***Please be warned that some of this post might be triggering.***
This is Steve.
This is Steve.
Steve has decided to seek help with his mental health. He really struggles with some things everyone else seems to find easy and it's making his life really hard. He often feels very distressed and people around him get hurt or angry. Steve isn't really sure what's going on; he just feels like something is wrong, and has been wrong for most of his life. He doesn't remember things ever being different but is desperate for them to change.
People often comment on the way Steve thinks about things. They tell him he is getting it wrong. He is really hard on himself, and seems to jump to extreme conclusions very quickly. He often thinks people are doing things deliberately to upset him or the world is against him. Steve experiences his emotions as loud and tidal. His mood changes often and he isn't really sure why. He quickly becomes overwhelmed and other people tell him he's being dramatic or seeking attention. Sometimes he manages his distress by being impulsive; hurting himself, drinking a lot, gambling, or sleeping with someone he doesn't even fancy.
Steve really struggles to maintain relationships. His family have washed their hands of him because they say he is "too much" and "too needy". He gets into arguments with his friends and they don't ever seem to make up. He lost his last job after he got into an argument with the manager.
When Steve just stops and tries to relax, he becomes aware of how empty he feels. It's a horrible feeling and one he tries to avoid wherever possible.
Steve often feels intensely distressed, and his difficulties upset, worry, and anger people around him. His mental health and behaviour have a significant impact on his ability to function day-to-day and prevent him from achieving the things he would like to achieve in his life.
Steve is showing symptoms of Personality Disorder.
What is a Personality Disorder?
A Personality Disorder is an enduring mental health problem, the onset of which is usually in at least early adulthood if not adolescence, and which is stable, pervasive, and present across a wide range of situations (DSM-5, American Psychiatric Association, 2013). Symptoms include an enduring tendency to think and behave in a way which is markedly different than other people of the same culture and age group; intense, changeable, and sometimes inappropriate emotional responses; difficulties in relationships; and impulse control problems. These symptoms cause distress and affect the person's ability to function.
"Personality Disorder" is an umbrella term covering ten types of Personality Disorder. It is not unusual for people to have a mixed diagnosis, meeting criteria for more than one disorder, or presenting with bits of several but not meeting the full criteria for any one in particular. Sometimes, people have some milder qualities of Personality Disorder, but function well for the most part. In these situations they might be said to have some "traits" of Personality Disorder which they may wish to seek help for, but they will not be given a full diagnosis.
As with all mental health problems, Personality Disorders can vary in terms of severity. At one end, people might have quite mild difficulties and function well with structure and supportive people around them, only ever coming to the attention of mental health services if something very stressful has happened; for example, the end of a long-term relationship, or redundancy. At the other end of the spectrum, people with severe Personality Disorder might be very disabled by their problems and require a high level of support from mental health services as well as supported housing.
This diagnosis is not uncommon, with an estimated 1 in 20 people in England having a Personality Disorder.
Why do people develop Personality Disorders?
This is a good question, and as with any mental health problem, there is not a definitive answer. However, our best theory at present is that there is an interplay between nature and nurture.
Think back to that earlier post about attachment. Attachments are likely to play a major role in the development of Personality Disorder. Adults with this diagnosis present with insecure attachment types. For Borderline Personality Disorder, this is most often a disorganised attachment style. (Here's a quick reminder of what that looks like in an infant.)
They really struggle in relationships with others, and those around them notice a push/pull phenomenon whereby the person wants to be close but then seems unable to tolerate it and pushes the other away. The other person might respect this and give them space, but the person with Personality Disorder then feels abandoned, neglected, or rejected, and responds with anger and distress. This pattern can be very difficult for others to manage, and difficult for the person with Personality Disorder to recognise and understand. It is a major contributor to their difficult relationships and is most likely to have originated from a difficult early attachment which taught them that caregivers are unpredictable and sometimes harmful, scary, or unresponsive or neglectful. Relationships activate the attachment system and the adult finds themselves playing out something very difficult from their early life.
We all have different temperaments when we are born.
Some babies sleep easily whilst others keep their parents awake all night. Some babies are placid and content whilst others are anxious or grizzly. It is likely that people who go on to develop Personality Disorders were more sensitive than the average bear to begin with. They were attuned to the emotions of others and might feel sad or worried more quickly than their peers. If life had been plain-sailing for them, they might have been the sort of adults who cried at films and preferred not to watch the news. However, it wasn't all plain-sailing after that, unfortunately. Somehow or another, their experiences got invalidated and they learned that their emotions were wrong, bad, attention-seeking, or harmful. They learned that their needs would not be easily met, and this made the world a confusing, scary place, in which they experienced extreme distress and there seemed to be no resolution.
This invalidation could have happened in a number of ways. On the less sinister end of it, it might have been that the child was just poorly matched with their parent/s in terms of temperament. Whilst the child was sensitive and felt things deeply, mum was a "stiff upper lip" type and the sort to just shrug things off. When presented with a child who cried easily she told them they couldn't possibly be as upset as they thought, because she couldn't conceive of this herself. It was alien to her. So every time her child became distressed by something she thought was ridiculous she assumed they were being dramatic or attention seeking, and told them so. And she didn't respond to that need, because as far as she was concerned, it wasn't real. She didn't mean any harm, but the child learned that their emotions weren't valid, and their need wouldn't be met. They were left with not only the initial distress, but now the additional emotion/s arising from knowing they were in the wrong - perhaps shame, anger, hurt, or fear that the distress would last forever.
