Does your 'difficult' friend have a personality disorder?

The patient sitting opposite me in my consulting room is describing a fraught pattern I’ve come to recognise only too well. Her relationships are a battleground. Other people call her ‘difficult,’ ‘dramatic’ or accuse her of overreacting. Yet she feels her emotions so intensely that any perceived slight can trigger despair.

Her moods can shift rapidly, sometimes within hours, triggering impulsive behaviour that is exhausting and bewildering for her and those around her, who may attribute it to attention-seeking or being over-dramatic.

But as a consultant psychiatrist I know that such behaviour has a clinical name – emotionally unstable personality disorder, or EUPD, sometimes also called borderline personality disorder.

People with the condition – which affects both sexes – have an emotional thermostat that is simply calibrated differently to that of other people.

It’s one of the most misunderstood conditions in psychiatry and is also surprisingly common.

Personality disorders affect about one in ten people, yet remain shrouded in stigma in a way that depression and anxiety no longer are. This means that many people suffer for years with EUPD without realising the cause – and, crucially, that it can be successfully treated.

Recognising the hallmarks of this disorder in a loved one or colleague can help you understand behaviour that might seem unreasonable or hurtful.

And while clearly only a psychiatrist or psychologist can reach a proper diagnosis, learning to spot it might help you encourage someone to seek support and also enable you to understand behaviour that may seem ­baffling or upsetting.

So apart from intense emotional swings, what other signs should you look out for?

Fear of abandonment is another clear symptom. Someone with EUPD may go to extraordinary lengths to prevent being left – becoming clingy, or conversely even pushing people away before they can be rejected.

Relationships tend to be intense and unstable, swinging between idealisation and bitter disappointment.

A new friend or partner is often seen as wonderful or perfect, then suddenly branded a terrible, untrustworthy enemy – often after a small ­incident that would not become an issue in normal relationships.

Many people with EUPD describe feeling empty inside. They may struggle to answer questions about who they really are, what they want from life, what their values are.

To an observer it can also seem as though their behaviour changes according to who they are with – and impulsivity is common too.

A&E failings 

One in ten patients spent more than 12 hours in A&E last year, a report claimed. That is 1.75million people. The Government calls it unacceptable and promises improvement. We have heard this for years. The system is failing staff and patients.

This might include spending sprees, reckless driving, substance misuse, binge eating, or unsafe sex. Tragically, self-harm is common, often used as a way of managing overwhelming emotions or a sense of internal numbness.

Suicidal thoughts are also more common in people with EUPD, which is why ­getting medical help is so vital.

Increasingly psychiatrists have moved away from rigid diagnostic labels and now recognise that personality disorders exist on a spectrum of severity and not everyone will necessarily have all the same features.

There is no single cause of EUPD but often difficult early experiences – such as trauma, neglect, abuse or chaotic family environments – can play a ­significant role.

And there is also a genetic component, which explains why some people emerge from difficult childhoods relatively unscathed while others develop lasting difficulties.

But the good news is that EUPD is treatable.

For years, the received wisdom was that personality disorders were lifelong and unchangeable. We now know this is not true.

Specialist therapies such as dialectical behaviour therapy, or DBT, which teaches practical skills for managing intense emotions, can be transformative.

Treatment takes time and commitment, but people do improve significantly – even to the point where they no longer meet the criteria for a diagnosis.

If you recognise these patterns in someone you care about, approach the conversation gently. Remember that their behaviour, however difficult, comes from profound distress, not conscious choice.

A conversation with their GP is a first step. Most NHS trusts have specialist personality disorder services, though waiting lists can be long.

If you recognise these traits in yourself please be reassured that your experience is real – it has a name, and help exists. You are someone with an illness that deserves compassion and proper treatment, just like any other.

Emma's heartfelt campaign

Emma Willis lived for 48 years with a hole in her heart – and had absolutely no idea. The broadcaster discovered her atrial septal defect at a routine health check in January last year, and two months later had keyhole surgery at the Royal Brompton Hospital to repair the wall between the two upper chambers of the heart.

Now she is campaigning to raise awareness of heart conditions – and her story is a big reminder of something I tell patients regularly: your body can harbour serious problems you know nothing about.

We tend to assume that if something were badly wrong, we would be aware of symptoms. But that is not always the case as the body can compensate, sometimes for a surprisingly long time. 

The NHS offers free health checks for adults aged 40 to 74. Private options exist too. Learn from Emma’s experience and take advantage of these.

It's not just the time teenagers spend on screens, it's about what they are seeing

A new study claims that screen time spent on social media or gaming does not cause mental health problems in teenagers. Ministers considering a social media ban for under-16s will no doubt take note. But I would urge caution with such findings, which only measure hours spent on screens. The harm from social media is not simply about duration. It is about what young people are seeing. This includes relentless comparison with curated, filtered lives and algorithms that push teenagers towards extreme content. Social media also enables bullying to follow them home and into their bedrooms and leads to disrupted sleep when phones glow under pillows at midnight. None of this is captured by counting hours.

Dr Max prescribes... knitting

Craft activities such as knitting reduce anxiety, stress and depression and boost mood and self-esteem, multiple studies show. Knitting is very effective because the motion is meditative and you end up with something tangible (even if it does have some holes). People with mental health problems described it as bringing calm and structure to their lives, according to University of Gothenburg researchers.