The truth about personality disorders

All mental health conditions attract stigma and stereotypes but few are more misunderstood than personality disorders. Ruby Hamad separates the facts from the fiction.

What are personality disorders?
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Between Hollywood films that sensationalise them, quizzes warning you may be dating them, and psychiatrists refusing to treat them, it’s no wonder many people suffering with personality disorders never get better.

The American Psychiatric Association defines a personality disorder as “a way of thinking, feeling and behaving that deviates from the expectations of the culture.”

The 10 disorders are grouped according to behaviour that is “eccentric,” such as paranoid personality,  “anxious,” such as avoidant personality, and “dramatic,” including the most notorious and misunderstood: borderline, narcissistic, and anti-social. 

A “personality disorder” is simply a name given for a group of symptoms that have a negative impact on a person’s life to the point they cause significant distress. 

“We’re all a bit borderline, we’re all a bit anti-social, a bit narcissistic,” Tony Merritt, founder of Sydney Clinical Psychology, tells SBS. “Everyone has little bits of these traits in them.” Personality is a spectrum and the stronger certain traits are, the more problematic they become. 

A “personality disorder” is simply a name given for a group of symptoms that have a negative impact on a person’s life to the point they cause significant distress. 

There are no available statistics on how many people in Australia suffer with these conditions, but, according to clinical psychologist and neuropsychologist Dr. John McMahon of the Sydney Clinical Psychologist Centre, 30 percent of all personality-related diagnoses are borderline, which affects two in every 100 people

To counter the stigma that still surrounds this type of mental illness, here are some common misconceptions about personality disorders – and the truths behind them.

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Myth 1: They're just personality flaws
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“The hallmark of someone with a personality disorder is an inflexible way of interacting with people."

“I have friends and family who refuse to accept my (borderline) diagnosis,” confides 25-year-old Kat. “They just think I am a horrible person.”

However, although influenced by genetics, “personality” is not our fixed traits, but the way we perceive and interact with the world.

“The hallmark of someone with a personality disorder is an inflexible way of interacting with people,” Merritt explains. These people have developed stubborn but self-defeating patterns of dealing with others that were useful in childhood but become maladaptive in adulthood, having the opposite to desired effect.

An angry three-year-old who screams “leave me alone” at their parent, for example, will likely be soothed by that parent. A distressed 30-year-old who unexpectedly shouts the same at a new partner may also need comforting, but will almost certainly drive her lover away.

Although influenced by genetics, “personality” is not our fixed traits, but the way we perceive and interact with the world.

And, chances are this is not the first lover she has put off. “Respisodes,” explains Dr. McMahon, “or repeating episodes of the same kind of drama over and over again,” is another hallmark of personality dysfunction.

Think of them as unconscious self-fulfilling prophecies. Someone with borderline traits may be so afraid of rejection they impulsively slam the brakes on a new relationship, only to wonder why they always end up alone. A sufferer of avoidant personality disorder may be so anxious of appearing foolish to co-workers, they make awkward and inappropriate comments, ensuring colleagues find them unlikeable.

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Myth 2: Personality disorders can't be treated
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Notoriously difficult to treat in the past, personality-related issues are still popularly regarded as a life sentence, with everyone else advised to run in the other direction. For this reason, Merritt is among a growing number of clinical psychologists shying away from making diagnoses that encourage the perception these people are “abnormal.”

 “It’s highly unusual for us to say, ‘Oh this person is borderline’,” he explains, “We say, ‘this person struggles with suicidal thoughts and unstable relationships 

“It can take years but they go from being really chaotic and harming themselves to living stable lives.”

Successful treatment depends on the nature and severity of symptoms but generally involves long-term therapy including dialectical behavioural therapy (DBT) for those experiencing overwhelming emotions, and schema therapy which helps patients recognise and resist their maladaptive patterns (schema).

“The idea that these people can’t be helped is just not the case,” Merritt continues. “It can take years but they go from being really chaotic and harming themselves to living stable lives.”

