Shedding light on personality disorder

Later this month a conference in Belfast will explore a complex group of mental health problems which affects one in 16 people. These people are widely stigmatised, poorly understood, even by many in the medical profession and their lives – on average – are 19 years shorter than the rest of us: personality disorder. Many are dissatisfied with the level of support they currently receive for their condition.

Even the medical term is controversial – many complain that it in itself is stigmatising, characterising those diagnosed as suffering from personality disorder as difficult.

In layman’s terms someone diagnosed with a personality disorder has attitudes, beliefs and  behaviours that can cause long standing problems in their life.

Typically he or she will feel unable to trust others, or may feel abandoned, causing unhappiness to themselves or others. They will struggle to start or keep friendships and to control their feelings and behaviour and these problems will have continued for a long time.

Sadly those with personality disorder can face bleak prospects. One in ten end their lives through suicide and there are high levels of long term unemployment, homelessness and alcohol and substance abuse.

A disproportionate number end up in prison: 64% of male and 50% of female prisoners have a personality disorder; 12 and 14 times the level in the general population respectively. Conversely people with mental health conditions are five times more likely to be a victim of assault, and three times more likely to be a victim of a household crime by someone they know than anyone in the general population.

These outcomes can be exacerbated by the stigma associated with personality disorder with people sometimes not being offered appropriate help because they are seen as being difficult, or else as a result of the misconception that they somehow cannot be helped.

Experts agree on the primary causes: Environmental, an unstable or chaotic family life, for example; traumatic experience in childhood, this could be the loss of a parent, physical or sexual abuse or involvement in an serious accident; there may also be genetic factors that make people liable to develop personality disorder

There are, depending on who you ask between 12 and 15 different types of personality disorder although this type of characterisation is in itself subject to dispute because people can display characteristics of more than one.

However the Northern Ireland Personality Disorder Strategy organises them into three types or clusters

One which it, perhaps a little insensitively, labels ‘odd or eccentric’ types which includes paranoid, schizoid, schizotypal disorders; a second it names ‘dramatic, emotional or erratic’ types including borderline or emotionally unstable, histrionic, narcissistic, anti-social types and the third ‘anxious and fearful’ types including obsessive/compulsive, dependent, avoidant disorders.

This is important because it helps us to understand that people with different personality disorders tend to  come into contact with health professionals through different routes. So, for example those in the third category are most commonly encountered in community and primary care settings whilst for male prisoners, anti-social personality disorder is most prevalent and borderline personality the most common amongst women.

Given the prevalence of mental ill health and personality disorder amongst prisoners the Department of Justice commissioned Mindwise to produce a guide for professionals working in the justice system. It is an important document and is proving very useful in helping identify and to help those with these problems, both victims and offenders in the justice system.  

It also provides guidelines for identifying the personality disorders most commonly found amongst prisoners. So for example signs of Borderline Personality Disorder, prevalent amongst female inmates are:

“Difficulty forming healthy relationships and instead engaging in unstable and emotionally intensive relationships; Fearing rejection or abandonment by partners or individual health professionals they have developed a relationship with; Strongly seeing themselves as part of couple or having a strong relationship with an individual health / CJS professional whom they can idealise; Difficulty managing emotions and experiencing severe mood swings; Being impulsive and engaging in dangerous activities putting their personal safety and health at risk; Having an eating disorder; Having previous experience of serious self-harming and suicide attempts.”

This is a very helpful definition which not only sheds light on how the condition manifests itself but also why professionals might otherwise regard the symptoms as signs of someone just being difficult, immature or socially awkward. It demonstrates the need for more information, generally, about the condition

The definition of anti-social personality disorder, so common amongst male prisoners is every bit as illuminating:

“Previous experience of coming into contact with the Criminal Justice Systeam (CJS) or being involved in offending; Being impulsive without considering the consequences or impact on others; Lacking empathy and sounding ‘scripted’ when discussing emotions; Being physically violent getting into a lot of fights; Having difficulty holding down a job or staying in education or training; Lying frequently and without difficulty; Enjoying doing risky things; Dependency on alcohol and drugs.”

It is not difficult to imagine someone with those characteristics getting involved in crime. But crucially the behaviour is not governed by the individual being a “bad” person, but symptoms of a mental illness that people can be helped to manage.

This is really important firstly because it helps to illustrate how people with these conditions first encounter the system through police, probation and prison officers, rather than medical professions. This highlights why it is vital that they have the training to identify the problem and know where to turn for help. Secondly it highlights that a majority of prisoners need help with mental ill health, and begs many questions about whether the prison environment is the best place to provide it.

It raises a bigger question as well. Many with personality disorders complain that they do not get enough support. Diagnoses are not always followed up with appropriate treatment and people are misunderstood, even stigmatised by professionals who should be offering them help.

Public understanding of mental health illness in general is rising. And that’s good. But it would appear that personality disorder is not understood and is still stigmatised to the extent that it can even be a barrier to receiving help and support from the vulnerable people who so desperately need it.

The Northern Ireland Personality Disorder Network’s conference at the La Mon House hotel on 21 June aims to share best practice and to shed new light on a condition that affects one in 16 of us.