Highlights
- Based on US data, about 6% to 9% of the population has a personality disorder.
- Personality disorders exist in several forms. Their influence on interpersonal functioning varies from mild to serious.
- Onset usually occurs during adolescence or in early adulthood.
- Anti-social personality disorder is frequently found among prisoners (up to 50%).
- Of hospitalizations for personality disorders in general hospitals, 78% are among young adults between 15 and 44 years of age.
What Are Personality Disorders?
Personality disorders cause enduring patterns of inner experience and behaviour that deviate from the expectations of society, are pervasive, inflexible and stable over time, and lead to distress or impairment.1
"Personality is seen today as a complex pattern of deeply imbedded psychological characteristics that are largely non-conscious and not easily altered, which express themselves automatically in almost every area of functioning."2
Personality characteristics or traits are expressed on a continuum of social functioning. Personality disorders reflect personality traits that are used inappropriately and become maladaptive.2 To some degree, this classification is arbitrary.
Some deviations may be quite mild and interfere very little with the individual's home or work life; others may cause great disruption in both the family and society. Specific situations or events trigger the behaviours of a personality disorder. In general, individuals with personality disorders have difficulty getting along with others and may be irritable, demanding, hostile, fearful or manipulative.
| Symptoms |
|---|
| Personality Disorders |
|
Personality disorders exist in many forms.1 Classification of personality disorders is arbitrary. Each person is unique, however, and can display mixtures of patterns.
Table 5-1 Types of Personality Disorders
| Type | Patterns |
|---|---|
| Borderline Personality Disorder | Instability in interpersonal relationships, selfimage and affects, and marked impulsivity. |
| Antisocial Personality Disorder | Disregard for, and violation of, the rights of others. |
| Histrionic Personality Disorder | Excessive emotionality and attention seeking. |
| Narcissistic Personality Disorder | Grandiosity, need for admiration, and lack of empathy. |
| Avoidant Personality Disorder | Social inhibition, feelings of inadequacy, and hypersensitivity to negative evaluation. |
| Dependent Personality Disorder | Submissive and clinging behaviour related to an excessive need to be taken care of. |
| Schizoid Personality Disorder | Detachment from social relationships and a restricted range of emotional expression. |
| Paranoid Personality Disorder | Distrust and suspiciousness in which others' motives are interpreted as malevolent. |
| Obsessive-Compulsive Personality | Disorder Preoccupation with orderliness, perfectionism and control. |
| Schizotypal Personality Disorder | Acute discomfort in close relationships, cognitive or perceptual distortions, and eccentricities of behaviour. |
How Common Are Personality Disorders?
Canadian data on the prevalence of personality disorders are lacking. United States estimates of the prevalence of diagnosis of any personality disorder, however, range from 6% to 9%, depending upon the criteria used for definition.3
Epidemiological studies most often measure and report antisocial personality disorder. A 1991 Ontario survey estimated that the 1- year prevalence rate of antisocial personality disorder in the general population was 1.7%.4 According to the Edmonton study in the 1980s, 1.8% of the population had an antisocial personality disorder in the 6-month period before the survey, and 3.7% reported a personality disorder at some point in their lives.5,6 Estimates of the prevalence of other personality disorders range from 1% to 10% of the population.
Impact of Personality Disorders
Who Develops a Personality Disorder?
There is a sex difference in the personality disorder types. For example, antisocial personality disorder is more common among men, while borderline personality disorder is more common among women. The dependent and hysterical personality disorders are also more common among women. Labelling biases among health professionals may lead to some of the sex differences.
Ideally, data from a population survey would provide information on the age/sex distribution of individuals with personality disorders. Statistics Canada's Canadian Community Health Survey (CCHS) will provide prevalence of self-reported obsessivecompulsive personality disorder in the future.
