Hardly a week goes by these days without mental health making the news; with everyone from celebrities to politicians keen to share their own struggles with depression or anxiety.
But there is one psychiatric condition that remains conspicuously absent from the discussions, even though an estimated one in ten of us will experience it at some point.
Unlike bipolar disorder or postnatal depression, people don’t seem to want to admit to having this condition — you won’t see them going on fun‑runs for it or talking about their experiences on morning TV.
Say word ‘psychopath’ and most people think of a character like Hannibal Lecter
That’s because for this condition, the stigma is still very much alive and kicking.
While most people could name one or two personality disorders (such as psychopath), there are actually ten types, and many of us will have at least one of them at some stage in our lives.
Yet many people do not even know personality disorder exists, leaving those affected — and the people around them — to suffer in silence.
Psychiatrists such as myself see many people with personality disorders and know the pain and distress they can cause.
Lots of people have aspects of a personality disorder. But unless it’s causing serious problems, then it’s often said they have ‘traits’ of a personality disorder, but not the full‑blown version — where the symptoms are a constant feature that hampers their life.
So in this way, personality disorder is really on a continuum.
For example, many surgeons and lawyers, score highly on psychopathic disorder scales, yet they have found a job where their ability to be cold and calculating, incredibly focused and to cut themselves off from the emotions of others actually helps them do their job.
While they might have psychopathic personality traits, we wouldn’t say they had a disorder.
Similarly, many celebrities have narcissistic personality traits. But it’s these traits that have enabled them to succeed, for example, by taking advantage of others and prioritising their own needs.
Many surgeons and lawyers score highly on psychopathic disorder scales
Some of the symptoms of personality disorders, in isolation, can seem to be advantageous. People with histrionic personality disorder, for example, are often great fun: the perfect ‘party person’.
However, this is enjoyable for only so long, and friends and family will often tire of such behaviour when they seek peace and quiet.
Despite being so common, personality disorders are shrouded in secrecy and shame, with even many doctors not fully understanding how to spot them. As a result, they can sometimes be misdiagnosed as depression or bipolar disorder because they appear to share some symptoms.
There is also general confusion around the terms used to describe personality disorders, and what — if any — treatments work.
It used to be thought, for instance, that people with a personality disorder had one for life, and there was little that could be done to help.
Research has now shown that people do get better and their symptoms can improve — with the right treatment.
The chances are you’re closely related to someone with the traits of a personality disorder, are married to one, or work with one. But how would you know if they have a personality disorder that needs treatment?
In this first part of a new series, I set out to demystify this hidden yet extremely common problem — and hopefully provide some of the answers to help you cope with it.
PERSONALITY IS A BIT LIKE BAKING
To understand what a personality disorder is, we first have to get to grips with what personality is — trickier than you might think, as how we behave towards people can differ from one situation to another. Generally speaking, though, personality is a combination of the key characteristics that govern how we behave, think and feel. While we all have similar traits, different people have different quantities in different combinations.
It’s a bit like baking. You can start with the same or similar ingredients, but depending on the quantities and how you combine them, you can end up with very different pastry.
Personality is a combination of the characteristics that govern how we behave, think and feel
In a fully formed personality, the traits should balance and complement each other so we can get on with our lives without too many problems.
However, in a personality disorder, these traits aren’t working together, and instead, some seem to dominate or are absent.
To go back to the cooking analogy, it’s as though some of the key ingredients are missing entirely or aren’t in the right proportions, so the pastry doesn’t turn out right.
This makes life very difficult for the person and those around them. People with a personality disorder often find that they struggle to make and maintain close relationships, get on with people at work, control their feelings and emotions and understand other people.
LINKED TO FAMILY UPHEAVAL
Exactly what causes a personality disorder has created a lot of debate, but it’s thought to be down to a combination of factors. A major one is upbringing.
Perhaps it’s no surprise to learn that people with a personality disorder are more likely to have had a difficult childhood.
During our formative years, just as we learn skills such as how to walk, read and write, so we also learn key skills like how to control and regulate our emotions, plus coping strategies. If the childhood environment prevented them from developing this aspect of themselves, then a personality disorder is more likely to develop.
This may mean an abusive or traumatic upbringing but could also include being brought up in a chaotic or unstable family home, with parents going through an acrimonious divorce, who were heavy drinkers or who didn’t provide adequate support, love or attention.
GETTING A DIAGNOSIS CAN BE TRICKY
Because personality is a complex thing, it’s not always easy to say for sure when someone has a disorder. The symptoms can also be mistaken for other mental health problems, such as depression or bipolar, as they can superficially seem very similar. The part of the brain responsible for our personality is the prefrontal cortex — found just behind your forehead above the eyes.
This area is still growing right up until our mid‑20s. Because of this, most doctors try to avoid diagnosing a personality disorder in people until they are at least in their 20s.
