I-RAP
Improving Recognition and Understanding of Autism and Personality Disorder
Information about autism and personality disorder
1. Highlights
Trigger warning: this section contains references to trauma.
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The concept of personality disorder refers to the idea that some people experience longstanding and extensive difficulties in how they think and feel about themselves and others, and consequently how they behave in relation to other people.
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The most commonly diagnosed type of personality disorder is borderline personality disorder.
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Borderline personality disorder is characterised by experiencing frequent and intense emotional distress, and reacting very strongly to feeling let down or uncared for by other people. This can lead to conflict and difficulties in sustaining relationships. People with this diagnosis may manage feelings of intense distress by self harming or other coping mechanisms like disordered eating or substance misuse. A person with this diagnosis may also feel unsure about who they are as a person, and may experience intense feelings of disconnection from reality (“dissociation”).
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The internal experiences, distress and behaviours of people diagnosed with a personality disorder – particularly borderline personality disorder – can often make sense when we understand how they have been shaped by early experiences of trauma, abuse and neglect.
2. Further Information
ICD-11, which is the diagnostic system used in the UK and Europe, defines personality disorder as personality traits that lead to longstanding and extensive difficulties in how a person thinks and feels about themselves and others, which impact their behaviour and relationships with other people [1, 2]. To be defined as a personality disorder, these difficulties need to be persistent (lasting a number of years), pervasive (affecting all areas of a person’s life) and problematic (causing significant distress and difficulties with coping with important aspects of life like education, work and relationships with other people.) Some possible examples described in the ICD-11 diagnostic system – each of which will only apply to some people and not to others - are:
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A tendency to experience a broad range of extreme negative emotions
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Avoiding social interactions and avoiding getting emotionally close to other people
or
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Avoiding experiencing and showing emotions
or
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Self-centredness and lack of empathy
or
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Impulsivity and irresponsibility
or
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Perfectionism and rigidity
The most commonly diagnosed type of personality disorder has historically been “borderline personality disorder” (as it is called in the American diagnostic system, the DSM-5) [3]. It’s a bit more complicated in (ICD-11) so we’ll stick to DSM-5 for now. DSM-5 defines borderline personality disorder as “(1) a pervasive pattern of instability of interpersonal relationships, self-image, and affects, and (2) marked impulsivity” [4]. This means a person can be quite changeable and swing between different extremes in how they feel about themselves and their relationships with other people, and their moods and emotions can be very changeable and swing between extremes too. They may also self-harm and/or do other things impulsively which damage their health. DSM-5 go on to say that these difficulties should have begun by early adulthood and should be present in a variety of contexts.
They say that to be given the diagnosis, someone should experience at least 5 of the following 9 difficulties:
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Frantic efforts to stop other people leaving or abandoning you.
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A pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization (thinking someone is perfect) and devaluation (thinking someone is awful).
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Markedly and persistently unstable self-image or sense of self e.g. frequent big changes in your beliefs, opinions, lifestyle, ambitions or career, or feeling like who you are as a person changes a lot, or you don’t know who you are.
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Impulsive behaviour in at least two areas that are potentially self-damaging (eg, spending, sex, substance abuse, reckless driving, binge eating) (this does not include self-harm).
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Repeated feelings of suicidality, or self-harm.
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Moods and emotions changing easily and swinging from one intense emotion to another.
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Profound feelings of emptiness.
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Intense anger or difficulty controlling anger.
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Temporarily feeling paranoid or feeling dissociated (like your consciousness is disconnected from your body or from reality), particularly when stressed.
Viewed through a trauma lens, the set of difficulties described above can be understood as necessary coping mechanisms, survival strategies and/or consequences of surviving trauma [5]. For example, if past experiences have taught you that even people who seem caring cannot be trusted and may be dangerous, to protect yourself it makes sense to react with anger and to quickly end relationships if you notice signs that a person may be untrustworthy or uncaring [6].
3. References
[1] Wood, H., Bolton, W., Lovell, K., & Morgan, L. (2014). Meeting the challenge, making a difference: Working effectively to support people with personality disorder in the community.
[2] World Health Organization (WHO) (2019). International Classification of Diseases, Eleventh Revision (ICD-11), https://icd.who.int/browse11.
[3] Tyrer, P. (2018). Accurate recording of personality disorder in clinical practice. British Journal of Psychiatry Bulletin, 42, 135-136.
[4] American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author.
[5] Brickel, R.E. (2019). A Compassionate Look at “Borderline Personality Disorder” From a Trauma-Informed Lens. https://brickelandassociates.com/borderline-personality-disorder-trauma-informed-lens
[6] Shaw, C., & Proctor, G. (2005). I. Women at the margins: A critique of the diagnosis of borderline personality disorder. Feminism & Psychology, 15, 483–490
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