Personality disorder (PD)

Overview and epidemiology

A personality disorder (PD) is characterised by pervasive and enduring patterns of inner experience and behaviour that deviate markedly from cultural expectations, are inflexible or maladaptive, and cause significant distress or impairment. These maladaptive patterns manifest in thoughts, emotions, interpersonal functioning, or impulse control. Personality disorder involves:

• Problems with the self (e.g. identity, self-worth, and self-direction).

• Interpersonal dysfunction (e.g. difficulties forming and sustaining relationships, empathising, and managing conflict).

Aetiology and risk factors

• Multifactorial aetiology, incorporating genetics and temperament, early life experiences (e.g. trauma, neglect), and ongoing maladaptive social experiences.

• Not all people with adverse childhood experiences develop PD, and conversely some people with PD report no obvious adversity.

• Early intervention and detection in adolescence or early adulthood can help moderate poor long-term outcomes.

Classification

Traditional (categorical) model (DSM-5 / ICD-10)

• Ten categories (e.g. borderline, narcissistic, antisocial, obsessive–compulsive, etc.). However, these often overlap and can lead to complex or “mixed” diagnoses.

Emerging (dimensional) model (ICD-11 / Alternative Model in DSM-5)

• Focuses on severity (mild, moderate, severe) plus specifiers describing prominent personality traits (e.g. negative affectivity, detachment, dissociality, disinhibition, and anankastia).

• A “borderline pattern” can be specified if pervasive interpersonal and self-image instability and marked impulsivity are present.

Diagnosis in general practice

When to suspect personality disorder

• Long-standing interpersonal difficulties, repeated crises, persistent patterns of dysfunctional coping, and self-harming or high-risk behaviour.

• A history of multiple mental health presentations or “frequent attender” patterns in primary care.

Key diagnostic criteria

• Maladaptive behaviour and internal experiences that are:

  1. Pervasive (across contexts).

  2. Long-standing (chronic and stable over time, typically evident from late adolescence/early adulthood).

  3. Cause significant distress or functional impairment.

  4. Not better explained by another mental disorder or by substance misuse or physical health issues.

Co-occurring disorders

• People with PD often have comorbid conditions (e.g. depression, anxiety, eating disorders, alcohol or other drug problems). High rates of comorbidity can obscure diagnosis.

Importance of timely diagnosis

• Untreated PD can lead to severe functional disability, chronic suicidal risk, and high service utilisation. Recognising PD helps tailor management towards psychosocial therapies rather than relying on pharmacotherapy alone.

Principles of management

Key approach

• A trusting, consistent therapeutic relationship is central.

• Emphasise compassion, empathy, open communication, and validation.

• Adopt a structured approach; clarify roles and boundaries.

• Encourage the patient’s ownership of decisions and responsibility for behaviour change.

• Address stigma by openly and respectfully discussing the diagnosis, emphasising that PDs are treatable.

Management plan

• Develop collaboratively with the patient (and, where appropriate, family/carers).

• Include:

  1. Key clinicians and contacts (including crisis and emergency supports).

  2. Risk assessment and crisis management strategies (especially for suicidal or self-harming behaviours).

  3. Short- and long-term treatment goals.

  4. Psychosocial interventions (first-line).

  5. If applicable, details on pharmacotherapy (targets, duration, and review timelines).

Team-based or multidisciplinary care

• In moderate-to-severe PD, a combined approach involving GPs, psychologists, psychiatrists, mental health nurses, social workers, and sometimes dedicated personality disorder services can improve outcomes.

Psychosocial interventions (first-line treatment)

Mainstay of treatment

• Psychosocial therapies are the foundation of PD management.

• Evidence-based therapies include:

  • Dialectical Behaviour Therapy (DBT)

  • Mentalisation-Based Therapy (MBT)

  • Schema Therapy

  • Transference-Focused Psychotherapy

  • Good Clinical (or Psychiatric) Management (structured, empathic care without a specific named modality)

Common factors of evidence-based psychosocial interventions

• A structured approach, focusing on problems relevant to PD (e.g. emotional dysregulation, interpersonal conflict).

• A strong therapeutic alliance with a validating but boundaried stance.

• Collaborative goal-setting and crisis planning.

• Linking feelings with triggers, and encouraging reflective capacity.

Pharmacological treatment

Limited role overall

• No medication “cures” personality disorder or addresses its core interpersonal and self-related difficulties.

• Medications may be used short-term to target specific severe symptoms (e.g. extreme anxiety, transient psychotic-like symptoms, severe agitation) if psychosocial approaches alone are insufficient.

• Caution is essential: people with PD can be at increased risk of misuse, dependence, and overdose.

Indications for medication in PD

• Cognitive-perceptual symptoms (e.g. transient paranoia, hallucinations): low-dose antipsychotics may be considered if severe, though evidence is limited.

• Affective dysregulation (e.g. dysphoria, marked mood lability, anxiety): consider antidepressants, particularly if comorbid mood or anxiety disorders are clearly present.

• Impulsivity / behavioural dyscontrol (e.g. severe self-harm, aggression): evidence is lacking; in complex cases, psychiatric advice is recommended.

Principles of use

• Always provide a clear rationale.

• Avoid polypharmacy; prefer sequential single-agent trials.

• Use time-limited prescriptions with regular review.

• Tailor choice to minimise risk (e.g. choose agents with lower lethality in overdose).

Short-term medication in crises

• A short course of a benzodiazepine or hypnotic may be considered for acute distress or insomnia.

• Cease once the crisis resolves and ensure the patient understands this plan to avoid dependence.

Acute crisis management

Presentation

• Often with severe distress, suicidality, or self-harm.

Principles

• Provide space for the patient to discuss concerns; listen with empathy.

• Use de-escalation and problem-solving first.

• Involve family or supports (with patient consent) to enhance safety.

• Keep to the agreed management plan if one is in place.

• If the patient remains extremely agitated or unsafe, short-term pharmacological sedation (e.g. with a benzodiazepine) may be required under close observation.

Special considerations

Perinatal context

• Women with borderline patterns often have higher risk of unplanned pregnancy, psychosocial stressors, and limited support.

• Preconception counselling is vital; discuss contraception and the potential added challenges of pregnancy and parenting.

• Robust psychosocial support, possibly involving perinatal mental health services, is crucial.

• Pharmacotherapy should be minimised in pregnancy or breastfeeding unless treating a clear comorbid disorder.

Stigma reduction

• “Personality disorder” is sometimes used pejoratively.

• Gently explaining the diagnosis with empathy can reduce self-stigma and improve engagement in care.

• As GPs, model respectful language and encourage your clinical team to do the same.