Personality Disorders in Psychotherapy: Beyond Labelling and Medical Diagnosis

Personality disorders have a profound impact on the quality of an individual's life, as they heavily influence self-image, self-esteem, and the perception of both self and others. Self-image is often unstable—something that is most evident in the case of borderline personality disorder (BPD). Personality disorders are also accompanied by intense affect, which often leads to impulsivity. Consequently, personality disorders do not only shape how a person experiences themselves; they fundamentally dictate the nature of one’s relationships—social, romantic, and family relationships.

Furthermore, personality disorders underpin symptoms that are frequently and mistakenly treated as independent mental disorders. These range from anxiety, depression, panic, eating disorders, addictions, and the repetitive cycle of toxic relationships.

The first traces of personality disorders usually emerge in adolescence. While BPD manifests relatively quickly due to the nature of its symptoms, the indication of narcissistic personality disorder (NPD) is often less evident. The reason for that is that its characteristics—especially in youth—are often socially acceptable or even idealised. Traits such as excessive (though fragile) self-esteem, arrogance framed as competitiveness, a drive for power, and dependency on social status are often socially accepted—even rewarded—in early adulthood, allowing their pathological foundation to remain hidden.

Cases of BPD are, however, different as the symptoms are more overt: anxiety, depressive states, panic attacks, intense and emotionally charged relationships, and a distinct fear of abandonment which often evokes panic that may have conscious or unconscious source. Within the psychotherapeutic relationship, this is often reflected in the client perceiving the therapist (sometimes unconsciously) simultaneously as a safe haven and a threat, triggering a strong—sometimes unconscious—need for control of the relationship.

It is worth emphasising that the definition of personality disorders is inherently controversial. The line between a "normally" functioning personality and a "disordered" one is arbitrary and often subjective. Difficulties in personality functioning exist on a continuum, ranging from less significant (adaptive) to more pathological (maladaptive) (McWilliams & Shedler, 2017). Research shows that an individual can face severe symptoms and relationship difficulties even when their personality traits do not meet the formal diagnostic threshold.

Are Personality Disorders "Curable"?

Personality disorders are inextricably linked to developmental trauma which tends to cause impairments in the development of individual’s personality. These later manifest as a fragile self-image, a lack of a clear sense of self, or a tendency to seek validation through the constant fulfilment of others' needs.

For effective treatment, it is therefore essential that psychotherapy does not focus solely on symptoms or difficulties in the individual’s functioning, but on the integration of the internal conflicts that cause these symptoms.

Unfortunately, also due to deficient diagnostics, treatment too often focuses on the accompanying issues—such as anxiety, depression, addiction, or eating disorders—while the underlying personality structure remains untouched.

Despite widespread urban myths of their incurability, personality disorders—especially BPD—actually have a very good prognosis when they are tackled with appropriate psychotherapeutic treatment. Moreover, especially in the case of BPD, psychotherapy actually represents the first line of its treatment (American Psychiatric Association, 2024; National Collaborating Centre for Mental Health, 2009).

Research even warns that pharmacotherapy (medication) is often ineffective or even contraindicated for personality disorders (Lieb et al., 2010; Stoffers-Winterling et al., 2021; 2022). When the medical model overlooks personality dynamics and focuses only on comorbid symptoms, it frequently leads to the unnecessary and excessive medicalisation of the individual (Paris, 2015).

How Common Are Personality Disorders?

Statistical data on the prevalence of personality disorders varies across studies, primarily due to different methodologies and population samples. However, a recent consensus suggests that personality disorders are significantly more common in the general population than we had previously assumed. Studies indicate that up to 12% of people present with a personality disorder (Volkert et al., 2018), with prevalence being higher in the developed world (Winsper et al., 2020).

An interesting paradox appears when we compare the general population with outpatient psychiatric setting. Although BPD is not the most common in community population, it strongly predominates in clinical settings (Volkert et al., 2018). The reason is simple: the nature of BPD causes such intense subjective distress and so severely impairs interpersonal functioning that one is often forced to seek help. In contrast, other forms, such as narcissistic personality disorder (NPD), often allow the individual a higher degree of social functioning (at least in the short term), so these individuals less frequently enter the therapeutic process voluntarily.