At the present time, however, hospitalization data provide the best available description of individuals with personality disorders. These data have limitations, however, because most people with personality disorders, unless they show suicidal behaviour, are treated in the community rather than in hospitals. Many are never diagnosed or treated. Individuals with borderline personality disorder have higher rates of admission than individuals with other disorders because of their high rate of suicidal behaviour. These limitations must be kept in mind, then, when interpreting the data presented in this report.
Among both women and men, the highest rates of hospitalization for personality disorders were among individuals between the ages of 15 and 44 years (Figure 5-1). Over three-quarters (78%) of all admissions were between these ages and rates were higher among women than men.
What Are the Effects of Personality Disorders?
Although the onset of personality disorders usually occurs in adolescence or early adulthood, they can also become apparent in mid-adulthood. To some extent, the timing depends on the type of personality disorder and the situation or events surrounding the individual. For example, borderline personality disorder usually peaks in adolescence and early adulthood, and then becomes less prominent by mid-adulthood. On the other hand, narcissistic personality disorder may not be identified until middle age when the individual experiences the sense of loss of opportunity or faces personal limitations.
Since personality disorders usually develop in adolescence or early adulthood, they occur at a time when most people develop adult relationship skills, obtain education, establish careers and generally "build equity" in their lives. The use of maladaptive behaviours during this life stage has implications that extend for a lifetime.
A history of alcohol abuse, drug abuse, sexual dysfunction, generalized anxiety disorder, bipolar disorder, obsessive-compulsive disorder, depressive disorder, eating disorder, and suicidal thoughts or attempts often accompany personality disorders.3 Up to onehalf of prisoners have antisocial personality disorder because its associated behavioural characteristics (such as substance abuse, violence and vagrancy) lead to criminal behaviour.3 Other social consequences of personality disorders include:
- Spousal violence
- Child maltreatment
- Poor work performance
- Suicide
- Gambling
Personality disorders have a major effect on the people who are close to the individual. The individual's fixed patterns make it difficult for them to adjust to various situations. As a result, other people adjust to them. This creates a major strain on all relationships among family and close friends and in the workplace. At the same time, when other people do not adjust, the individual with the personality disorder can become angry, frustrated, depressed or withdrawn. This establishes a vicious cycle of interaction, causing the individuals to persist in the maladaptive behaviour until their needs are met.
Stigma Associated with Personality Disorders
Since the behaviours shown in some personality disorders remain close to what is considered "normal", others often assume that the individuals can easily change their behaviour and solve the interpersonal problem. When the behaviour persists, however, it may be perceived as a lack of will or willingness to change. The fixed nature of the trait is not well understood by others.
Causes of Personality Disorders
Personality disorders likely result from the complex interplay of early life experience, genetic and environmental factors. In principle, genetic factors contribute to the biological basis of brain function and to basic personality structure. This structure then influences how individuals respond to and interact with life experiences and the social environment. Over time, each person develops distinctive patterns or ways of perceiving their world and of feeling, thinking, coping and behaving.
Although little is known to date about possible biological correlates of personality disorder, individuals with personality disorders may have impaired regulation of the brain circuits that control emotion. This difficulty, combined with psychological and social factors such as abuse, neglect or separation, puts an individual at higher risk of developing a personality disorder. Strong attachments within the family or a supportive network of people outside the family, in the school and in the community help an individual develop a strong sense of self-esteem and strong coping abilities. Opportunities for personal growth and for developing unique abilities can enhance a person's self-image. This supportive environment may provide some protection against the development of a personality disorder.
For biologically predisposed individuals, the major developmental challenges that are a normal part of adolescence and early adulthood - separation from family, selfi-dentity, and independence - may be the precipitating factors for the development of the personality disorder. This may explain why personality disorders usually begin in these years.
Treatment of Personality Disorders
Personality disorders are difficult to treat because of self-denial about the presence of the problem and the pessimism of health professionals based on a lack of success in previous efforts.
Intensive individual and group psychotherapy, combined with anti-depressants and mood stabilizers, can be at least partially effective for some people. Difficulties arise from both the persistence of symptoms and the negative impact of these symptoms on the therapeutic relationship.