Early bereavement or being involved in major accidents or multiple upheavals such as moving home or schools a lot can also contribute.
This isn’t the whole picture, though: siblings can go through the same difficulties, yet one will develop a personality disorder and the other won’t. Similarly, not everyone who has a personality disorder has had a difficult childhood. This suggests that there is also a genetic element.
As our personality is not fully formed until our mid-20s, often the problems from a personality disorder do not become evident until then, although that person might have started exhibiting symptoms in their late teens.
Sometimes people have had traits for many years but have been in a relationship with someone that’s helped contain the most difficult aspects, so the full symptoms don’t become apparent until something happens and that other person either leaves or dies.
Other triggers can include money problems, stressful situations, important events and drinking a lot of alcohol.
WARNING SIGNS TO LOOK FOR
It’s important to emphasise that it’s normal to struggle with life at times and to feel overwhelmed. What distinguishes a personality disorder is that the symptoms are recurring and have a serious impact on someone’s life
Broadly speaking, the personality disorders fall into three broad clusters, based on the type of emotional problem underlying them. These are:
Cluster A: Odd or Eccentric.
Cluster B: Dramatic, Emotional or Erratic.
Cluster C: Anxious or Fearful.
Generally, to be diagnosed with a personality disorder, people need to have three or four of the characteristics of one type — few will have all the symptoms.
You can also have symptoms of more than one type of personality disorder, and so might be diagnosed with ‘mixed type’.
Today we will focus on the Cluster B group, because they contain some of the personalities most people have heard of, such as psychopathic.
Essentially, Cluster B types behave in unpredictable or overly emotional ways.
There are four different types of personality in this group: antisocial (the proper medical term for psychopathic), histrionic, borderline and narcissistic. Here, we look at the first three…
A PSYCHOPATH IN ALL OF US?
The following are characteristics of antisocial (sometimes called dissocial)) personality disorder, the medical term for ‘psychopathic’. Could your loved one or even boss be affected? Do they:
- Put themselves in dangerous or risky situations, often without considering the consequences for themselves or others, for instance?
- Get bored and frustrated very easily and act on impulse — they may find it difficult to hold down a job for long?
- Behave aggressively and get into fights easily?
- Act in ways that are unpleasant for others or appear cruel, uncaring, cold and unemotional
- Appear superficially charming and charismatic?
- Do things to get what they want, putting their needs above others — even though they may hurt people and feel no sense of guilt if they have mistreated others?
Say the word ‘psychopath’ and most people think of a woman in a shower screaming as a man approaches with a large knife, or of Hannibal Lecter in a mask.
We tend to assume all psychopaths are cold, brutal, callous murderers with no regard for the feelings of others; or sadists, gaining pleasure from other people’s pain.
While certainly there are some notorious murderers who exhibit psychopathic traits, the term psychopath is greatly misunderstood.
I’ve seen this recently with political commentators claiming that Donald Trump is a psychopath, basing this on his scant regard for what others think and his apparent glee at causing anger and hostility among liberal Americans.
I’m not at all convinced. Being a psychopath is a serious, profound mental health issue, whereas being generally offensive is not a mental illness.
Psychopaths are characterised by a lack of remorse and difficulties with empathy
You can disagree with him and not like him, but that doesn’t mean Trump has a serious psychological problem.
The term psychopath refers to someone with antisocial personality disorder. It is characterised by a lack of remorse, difficulties with empathy and yet a superficial charm. Those affected are also unwilling to accept responsibility. They lack behavioural control, so they will feel emboldened to do whatever they like, even if it’s against the law or social convention, and are impulsive. As you’d imagine, it’s strongly linked to criminal behaviour.
I’ve worked with many ‘psychopaths’ in a secure hospital who had either murdered or seriously injured their victims.
These patients seemed very normal. They didn’t try to attack me, just shuffled about, asking if they could use the exercise yard or complaining about the food. Superficially, it was hard to see what all the fuss was about.
Over time, though, I realised that while someone can appear psychologically normal in straightforward interactions, they can still have profound underlying problems.
Psychopaths lack behavioural control, so they will feel emboldened to do whatever they like
One patient, for example, had subjected several women to horrific sexual attacks but was perfectly pleasant and polite on the ward. It was hard to reconcile what he had done with the person who would stand in front of me each day.
The patient was allocated a young female psychologist and, over several months, he began to open up about the attacks, going into more and more detail.
I assumed this was a sign of progress, yet it began to become apparent that the psychologist was becoming more distressed by the details.
The sessions were abruptly stopped as it became clear the patient wasn’t recalling the details for therapeutic reasons, but was gaining immense sadistic pleasure from the distress he was causing the psychologist.
But many people with psychopathic traits are not sadists, and not everyone with this type of personality disorder is a criminal.
In fact, we all have – to a greater or lesser extent — aspects of our personality that are psychopathic.
