The person seems to think differently, have unpredictable moods and behave in a way that seems unusual compared with others. They break normal cultural and social rules and can be considered extremely demanding, needy, highly insecure, and lacking in empathy. It is not a trivial issue, it can be a cause of great distress.
Self-harming can be a frequent feature and it is unlikely that relationships and jobs will remain unaffected. About 6% of the population seem to have some traits; a great many are undiagnosed, although they may live on the edges of society particularly regarding drug and alcohol use.
As yet, no clear cause has been identified, even genetically, although some signs are often visible in childhood and increase gradually over time rather than a sudden onset.
There are three ‘clusters’ of PDs.
- Cluster A results in being socially withdrawn, not forming relationships and maybe being (unusually) suspicious of others.
- Cluster B involves extreme reactions, both positive and negative. So they may be wildly enthusiastic or terribly angry in quick succession. They may behave impulsively and take risks, and are hard to live with because of these intense reactions to situations.
- Cluster C are people with high levels of anxiety who avoid new people and experiences. They have low self-esteem and may be very dependent on others.
A very, very small number of people with specific types of PD can be dangerous and violent.
A Carer needs to be firm under pressure and put boundaries in place which are kept consistently, not an easy task when the reactions can be extreme. It is also helpful to point out where a reaction has had a negative consequence and to consider options: ‘maybe this happened because you did that’. This may be a bit of a challenge!
Borderline personality disorder (BPD) is one of the most frequently diagnosed. This comes
under Cluster B and involves impulsive behaviour, which is often emotionally erratic, and with a focus on suicide and/or self-harm. People report frequent feelings of emptiness. They may find it impossible to consider the feelings of others and be very detached. This makes it difficult to sustain a relationship with them as they can be demanding and really hard to please.
Recently there has been a much better chance of getting effective support. There are programmes of treatment available but these work only when the person can come
to recognise the need for changes to their thoughts and behaviours! The book ‘Introduction Mental Health’ is especially helpful in describing approaches to Personality Disorders (see Resources).
This is not in itself a MH diagnosis but may occur as a result of someone’s high levels of distress. It is a frightening discovery that someone you care about is hurting themselves. Although many of us do take risks or are careless with our wellbeing, self-harm usually refers to deliberate acts like cutting, burning or drinking harmful substances.
The person is usually suffering a high level of emotional distress and they are trying to retain control. The pain acts as a distraction and also releases chemicals into the body which are immediately soothing. In short it is a coping strategy which enables people to keep going in very difficult circumstances. It can be confused with suicidal behaviour, but self-harm often is a means to avoid suicide – a crucial point in understanding it.
It is often not attention seeking as many people harm themselves where they can hide the effects and don’t tell anyone. It may be comforting when treatment is given and you are looked after, but Accident and Emergency department staff can be unsympathetic with repeated visits, sometimes seeing self-harm injury as a waste of valuable nursing time.
If you find out someone is self-harming it is not always necessary to treat it as an emergency. If they are at risk from their wounds the first step is clearly to get medical help, otherwise it may be a priority to ensure that razor blades or similar tools are sterilised and the wound can be disinfected and covered with a clean bandage or cling film. It may sound drastic to support this behaviour but aggressive pressure to stop could contribute to the need to seek a release and make it more likely to occur. A service user said:
‘The situation only improved when I finally realised I was the only person well enough to do things differently. Finding ways to reduce the tension eventually made a big difference.’
These are not in themselves a MH issue either but can be a response to one. Carers can try to support the person to get help but can’t just make them stop, only the person themselves can do that. It can be heart-breaking to accept this. Practical and emotional support may encourage the person to give up the addiction, but it is strongly recommended that you avoid giving any help in getting their drugs/alcohol (i.e. giving money) no matter how desperate they appear. Sometimes ‘tough love’ and saying no is the best help in the long term.