Epidemiology: Personality Disorders

Evidence has shown that personality disorders are more common than previously thought. Personality disorders span a variety of types, with some more rare and less studied than others. Often personality disorders are paired with other illnesses or may be the cause of another mental illness such as substance abuse. The prevalence of personality disorders may be as low as 4 percent or has high as 12 percent, yet they often go undiagnosed too. Nurse Practitioners should understand the diagnosis and treatment of the most common types of personality disorders and their epidemiology so they can promote early diagnosis and treatment, and can develop useful interventions to help populations that may not have access to specialized treatment programs for personality disorders.

Background and Significance

Skodol (2018) of Merck Manual: Professional Version defines personality disorders as pervasive and enduring patterns of perception, reaction and relation to others and the environment that cause dysfunction, distress and/or impairment (Skodol, 2018). Several different types of personality disorders exist and vary in their expressions. However, they all are believed to be caused by a combination of genetic and environmental factors. Most personality disorders first appear around adolescence into young adulthood, and often become gradually less severe with age. Traits of the disorder may remain in some degree for the person’s entire life. Personality disorders are diagnosed clinically and treated with psychological and/or drug therapy (Skodol, 2018). People who have personality disorders may not understand that they do. Instead, they may seek psychological help for the distress that their disorder causes them.

The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) lists 10 different types of personality disorders. Many people are diagnosed with more than one type. The DSM-5 clusters the 10 personality disorder types into three categories. Cluster A is characterized by odd or eccentric behavior such as paranoia characterized by mistrust and suspicion, schizoid behavior, or disinterest in others, and schizotypal or eccentric ideas and behavior. Cluster B is characterized by behavior that is dramatic, emotional or erratic. It includes antisocial behavior such as social irresponsibility, disregard for others, deceitfulness, and manipulation of others for personal gain. Borderline antisocial behavior a cluster B disorder is an intolerance for being alone and an imbalance in emotions, histrionic or attention seeking behavior, and narcissism is an underlying imbalance of a fragile self-esteem and outward grandiosity. Cluster C is characterized by anxious and/or fearful behavior including avoidance of interpersonal contact out of fear of rejection, dependency or submissiveness and a need to be taken care of, and obsessive-compulsive disorders (OCD) characterized by perfectionism, rigidity and obstinacy (Skodol, 2018). The antisocial and borderline personality disorders will usually lessen with age, but others such as OCD or schizotypal usually do not.

Personality disorders are generally problems with self-identity and interpersonal functioning. Self-identity issues include self-image, inconsistencies in values, goals and appearance. For instance, some people with self-identity personality disorder may want others to see them as religious and pious, but when they feel they are safe, they will engage in behavior that they themselves would condemn in their pious personality iteration such as swearing, drinking excessively and/or having casual and/or extramarital sex. Those with personality disorders that have interpersonal functioning problems have trouble making and maintaining relationships with others. They often are unable to empathize with others, and are inconsistent, confusing and frustrating to other people including the professionals who treat them. People with interpersonal functioning personality disorders may not understand boundaries. Their self-esteem may be high or low and they may be detached, over emotional, abusive and irresponsible (Skodol, 2018).

Personality disorders span socioeconomic status, class, race and gender although there are some distinctions in gender. For instance, Skodol (2018) says that approximately 10 percent of the population and half the patients in psychiatric hospitals have personality disorders. Men have antisocial personality disorders at a ratio of 6:1 over women, but in borderline personality disorders, women outnumber men 3:1; however, the later statistic is only in clinical settings. Heritability is thought to be about 50 percent, which refutes the belief that personality disorders are character flaws caused by an adverse environment (Skodol, 2018).

Location	Any Personality Disorder %	DSM A %[1]	DSM B %	DSM C %	OCD	Dependent Personality Disorder
Western Countries[2]	12.6	5.53-7.23	5.53-7.23	5.53-7.23	4.32	0.78
United[3] States	9.1		1.4
New Jersey
Madison, NJ

[1] Cluster A (the "odd, eccentric" cluster);
Cluster B (the "dramatic, emotional, erratic" cluster); and,
Cluster C (the "anxious, fearful" cluster)

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

[3] NIH. (2017, November). Personality Disorders. Retrieved from National Institute of Mental Health: https://www.nimh.nih.gov/healt...

Surveillance and Reporting

Surveillance of personality and other mental health disorders is done so that accurate reporting of these types of conditions can be accomplished. Reporting is done in order to obtain adequate funding for addressing the issues revealed in surveillance. Healthcare delivery funding can only reach so far, so knowing what issues are most prevalent helps those who must decide how to allocate funds to apportion funding appropriately. Surveillance data should be reflective of the population served so that priorities can be set. Surveillance and reporting data is also useful for allocating educational and behavioral interventions that may help to reduce costs and improve the health status of the population.