It’s very useful for all of us to get in touch with our inner psychopath at times, as it helps us be focused, to prioritise what we want.
Sometimes we need to be a little callous and self-centred — to cut ties with someone who’s upset you, for example, or challenge people despite it being socially awkward to do so.
People in many professions score highly on psychopath tests, and that’s a good thing as it helps them do their job.
Consider, for example, a barrister who has to stand up and defend someone they may well think is guilty, yet they absolutely cannot allow the court to see this. They effectively have to lie to a room full of people and make it convincing.
Psychopathic patients in secure hospitals like Broadmoor (pictured) may have either murdered or seriously injured their victims, but may outwardly seem very normal
This is a good thing because being represented in court and having your version of events heard is the cornerstone of a just society.
Similarly, imagine a surgeon’s work. Cutting into someone is a strange thing to do — you have to suspend the fact that they’re another human being and instead treat them as a machine that needs to be fixed. That’s a very psychopathic thing to be able to do.
Captains of industry also often score very highly on psychopathic personality disorder scales.
Again, they have to be incredibly hard-headed and focused in order to have risen up the ranks, often prioritising their own needs over other colleagues.
They will have had to be manipulative and conniving to get where they are, and then focused and, at times, callous in order to maintain their position.
Firing someone is an incredibly difficult thing to do — it’s often catastrophic for the employee and their family.
Yet bosses have to do this routinely. Psychopathic traits enable them to get on with the job without being overwhelmed with guilt.
Psychopaths and those with psychopathic traits can often be very charming superficially because it’s part of being able to manipulate and inveigle themselves into others’ lives and get their trust quickly.
But, ultimately, it is incredibly difficult to form longstanding relationships with them.
They can sometimes maintain their charming persona for some people but not others, to the extent that two people’s description of the same person might seem utterly different.
‘DRAMA QUEEN’ PERSONALITY
The proper medical term for this personality is histrionic.
Most of us will know someone like this. They might be labelled ‘drama queens’, which rather belittles what is actually a very distressing condition.
So how can you tell if your loved one, friend or colleague is affected?
Use the following checklist (remember, they’d need three or four characteristics to be considered to have this personality disorder). Do they:
- Worry a lot about their appearance?
- Crave new and exciting things and never feel satisfied?
- Feel very uncomfortable if not the centre of attention, and much more at ease as the ‘life and soul of the party’?
- Feel they have to entertain people (possibly flirt or behave provocatively to ensure they remain the centre of attention)?
- Have a reputation for being over-emotional?
- Feel dependent on the approval of others?
- Allow themselves to be easily influenced by others?
Part of the problem is that people struggle to sympathise with them or to understand their behaviour as a symptom of a serious problem with their personality, rather than them just liking a bit of drama and excitement in their life.
They’re often great fun to have around at first. But as soon as the attention is not on them, things turn sour.
They have a tendency to be overemotional, which can be difficult and draining after a while. So although it’s enjoyable spending short periods of time with them, they are hard to see regularly, which can make the person feel let down. They can suffer severe low mood and a profound sense of being rejected and lost.
When the attention is not on them, things tend to turn sour with those with personality disorders
Because histrionic types tend to dramatise things, other people often end up taking everything they say with a pinch of salt.
Again, as they are keen for the approval of others, this can be very upsetting for them.
This type is often dismissed as simply being dramatic and attention-seeking.
But it indicates a profound problem and, if left untreated, these people can experience suicidal thoughts and become very isolated as their friends and family tire of them.
Overwhelmed by their own emotions
The following checklist lists the characteristics of someone with borderline personality disorder. Ask yourself, do they:
- Find it hard to control their emotions?
- Feel bad about themselves and/ or empty?
- Feel very worried about people abandoning them, and would do anything to stop that happening?
- Have very intense emotions that last from a few hours to a few days, and that can change quickly?
- Not have a strong sense of who they are or their identity, but feel as though they’re having to ‘act’ or ‘play a role’ with people?
- Make friends easily but find it very difficult to keep them?
- Act impulsively and do things that could harm them (such as cutting themselves)?
- When stressed, hear voices or see things that other people don’t?
People are often confused by the term ‘borderline’, thinking it means this personality disorder is mild. In fact, the term ‘borderline’ comes from an older system meaning on the border between a psychotic and a neurotic illness.
(Mental illness used to be characterised into psychotic illness — where people would have unusual experiences such as seeing or hearing things — and neurotic, which meant the symptoms related to mood and feelings.)
It is often one of the most debilitating of the personality disorders. People with emotionally unstable personality disorder (EUPD), as it’s also known, will really struggle with life.
It can also be extremely tough on those close to them because their behaviour can often be very distressing and scary to witness as someone with EUPD may express suicidal thoughts.
Friends and family will often be very involved to start with, and then over time may become exhausted or start to feel used or manipulated.