm your body and thoughts again. And you can give yourself time to understand what is happening.

If, instead, you have a personality disorder, feelings such as shame, anxiety and anger will create insecurity and great discomfort. Due to your basic insecurity, your ability to deal with and contain your emotions will be disturbed. You will therefore experience that you cannot calm yourself down. Nor will you be able to control intrusive and perhaps incomprehensible feelings.

This will lead to a strong urge to fight or escape from these feelings. You can do this either by suppressing your feelings or by trying to eliminate their source. You will quickly feel stressed out and find it difficult to see the big picture. This will reduce your ability to be aware of other things, to stick to a goal or to adapt to a situation.

Because of the urge to numb or remove the discomfort, you will often react impulsively, for example with self-harm.  There is a risk that this will result in a feeling of emptiness.

Self-harm is a serious symptom of a limited ability to contain intense or unpleasant feelings. People with an emotionally unstable personality structure are particularly prone to attempt to deal with negative feelings by physically harming themselves.

When self-harm is a symptom in connection with personality disorder, it will often be a recurring behaviour. The purpose is to numb emotions that you cannot communicate in any other way. This will typically be in situations in which you feel let down or rejected.

In these situations, you may find that you cannot contain or modify your feelings. You cannot find words to tell others about your experiences. Nor are you able to calm yourself in other ways. Instead, you try to fight the feeling by cutting yourself, hitting yourself or burning yourself. There may also be situations in which you try to get others to hurt you.

Cutting

Cutting is a milder form of self-harm. This phenomenon can also be seen in people with other mental illness, for example depression. It is also seen in some adolescent teenage girls in connection with crises.

• The best advice if you have a personality disorder is to seek treatment.
  
  
• Once you have started treatment, it is important to be patient and trust that your therapists are trying to help. You will not feel an effect immediately but, in the long term, you will find that something has changed.
  
  
• You must expect that the difficulties you have in relation to others will also make themselves felt in your relationship with your therapist or other group participants. This provides an opportunity to examine and change your views of yourself and of other people.
  
  
• Participate actively in your treatment. One or two years may sound like a long time. But it takes a long time to change ingrained habits and views. The more you try to examine experiences and patterns and contain difficult feelings, the quicker you will be able to develop.
  
  
• Participate in psychoeducation if it is offered. This will give you a better opportunity to understand the patterns you exhibit, and what it takes to change them.
  
  
• Be careful about seeking information on the Internet. Some of the information you can is quite useful. But there is also a lot of outdated and outright incorrect information.
  
  
• Avoid drugs and alcohol. They often exacerbate your symptoms.
  
  
• Make sleep a priority. A good night’s sleep prevents stress. It gives you more energy to devote to yourself and your treatment.
  
  
• Do not expect to have ‘finished’ once your treatment ends. You will have to continue to work with what you have learned in your treatment, also after your treatment has been concluded.

• Seek out knowledge about personality disorders. For example, participate in psychoeducation if it is offered to relatives, or participate in theme evenings organised by Central Denmark Region’s psychiatric information centre PsykInfo Midt.
  
  
• If the person who has a personality disorder reacts in ways that seem excessive or violent, try not to take it personally. Remember: these reactions are due to the personality disorder.
  
  
• Remember to take care of yourself. Being close to someone with a personality disorder can take its toll. If you need to provide long-term support and help to a person close to you who has a personality disorder, it is important that you also take care of your own needs.
  
  
• You must accept that you will not always have the energy to help. No one can be present, positive and available all the time.
  
  
• Consider getting in touch with patient-and-carer organisations such as SIND (the Danish Association for Mental Health) or Bedre Psykiatri, which can help you with advice and support.
  
  
• In emergency situations, for example if the person close to you is self-harming or has suicidal thoughts, you can contact your doctor, a psychiatric emergency department or the psychiatric advisory hotline.