Surveillance is done through the careful recording of incidence of data and making inferences about relationships among the most important variables. Surveillance research be focused on the greatest need in the community and the most urgent need for population health improvement. Policy makers use surveillance data to create new laws and regulations that address the population needs. However, the types of data collected and the level of detail used in collection may vary. For example, some states provides statistics on mental health, but do not separate different types of mental health issues in their reporting.

Epidemiological Analysis

Much of the literature on personality disorders points out that few studies have been done that reveal prevalence. Some of the literature refers to one specific class of personality disorders and not others. Most commonly it is the B cluster or borderline disorders. Some also look at antisocial disorders, but it is difficult to find consensus on personality disorder epidemiology as a whole. Tyrer, Reed and Crawford (2015) of The Lancet cite cross-sectional community based surveys from North America and Western Europe that place prevalence between 4 percent and 15 percent. One international study reported international prevalence at 6.1 percent with the lowest prevalence in Europe and the highest in North and South America (Tyrer, Reed, & Crawford, 2015, p. 720). Werner, Few, and Bucholz (2015) of Psychiatric Annals found that the prevalence of anti-social personality disorders (ASPD) in the United States ranged from 1 percent to 4 percent (Werner, Few, & Bucholz, 2015, p. 2). However, lack of research is not the only issue associated with the epidemiology of personality disorders.

Consensus also seems to be lacking especially on the determinants of personality disorders. Some studies say that traits such as age, gender, race and nationality do not affect the prevalence of personality disorders, but several studies point out that some personality disorders are more common in one sex or the other. Werner, Few, and Bucholz (2015) say, “Gender also seems to play a role in ASPD, as males are 3 to 5 times more likely to be diagnosed with ASPD than females, with 6% of men and 2% of women meeting DSM-IV criteria for ASPD in the general population, which holds as well for clinical samples based on primary care clinics (8% of men v 3% of women)” (Werner, Few, & Bucholz, 2015, p. 2). In male populations with substance abuse disorders, the prevalence is as high as 70 percent (Werner, Few, & Bucholz, 2015, p. 2). Yet, Tyrer, Reed, and Crawford say, “By contrast with community settings, the prevalence of personality disorder in clinical services is higher in women than in men, probably a result of higher rates of help seeking in women than in men” (Tyrer, Reed, & Crawford, 2015, p. 720). Several studies also point out that there are common comorbidities to personality disorders such as substance abuse disorders.

Tyrer, Reed and Crawford (2015) agree that personality disorders in the general population are more common in men than in women and at least as common in ethnic minorities if not more common than in majority populations. They also agree with Werner, Few, and Bucholz (2015) that people in treatment for another type of mental disorder are more likely to be diagnosed with a personality disorder. Tyrer, Reed, and Crawford (2015) say that approximately 25 percent of patients in primary care and 50 percent of patients in psychiatric outpatient treatment meet the criteria for personality disorders. Probably not too surprising is that “the highest prevalence of personality disorder is noted in people in contact with the criminal justice system, with two-thirds of prisoners having personality disorder” (Tyrer, Reed, & Crawford, 2015, p. 720). Other determinants of the prevalence of personality disorders include a younger age and lower levels of education. The decline in the prevalence with age may be connected with the general mellowing of age that most people experience, but it may also be associated with the high mortality rates of people with antisocial personality disorders (Werner, Few, & Bucholz, 2015, p. 3).

Costs associated with personality disorders cannot be adequately determined because people with personality disorders may not know that they have an issue and may lose jobs and other opportunities because of the associated behavior. These losses could add up to a high cost and a disadvantaged socioeconomic status. The costs of treatment is easier to determine. Kvarstein, et al. (2013) of BMC Psychiatry discuss two types of treatment programs for general personality disorders: intensive hospital-based treatment programs and the more commonly accessed outpatient treatment programs. Both types are expensive, but worth it because studies have shown that both are successful in terms of clinical improvements and prevention of suicide (Kvarstein, et al., 2013, p. 2). Specialized intensive treatments are more expensive, but may be balance by reductions in other areas such as emergency costs. Because the outpatient treatment usually involves group therapy and often are standard treatment for a number of the various types of personality disorders, resources are preserved (Kvarstein, et al., 2013, p. 2).

When one considers the social costs of personality disorders, the cost for treatment does not seem out of line. The result of not treating personality disorders include job loss, low income, reliance on social welfare, homelessness, poor relationship quality, dysfunctional family and, too frequently, suicide. Personality disorders can affect a person without them even knowing they have an issue. They may feel that they suffer from bad luck or that fate is out to get them, and they may never seek help. This may affect their stress levels and result in cancer, obesity, heart disease, anxiety, withdrawal and other possible stress-related behaviors throughout their lives.

