Personality disorder is a condition that must be managed sensitively. Dr Guy Roberts explains what an organisation can do if a member of staff presents with the symptoms.
Personality disorders are recognised conditions that are classified in the International Classification of Diseases (ICD-10) or the US equivalent Diagnostic and Statistical Manual of Mental Disorders (DSM-IV). Both classification systems are valid and share more similarities than differences.
The ICD-10 classification of mental and behavioural disorders defines personality disorders as “severe disturbances in the personality and behavioural tendencies of the individual not directly resulting from disease, damage or other insult to the brain or from another psychiatric disorder. They usually involve several areas of the personality and are nearly always associated with considerable personal distress and social disruption” (Cooper, 1994).
Personality disorders affect the way an individual relates to the world around them, including their social, occupational and personal relationships.
For most of us, our personalities can be considered “normal”, although we all have some traits that help us to deal with our general relationships or any challenges. We are able to hold down a job and function in the everyday world.
The behaviour and attitude of someone with a personality disorder can cause considerable problems for the sufferer and for others.”
A publication by the Department for Work and Pensions (2008) describes some characteristics of personality disorders: “The behaviour and attitude of someone with a personality disorder can cause considerable problems for the sufferer and for others. It may be that these individuals are particularly inflexible, vulnerable, difficult to talk to, irrational or have limited and fragile coping mechanisms.”
Matters are further complicated by the fact that individuals with personality disorders are more vulnerable to other mental health conditions such as depression, anxiety or substance misuse.
It needs to be remembered that “normal” encompasses a rather broad spectrum. When we consider personality disorders, we are looking at extremes of behaviours.
The Royal College of Psychiatrists (RCP) has published a helpful guide to personality disorders (RCP, 2011), which explains that DSM-IV outlines 10 personality disorders. These fall into three clusters:
Cluster A: odd/eccentric (paranoid, schizotypal, schizoid)
A very simplistic characterisation of the people that fall into this cluster are that they tend to be suspicious, unforgiving, cold and have difficulties in maintaining relationships. Many have little interest in relationships and, in some cases, can think obsessively about subjects that are often of a sexual or violent nature.
Cluster B: dramatic/emotional/erratic
People in this category are often antisocial, borderline, histrionic and/or narcissistic. Individuals with antisocial personality disorders have a tendency to commit criminal acts without feeling guilt. So far, we have not identified such an individual in a workplace setting.
Individuals with borderline/emotionally unstable personality disorder find emotional control difficult. They often self-harm, and make and lose relationships very quickly. In our OH practice this has been the most common personality disorder we have encountered. We think this reflects the fact that this type of disorder is the most common and the disorders cause fear and concern among colleagues.
These individuals are diagnosed as “borderline” because they lie between neuroses and psychoses.
Cluster C: anxious and fearful
There are three sections in cluster C. The first is obsessive-compulsive – also known as anankastic – and should not be confused with obsessive-compulsive disorder, which is a separate condition. These individuals are very rigid, can be highly judgmental and are perfectionists.
The second section within this cluster is the avoidant personality, also known as anxious/avoidant. These individuals are anxious, tense and worry a lot. They react badly to perceived criticism.
The third section comprises the dependent personalities: those people who are passive, reliant on others and very easily feel abandoned.
In all cases and types of personality disorder, the individual is focused on themselves and the requirement to meet their own needs. Their perception of situations will be seen through a prism of their disorder. They may have skills that make them valuable to an organisation, but generally they exhibit challenging behaviours if circumstances do not match their world view.
Equally, those with personality disorders may have had extremely difficult upbringings. One clinical viewpoint is that they sustained harm at an early age and were unable to develop appropriately.
Personality disorders often appear almost impossible to deal with in a workplace setting, but our practice has given us cause for optimism.”
Imagine if you saw the world as a frightening place and one where nobody can love you and your trust in others is blighted. Core beliefs and your perception of reality become distorted.
Personality disorders often appear almost impossible to deal with in a workplace setting, but our practice has given us cause for optimism. One set of figures reveals that around two million people in the UK have personality disorders (National Institute for Health and Clinical Excellence (NICE), 2009). We believe that many of them are active in the workforce.
Although personality disorders can cause extreme behaviour, it is a spectral range of disorders that, it can be argued, include the normally functioning employee whose traits are unveiled when change occurs in their occupational or personal environment.
Why diagnosis is important
Diagnosis in a workplace setting is valuable because it allows the employee, employer and the OH team to understand the impact such a disorder can have and allows for effective management.
