Personality disorder

Personality disorders
Classification and external resources
ICD-10 F60
ICD-9 301.9
DiseasesDB 9889
MedlinePlus 000939
MeSH D010554

Personality disorders are a class of mental disorders characterized by enduring maladaptive patterns of behavior, cognition, and inner experience, exhibited across many contexts and deviating markedly from those accepted by the individual's culture. These patterns develop early, are inflexible, and are associated with significant distress or disability.[1] The definitions may vary somewhat, according to source.[2][3]

Official criteria for diagnosing personality disorders are listed in the [4]

Personality, defined psychologically, is the set of enduring behavioral and mental traits that distinguish human beings. Hence, personality disorders are defined by experiences and behaviors that differ from societal norms and expectations. Those diagnosed with a personality disorder may experience difficulties in cognition, emotiveness, interpersonal functioning, or control of impulses. In general, personality disorders are diagnosed in 40–60 percent of psychiatric patients, making them the most frequent of all psychiatric diagnoses.[5]

These behavioral patterns in personality disorders are typically associated with substantial disturbances in some behavioral tendencies of an individual, usually involving several areas of the personality, and are nearly always associated with considerable personal and social disruption. A person is classified as having a personality disorder if their abnormalities of behavior impair their social or occupational functioning. Additionally, personality disorders are inflexible and pervasive across many situations, due in large part to the fact that such behavior may be ego-syntonic (i.e. the patterns are consistent with the ego integrity of the individual) and are, therefore, perceived to be appropriate by that individual. This behavior can result in maladaptive coping skills, which may lead to personal problems that induce extreme anxiety, distress, or depression.[6] These patterns of behavior typically are recognized in adolescence and the beginning of adulthood and, in some unusual instances, childhood.[1]

Many issues occur with classifying a personality disorder.[7] There are many categories of definition, some mild and some extreme.[7] Because the theory and diagnosis of personality disorders occur within prevailing cultural expectations, their validity is contested by some experts on the basis of invariable subjectivity. They argue that the theory and diagnosis of personality disorders are based strictly on social, or even sociopolitical and economic considerations.[8][9][10][11]

Classification

The two major systems of classification, the ICD and DSM, have deliberately merged their diagnoses to some extent, but some differences remain. For example, ICD-10 does not include narcissistic personality disorder as a distinct category, while DSM-5 does not include enduring personality change after catastrophic experience or after psychiatric illness. ICD-10 classifies the DSM-5 schizotypal personality disorder as a form of schizophrenia rather than as a personality disorder. There are accepted diagnostic issues and controversies with regard to distinguishing particular personality disorder categories from each other.[12] ICD classifies Transsexualism as a personality disorder;[13] while the DSM-5 instead addresses Gender dysphoria.[14]

World Health Organization

The ICD-10 section on mental and behavioral disorders includes categories of personality disorder and enduring personality changes. They are defined as ingrained patterns indicated by inflexible and disabling responses that significantly differ from how the average person in the culture perceives, thinks, and feels, particularly in relating to others.[15]

The specific personality disorders are: paranoid, schizoid, dissocial, emotionally unstable (borderline type and impulsive type), histrionic, anankastic, anxious (avoidant), and dependent.[16]

There is also an 'Others' category involving conditions characterized as eccentric, haltlose (derived from German haltlos "drifting, aimless, irresponsible"),[17] immature, narcissistic, passive-aggressive, or psychoneurotic. An additional category is for unspecified personality disorder, including character neurosis and pathological personality.

There is also a category for Mixed and other personality disorders, defined as conditions that are often troublesome but do not demonstrate the specific pattern of symptoms in the named disorders. Finally there is a category of Enduring personality changes, not attributable to brain damage and disease. This is for conditions that seem to arise in adults without a diagnosis of personality disorder, following catastrophic or prolonged stress or other psychiatric illness.