Individuals with borderline personality disorder have more frequent hospitalizations, use outpatient psychotherapy more often, and make more visits to emergency rooms than individuals with other personality disorders.7
In 1999, in all age groups, personality disorders were more likely to be a contributing rather than the main factor determining length of stay in hospital (Figure 5-2). This reflects the fact that personality disorders are associated with other conditions, such as suicidal behaviour, that may need hospitalization.
Rates of hospitalization for personality disorders among both men and women increased during the early 1990s and decreased in the later years of the decade (Figure 5-3).
The increase in hospitalization rates for personality disorders in the early 1990s was due to an increase among women in the 15-24 and 25-44 year age groups (Figure 5-4). These same age groups, along with those 65 years of age and older, showed a decline in the later 1990s.
Between 1987 and 1999, men aged 15- 24 years showed the greatest decrease in hospitalization rates for personality disorders (Figure 5- 5). During the early 1990s, rates of hospitalization increased slightly among men aged 25-44 years, and this was followed by a slight decrease later in the decade.
The average length of stay in general hospitals due to personality disorders was 9.5 days in 1999, a decrease of nearly 50% since 1991 (Figure 5-6).
Discussion of Hospitalization Data
Most personality disorders are treated outside of the hospital. Thus, the hospitalization data provide a very limited picture of personality disorders in Canada.
The higher rates of hospitalization for personality disorder in general hospitals among young women than men supports the clinical experience that women are more likely to have borderline personality disorder with its associated suicidal behaviour, leading to hospitalization.
High rates among adolescents and young adults support the negative impact of these disorders on young people at a critical time in their lives.
The length of stay in hospital associated with personality disorders decreased during the 1990s. Further research is needed to determine the reason for this trend: What has been the impact on hospital bed closures on length of stay and treatment outcome? Have treatment methods changed and have outcomes improved?
Future Surveillance Needs
Personality disorders are common in the general population, causing not only a great deal of personal and family distress but also impairment of social functioning.
Existing data provide a very limited profile of personality disorders in Canada. The available hospitalization data needs to be complemented with additional data to fully monitor these disorders in Canada. Priority data needs include:
- Incidence and prevalence of each of the personality disorders by age, sex and other key variables (for example, socio-economic status, education and ethnicity)
- Impact of personality disorders on the quality of life of the individual and family
- Access to and use of primary and specialist health care services
- Impact of personality disorders on the workplace and the economy
- Impact of personality disorders on the legal and penal systems
- Stigma associated with personality disorders
- Access to and use of public and private mental health services
- Access to and use of mental health services in other systems, such as schools, criminal justice programs and facilities, and employee assistance programs
- Treatment outcomes
- Exposure to known or suspected risk and protective factors
References
- American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th edition. Washington, DC: American Psychiatric Association, 1994.
- Millon T, Blaneyu PH, Davis R, ed. Oxford Textbook of Psychopathology. New York: Oxford University Press, 1999:510.
- Samuels JF, Nestadt G, Romanoski AJ, Folstein MF, McHugh PR. DSM-III personality disorders in the community. Am J Psychiatry 1994;151:1055-1062.
- Offord DR, Boyle MH, Campbell D, Goering P, Lin E, Wong M, Racine YA. One-year prevalence of psychiatric disorder in Ontarians 15 to 64 years of age. Can J Psychiatry 1996;41:559-563.
- Bland RC, Newman SC, Orn H. Period prevalence of psychiatric disorders in Edmonton. Acta Psychiatr Scand 1988;77(Suppl 338):33-42.
- Bland RC, Orn H, Newman SC. Lifetime prevalence of psychiatric disorders in Edmonton. Acta Psychiatr Scand 1988;77(Suppl 338):24-32.
- Bender DS, Dolan RT, Skodol AE, Sanislow CA, Dyck IR, McGlashan TH, Shea MT, Zanarini MC, Oldham JM, Gunderson JG. Treatment utilization by patients with personality disorders. Am J Psychiatry 2001;158:295-302.
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