Dr. Ali Al Farhan
Consultant Psychologist and Psychotherapist · Associate Professor of Psychology
The relationship changes, but the conflict feels familiar. You begin feeling close and secure, then feel unimportant and respond by protesting or pulling away. You may promise yourself to express your needs clearly, yet when rejection feels possible, say, "I do not need anyone."
Repetition can also appear in your relationship with yourself: you appreciate your work in the morning, then hear a small criticism and feel worthless. Or you work hard to control every detail, only to find that the care which initially helped you now exhausts you and restricts your life.
These experiences deserve understanding, but they do not, by themselves, establish a personality disorder. Assessment considers how persistent and flexible the pattern is, where it appears, and the distress or impairment it causes.
Personality refers to our usual patterns of thinking, feeling, behaving and relating. A personality disorder may be considered when some patterns endure over time, become inflexible and create significant difficulties in life or relationships, taking culture and developmental stage into account. [1]
A trait such as sensitivity, reserve or a preference for order is not enough for a diagnosis. It also matters whether someone can adapt their response to changing circumstances and sustain relationships and goals they can live with. [1]
A diagnosis is a clinical description that helps guide treatment. It does not define a person's moral character or worth, and should not become a label assigned to a partner or relative after an argument.
Alongside symptoms, the therapist explores the person's experience of themselves and others, how they regulate emotions, and how they protect themselves against fear, shame and loss. Nancy McWilliams's work offers a framework for understanding these differences and their significance within therapy. [2]
Some illustrative questions bring this closer to everyday experience:
These questions are not a home diagnostic test. They open a broader conversation about experience, history and circumstances.
Otto Kernberg's model of personality organisation focuses on areas including identity integration, defences and reality testing. Reality testing here means being able to distinguish internal experience from external reality. Structured interviews such as the STIPO have been developed to assess aspects of this model. [3]
An everyday example can clarify this interest in representations of self and others: I can be angry with a friend while remembering their past support; I can acknowledge a mistake while retaining a sense of my abilities and worth.
When strong emotion narrows that capacity, one aspect may dominate the whole picture: "They do not care about me at all," or "I fail at everything." This illustrates a concept; occasionally having such an experience is not enough to identify someone's level of personality organisation.
It is important to distinguish borderline personality organisation, a concept within a psychodynamic model, from borderline personality disorder, a specific diagnosis. They are not interchangeable terms. [3]
The following scenes are fictional. They are not accounts of clients or ready-made diagnostic descriptions.
"Nasser" makes new friends. He enjoys seeing them, but monitors tones and comments for signs that he is unwanted. When one friend forgets to invite him to an event, he stops replying to the entire group.
He says, "It does not matter," yet spends days thinking about it.
One possible understanding is that withdrawal protects him from waiting for a rejection he fears. Yet it also puts him outside the relationship before he knows what happened: Was the exclusion deliberate? Was the event small? Did his friend make a mistake?
The work can explore the distance between a feeling and a conclusion. "I felt unimportant" describes an experience worth listening to; "Nobody wants me" calls for further examination. The relationship may indeed prove harmful, in which case setting boundaries becomes part of the work.
This example does not diagnose avoidant personality disorder. Withdrawal may arise for many reasons, including anxiety, earlier experiences or the circumstances of this particular relationship.
Defences are psychological processes that reduce feelings that are difficult to bear, and many operate outside direct awareness. Therapy considers their function, flexibility and cost. Temporarily stepping back may help someone settle their anger; permanent withdrawal may deprive them of support. [2]
Imagine "Mona," who redoes her colleagues' work because she cannot tolerate the possibility of error. She works late and resents carrying so much responsibility, yet struggles to delegate any of it.
We might ask: What would a mistake mean? Is she concerned about realistic professional consequences? Does any imperfection feel as if it would expose her as incompetent? Has controlling details become her only way of feeling safe?
Here, one aim may be to distinguish what needs close scrutiny from what can be completed adequately, while understanding the anxiety involved in relinquishing some control. Perfectionism or diligence alone does not establish a personality disorder.
Mentalizing means trying to understand our own and others' behaviour in terms of feelings, thoughts and intentions, while recognising that our understanding can be mistaken. It is central to mentalization-based treatment associated with Peter Fonagy and Anthony Bateman. [4]
"Layan" receives a brief reply from her partner and immediately concludes, "They have grown tired of me." It may help to trace the experience: she saw a short reply, felt afraid, then treated that fear as evidence of her partner's intention.
She might instead say, "Your short reply worried me. Is something on your mind?" This creates room to ask before acting on a single interpretation. The conversation may reveal a real problem that needs attention. Mentalizing does not mean excusing another person's behaviour or denying harm.
Diagnostic classifications describe patterns including borderline, avoidant, dependent, narcissistic and obsessive-compulsive personality disorders. They differ in their areas of difficulty, and traits or diagnoses can overlap. A person's personality cannot be reduced to a popular label such as "narcissist" or "borderline." [1]
Someone may experience emotional shifts in relationships without having bipolar disorder, or a mood disorder may temporarily affect their behaviour. Mood and personality disorders may also coexist. Assessment follows difficulties over time instead of judging from one incident or the worst period of someone's life. [1, 7]
Specific goals can be agreed, such as reducing impulsivity, tolerating disagreement more effectively, expressing needs or retaining a more balanced view of oneself when criticised.
Some patterns may appear in sessions. A person who fears rejection may struggle to tell the therapist that they felt misunderstood. Exploring this can provide an opportunity to examine what they expected and what actually happened, including the therapist's contribution to the misunderstanding. This illustrates therapeutic work; it does not assume that every difficulty in therapy originates with the client. [2]
Guidelines recommend structured psychological treatments for borderline personality disorder. Several approaches are available, including mentalization-based treatment and approaches such as dialectical behaviour therapy. Choice depends on needs, goals and available clinical expertise. [5]
A 2023 review in World Psychiatry also found support for psychodynamic psychotherapy in the field of adult personality disorders, with variation and limitations in the evidence. This does not mean that all personality disorders have been studied equally or that one treatment protocol suits everyone. [6]
Co-occurring conditions such as depression may warrant assessment for medication. Medication is not treated as a way of changing personality; the plan remains individual and assessment-led. [1]
A well-established pattern is not an inevitable destiny. Change may begin when you can notice what happens before acting: recognising fear of rejection and asking before ending a relationship; acknowledging anger and setting a boundary without causing harm; or allowing a limited mistake without losing self-respect.
These are examples of possible goals. Progress and the time it takes vary. The plan should be reviewed in light of what improves and what remains difficult, rather than requiring someone to transform themselves all at once.
Therapy can open a space between feeling and response, allowing choice where it once felt as though the pattern was choosing for you.
If recurring patterns strain your relationships, work or sense of self, a professional assessment can help you understand them. If there is a risk of harm to yourself or others, urgent help takes priority. This content is educational and should not be used to diagnose yourself or someone else.