McMahon describes therapy as helping people rebuild their personality. “I have seen people radically change their lives,” he says. 

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Myth 3: They're a result of childhood trauma
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Although it can be true, this statement is a stereotype: it’s not always the case that adults with personality problems were abused sexually or physically in childhood. Conversely, many people who are abused don’t develop any type of mental illness.

Psychological trauma, McMahon explains, can be rooted in specific incidents of abuse, or in emotional neglect. According to Merritt, narcissism typically manifests in people who grow up expected to achieve great things but are regularly criticised. Borderline traits can develop from abuse or neglect, but occasionally occurs in people who report no adverse conditions growing up.

This indicates a genetic as well as environmental component to some personality disorders, but again, not everyone biologically predisposed to a particular condition will develop it.

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Myth 4: Everyone with the same disorder acts exactly the same
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“You’re too nice to be a borderline,” is a typical response 38-year-old Andrew gets when he reveals his diagnosis. Personality disorders, however, are not as easy to spot as many seem to think. Although each disorder has a core issue, the diagnostic criteria includes a wide range of behaviours with few people meeting all of them.

For example, people with borderline personality all experience some level of difficulty in regulating their emotions, but their outward behaviours will vary since of the nine criteria associated with the disorder, only five are required for diagnosis. This means, explains McMahon, “two people can be diagnosed borderline but only share one or two traits in common”.

Some people with borderline traits may be suicidal and clingy, but others will be “high functioning,” throwing themselves into work as a means of detaching from their painful emotions. Some narcissists are malignant and exhibitionistic but many are vulnerable and depressive

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Myth 5: People with personality disorders are all manipulative
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Manipulation generally requires planning, which, Merritt says, conflicts with another defining feature of personality dysfunction: poor impulse control. Even those with anti-social personalities (often confused with psychopaths) will act on what feels good in the moment, without considering the consequences.

Narcissists are notorious for treating people as objects that exist to serve their needs. However, John Costican, a 33-year-old American who blogs on Quora under a pseudonym about her narcissism diagnosis, tells SBS she “can be controlling” and has “a profound lack of empathy,” but denies consciously manipulating others.

Even those with anti-social personalities (often confused with psychopaths) will act on what feels good in the moment, without considering the consequences.

“I don’t go around thinking about who I’m going to victimise and how,” she says, “I just blunder haplessly across people’s boundaries without noticing their feelings.”

Also dismissed as manipulative and attention-seeking, is the self-harming behaviour associated with borderlines. However, counters Merritt, the two main reasons people harm themselves are, “to reduce the intensity of their emotions, or if they’re feeling numb, to feel alive.” 

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Myth 6: They're just selfish or snobbish
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“No one is born with the desire to have (a) personality disorder,” Merritt says. “They developed these conditions because the world they grew up in has been hostile to them in some way.”

This can manifest in the indifference of “loner” schizoid personalities who show no desire for closeness, or avoidant personality where desire is stifled by severe anxiety. For some, the urge for intimacy is strong even though their behaviour makes genuine connections unlikely.

Fuelled by mood swings and insecurity, borderlines may burn through one intense but brief relationship after another. Overcompensating for low self-esteem, narcissists may insist friends defer to their needs, exploding with rage when refused. 

“I only started to improve when I found people willing to help me work on my issues,” says Kat.

Although baffling for others, these are reactions, not to the current situation, but to inner turmoil rooted in past experience. Whether they realise it or not (and many don’t), individuals with severe symptoms associated with some personality dysfunction can be abusive and cause immense suffering to those around them.

But recognising that these are genuine mental health problems can help break the intergenerational cycle of pain and trauma. “I only started to improve when I found people willing to help me work on my issues,” says Kat. “Getting better is not something we can do on our own."

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If you need support...
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If you need help, or this story has raised issues for you, please call Lifeline on 13 11 14 or beyondblue on 1300 22 46 36.

Two-part documentary series How ‘Mad’ Are You? airs over two weeks, starting Thursday 11 October at 8.30pm on SBS and SBS On Demand.