The Problem of Underdiagnosis

Despite their frequency, we face significant underdiagnosis of personality disorders. This is partly due to the reluctance of health professionals to diagnose them. The clinical attention is, in contrast, shifted toward the symptoms that merely accompany the disorder—such as anxiety, depression, addiction, eating disorders, or relationship issues.

Research vividly confirms this gap. Tate et al. (2022) found in Sweden that only 0.6% of the population had an official BPD diagnosis, while national surveys revealed the actual prevalence was three to four times higher.

Even more telling are the data from Zimmerman and Mattia (1999): their study revealed that in an outpatient psychiatric population, an official BPD diagnosis was recorded in only 0.4% of cases. However, when the same patients were assessed using in-depth, semi-structured clinical interviews, it turned out that 14.4% of individuals should have actually received the BPD diagnosis. This massive discrepancy shows that personality dynamics are too quickly left unrecognised in the classical diagnostic process.

Prevalence in Psychiatric Setting

If the prevalence of personality disorders in the general population seems high, these numbers literally jump in outpatient psychiatric care. Studies show that 40% or even more of individuals in outpatient psychiatric setting deal with a personality disorder (Beckwith et al., 2014; Newton-Howes et al., 2010). Among them, BPD again leads, appearing in approximately 15% of outpatients, while in inpatient setting, the prevalence increases to as much as 22% (Leichsenring et al., 2024).

What do these data tell us? Considering the high prevalence, general underdiagnosis, and the fact that people suffer even with milder (subclinical) forms that do not reach the diagnostic threshold, one thing becomes clear: attention to personality dynamics in psychotherapeutic treatment is not just an option, but a necessity. Without understanding the personality structure, it is difficult to truly understand the distress the individual is experiencing.

Furthermore, whilst there is a lack of research that would be looking at the prevalence figures of personality disorders amongst individuals seeking help within private psychotherapy setting, we can intuitively assume that prevalence is similar to the numbers found in outpatient psychiatric setting. Many individuals who present with personality disorder, especially BPD, but that may not present with clinical levels for diagnosis, will usually seek help in private psychotherapy setting.

Issues with Diagnosing Personality Disorders

The diagnosis of personality disorders is surrounded by controversy stemming from numerous issues. These range from the inadequacy of the still-dominant categorical or "medical" diagnostic models to the focus on the origin of the disorder—which often stems from developmental trauma—to the stigma the diagnosis brings, and finally, to the problems in diagnostics often related to the discomfort of medical professional sin making the diagnosis. I will limit myself here to the problem of medical diagnostics based on categorical models related to the Diagnostic and Statistical Manual of Mental Disorders (DSM) and the International Classification of Diseases (ICD).

Historically, the diagnosis of personality disorders has largely been based on a medical model that relies on categorical diagnoses. Unfortunately, such diagnoses rely only on the observable characteristics of individual mental issues—such as their symptoms and difficulties in functioning—and not on the personality dynamics which the distress is based on.

Also, categorical modals—so, the predominant "medical model" of diagnosis—largly treats personality disorders, as well as their comorbid disorders, as distinct and unrelated, which is illusory and does not reflect reality nor does it account for the origin of mental distress (Caspi & Moffitt, 2018; Kotov et al., 2017).

This type of diagnosis creates an "all or nothing" illusion—that if someone meets a certain number of criteria, they have the disorder; otherwise, they do not. A view that is fundamentally flawed. Personality disorders denote difficulties in personality functioning: in self-image and the way one experiences oneself and others. These problems directly shape symptoms (anxiety, depression, panic, impulsivity, need for control) and strongly influence relationships (dependency, co-dependency, toxic relationships, commitment issues).

Personality impairment is not simply present or absent; it exists on a continuum—from relatively healthy functioning that an individual controls in life, to pathological functioning where symptoms and relationships are severely impaired. This is why modern procedures, especially those supporting psychotherapy, are moving away from rigid categories of medical model diagnosis toward diagnosing the dynamics and functioning of one’s of personality.

Absence of Diagnosis Does Not Mean Absence of Difficulties or Distress

When it comes to diagnosis, we must understand two key aspects. The first is the aforementioned underdiagnosis. The second, and perhaps more important, is the existence of problems that are not pronounced enough for a formal diagnosis but still severely impair life—so, the subclinical levels of personality disorder. Research confirms that problems at the subclinical level can be just as devastating (Ellison et al., 2016) as those at clinical levels—so, levels that meet the formal diagnostic criteria.