Personality disorder is something that is changeable and adaptable to an extent. Moderation may be slow and hard, but it can be achieved with skilled psychological intervention and a willingness to engage on the part of the employee.
If someone’s behaviours – which can include excessive absenteeism, personality “clashes”, multiple grievances, drink problems, rudeness towards clients or colleagues, or a change in behaviour in response to work change – are arousing serious concerns, a personality disorder may be the cause.
If someone’s behaviours are arousing serious concerns, a personality disorder may be the cause.”
The quality of the referral is important in determining the next step. If the employer is able on the referral to give a clear outline of the presenting situation with pertinent questions, it is likely that the adviser will recognise that a diagnosis is needed and will refer to an OH practitioner or, if enough evidence is provided, seek an independent psychiatric assessment.
A diagnosis of a personality disorder can be made by a psychiatrist. Importantly, they are able to advise on matters such as the insight shown by the individual and possible workplace adjustments.
With the employee’s permission, a psychiatrist can also liaise with the GP and perhaps persuade the person to take an appropriate care pathway. Early diagnosis means effective and realistic advice can be offered.
The treatment for personality disorders tends to be lengthy because moderation and new, less harmful, strategies need to be learned and then practised. A range of therapies can be used. Of contemporary interest are dialectical behavioural therapy and cognitive behavioural therapy (CBT). However, NICE states that more research is needed, particularly among men and young people, before definitive guidelines are issued.
Sometimes medication is given to alleviate some of the symptoms, such as anxiety, but personality disorders in themselves are not responsive to medication, and treating with drugs may do more harm than good.
The NICE 2009 guidelines for the management of people with borderline personality disorder – identified by the organisation as the most common, along with antisocial personality disorder – is that “community mental health services should be responsible for the routine assessment, treatment and management of people with borderline personality disorder”.
What should you do?
Many advisers do not automatically have OH physicians and psychiatrists to refer to. If this is the case in your workplace, there are key signals to look for. For instance, is the referral delineating a pattern of:
- poor impulse control;
- poor relationships with others (including multiple grievances);
- behaviour that is unacceptable in the workplace;
- acute anxiety or withdrawing from relationships in and out of work; or
- any of the other signs of some form of mental health condition?
Patterns of behaviour are highly significant. However, all of the above can be symptoms of other conditions. Until a diagnosis is obtained, it will be difficult to deal fairly with both the employee and employer. Best placed to look at the whole picture and reach effective diagnosis is a psychiatrist – and in the short and long term, it is likely to save considerable time and money for the employer to refer to one, while also increasing the possibility of the employee receiving suitable care.
People with personality disorders can be among the most challenging for organisations to deal with. Such individuals can operate in a framework that seems to have little relationship to any external reality.
In order to ensure that they are managed in an objective and fair way, a diagnosis is essential. The diagnosing clinician must:
- advise on possible adjustments;
- provide OH with information regarding the individual’s insight into their situation and likely engagement with any treatment suggested; and
- write to the person’s GP with their diagnosis and recommendations, after gaining the employee’s consent.
Once the effects of the underlying medical condition are made known by OH to the employer, they will be in a position not only to discuss the future employment relationship and set out expected behaviours and goals, but also make adjustments to maximise the potential of the employee’s skills.
Dr Guy Roberts MBBS BSc Hons MRC Psych DOcc Med is director of mental health at Occupational Health Consultancy, and a consultant psychiatrist at the Southern Health Foundation NHS Trust
Cooper JE (1994). Pocket Guide to the ICD-10 Classification of Mental and Behavioural Disorders. London; Churchill Livingstone.
Department for Work and Pensions (2008). Medical conditions.
Royal College of Psychiatrists (2011). “Personality disorders”.
National Institute for Health and Clinical Excellence (2009). New NICE guidelines set to improve treatment and management of people with borderline personality disorder.
National Institute for Health and Clinical Excellence (2009). Borderline personality disorder.
Jane Biddlecombe, a solicitor specialising in employment law at Paris Smith LLP, writes: “The Equality Act 2010 prohibits disability discrimination. Those making such claims must show that they have a ‘disability’. This is defined as a physical or mental impairment that has a substantial and long-term effect on a person’s ability to carry out normal day-to-day activities.
“Personality disorders are mental impairments and tend to be long term. Therefore, whether someone with a personality disorder has a disability is likely to depend on whether or not the disorder has an adverse effect on their ability to carry out normal day-to-day activities and whether or not that effect is substantial. A medical report will be needed to establish these matters and any referral to OH should specifically ask these kinds of questions.
