Comorbidity
personality disorder and emotional regulation
What is it all about?
The notion that people have varied personalties is well accepted. It is common place to talk about someone being ‘obsessive’ or ‘neurotic’ or ‘outgoing’ or ‘antisocial’. Personality disorder, however, is a controversial subject. As with common mental health problems such as anxiety and depression, there is the idea of a normal range, in this case of personality traits, and extreme versions of these which are then called personality disorders.
What kinds of personality disorder are there?
The International Classification of Diseases, ICD-11, categorises both the nature and the severity of traits, that are continuous with normal personality characteristics in individuals who do not have personality difficulties, as personality disorders. These are not diagnostic categories, but rather represent a set of dimensions that correspond to the underlying structure of personality.
Emotionally expressive :: frequent and intense negative emotions, negative attitudes, emotional lability and poor emotional control, low self-esteem and mistrustful.
Emotionally cold :: social detachment, avoidance of intimacy, few friendships, reserved and aloof, with limited emotional expression.
Narcissistic :: self-centredness, feeling of entitlement, temper tantrums, denigration of others, a lack of empathy, and an indifference to the consequences of any behaviours for other people.
Outgoing :: impulsive actions, pursuit of immediate gratification, easily distracted, lack of responsibility or sense of accountability, over-confident and reckless behaviour.
Obsessional :: rigid standard of perfection and of right and wrong, rigid control over emotional expression, stubbornness and inflexibility, risk-avoidance, and perseveration.
Are these useful categories?
Well, yes and no. On the one hand, each of these categories says a lot about what somebody is like, and how they are likely to behave. Most people will recognise these different sorts of individual, perhaps among family and friends. Also people who are distressed by their experience of living with their personality may want an understanding of what is happening to them, as might their family and friends. On the other hand, there can be a stigma attached to being labelled with a personality disorder, and the prognostic and treatment implications are modest. Current thinking leaves a couple of moot points:
① If, as ICD-11 suggests, personality disorder categories are not to be taken as diagnostic, then in what way do they differ from anxiety or depression where both normal and disorder states are accepted? Should previously diagnosed personality disorders be reconsidered and given a mental illness label?
② If a personality disorder label is stigmatising, does it follow that the concept be abandoned? Drug and alcohol labels are seen by some as stigmatising but does anybody want to abandon their existence? The behaviour of people falling into these groups can be challenging and they may be hard to engage, but doesn’t this call for better education of the public and specialist services committed to helping?
Personality problems find their roots in childhood and early development. Important early life factors include: trauma from emotional, physical or sexual abuse; exposure to long-term fear or distress, which could arise from mental health problems in the family; and neglect by parents. There are no specific medications for this kind of problem and any use of drugs for symptomatic relief will need caution given the risks of impulsive misuse.
This is what can be done about it…
Aberrant emotional regulation is a recurring theme with personality problems. People who are emotionally over expressive often misuse alcohol or drugs and commonly seek help from addiction services. To help with emotional regulation Dialectical Behaviour Therapy, DBT, delivered by a suitably qualified practitioner is the treatment of choice, but all practitioners with an awareness of the general principles outlined below will be able to improve their interventions.
Family, friends and colleagues at work are more likely than helping agencies to have regular contact with people who have difficulty with emotional regulation. It can be very demanding of these individuals. So, it is a good idea for everybody to be familiar with what can be done to help. DBT is a very specialist mental health treatment but it can be useful for anybody trying to help to be aware of the principles involved.
Four key areas aimed at enhancing life skills are addressed:
Distress tolerance: Feeling intense emotions like anger without reacting impulsively or using self-injury or substance abuse to dampen distress.
Emotional regulation: Recognising, labelling, and adjusting emotions.
Mindfulness: Becoming more aware of self and others and attentive to the present moment.
Interpersonal effectiveness: Navigating conflict and interacting assertively.
The treatment is delivered in a rolling programme with four stages:
Stage 1: Treats the most self-destructive behaviour, such as suicide attempts or self-injury.
Stage 2: Begins to address quality-of-life skills, such as emotional regulation, distress tolerance, and interpersonal effectiveness.
Stage 3: Focuses on improved relationships and self-esteem.
Stage 4: Promotes more joy and relationship connection.
The mode of delivery can be face-to-face or on-line and use a flexible structure agreed locally and varied to suit individual needs:
Weekly DBT skills training group
Individual therapy
Phone coaching, if needed for crises between sessions (usually within office hours)
Weekly Consultation group for the DBT team, to stay motivated and discuss patient care
In this video Dani Brown talks about…
The conceptual basis of DBT
The component parts
The core practices
Methods of treatment delivery
Dani Brown is a Mental Health Nurse, Specialist in Addiction and DBT Practitioner
This is one person’s experience of DBT…
“DBT has changed my life in a way I didn’t believe was possible. I always thought that I had too many problems and no-one could understand how much I was struggling with my mental health. I’d tried so many other forms of therapy and healing, and nothing had worked. DBT provided me with the answers I’d been looking for, for so many years! It’s so simple and concise and makes it really easy to understand how you can take control of your emotions and create a better life for yourself. Plus, having constant support available from the DBT team was truly invaluable. It’s also amazing to meet so many people who are struggling with similar things, and to see them grow and get better as well.
I’ve definitely made life-long friends from my time in DBT and my life is better than it’s ever been. It’s a hard journey but if you trust the process and give it your all, it really does work!"
Dani Brown demonstrates a simple skill that can be applied in any situation to dissipate anger
Dani Brown’s team achieved these outcomes for people with addiction problems…
Leeds Dependence Questionnaire
Scores lower than 11 indicate low dependence, 11 to 22 indicates medium dependence and scores over 22 high dependence, up to a maximum of 30.
Clinical Outcomes in Routine Evaluation (CORE)
85+ indicates severe distress, 68-84 indicates moderate to severe distress, 51-67 indicates moderate distress, 34-50 indicates mild distress, 21-33 indicates low level distress, 1-20 indicates psychological health.
The Borderline Symptom List 23 (BSL 23)
A cut-off score of 1.5 is able to distinguish people with Borderline Personality Disorder from those with other mental health problems such as anxiety disorders, major depressive disorders or schizophrenia. Note that the Difficulties in Emotion Regulation Scale is now used in preference to the BSL.
