Personality Disorder
The previous Matrix recommendations in 2014 were focussed on what was then described as Borderline Personality Disorder (BPD) and based on NICE (2009) Overview | Borderline personality disorder: recognition and management | Guidance | NICE. This (1) NICE guidance has not been further updated to reflect the change in the way that Personality Disorder as a diagnosis is understood following the publication of ICD-11 (WHO 2019). The Matrix Advisory Group for Personality Disorder met to discuss options for inclusion of this topic in the current Matrix and the following decisions were agreed.
- Personality Disorder is of clinical, service and personal relevance to many people in Scotland and should be represented in The Matrix. However, this should reflect the changing context of ICD-11 (2) and the range of views in terms of the use of this diagnosis.
- The use of the 2014 evidence table, with minimal updates mainly informed by recent systematic review (3,4) represents a reasonable interim position whilst the evidence base shifts to reflect the new diagnostic approach.
- It was valuable to develop ‘hexagon tools’ to provide further information on the available evidence-based psychological therapies and interventions to be of benefit to clinicians, the public accessing services and service managers.
- This summary will be continued to be reviewed as evidence emerges.
It is acknowledged that “personality disorder” as a diagnosis (and even as a concept) is associated with a broad range of views across stakeholder groups and is a subject of on-going debate. The use of the term “personality disorder” in this document has been a practical decision which reflects the World Health Organisation (WHO) terminology used in ICD-11 and should not be taken to disregard any alternative viewpoint relating to the validity of the term or concept.
Personality refers to an individual’s characteristic way of behaving, experiencing life, and of perceiving and interpreting themselves, other people, events, and situations. Personality disorder is characterised by problems in functioning of aspects of the self (e.g., identity, self-worth, accuracy of self-view, self-direction), and/or interpersonal dysfunction (e.g., ability to develop and maintain close and mutually satisfying relationships, ability to understand others’ perspectives and to manage conflict in relationships) that have persisted over an extended period of time (e.g., 2 years or more). This becomes apparent in patterns of cognition, emotional experience, emotional expression, and behaviour that are maladaptive or causing problems for the person (e.g., inflexible or poorly regulated) and can be present across a range of personal and social situations (i.e., is not limited to specific relationships or social roles). Typical challenges or consequences for people with personality disorder diagnoses and / or those around them include intense variability of mood, accompanied by difficulty understanding themselves and others. In some cases, the difficulties can result in episodes of self-harm.
For personality disorder to be considered, the patterns of behaviour that cause problems for the individual are not developmentally appropriate and cannot be explained primarily by social or cultural factors, including socio-political conflict. The disturbance will be associated with substantial distress or significant impairment in personal, family, social, educational, occupational or other important areas of functioning (ICD-11).
The adoption of ICD-11 in 2022 saw a fundamental shift in the classification of personality disorder away from a categorical system based on prototypes towards a dimensional system, which has a firmer basis in the science of personality (5,6). Other changes from ICD-10 include revision of the age criterion (which now allows the diagnosis to be applied in adolescence and for first presentations later in life) and the persistence criterion (the problems need to be present for 2 years or more as opposed to being present from early adulthood in ICD-10).
Diagnosis of personality disorder within ICD-11 comprises up to four steps, not all of which will need to be used, depending on the clinical situation.
- First, the essential criteria must be met. As described above these include problems in functioning of aspects of the self and/or interpersonal dysfunction that have persisted over an extended period of time (e.g., 2 years or more).
- Second, severity is specified as mild, moderate or severe. Severity relates to the pervasiveness and intensity of the problems the associated impairment of functioning and level of risk to self and others.
- Third, if appropriate, up to five ‘trait domain specifier’s can be applied to further describe the characteristics of an individual’s personality that are most prominent and that contribute to their difficulties. The five trait domain specifiers are known as Negative Affectivity, Detachment, Dissociality, Disinhibition and Anankastia (5).
- Fourth, the Borderline Pattern may be applied, often to facilitate the identification of individuals who may respond to certain psychological therapies. The Borderline Pattern has essentially equivalent criteria to DSM- 5 (7) Borderline Personality Disorder (BPD).
The 2014 Matrix related only to Borderline Personality Disorder as until recently the majority of the evidence base for the treatment of personality disorder was based on interventions using the DSM- 5 (APA 2013) diagnosis of Borderline Personality Disorder. This iteration relates to Personality Disorder more broadly, reflecting the changes in ICD-11 where possible and where there is evidence available. From the perspective of the ICD-11 classification, the people in the relevant trials for treatment of personality disorder would be likely to have met criteria for the application of the ‘Negative Affectivity’ (emotional lability) and ‘Disinhibition’ trait domain specifiers. Some would also have met criteria for the ‘Borderline Pattern’ but some would not. It seems impractical or impossible to disentangle these different groups after the fact, but it does not seem unreasonable to assume that the treatments benefited both groups. Ultimately, no-one should be denied potentially beneficial treatment because of changes to the diagnostic classification system. Over time, new evidence will emerge with selection of people accessing services and problem areas reflecting the new classification system.