“It is worth noting that there are some conditions that are expressly stated not to be disabilities for the purposes of the Equality Act, and these include exhibitionism or a tendency to steal, or to physically or sexually abuse others.”
Brian was referred to further help after several appointments with occupational health. He had worked for 15 years in a highly technical and detailed engineering role. His manager was hands off in his approach and recognised Brian’s considerable skill. Brian was able to work to relaxed deadlines. He worked on his own and his daily routine was clearly defined.
When the facility was taken over by another company, Brian was transferred – along with the other staff – to the new organisation.
Understandably, this made him anxious, although his new employer had a good reputation. At first, everything was fine. However, the new employer preferred a collaborative approach and Brian had to move to an open-plan office. His colleagues were genial and highly qualified.
But the new manager identified that Brian was not sharing work and did not join in any team meetings. Brian appeared contemptuous of his co-workers and they, in turn, found him “tricky” and “cold”.
Brian had been off work for six months with “work-related stress and anxiety”. Several attempts had been made by his employer, along with the OH team, to rehabilitate him in the workplace.
The preferred diagnosis by the OH adviser was anankastic personality disorder (ICD-10 F60.5). This diagnosis would fit with Brian’s tendency to be highly critical of his co-workers who, in his opinion, did not work to the standards he had set.
On reflection, Brian was able to agree. He appeared eager to seek help and was able to communicate with his GP. He attended appointments with his GP and underwent treatment using cognitive behavioural therapy.
Advice to his employer was that Brian had a “significant underlying condition” and demonstrated good insight. The employer was able to accommodate some adjustments: for example, Brian only had to take his research to the others at clearly defined points in his work. In return, Brian worked hard at tempering his behaviours and reframing his view of the work team.
He is not “cured”. He is still challenging to manage. However, his technical skills are highly valued and his organisation can accommodate him but, in return, he has agreed to very clear boundaries.
Lucy, 22, started work as a care assistant. Her job was as a support worker in accommodation for learning-disabled adults. This included helping residents with shopping, cooking and assisting them with housework. She worked in a team of five under a manager.
Initially very bright and caring, she got on well with her colleagues. Although she lacked self-confidence, she progressed through her three-month probation period and seemed eager to learn. Colleagues had mentioned to the manager that she was doing very well “considering her difficult background”.
The manager was unaware of any underlying background issues. Soon after her probation period ended, Lucy told the manager that her life outside work had become difficult.
Her former boyfriend was pestering her but she could not return to her family home because her mother was an alcoholic. She said she just wanted her manager to know what had been happening, but also that she loved her job.
Soon after this Lucy did not turn up for a night shift. Her colleagues were very concerned – one told the manager that she had seen scars on Lucy’s arms and that they knew her boyfriend had previously been violent. The manager was unable to contact Lucy until the next morning. She apologised and explained that she had been so worn out by the “stuff that was going on” that she had forgotten her shift, stayed at a friend’s house to get some sleep and had turned her phone off.
This began a pattern of non-attendance or late attendance. Her colleagues were concerned for her. They reported that she seemed “exhausted and frightened”. Her personal appearance deteriorated and she started to wear long-sleeved tops.
Attendance at work became erratic. Matters culminated when, in front of clients, Lucy took a knife and held it over her arm, weeping. Her employers referred her to OH. They provided a comprehensive referral, describing the background and providing a job description. They wanted to know how best to support Lucy to enable her to return to her duties. The practitioners were also concerned for the care setting’s clients and their wellbeing, and safety was paramount.
When triaged, Lucy’s situation clearly fulfilled the criteria for a psychiatric assessment that focused on the workplace issues she had been experiencing. On review, using a full psychiatric history, a preferred diagnosis of emotionally unstable personality disorder of the borderline type was made (Cooper, 1994).
Since Lucy lacked insight and was not capable of providing the focused and safe care her client group needed, she was deemed unfit for her present role. Nor was she able to provide regular and sustained service to her employer.
With her consent, a letter was sent to primary care identifying a likely diagnosis and suggesting a treatment plan.
In the letter to her employer, it was recommended that Lucy did not work with a vulnerable client group until she was able to manage her condition.
The employer succeeded in finding her an administrative role. She still presented an erratic pattern of attendance and she did not attend her GP appointments or recognise any problem with her actions.
In addition, her colleagues reported that Lucy had become increasingly “needy and disruptive”. Her behaviour had become unsustainable and, eventually, her employer had no option but to dismiss her.