American Psychiatric Association

The Diagnostic and Statistical Manual of Mental Disorders (currently the DSM-5) provides a definition of a General personality disorder that stress such disorders are an enduring and inflexible pattern of long duration that lead to significant distress or impairment and are not due to use of substances or another medical condition. DSM-5 lists ten personality disorders, grouped into three clusters. The DSM-5 also contains three diagnoses for personality patterns that do not match these ten disorders, but nevertheless exhibit characteristics of a personality disorder.[18]

Cluster A (odd disorders)

This disorder is often associated with schizophrenia, one in particular being Schizotypal personality disorder in that people with the disorder are often described as having a pattern of acute discomfort in close relationships, cognitive or perceptual distortions, and eccentricities of behavior. However, people diagnosed with an odd-eccentric personality disorder tend to have a greater grasp on reality than those diagnosed with schizophrenia. In general, patients suffering from the disorder can be paranoid, have difficulty being understood by others as they have an odd or eccentric manner of speaking and a lack of close relationships. Though their perceptions may be unusual, it is important to distinguish them from delusions or hallucinations as people suffering from these would be diagnosed with a different disorder entirely. There is significant evidence that suggests that a small proportion of people with Type A personality disorder, specifically schizotypal personality disorder, have the potential to develop schizophrenia or another psychotic disorder. These disorders also have a higher risk to occur among individuals whose first-degree relatives have either schizophrenia or Cluster A personality disorder. [19]

Cluster B (dramatic, emotional or erratic disorders)

Cluster C (anxious or fearful disorders)

Other personality disorders

  • Personality change due to another medical condition – a personality disturbance due to the direct effects of a medical condition.
  • Other specified personality disorder – symptoms characteristic of a personality disorder but fails to meet the criteria for a specific disorder, with the reason given.
  • Personality disorder not otherwise specified

Other

Some types of personality disorder were in previous versions of the diagnostic manuals but have been deleted. This includes two types that were in the DSM-III-R appendix as "Proposed diagnostic categories needing further study" without specific criteria, namely sadistic personality disorder (a pervasive pattern of cruel, demeaning, and aggressive behavior) and self-defeating personality disorder (masochistic personality disorder) (characterised by behaviour consequently undermining the person's pleasure and goals).[20] The psychologist Theodore Millon and others consider some relegated diagnoses to be equally valid disorders, and may also propose other personality disorders or subtypes, including mixtures of aspects of different categories of the officially accepted diagnoses.[21]

Personality disorder diagnoses in each edition of American Psychiatric Association's Diagnostic Manual[22]
DSM-I DSM-II DSM-III DSM-III-R DSM-IV(-TR) DSM-V Proposals
Personality
Pattern disturbance:
Inadequate Inadequate
Schizoid Schizoid Schizoid Schizoid Schizoid
Cyclothymic Cyclothymic
Paranoid Paranoid Paranoid Paranoid Paranoid
Schizotypal Schizotypal Schizotypal Schizotypal*
Personality
Trait disturbance:
Emotionally unstable Hysterical Histrionic Histrionic Histrionic
Borderline Borderline Borderline Borderline
Compulsive Obsessive-compulsive Compulsive Obsessive-compulsive Obsessive-compulsive Obsessive-compulsive
Passive-aggressive:
Passive-depressive subtype Dependent Dependent Dependent
Passive-aggressive subtype Passive-aggressive Passive-aggressive Passive-aggressive
Aggressive subtype
Explosive
Asthenic
Avoidant Avoidant Avoidant Avoidant
Narcissistic Narcissistic Narcissistic Narcissistic**
Sociopathic personality
Disturbance:
Antisocial reaction Antisocial Antisocial Antisocial Antisocial Antisocial-psychopathic
Dyssocial reaction
Sexual deviation
Addiction
Appendix: Appendix: Appendix:
Self-defeating Negativistic Dependent
Sadistic Depressive Histrionic
Paranoid
Schizoid
Negativistic
Depressive

* – Not actually to be classified as a personality disorder; classified instead as a form of schizophrenia-spectrum disorder.
** – Originally proposed for deletion; status remains unclear for DSM-5.

Millon's description

Psychologist Theodore Millon, who has written numerous popular works on personality, proposed the following description of personality disorders:

Millon's brief description of personality disorders[23]
Type of personality disorder Description
Paranoid Guarded, defensive, distrustful and suspiciousness. Hypervigilant to the motives of others to undermine or do harm. Always seeking confirmatory evidence of hidden schemes. Feels righteous, but persecuted. People with paranoid personality disorder are characterized by a pattern of pervasive distrust and suspiciousness of others which last for a long time. They are generally difficult to work with.[24]
Schizoid Apathetic, indifferent, remote, solitary, distant, humorless. Neither desires nor needs human attachments. Withdrawal from relationships and prefer to be alone. Little interest in others, often seen as a loner. Minimal awareness of feelings of self or others. Few drives or ambitions, if any. Is an uncommon condition in which people avoid social activities and consistently shy away from interaction with others. It affects more males than females. To others, you may appear somewhat dull or humorless. Because you don't tend to show emotion, you may appear as though you don't care about what's going on around you.[25]
Schizotypal Eccentric, self-estranged, bizarre, absent. Exhibits peculiar mannerisms and behaviors. Thinks can read thoughts of others. Preoccupied with odd daydreams and beliefs. Blurs line between reality and fantasy. Magical thinking and strange beliefs. People with schizotypal personality disorder are often described as odd or eccentric and usually have few, if any, close relationships. They generally don't understand how relationships form or the impact of their behavior on others.[26]
Antisocial Impulsive, irresponsible, deviant, unruly. Acts without due consideration. Meets social obligations only when self-serving. Disrespects societal customs, rules, and standards. Sees self as free and independent. People with antisocial personality disorder depicts a long pattern of disregard for other people's rights. They often cross the line and violate these rights.[27]
Borderline Unpredictable, manipulative, unstable. Frantically fears abandonment and isolation. Experiences rapidly fluctuating moods. Shifts rapidly between loving and hating. Sees self and others alternatively as all-good and all-bad. Unstable and frequently changing moods. People with borderline personality disorder has a persuasive pattern of instability in interpersonal relationships.[28]
Histrionic Dramatic, seductive, shallow, stimulus-seeking, vain. Overreacts to minor events. Exhibitionistic as a means of securing attention and favors. Sees self as attractive and charming. Constant seeking for others' attention. Is characterized by constant attention-seeking, emotional overreaction, and suggestibility. This personality's tendency to over-dramatize may impair relationships and lead to depression, but sufferers are often high-functioning.[29]
Narcissistic Egotistical, arrogant, grandiose, insouciant. Preoccupied with fantasies of success, beauty, or achievement. Sees self as admirable and superior, and therefore entitled to special treatment. is a mental disorder in which people have an inflated sense of their own importance and a deep need for admiration. Those with narcissistic personality disorder believe that they're superior to others and have little regard for other people's feelings.[30]
Avoidant Hesitant, self-conscious, embarrassed, anxious. Tense in social situations due to fear of rejection. Plagued by constant performance anxiety. Sees self as inept, inferior, or unappealing. They experience long-standing feelings of inadequacy and are very sensitive of what others think about them.[31]
Dependent Helpless, incompetent, submissive, immature. Withdraws from adult responsibilities. Sees self as weak or fragile. Seeks constant reassurance from stronger figures. They have the need for a person to be taken care of and the fear of being abandoned or separated from important people in their life.[32]
Obsessive–compulsive Restrained, conscientious, respectful, rigid. Maintains a rule-bound lifestyle. Adheres closely to social conventions. Sees the world in terms of regulations and hierarchies. Sees self as devoted, reliable, efficient, and productive.
Depressive Somber, discouraged, pessimistic, brooding, fatalistic. Presents self as vulnerable and abandoned. Feels valueless, guilty, and impotent. Judges self as worthy only of criticism and contempt. Hopeless, Suicidal, Restless. Can lead to aggressive acts. May cause hallucinations.[33]
Passive–aggressive (Negativistic) Resentful, contrary, skeptical, discontented. Resists fulfilling others’ expectations. Deliberately inefficient. Vents anger indirectly by undermining others’ goals. Alternately moody and irritable, then sullen and withdrawn.Withholds emotions. Will not communicate when there is something problematic to discuss.[34]
Sadistic Explosively hostile, abrasive, cruel, dogmatic. Liable to sudden outbursts of rage. Feels self-satisfied through dominating, intimidating and humiliating others. Is opinionated and close-minded. Enjoys performing brutal acts on others. Finds pleasure is abusing others. Would likely engage in a sadomasochist relationship, but will not play the role of a masochist.[35]
Self-defeating (Masochistic) Deferential, pleasure-phobic, servile, blameful, self-effacing. Encourages others to take advantage. Deliberately defeats own achievements. Seeks condemning or mistreatful partners. They are suspect of people who treat them well. Would likely engage in a sadomasochist relationship.[36]

Additional classification factors

Except for classifying by category and cluster, it is possible to classify personality disorders using such additional factors as severity, impact on social functioning, and attribution.[37]

Severity

This involves both the notion of personality difficulty as a measure of subthreshold scores for personality disorder using standard interviews and the evidence that those with the most severe personality disorders demonstrate a “ripple effect” of personality disturbance across the whole range of mental disorders. In addition to subthreshold (personality difficulty) and single cluster (simple personality disorder), this also derives complex or diffuse personality disorder (two or more clusters of personality disorder present) and can also derive severe personality disorder for those of greatest risk.

