©2021 Bill Eddy, LCSW, Esq.
Personality Disorders—An Enduring Pattern of Dysfunctional Interpersonal Behavior
The term personality disorder has been familiar to mental health professionals for over forty years. However, most other professionals and the general public know little about the meaning of such disorders and often operate with misconceptions about their patterns of dysfunctional behavior. Personality disorders are officially a category in the Diagnostic and Statistical Manual of Mental Disorders published by the American Psychiatric Association and used throughout the world. The current version of this manual is the fifth edition, which was published in 2013 and is known as the DSM-5.
I was first trained in the DSM-3 when it was published in 1980, the year I was in a field placement at the San Diego Child Guidance Clinic during my master’s in social work (MSW) degree program. This was when personality disorders were first clearly included as a category of specifically defined disorders, each with its own list of criteria. Over the next forty years I have learned a lot more about personality disorders that I now take for granted, but I still find that most people know little about them.
In short, personality disorders are an enduring pattern of dysfunctional interpersonal behavior. The following are some of the most common misunderstandings:
#1: Personality disorders are rare.
No. In fact, the DSM-5 refers to a study that indicates that 15% of adults in the United States have one. Other studies indicate 10-13%. This is equal to or more common than the percent of people with a substance use disorder (addictions), yet most people know little about personality disorders and they are not talked about much in public. In many ways, society is treating personality disorders like it used to treat addictions fifty years ago, as hush-hush. Now there is widespread public awareness and discussion, court-ordered drunk driving programs, hospital treatment programs, insurance funding for treatment, and many families and companies can push their loved ones and employees into substance abuse treatment with “interventions.” We are just starting to see some of this awareness beginning in regard to personality disorders.
#2: Personality disorders are obvious.
No. Personality disorders are generally hidden disorders. There is a full range of severity of these disorders. Some people with personality disorders can function well in their jobs and communities but have serious problems in close relationships (such as families), while others cannot even work because they are so dysfunctional. People with these disorders are often not obvious to people who are dating them until they have known them for six to twelve months, or people who hire them, who often do not know until they are settled deeply into the job. They can get by in many settings for a long time. They look like everyone else on the surface.
#3: Someone would know if they had a personality disorder.
Usually not. Most people who have one do not know they have it. Personality disorders are enduring patterns of behavior that develop before adulthood, most commonly in early childhood. They lack self-awareness of their own disorders and of the impact of their own behavior on those around them. When they get feedback for their negative behavior, they tend to become highly defensive rather than having insight into their part in the problem, which is often substantial. This is a big part of why they have an enduring pattern of dysfunctional behavior; it seems normal and necessary to them. But it does not work, and they often are unhappy.
#4: Personality disorders can never change.
Not necessarily. Historically, many people (including therapists) thought that personality disorders were unchangeable and therefore therapy was pointless. However, over the past 2-3 decades there have been breakthrough treatments that have succeeded at improving the behavior of some people with personality disorders. For example, there is a fairly successful treatment approach for borderline personality disorder called Dialectical Behavior Therapy, or DBT, which has helped many people overcome the diagnosis with improved self-awareness and self-control. Also, some people with other personality disorders (there are ten) have made some progress in therapy, such as some of those with narcissistic personality disorder. However, the vast majority of people with personality disorders do not seek or get treatment and remain stuck in dysfunction.
#5: People with personality disorders know they are acting inappropriately.
Usually not. This is one of the hardest things to accept about personality disorders. But they really, truly lack self-awareness of their part in their problems. They honestly believe that others have treated them unfairly for no good reason when others are usually reacting to their behavior or trying to set limits on their behavior. Since they cannot see their own part in their own problems, they are always searching for other explanations. Some blame life in general or the universe, while others blame specific people (these are the ones with high conflict personalities, who are preoccupied with targets of blame).
#6: People with personality disorders could change if they just wanted to.
Unlikely. Remember, a personality disorder is an “enduring pattern” of dysfunctional behavior. They cannot see their part in their problems and conflicts. In many ways, this problem is like that of alcoholics and addicts, who cannot see the connection of their own behavior to their problems in life. Only it’s even harder with personality disorders because the person has experienced their own patterns of behavior usually since early childhood as normal and necessary. There is no obvious cause of their difficulties, so people assume their behavior is knowingly bad and intentional. In reality, this is the problem: they cannot connect the dots from their own behavior to how others respond, and how they could change.
#7: You should try to give them insight into their own behavior.
Do not do this! Since they lack self-awareness and have an enduring pattern of behavior that they rarely change, feedback—even “constructive” feedback—feels like a personal attack to them. Not only do they not benefit from the feedback, but it harms your relationship with them. Most people put their energy into trying to get those with personality disorders to “just stop” whatever extreme behavior they are engaged in. But it is similar to alcoholism and addiction: it’s more helpful to learn new behaviors than to try to stop old behaviors. It is better to focus them on what to do now, rather than what not to do.
#8: You should confront them with their past inappropriate behavior.
Do not do this! People with personality disorders chronically feel stuck in the past because they do not go through the normal grieving and healing process. They do not get things off their chest. It is sad, but they keep trying to re-work the past to help themselves feel better. But their interpretation of the past is often distorted and arguing about it does not help them or those around them. It is better to focus on the future and choices about what to do now. If they have behaved badly, confronting their past behavior usually just triggers more defensiveness and does not lead to behavior change. It is better to focus on the future behavior that you desire and the benefits of doing it, and the consequences if they do not.
#9: You should tell them how you feel about their difficult behavior.
Do not do this! This really blows up because their unresolved feelings are often so negative, it just triggers a bigger emotional upset for them, and they cannot calm themselves very easily. They can also do anger and upset better than ordinary people, usually because it has been a life-long struggle and their emotions remain unresolved. It is better to focus on the future and what you would like them to do or set limits by talking about the consequences of future non-compliance with family rules or workplace policies.
#10. There is no hope for people with personality disorders.
Not true! We have learned that people with personality disorders are somewhat influenced by their environment and how people treat them. As mentioned above, some people are in recovery from having a personality disorder after working hard in therapy. As with substance abuse, the more society learns about personality disorders the more we will be able to help them. They are mostly like everyone else, except they are stuck with interpersonal dysfunction, especially around close relationships and conflict situations. The biggest problem right now is ignorance of these disorders so that people tend to reinforce their inappropriate blaming behavior or give up on them. There are treatments that can help in most cases, but they are not being used or widely available, and those around people with personality disorders often cannot see what the problem is.
Hopefully, over the next few decades, we as a society will come to understand this problem and help people overcome it in a structured, treatment-focused way, rather than responding with ignorance, judgment, tolerance, or helplessness. We can and should talk more about personality disorders. We have made a lot of progress as a society with drug and alcohol understanding and treatment, so we know we have the potential to manage this hidden problem that affects so many individuals and families today.
This article has focused on misunderstandings. There are many articles, books, and training videos on our website that further explain personality disorders and how to manage them in interpersonal situations: www.HighConflictInstitute.com.
BILL EDDY, LCSW, ESQ. is the co-founder and Chief Innovation Officer of the High Conflict Institute in San Diego, California. He pioneered the High Conflict Personality Theory (HCP) and is viewed globally as the leading expert on managing disputes involving people with high conflict personalities. He has written more than twenty books on the topic and has taught professionals in the U.S. and more than ten countries.