Using BPD as an example: when considering only those who meet all strict diagnostic criteria, the prevalence is low. But if we include individuals with significantly impaired functioning and pronounced symptoms who are "below the threshold," that share rises from under 7% to nearly 27% (Prasad et al., 2022). This means a huge part of the population lives with serious personality challenges without ever being officially recognised within the healthcare system.

Indicators of Difficulties in Personality Functioning

This is why modern diagnostics are shifting from symptoms to a dimensional diagnostic models. This means that the focus in on assessing how the personality is functioning, so looking at the stability of identity, the quality of self-image, (often unconscious) perceptions of others, and issues with emotion regulation.

Below are several characteristics that may indicate problems in personality functioning, though they do not necessarily represent formal diagnostic categories. These indicators often appear at the subclinical level.

Identity, Self-Image, and Life Goals

• Fragmented Identity and Dependency: Individuals with personality disorder often cope with a fragile sense of self that one tries to compensate for through relationships and external validation. Self-image is often unstable and highly dependent on current relationships or, especially in the case of narcissism, success, achievements, and social status.

  
  

• Unstable Life Goals: Chronic confusion regarding personal and career goals. Enthusiasm is usually short-lived, followed by commitment issues. There is often no "internal compass" that would be guiding the individual through life. As such, one may feel lost or as though they are drifting through life.

  
  

• Chronic Feelings of Emptiness and Boredom: This is a common issue with individuals presenting with personality disorder. There is often a deep sense of inner emptiness or the pointlessness of one’s existence, which can be only temporarily silenced by external stimuli (excitement, escapism, addictions, toxic relationships).

  
  

• Confusion Regarding One’s Own Needs: Whilst this is a common characteristic of personality disorder, it is most vividly experienced by those presenting with BPD. It encompasses difficulty distinguishing genuine needs from the expectations of others, which often resulting in "people-pleasing", appearing indecisive, and taking on opinions of others.

Relationships as a Mirror of Personality

• Mistaken Perception of Empathy: Personality disorders are characterised by a general impairment in the capacities for empathy and intimacy. The lack of empathy is also hidden behind a mask of "excessive helpfulness", pleasing and clinging that usually accompany especially BPD. A person who sees their mission in saving others often (unconsciously) projects their own needs onto them, thereby overlooking the actual needs of their loved ones.

  
  

• Lack of Emotional Intimacy and Authenticity: Relationships are often volatile or marked by "clinging" or "avoidance." Friendships may look intimate on the outside but serve only to regulate internal distress and prevent one from experiencing abandonment fears.

  
  

• Extremes Between Dependency and Abandonment: Rushing from relationship to relationship to alleviate the fear of loneliness and abandonment, or pathologically avoiding them due to a fear of vulnerability are common characteristics of personality impairments.

  
  

• Difficulties with Separation-Individuation: This can manifest as an "infantile" dependence on parents (or the entire family of origin) that persists into adulthood. In adulthood, one may thus present with an over-attachment to their family of origin or pathological rejection filled with anger and resentment.

  
  

• Toxicity and Interpersonal Dependency: Individuals with significant personality impairments may find themselves engaging in continuous co-dependent and sometimes emotionally exploitative or abusive relationships, which usually stem from deep intrapsychic dependency of both participants (Zivkovic, 2023).

  
  

• Internal Loneliness or “Alone Together”: Many individuals will tend to present with a feeling of not being seen, heard, or understood. A person may feel completely isolated even though their social life appears rich. What they will tend to experience is a sense of being alone together: an experience of being lonely within their romantic or social relationships.

  
  

• Compartmentalization of Social Environments: Unconsciously keeping social circles separate (e.g., not mixing friends with coworkers or not mixing various groups of friends) is an external manifestation of the internal identity diffusion.

The Illusion of Comorbidity

There is a general belief in the high "comorbidity" of personality disorders with other mental health issues, such as anxiety, depression, addictions, and eating disorders. While these problems do occur together, viewing them as independent disorders is narrow and potentially dangerous for treatment.