Dimensional System of Classifying Personality Disorders[38]
Level of Severity Description Definition by Categorical System
0 No Personality Disorder Does not meet actual or subthreshold criteria for any personality disorder
1 Personality Difficulty Meets sub-threshold criteria for one or several personality disorders
2 Simple Personality Disorder Meets actual criteria for one or more personality disorders within the same cluster
3 Complex (Diffuse) Personality Disorder Meets actual criteria for one or more personality disorders within more than one cluster
4 Severe Personality Disorder Meets criteria for creation of severe disruption to both individual and to many in society

There are several advantages to classifying personality disorder by severity:[37]

  • It not only allows for but also takes advantage of the tendency for personality disorders to be comorbid with each other.
  • It represents the influence of personality disorder on clinical outcome more satisfactorily than the simple dichotomous system of no personality versus personality disorder.
  • This system accommodates the new diagnosis of severe personality disorder, particularly "dangerous and severe personality disorder" (DSPD). Politicians and the public both want to know who comprise the most dangerous group.

Effect on social functioning

Social function is affected by many other aspects of mental functioning apart from that of personality. However, whenever there is persistently impaired social functioning in conditions in which it would normally not be expected, the evidence suggests that this is more likely to be created by personality abnormality than by other clinical variables.[39] The Personality Assessment Schedule[40] gives social function priority in creating a hierarchy in which the personality disorder creating the greater social dysfunction is given primacy over others in a subsequent description of personality disorder.

Attribution

Many who have a personality disorder do not recognize any abnormality and defend valiantly their continued occupancy of their personality role. This group have been termed the Type R, or treatment-resisting personality disorders, as opposed to the Type S or treatment-seeking ones, who are keen on altering their personality disorders and sometimes clamor for treatment.[37] The classification of 68 personality disordered patients on the caseload of an assertive community team using a simple scale showed a 3 to 1 ratio between Type R and Type S personality disorders with Cluster C personality disorders being significantly more likely to be Type S, and paranoid and schizoid (Cluster A) personality disorders significantly more likely to be Type R than others.[41]

Signs and symptoms

In the workplace

Depending on the diagnosis, severity and individual, and the job itself, personality disorders can be associated with difficulty coping with work or the workplace - potentially leading to problems with others by interfering with interpersonal relationships. Indirect effects also play a role; for example, impaired educational progress or complications outside of work, such as substance abuse and co-morbid mental diseases, can plague sufferers. However, personality disorders can also bring about above-average work abilities by increasing competitive drive or causing the sufferer to exploit his or her co-workers.[42][43]

In 2005, psychologists Belinda Board and Katarina Fritzon at the University of Surrey, UK, interviewed and gave personality tests to high-level British executives and compared their profiles with those of criminal psychiatric patients at Broadmoor Hospital in the UK. They found that three out of eleven personality disorders were actually more common in executives than in the disturbed criminals:

According to leading leadership academic Manfred F.R. Kets de Vries, it seems almost inevitable these days that there will be some personality disorders in a senior management team.[45]

Relationship with other mental disorders

The disorders in each of the three clusters may share some underlying common vulnerability factors involving cognition, affect and impulse control, and behavioral maintenance or inhibition, respectively, and may have a spectrum relationship to certain syndromal mental disorders:[46]

Diagnosis

Diagnostic Criterion

In the most recent edition of the DSM, DSM-V, the diagnostic criteria of a personality disorder have been revised. The general criterion for a personality disorder specifies that an individual's personality must deviate significantly from what is expected within their culture. [47] Also, particular personality features must be evident by early adulthood.