On the nastier end of the scale, a child's feelings and experiences might be intentionally invalidated. In the case of child abuse, an abuser might tell the child they like something they do not, or that their distress is not real. Tragically, they might also be disbelieved when making disclosures about their experiences.
Somewhere in the middle of the two are parents whose own mental health or extreme social stressors limit their ability to be available to their children, resulting in emotional neglect, whether intentional or not. People with Personality Disorders often report early experiences of abuse or neglect, or parents with mental health or substance use problems which were poorly managed.
If the parenting a child receives does not involve them being taught to label their emotions or learning how to manage them, e.g. by a parent noticing they are sad and comforting them, they will struggle to understand their own emotions or know how to manage them in later life. Adults with Personality Disorder frequently feel like their emotions change without any real cause, have difficulty labelling their feelings, and feel unable to soothe themselves when distressed.
Keeping in mind the kinds of difficulties people with Personality Disorder have and just how understandable this is given their early experiences is helpful in ensuring a compassionate, thoughtful response to people whose behaviour and distress can be challenging and upsetting to those around them.
Check back for posts about specific Personality Disorders!
The Bear xXx
As with all mental health problems, Personality Disorders can vary in terms of severity. At one end, people might have quite mild difficulties and function well with structure and supportive people around them, only ever coming to the attention of mental health services if something very stressful has happened; for example, the end of a long-term relationship, or redundancy. At the other end of the spectrum, people with severe Personality Disorder might be very disabled by their problems and require a high level of support from mental health services as well as supported housing.
This diagnosis is not uncommon, with an estimated 1 in 20 people in England having a Personality Disorder.
Why do people develop Personality Disorders?
This is a good question, and as with any mental health problem, there is not a definitive answer. However, our best theory at present is that there is an interplay between nature and nurture.
Think back to that earlier post about attachment. Attachments are likely to play a major role in the development of Personality Disorder. Adults with this diagnosis present with insecure attachment types. For Borderline Personality Disorder, this is most often a disorganised attachment style. (Here's a quick reminder of what that looks like in an infant.)
They really struggle in relationships with others, and those around them notice a push/pull phenomenon whereby the person wants to be close but then seems unable to tolerate it and pushes the other away. The other person might respect this and give them space, but the person with Personality Disorder then feels abandoned, neglected, or rejected, and responds with anger and distress. This pattern can be very difficult for others to manage, and difficult for the person with Personality Disorder to recognise and understand. It is a major contributor to their difficult relationships and is most likely to have originated from a difficult early attachment which taught them that caregivers are unpredictable and sometimes harmful, scary, or unresponsive or neglectful. Relationships activate the attachment system and the adult finds themselves playing out something very difficult from their early life.
We all have different temperaments when we are born.
Some babies sleep easily whilst others keep their parents awake all night. Some babies are placid and content whilst others are anxious or grizzly. It is likely that people who go on to develop Personality Disorders were more sensitive than the average bear to begin with. They were attuned to the emotions of others and might feel sad or worried more quickly than their peers. If life had been plain-sailing for them, they might have been the sort of adults who cried at films and preferred not to watch the news. However, it wasn't all plain-sailing after that, unfortunately. Somehow or another, their experiences got invalidated and they learned that their emotions were wrong, bad, attention-seeking, or harmful. They learned that their needs would not be easily met, and this made the world a confusing, scary place, in which they experienced extreme distress and there seemed to be no resolution.
This invalidation could have happened in a number of ways. On the less sinister end of it, it might have been that the child was just poorly matched with their parent/s in terms of temperament. Whilst the child was sensitive and felt things deeply, mum was a "stiff upper lip" type and the sort to just shrug things off. When presented with a child who cried easily she told them they couldn't possibly be as upset as they thought, because she couldn't conceive of this herself. It was alien to her. So every time her child became distressed by something she thought was ridiculous she assumed they were being dramatic or attention seeking, and told them so. And she didn't respond to that need, because as far as she was concerned, it wasn't real. She didn't mean any harm, but the child learned that their emotions weren't valid, and their need wouldn't be met. They were left with not only the initial distress, but now the additional emotion/s arising from knowing they were in the wrong - perhaps shame, anger, hurt, or fear that the distress would last forever.
On the nastier end of the scale, a child's feelings and experiences might be intentionally invalidated. In the case of child abuse, an abuser might tell the child they like something they do not, or that their distress is not real. Tragically, they might also be disbelieved when making disclosures about their experiences.
Somewhere in the middle of the two are parents whose own mental health or extreme social stressors limit their ability to be available to their children, resulting in emotional neglect, whether intentional or not. People with Personality Disorders often report early experiences of abuse or neglect, or parents with mental health or substance use problems which were poorly managed.
If the parenting a child receives does not involve them being taught to label their emotions or learning how to manage them, e.g. by a parent noticing they are sad and comforting them, they will struggle to understand their own emotions or know how to manage them in later life. Adults with Personality Disorder frequently feel like their emotions change without any real cause, have difficulty labelling their feelings, and feel unable to soothe themselves when distressed.
Keeping in mind the kinds of difficulties people with Personality Disorder have and just how understandable this is given their early experiences is helpful in ensuring a compassionate, thoughtful response to people whose behaviour and distress can be challenging and upsetting to those around them.
Check back for posts about specific Personality Disorders!
The Bear xXx
