The term "personality disorder" was developed decades ago to describe patients who had a superficially normal presentation without psychosis but who, under psychoanalysis, were revealed to have deep disturbances in their psychological functioning. Many of these patients had chronic problems in interpersonal relationships or social/occupational functioning. Some had symptoms of "neurosis" such as anxiety or depression, whereas others had none. To this day, personality disorders remain difficult to treat. Yet, a large percentage of any psychotherapist's caseload is composed of persons with such disorders, as they comprise approximately 10-20 percent of the general population.
Traditionally, psychotherapists believed that personality disorders were untreatable. This view has changed over time, but whether the view has changed because my profession has become better at treating personality disorders or the view has changed simply because no one wants to admit that a large percentage of patients are only partially treatable at best is open to question. What I have found in my practice is that most people with personality disorders present with depression or anxiety that can be treated, but that their core personality problems are treatable some, but not all, of the time.
The theories of my profession have held that real psychological treatment occurs in the relationship between the patient and the therapist, and my 20 years of experience has shown me that this is true. The reason that personality disorders are difficult to treat is because the personality disorder has a tendency to destroy the patient-therapist relationship. Persons with personality disorders have a tendency to hide important information from the therapist, because either consciously or unconsciously, they are unable to admit what they believe to be shameful information or feelings. This is because they either have an inflated ("grandiose") sense of self that does not allow weakness, or they have an inordinate fear of judgment that is a product of their projection.
What is a personality disorder? In short, it is a malformation of the ego, the part of the psyche that mediates between pleasure-seeking urges and reality. We all make emotional compromises to deal with the fact that reality doesn't always give us what we want. A person with a personality disorder, either because of genetic tendencies, a history of early childhood trauma or both that have disrupted normal processes of maturation, distorts reality instead of compromising with it (people who are simply neurotic, in contrast, engage in "compromise formations" which often involve symptoms that are easily identifiable to both the patient and the therapist). I have found that many of my patients with personality disorders live in a fantasy world. They are unable to see what people around them are really like because they only see what they have projected onto those people, which may be what they wish others to be like, or, a projection of a part of themselves that they don't like. Consequently, others may be either idealized or devalued.
There are many other aspects of personality disorders-- this is a complex subject that cannot be adequately explained in a blog post. If you suspect that you have a personality disorder, the path to recovery is to be completely honest with your therapist, even if it feels uncomfortable. Ultimately this honesty breaks down the pathological defenses that comprise a personality disorder, leading to the formation of an acceptance of reality, a realistic self-image, and perceptions of others that aren't so distorted.