The perception of “comorbidity” stems from categorical diagnostics that "compartmentalise" symptoms instead of looking for their origin. A deeper look, however, reveals that symptomatic issues are often just the manifestation of a deeper personality impairment.

Because symptoms stem from personality dysfunction:

• Nearly 70% of people with BPD have three or more accompanying mental diagnoses (Zimmerman & Mattia, 1999).

  
  

• Between 35% and 52% of those with anxiety disorders have an underlying personality disorder (Friborg et al., 2013).

  
  

• 52% of people with eating disorders have an indicated personality disorder (Martinussen et al., 2017), rising to 65% among those with BPD (Khosravi, 2020).

Instead of seeing these as separate diseases, it is imperative to understand them as an intertwined system. Treating only the symptoms without addressing the personality structure is often ineffective but can also be hazardous.

Conclusion

When clients present for psychotherapy, it is essential to look beyond the constraints of medical labels—or the absence of them—and recognise that their distress often originates from deeply rooted difficulties in personality functioning. A formal diagnosis of a personality disorder, much like the lack of one, should never be taken as a definitive or exhaustive guide for further psychotherapeutic treatment.

Effective psychotherapeutic intervention requires us to move past categorical "all-or-nothing" thinking and instead focus on a comprehensive clinical formulation. By assessing the underlying personality structure—including one’s identity integration, defence mechanisms, and relational patterns—we can address the person as a whole, rather than merely treating the symptoms that brought them to psychotherapy.

Ales Zivkovic, MSc (TA Psych), CTA(P), TSTA(P), Psychotherapist, Counsellor, Supervisor

Ales Zivkovic is a psychotherapist, counsellor, and clinical supervisor. He holds an MSc in Transactional Analysis Psychotherapy awarded by Middlesex University in London, UK. He is also a Teaching and Supervising Transactional Analyst (TSTA-P) and a Certified Transactional Analyst in the field of Psychotherapy (CTA-P). Ales gained extensive experience during his work with individuals and groups in the UK National Health Service (NHS) and his private psychotherapy, counselling, and clinical supervision practice in central London, UK. He is also a full clinical member of the United Kingdom Council for Psychotherapy (UKCP). Ales works with individuals, couples, and groups. In clinical setting, he especially focuses on the treatment of issues of childhood trauma, personality disorders, and relationship issues. A large proportion of his practice involves online psychotherapy as he works with clients from all over the world. Ales developed a distinct psychotherapeutic approach called interpretive dynamic transactional analysis psychotherapy (IDTAP). More about Ales, as well as how to reach him, can be found here.

References:

American Psychiatric Association. (2024). The American Psychiatric Association Practice Guideline for the Treatment of Patients With Borderline Personality Disorder (2nd ed.). American Psychiatric Association. https://doi.org/10.1176/appi.books.9780890428009

Beckwith, H., Moran, P. F., & Reilly, J. (2014). Personality disorder prevalence in psychiatric outpatients: a systematic literature review. Personal Ment Health, 8(2), 91-101. https://doi.org/10.1002/pmh.1252

Caspi, A., & Moffitt, T. E. (2018). All for One and One for All: Mental Disorders in One Dimension. Am J Psychiatry, 175(9), 831-844. https://doi.org/10.1176/appi.ajp.2018.17121383

Ellison, W. D., Rosenstein, L., Chelminski, I., Dalrymple, K., & Zimmerman, M. (2016). The Clinical Significance of Single Features of Borderline Personality Disorder: Anger, Affective Instability, Impulsivity, and Chronic Emptiness in Psychiatric Outpatients. Journal of Personality Disorders, 30(2), 261-270. https://doi.org/10.1521/pedi_2015_29_193

Kotov, R., Krueger, R. F., Watson, D., Achenbach, T. M., Althoff, R. R., Bagby, R. M., Brown, T. A., Carpenter, W. T., Caspi, A., Clark, L. A., Eaton, N. R., Forbes, M. K., Forbush, K. T., Goldberg, D., Hasin, D., Hyman, S. E., Ivanova, M. Y., Lynam, D. R., Markon, K.,…Zimmerman, M. (2017). The Hierarchical Taxonomy of Psychopathology (HiTOP): A dimensional alternative to traditional nosologies. J Abnorm Psychol, 126(4), 454-477. https://doi.org/10.1037/abn0000258