Screening and Guidelines

Personality disorders are diagnosed using clinical criteria from the DSM-5. A clinician may suspect a patient has a personality disorder, and evaluate the cognitive, affective, interpersonal and behavioral tendencies using specific diagnostic criteria such as a screening test. Skodol (2018) says that diagnosis of a personality disorder requires recognition of the presence of the following characteristics:

• A persistent, inflexible, pervasive pattern of maladaptive traits involving cognition, affectivity, interpersonal functioning, and/or impulse control

• Significant distress or impaired functioning resulting from the maladaptive pattern

• Relative stability and early onset of the pattern. (Skodol, 2018)

Other causes for the maladaptive behavior should be eliminated such as substance abuse or head trauma. Antisocial personality disorders cannot be diagnosed in patients younger than 18. For other personality disorders, the pattern of behavior must have been present for more than 1 year. Clinicians should obtain treatment history from other clinicians who have treated the patient in the past to get a full understanding of the patient’s condition (Skodol, 2018).

One screening tool that is used to diagnose personality disorders is the Personality Inventory for DSM-5 (PID-5)—Adult. It is a 220 item self-rated personality trait assessment scale for people age 18 and older. The Personality Inventory assesses 25 personality traits including: Anhedonia, Anxiousness, Attention Seeking, Callousness, Deceitfulness, Depressivity, Distractibility, Eccentricity, Emotional Lability, Grandiosity, Hostility, Impulsivity, Intimacy Avoidance, Irresponsibility, Manipulativeness, Perceptual Dysregulation, Perseveration, Restricted Affectivity, Rigid Perfectionism, Risk Taking, Separation Insecurity, Submissiveness, Suspiciousness, Unusual Beliefs and Experiences, and Withdrawal (APA-DSM5, 2013). Each trait is represented by 4 to 14 questions, and similar and corresponding traits can be grouped into the broader trait domains of Negative Affect, Detachment, Antagonism, Disinhibition, and Psychoticism (APA-DSM5, 2013). The screening tool is given to the patient to fill out before visiting the clinician. The patient is asked to score how well the trait describes him or her generally. Each item is rated on a 4-point scale. Several of the items are reverse-coded (APA-DSM5, 2013).

The current national guidelines for treatment of personality disorders, the American Psychiatric Association Guideline (2007) include one for borderline personality disorder that recommends psychotherapy as the primary treatment for the disorder complemented by pharmacotherapy that targets specific symptoms. Other activities and interventions from a wide range of possibilities could also be used to treat patients with borderline personality disorder. Some of the components of the psychiatric management of treatment include “responding to crises and monitoring the patient’s safety, establishing and maintaining a therapeutic framework and alliance, providing education about borderline personality disorder and its treatment, coordinating treatment provided by multiple clinicians, monitoring the patient’s progress, and reassessing the effectiveness of the treatment plan” (Oldham, et al., 2010, pp. 9-10). For obsessive compulsive disorder (OCD), the APA Guideline (2007) says that treatment for OCD is needed when the symptoms of the disorder interfere with daily functioning or cause distress. Psychiatric management of OCD includes a wide variety of therapies of varying intensities that should be matched with the intensity of the patient’s symptoms. Treatment should also be coordinated with other healthcare providers, clinicians and social agencies with whom the patient may also have ongoing therapy (Koran, Hanna, Hollander, Nestadt, & Simpson, 2007, p. 9).

Plan: Integrating Evidence

Nurse practitioners (NPs) may come into contact with patients who have both diagnosed and undiagnosed personality disorders. One intervention for those who may not know they have a personality disorder is assessing the patient and referring him or her to a clinician who can diagnose the disorder. Maryniak (2015) of RN.com explains that suspected personality disorders may be revealed during a physical examination. Some indications may be signs self-mutilation or substance abuse. Lab tests can indicate substance use, nutritional issues, and sexually transmitted diseases that may all be symptoms of a personality disorder (Maryniak, 2015, p. 12). The patients themselves may not be honest when providing subjective health information. Other clues to a personality disorder may be general appearance and speech patterns. For instance, blunt or guarded behavior may indicate a Cluster A personality disorder. Communication may be difficult to follow with patient with this disorder, patients may show paranoid or hallucinatory behavior. Abrupt behavior with inappropriate emotions may indicate a Cluster B or C disorder. Interventions for some patients suspected of having a personality disorder may be a referral to a clinician who can diagnose and treat the disorder. In some cases though, the NP’s intervention may be admitting the patient to a hospital if he or she is demonstrating the potential to harm themselves or others. Maryniak (2015) also says that NPs may want to use one of the common assessment tools such as the Personality Inventory for DSM-5 (PID-5)—Adult or the Minnesota Multiphasic Personality Inventory-2 (MMPI-2). The NP can then distinguish the type of disorder the patient has and have a better idea what sort of treatment referral to make (Maryniak, 2015, p. 12).