People with this diagnosis may benefit from psychiatric and psychological treatment and, in rare cases, may require a time-limited admission to hospital, particularly to manage risk. People who are close to those who meet criteria for Borderline Personality Disorder may also experience significant distress as a consequence of the problems listed above.
It is important to note that approximately 60% of people with the diagnosis no longer met the criteria for diagnosis at follow up of less than a decade, and particularly for those who were younger at baseline (8). This is important to stress as it may give hope to people with the condition and clinicians working with this group. As a counterpoint though it is also important to note that Temes et al (9) report that over a 24 year follow up, 5.9% of patients with a BPD diagnosis died by suicide compared with 1.4% with a non-BPD PD diagnosis – alongside 14% of patients with BPD who died through non-suicide causes compared to 5.5% non BPD diagnosed people. Once again, stressing how important is for this group to be adequately treated in order to reduce this risk.
Personality Disorder is considered to be one of the most under-diagnosed of mental health conditions (10). It is critical for care-providers to pro-actively work with people in a non-stigmatising way that does not endorse personality disorder as a ‘diagnosis of exclusion’.
There is considerable debate in the literature regarding the overlap with other diagnostic categories such as Complex Post Traumatic Stress Disorder. However, in reviewing the evidence concluded that there was overlapping but distinctive difficulties (11). Nonetheless, the prevalence of trauma is common for people with a diagnosis of PD (12) and, along with all mental health services this can be supported by the use overall of trauma informed and responsive approaches. Where other mental health difficulties are present, please refer to the relevant pages of the Matrix.
More generalist interventions, such as ‘Structured Clinical Management (SCM)’ and ‘Good Psychiatric Management (GPM)’ (including GPM for adolescents) should not be confused though with general psychiatric care ‘as usual’, this is because both for example, requires a shift of emphasis and resource towards providing specific types of care (13-15). In addition, generalist approaches should be coherent, thought through and delivered in line with existing evidence. It is vital for services to organise themselves in ways that adhere to the general principles of how to work helpfully with this group (e.g. Royal College of Psychiatrists (16). There is evidence that ‘General Psychiatric management’ (GPM) and ‘Structured Clinical Management’ (SCM) (13,14) (2009) is as effective as DBT or MBT though it is recognised that for people who are more severely affected then formal psychological therapies interventions will lead to better outcomes.
Estimates of the prevalence of PD is estimated to be 7.8% of the adult community worldwide (17). Community prevalence for Personality Disorder is equal in males and females though there is a high prevalence of females in the clinical population. It is hypothesised that this greater prevalence may be due to greater help-seeking behaviour amongst women (Royal College of Psychiatry 2018). It is estimated to be present in 10-30% of psychiatric outpatients and 20% of inpatients. Prevalence of BPD is particularly high in prison populations, e.g. it is estimated to be 23% among male remand prisoners in England and Wales and 20% in female prisoners (18).
Within the new ICD-11 framework it is more explicit on how to recognise and diagnose Personality Disorder in adolescence although care should be taken if applying the diagnosis to both keep in mind the presentation of normal development, the plasticity of personality, or capacity to change, in adolescence and how cultural norms may present. Most prevalence studies predate the new dimensional classification introduced in ICD 11. Published prevalence data based on 1-year criteria for impairment (ICD 10 and DSM IV) suggests 1-3% of general adolescent population fulfils criteria for personality disorder and this increases to 11% in mental health outpatients and 33% for inpatients with an even higher rates for emergency department presentation with suicidality (19).
Estimates of the prevalence of one or more PDs among older adults in the general population is estimated to be approximately 10.7% (20) to 14.5% (21). Reported prevalence figures among older inpatients in mental healthcare can range from 7% to as high as 80% (22).
But there are issues with diagnosis in later life due to the nature of ICD-11 and DSM-V criteria not being designed with older people in mind. One review found that rates of diagnosis were significantly higher in those with cognitive impairment and dementia, suggesting that the standard diagnostic criteria does not account for the variations in cognitive functioning in later life (23).
Currently, it was not possible to estimate the prevalence in community of people with learning disabilities because of the range found in studies of 1-91% (24) (Alexander and Cooray 2003).
This topic introduction page covers evidence-based psychological interventions used to treat personality disorder (with a particular focus on Borderline Personality Disorder (BPD) because of the historic focus of the evidence) in young people, and adults, and the psychological practice/settings in which these interventions can be delivered.
This topic does not cover pharmacological interventions or interventions which are not informed by psychological theory. It also does not include approaches that are whole team or systemic approaches. There are a wider range of non-psychological interventions and supports that are beyond the scope of this topic and full guidance on best practice can be found here.
Overview of Evidence for CYP
The new ICD-11 (WHO 2019) diagnostic framework can be used from adolescence. This is a change from previous guidance and means that there is very little published evidence on which to base recommendations can be based at this point in time.
