There is not much data on the rate of personality disorders among people. What is known is that personality disorders lead to people having other problems, being on medication, and making their lives a misery. What is less certain is how personality disorders fit together, with but one common observation: the current DSM system, carried over from the last edition, does not work well.
The categories of personality disorder in successive DSM and ICD revisions since 1968 have dominated diagnosis in personality disorder and hindered progress. The obvious attractions of the specific labels first introduced by Schneider (1923) were distracting, as they focused attention unduly on specific rather than the arguably more important general features of personality disorder, and only two of these, antisocial and borderline personality disorder (plus schizotypal personality disorder, which we discuss subsequently), achieved a degree of general usage. In particular, these have helped to promote research and, more recently, have led to the development of treatments, such as dialectical behaviour therapy (Linehan, Armstrong, Suarez, Allmon and Heard, 1991), mentalizing-based therapy (Bateman & Fonagy, 1999, 2001), schema-focused and cognitive behaviour therapy for personality disorders (Davidson et al., 2006; Giesen-Bloo et al., 2006) and Systems Training for Emotional Predictability and Problem Solving (Blum et al., 2008), which have helped to scotch the old view that because nothing could be done to help people with this condition, there was no point in making the diagnosis. But these changes cannot hide the fundamental problem of the diagnostic categories in both DSM and ICD: They were diagnoses made by committees, based largely on unsystematic clinical experience, for which there was little to no research-based evidence that supported their existence as discrete categories. They failed to recognize the importance of the basic trait dimensions of personality that were well established and that had a consistent structure regardless of the presence or absence of personality disorder (Clark, Livesley & Morey, 1997; Eaton, Krueger, South, Simms and Clark, in press). They also did not address the problem of overlapping criteria (i.e. similar criteria across disorders) and the related problem that the criteria have been shown repeatedly to have a different factor structure from that implied in their formal definitions (Blackburn & Coid, 1999; Blais & Norman, 1997; Clark, 2007; Livesley, Schroeder, Jackson & Jang, 1994).
Now, the paper I am quoting today uses those paradigms, and has to be taken with a kilo of salt. The checklists are too vague and too inclusive. Having said that, the authors used the best available semi structured interview (The Structured interview for DSM IV non patient personality questionairre) and a population selected from the female population.
Why female? The original cohort was selected to ascertain risk factors for osteoporosis. One does not know what the male rates of personality disorders are.
My reading of this is that the rates are over estimitated. OF more interest is the correlations with personality difficulties.
Objective: We aimed to describe the prevalence and age distribution of personality disorders and their comorbidity with other psychiatric disorders in an age-stratified sample of Australian women aged ?25?years.
Methods: Individual personality disorders (paranoid, schizoid, schizotypal, histrionic, narcissistic, borderline, antisocial, avoidant, dependent, obsessive-compulsive), lifetime mood, anxiety, eating and substance misuse disorders were diagnosed utilising validated semi-structured clinical interviews (Structured Clinical Interview for DSM-IV-TR Axis I Disorders, Research Version, Non-patient Edition and Structured Clinical Interview for DSM-IV Axis II Personality Disorders). The prevalence of personality disorders and Clusters were determined from the study population (n?=?768), and standardised to the Australian population using the 2011 Australian Bureau of Statistics census data. Prevalence by age and the association with mood, anxiety, eating and substance misuse disorders was also examined.
Results: The overall prevalence of personality disorders in women was 21.8% (95% confidence interval [CI]: 18.7, 24.9). Cluster C personality disorders (17.5%, 95% CI: 16.0, 18.9) were more common than Cluster A (5.3%, 95% CI: 3.5, 7.0) and Cluster B personality disorders (3.2%, 95% CI: 1.8, 4.6). Of the individual personality disorders, obsessive-compulsive (10.3%, 95% CI: 8.0, 12.6), avoidant (9.3%, 95% CI: 7.1, 11.5), paranoid (3.9%, 95% CI: 3.1, 4.7) and borderline (2.7%, 95% CI: 1.4, 4.0) were among the most prevalent. The prevalence of other personality disorders was low (?1.7%). Being younger (25–34?years) was predictive of having any personality disorder (odds ratio: 2.36, 95% CI: 1.18, 4.74), as was being middle-aged (odds ratio: 2.41, 95% CI: 1.23, 4.72). Among the strongest predictors of having any personality disorder was having a lifetime history of psychiatric disorders (odds ratio: 4.29, 95% CI: 2.90, 6.33). Mood and anxiety disorders were the most common comorbid lifetime psychiatric disorders.
Conclusions: Approximately one in five women was identified with a personality disorder, emphasising that personality disorders are relatively common in the population. A more thorough understanding of the distribution of personality disorders and psychiatric comorbidity in the general population is crucial to assist allocation of health care resources to individuals living with these disorders.
Now, I have heard authors from ICD-11 talk on many occaisons. They have a much simpler classification.
- No personality difficulty: about a quarter of the population. Never have problems. Boring
- Personality difficulties. Copes well except when put in certain circumstances, and in those becomes a right pain in the neck. About half the population
- Mild personality disorder. Ongoing difficulties in some aspects of life. Hard to get along with, but generally employed, generally has relationships, but may not sustain them. Probably 15 — 20 % of population
- Moderate personality disroder. Generally can’t sustain relationships. Difficulty working. Five to ten percent of population
- Severe personality disorder. Fragile. Often marked difficulty in sustaining relationships or jobs or both. Often suicidal, frequently has mood disorders and substance abuse. Three to five percent of population
Now look at the table again. Let us assume that the 25% capture is the mild to moderate end of personality difficulties. The women are generally younger, but are much more likely to be single, obese, and on medication. It may be that we are picking up some other factors, but pragmatically these are useful markers for those who are courting.
There is but one hopeful point. People can move, and can change. The older women have much less personality problems. Perhaps that is called maturity. Or that most women, like men, learn from their mistakes.
My ex-wife has borderline. She is at least level 4 (won’t ever have a job, can’t sustain relationships). This issue of personality disorder needs a lot more attention. Those at levels 4 and 5, for instance, do much damage to the people they are in relationships with. They are likely to do this damage to more than one person over the course of a lifetime, so have an effect above their numbers. There doesn’t seem to be an easy cure, but better diagnosis would help.
You have my sympathy. Look after yourself and your children.
The trouble is that we only use two of the personality disorders clinically: Borderline and antisocial. The second is not really used either: the old term psychopath still exists (particularly in UK law) and the dynamic of having expunged your conscience (which is the core feature of the psychopath) is missing from DSM because the idea of a conscience was icky to the people who wrote it.
There is a big difference of opinion between the USA and the rest of the world here. The rest of the world sees severe and sees that they cost a lot and cause damage and all the things that may help (Dialectical Behaviour Therapy, intensive case management) cost megabucks.
The ICD-11 has to work everywhere. In low income countries. In France. In Switzerland, In China. And this is where the knowledge is. The paper I quoted from is not even printed yet.