For NPs with a more generalized community approach to personality disorders, promotion and prevention can be the goals of their interventions. Thomas, et al. of the London Journal of Primary Care says that promotion and prevention can be integrated using “biopsychosocial approaches, adapting national mental health strategies to the local context and ensuring good communication and mutual learning between all involved” (Thomas, et al., 2016, p. 3). Thomas, et al. (2016) also suggest collaboration with other organizations to map risk factors, resources and access and to promote early intervention.

Finally, when an NP suspects a patient may have a borderline personality disorder, there are interventions that can be attempted with great success that do not involve referrals and other resource limited methods. This type of intervention is especially useful for NPs who work in urban clinics or college counseling center. Finch, Brickell, and Choi-Kain (2019) of the Journal of College Student Psychotherapy explain that training and time needed for expensive interventions for personality disorders in college students may not exist, so they suggest using a pared-down adaptation of dialectical behavior therapy (DBT) such as a short-term skills group and cites support for the efficacy of this type of intervention (Finch, Brickell, & Choi-Kain, 2019, p. 164).

Conclusion

Personality disorders may be more prevalent than some of the research says. Three clusters of personality disorders exist. Gender may be a determinant and so may age. Diagnosis can be made with assessment tools. Treatment for personality disorders includes psychotherapy and possibly medication. Therapy is helpful for most disorders, but may be too time-consuming or expensive for some patients, so NPs can use pared down versions. NPs can also intervene by promoting early diagnosis and treatment within a community setting.

References

APA-DSM5. (2013). The Personality Inventory for DSM-5 (PID-5)—Adult. Retrieved from APA-DSM5: APA_DSM5_The-Personality-Inventory-For-DSM-5-Full-Version-Adult.pdf

Finch, E. F., Brickell, C. M., & Choi-Kain, L. W. (2019). General psychiatric management: An evidence-based treatment for borderline personality disorder in the college setting. Journal of College Student Psychotherapy, 33(2), 163–175. Retrieved from https://www.tandfonline.com/do...

Koran, L. M., Hanna, G. L., Hollander, E., Nestadt, G., & Simpson, H. B. (2007). Practice Guidline for the Treatment of Patients with Obsessive-Compulsive Disorder. Arlington, VA: American Psychiatric Association. Retrieved from https://psychiatryonline.org/p...

Kvarstein, E. H., Arnevik, E., Halsteinli, V., Rø, F. G., Karterud, S., & Wilberg, T. (2013). Health service costs and clinical gains of psychotherapy for personality disorders: a randomized controlled trial of day-hospital-based step-down treatment versus outpatient treatment at a specialist practice. BMC Psychiatry, 13(315), 1-13. Retrieved from https://bmcpsychiatry.biomedce...

Maryniak, .. (2015, March 4). Personality Disorders: Identification, Assessment, and Interventions. Retrieved from RN.com: https://lms.rn.com/getpdf.php/...

NIH. (2017, November). Personality Disorders. Retrieved from National Institute of Mental Health: https://www.nimh.nih.gov/healt...

Oldham, J. M., Gabbard, G. O., Goin, M. K., Gunderson, J., Soloff, P., Spiegel, D., . . . Phillips, K. A. (2010). Practice Guidelines for Patients with Borderline Personality Disorder. Arlington, VA: American Psychiatric Association. Retrieved from https://psychiatryonline.org/p...

Skodol, A. (2018, May). Overview of Personality Disorders. Retrieved from Merck Manual Professional Version: https://www.merckmanuals.com/p...

Thomas, S., Jenkins, R., Burch, T., Calamos Nasir, L., Fisher, B., Giotaki, G., & Wright, F. (2016). Promoting Mental Health and Preventing Mental Illness in General Practice. London Journal of Primary Care, 8(1), 3-9. Retrieved from https://www.ncbi.nlm.nih.gov/p...

Tyrer, P., Reed, G. M., & Crawford, M. J. (2015). Classification, assessment, prevalence, and effect of personality disorder. The Lancet, 385(9969), 717-726. Retrieved from http://psychiatrytraining.heal...

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

Werner, K. B., Few, L. R., & Bucholz, K. K. (2015). Epidemiology, Comorbidity, and Behavioral Genetics of Antisocial Personality Disorder and Psychopathy. Psychiatric Annals, 45(4), 1-8. Retrieved from https://www.ncbi.nlm.nih.gov/p...