Jørgensen (25) systematic review of psychological therapies found them to be underpowered, with a high risk of bias and a high attrition rate leaving it difficult to draw any conclusions on the efficacy of specific psychological therapies for BPD in adolescence. No evidence table is therefore provided at this stage, although this will be kept under review. However, it is expert opinion that people using services are likely to benefit from CAMHs service developing highly specialised intervention aligned with the adult evidence below for those in late adolescence and adapted as per The Matrix - Delivering effective psychological therapies and interventions to children and young people. In addition, a framework of generic care as a culture in CAMHS (such as GPM-A) should be available for all of the workforce. Publishing service data will inform and grow the available evidence base.
Overview of Evidence for Adults
In a recent systematic review of the evidence specifically for people with borderline personality disorder (Storebø et al 2020), dialectical behaviour therapy (DBT) and mentalization based treatment (MBT) was associated with the highest amount of evidence but overall the psychological therapies and interventions included were associated with an improved outcome across all primary outcomes (including self-harm, suicide related outcomes and improved functioning) as opposed to treatment as usual (TAU). It is important to recognise that throughout the evidence base for psychological treatment of borderline personality disorder there are recognised deficits in the level of certainty of efficacy (3,26).
Evidence for Intellectual disabilities
A systematic review of the evidence for use of Dialectical Behaviour Therapy (DBT) for people with learning disabilities indicated that both DBT and the DBT skills group could be adapted for people with learning/intellectual disabilities, but that further research would be required to assess efficacy or effectiveness (27). If adapting evidence-based practice please refer to The Matrix - Delivering effective psychological therapies and interventions to people with intellectual / learning disabilities.
Overview of Evidence for Harms and Adverse Effects
Like all treatments, psychological therapies also have the potential to have adverse effects. Until recently, information on potential harms and rates of adverse effects have not been gathered systematically (see information relating to safety in the delivery of psychological therapies). Reports of adverse events are increasingly included in research trials and gathered as part of service provision and in this area was evaluated as part of a Cochrane systematic review (3), which indicated no obvious unwanted reactions following psychological treatment.
| Recommendation | Who for? | List of Interventions | Type of psychological practice | Evidence | Efficacy |
| First line recommendation | Adults meeting the diagnostic criteria for Borderline Personality Disorder (BPD) | Dialectic Behaviour therapy (DBT)- full programme including group and individual treatment (3,26) | Specialist | A | Medium -high |
| Mentalization based therapy (MBT) (3,26) | Specialist | A | Medium - high | ||
| CBT for personality disorders (3,26) | specialist | A | Small- medium | ||
| Schema Focussed CBT (3) | specialist | A | Small- medium | ||
| Transference focussed psychotherapy (3) | specialist | B | Small-medium | ||
| Adjunctive for adults with mild to moderate difficulties | Systems Training for Emotional Predictability and Problem Solving (STEPPS) (28) | enhanced/specialist | A | Small- medium | |
| Alternative recommendation | Adults meeting criteria for Personality Disorder | Cognitive Analytic Therapy (CAT) (28-30) | specialist | A | NA |
With thanks to Dhuana Affleck, Tim Agnew, Kirsty Banks, Sandra Ferguson, Fiona Johnstone, Anne Joice, Kandarp Joshi, Joe Judge, Jon Patrick, Leeanne Nicklas, Mark Ramm, Stephanie Scott, Leonie Sweeney, Michele Veldman, Andrea Williams.
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25.Jorgensen M.S., Storebo O.J., StoffersWinterling J.M., Faltinsen E., Todorovac A., Simonsen E. Psychological therapies for adolescents with borderline personality disorder (BPD) or BPD features-A systematic review of randomized clinical trials with meta-analysis and Trial Sequential Analysis. PLoS ONE 2021;16(1 January) (pagination):Article Number: e0245331. Date of Publication: 01 Jan 2021.
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27.McNair L, Woodrow C, Hare D. Dialectical Behaviour Therapy [DBT] with People with Intellectual Disabilities: A Systematic Review and Narrative Analysis. J Appl Res Intellect Disabil 2017 -09;30(5):787–804.
28.Ekiz E., van Alphen S.P.J., Ouwens M.A., Van de Paar J., Videler AC. Systems Training for Emotional Predictability and Problem Solving for borderline personality disorder: A systematic review. Personality and mental health 2023;17(1):20–39.
29.Clarke S., Thomas P., James K. Cognitive analytic therapy for personality disorder: Randomised controlled trial. British Journal of Psychiatry 2013;202(2):129–134.
30.Hallam C., SimmondsBuckley M., Kellett S., Greenhill B., Jones A. The acceptability, effectiveness, and durability of cognitive analytic therapy: Systematic review and meta-analysis. Psychology and psychotherapy 2021;94(Supplement 1) (pp 8-35):Date of Publication: 01 Mar 2021.