In order to diagnose a personality disorder, the following criteria must be met:

  • "Significant impairments in self (identity of self-direction) and interpersonal (empathy or intimacy) functioning." [48]
  • "One or more pathological personality traits domains or trait facets." [48]
  • "The impairments in personality functioning and the individual's personality trait expressions are relatively stable across time and consistent across situations." [48]
  • "The impairments in personality functioning and the individual's personality trait expressions are not better understood as normative for individual's developments stage or sociocultural environment." [48]
  • "The impairments in personality functioning and the individual's personality trait expressions are not solely due to the direct physiological effects of a substance (e.g., a drug of abuse, medication) or a general medical condition (e.g., severe head trauma)." [48]

The ICD-10 'clinical descriptions and diagnostic guidelines' introduces its specific personality disorder diagnoses with some general guideline criteria that are similar. To quote:[49]

  • Markedly disharmonious attitudes and behavior, generally involving several areas of functioning; e.g. affectivity, arousal, impulse control, ways of perceiving and thinking, and style of relating to others;
  • The abnormal behavior pattern is enduring, of long standing, and not limited to episodes of mental illness;
  • The abnormal behavior pattern is pervasive and clearly maladaptive to a broad range of personal and social situations;
  • The above manifestations always appear during childhood or adolescence and continue into adulthood;
  • The disorder leads to considerable personal distress but this may only become apparent late in its course;
  • The disorder is usually, but not invariably, associated with significant problems in occupational and social performance.

The ICD adds: "For different cultures it may be necessary to develop specific sets of criteria with regard to social norms, rules and obligations."

In clinical practice, individuals are generally diagnosed by an interview with a psychiatrist based on a mental status examination, which may take into account observations by relatives and others. One tool of diagnosing personality disorders is a process involving interviews with scoring systems. The patient is asked to answer questions, and depending on their answers, the trained interviewer tries to code what their responses were. This process is fairly time consuming.

Normal personality

The issue of the relationship between normal personality and personality disorders is one of the important issues in personality and clinical psychology. The personality disorders classification (DSM IV TR and ICD-10) follows a categorical approach that views personality disorders as discrete entities that are distinct from each other and from normal personality. In contrast, the dimensional approach is an alternative approach that personality disorders represent maladaptive extensions of the same traits that describe normal personality. Thomas Widiger[50] and his collaborators have contributed to this debate significantly. He discussed the constraints of the categorical approach and argued for the dimensional approach to the personality disorders. Specifically, he proposed that Five Factor Model of personality is alternative to the classification of personality disorders. For example, this view specifies that Borderline Personality Disorder can be understood as a combination of emotional lability (i.e., high neuroticism), impulsivity (i.e., low conscientiousness), and hostility (i.e., low agreeableness). Many studies across cultures have explored the relationship between personality disorders and the Five Factor Model.[51] This research has demonstrated that personality disorders largely correlate in expected ways with measures of the Five Factor Model[52] and has set the stage for including the Five Factor Model within the upcoming DSM-5.[53]