Leichsenring, F., Fonagy, P., Heim, N., Kernberg, O. F., Leweke, F., Luyten, P., Salzer, S., Spitzer, C., & Steinert, C. (2024). Borderline personality disorder: a comprehensive review of diagnosis and clinical presentation, etiology, treatment, and current controversies. World Psychiatry, 23(1), 4-25. https://doi.org/10.1002/wps.21156

Lieb, K., Völlm, B., Rücker, G., Timmer, A., & Stoffers, J. M. (2010). Pharmacotherapy for borderline personality disorder: Cochrane systematic review of randomised trials. Br J Psychiatry, 196(1), 4-12. https://doi.org/10.1192/bjp.bp.108.062984

McWilliams, N., & Shedler, J. (2017). Personality syndromes—P axis. In Psychodynamic diagnostic manual: PDM-2, 2nd ed. (pp. 15-67). The Guilford Press.

National Collaborating Centre for Mental Health. (2009). National Institute for Health and Care Excellence: Guidelines. In Borderline Personality Disorder: Treatment and Management. The British Psychological Society and The Royal College of Psychiatrists.

Newton-Howes, G., Tyrer, P., Anagnostakis, K., Cooper, S., Bowden-Jones, O., & Weaver, T. (2010). The prevalence of personality disorder, its comorbidity with mental state disorders, and its clinical significance in community mental health teams. Soc Psychiatry Psychiatr Epidemiol, 45(4), 453-460. https://doi.org/10.1007/s00127-009-0084-7

Prasad, D., Kuhathasan, N., de Azevedo Cardoso, T., Suh, J. S., & Frey, B. N. (2022). The prevalence of borderline personality features and borderline personality disorder during the perinatal period: a systematic review and meta-analysis. Archives of Women's Mental Health, 25(2), 277-289. https://doi.org/10.1007/s00737-022-01218-8

Stoffers-Winterling, J., Völlm, B., & Lieb, K. (2021). Is pharmacotherapy useful for treating personality disorders? Expert Opinion on Pharmacotherapy, 22(4), 393-395. https://doi.org/10.1080/14656566.2021.1873277

Stoffers-Winterling, J. M., Storebø, O. J., Pereira Ribeiro, J., Kongerslev, M. T., Völlm, B. A., Mattivi, J. T., Faltinsen, E., Todorovac, A., Jørgensen, M. S., Callesen, H. E., Sales, C. P., Schaug, J. P., Simonsen, E., & Lieb, K. (2022). Pharmacological interventions for people with borderline personality disorder. Cochrane Database Syst Rev, 11(11), Cd012956. https://doi.org/10.1002/14651858.CD012956.pub2

Tate, A. E., Sahlin, H., Liu, S., Lu, Y., Lundström, S., Larsson, H., Lichtenstein, P., & Kuja-Halkola, R. (2022). Borderline personality disorder: associations with psychiatric disorders, somatic illnesses, trauma, and adverse behaviors. Molecular Psychiatry,27(5), 2514-2521. https://doi.org/10.1038/s41380-022-01503-z

Volkert, J., Gablonski, T. C., & Rabung, S. (2018). Prevalence of personality disorders in the general adult population in Western countries: systematic review and meta-analysis. Br J Psychiatry, 213(6), 709-715. https://doi.org/10.1192/bjp.2018.202

Winsper, C., Bilgin, A., Thompson, A., Marwaha, S., Chanen, A. M., Singh, S. P., Wang, A., & Furtado, V. (2020). The prevalence of personality disorders in the community: a global systematic review and meta-analysis. The British Journal of Psychiatry,216(2), 69-78. https://doi.org/10.1192/bjp.2019.166

Zimmerman, M., & Mattia, J. I. (1999). Axis I diagnostic comorbidity and borderline personality disorder. Compr Psychiatry, 40(4), 245-252. https://doi.org/10.1016/s0010-440x(99)90123-2

Zivkovic, A. (2023). Dependent personality and interpersonal dependency: At the intersection of developmental, identity and interpersonal aspects. British Journal of Psychotherapy, 39(1), 212-231. https://doi.org/10.1111/bjp.12802