DSM-IV-TR Personality Disorders from the Perspective of the Five-Factor Model of General Personality Functioning[46]
Factors PPD SzPD StPD ASPD BPD HPD NPD AvPD DPD OCPD PAPD DpPD
Neuroticism (vs. emotional stability)
Anxiousness (vs. unconcerned) n/a n/a High Low High n/a n/a High High High n/a n/a
Angry hostility (vs. dispassionate) High n/a n/a High High n/a High n/a n/a n/a High n/a
Depressiveness (vs. optimistic) n/a n/a n/a n/a High n/a n/a n/a n/a n/a n/a High
Self-consciousness (vs. shameless) n/a n/a High Low n/a Low Low High High n/a n/a High
Impulsivity (vs. restrained) n/a n/a n/a High High High n/a Low n/a Low n/a n/a
Vulnerability (vs. fearless) n/a n/a n/a Low High n/a n/a High High n/a n/a n/a
Extraversion (vs. introversion)
Warmth (vs. coldness) Low Low Low n/a n/a n/a Low n/a High n/a Low Low
Gregariousness (vs. withdrawal) Low Low Low n/a n/a High n/a Low n/a n/a n/a Low
Assertiveness (vs. submissiveness) n/a n/a n/a High n/a n/a High Low Low n/a Low n/a
Activity (vs. passivity) n/a Low n/a High n/a High n/a n/a n/a n/a Low n/a
Excitement seeking (vs. lifeless) n/a Low n/a High n/a High High Low n/a Low n/a Low
Positive emotionality (vs. anhedonia) n/a Low Low n/a n/a High n/a Low n/a n/a n/a n/a
Openness (vs. closedness)
Fantasy (vs. concrete) n/a n/a High n/a n/a High n/a n/a n/a n/a n/a n/a
Aesthetics (vs. disinterest) n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a
Feelings (vs. alexithymia) n/a Low n/a n/a High High Low n/a n/a Low n/a n/a
Actions (vs. predictable) Low Low n/a High High High High Low n/a Low Low n/a
Ideas (vs. closed-minded) Low n/a High n/a n/a n/a n/a n/a n/a Low Low Low
Values (vs. dogmatic) Low n/a n/a n/a n/a n/a n/a n/a n/a Low n/a n/a
Agreeableness (vs. antagonism)
Trust (vs. mistrust) Low n/a n/a Low n/a High Low n/a High n/a n/a Low
Straightforwardness (vs. deception) Low n/a n/a Low n/a n/a Low n/a n/a n/a Low n/a
Altruism (vs. exploitative) Low n/a n/a Low n/a n/a Low n/a High n/a n/a n/a
Compliance (vs. aggression) Low n/a n/a Low n/a n/a Low n/a High n/a Low n/a
Modesty (vs. arrogance) n/a n/a n/a Low n/a n/a Low High High n/a n/a High
Tender-mindedness (vs. tough-minded) Low n/a n/a Low n/a n/a Low n/a High n/a n/a n/a
Conscientiousness (vs. disinhibition)
Competence (vs. laxness) n/a n/a n/a n/a n/a n/a n/a n/a n/a High Low n/a
Order (vs. disorderly) n/a n/a Low n/a n/a n/a n/a n/a n/a n/a High Low
Dutifulness (vs. irresponsibility) n/a n/a n/a Low n/a n/a n/a n/a n/a High Low High
Achievement striving (vs. lackadaisical) n/a n/a n/a n/a n/a n/a n/a n/a n/a High n/a n/a
Self-discipline (vs. negligence) n/a n/a n/a Low n/a Low n/a n/a n/a High Low n/a
Deliberation (vs. rashness) n/a n/a n/a Low Low Low n/a n/a n/a High n/a High

Abbreviations used: PPD – Paranoid Personality Disorder, SzPD – Schizoid Personality Disorder, StPD – Schizotypal Personality Disorder, ASPD – Antisocial Personality Disorder, BPD – Borderline Personality Disorder, HPD – Histrionic Personality Disorder, NPD – Narcissistic Personality Disorder, AvPD – Avoidant Personality Disorder, DPD – Dependent Personality Disorder, OCPD – Obsessive-Compulsive Personality Disorder, PAPD – Passive-Aggressive Personality Disorder, DpPD – Depressive Personality Disorder, n/a – not available.

Causes

There are numerous possible causes of mental disorders, and they may vary depending on the disorder, the individual, and the circumstances. There may be genetic dispositions as well as particular life experiences, which may or may not include particular incidents of trauma or abuse.

A study of almost 600 male college students, averaging almost 30 years of age and who were not drawn from a clinical sample, examined the relationship between childhood experiences of sexual and physical abuse and currently reported personality disorder symptoms. Childhood abuse histories were found to be definitively associated with greater levels of symptomatology. Severity of abuse was found to be statistically significant, but clinically negligible, in symptomatology variance spread over Cluster A, B and C scales.[54]

Child abuse and neglect consistently evidence themselves as antecedent risks to the development of personality disorders in adulthood.[55] In the following study, efforts were taken to match retrospective reports of abuse with a clinical population that had demonstrated psychopathology from childhood to adulthood who were later found to have experienced abuse and neglect. In a study of 793 mothers and children, researchers asked mothers if they had screamed at their children, and told them that they did not love them or threatened to send them away. Children who had experienced such verbal abuse were three times as likely as other children (who did not experience such verbal abuse) to have borderline, narcissistic, obsessive-compulsive or paranoid personality disorders in adulthood.[56] The sexually abused group demonstrated the most consistently elevated patterns of psychopathology. Officially verified physical abuse showed an extremely strong correlation with the development of antisocial and impulsive behavior. On the other hand, cases of abuse of the neglectful type that created childhood pathology were found to be subject to partial remission in adulthood.[55]

Epidemiology

The prevalence of personality disorder in the general community was largely unknown until surveys starting from the 1990s. In 2008 the median rate of diagnosable PD was estimated at 10.6%, based on six major studies across three nations. This rate of around one in ten, especially as associated with high use of services, is described as a major public health concern requiring attention b