Personality Disorders – The Common Bizarre Behaviors Part II: Co-Morbidity, Prevalence, and Clinical History & Treatment

Co-Morbidity

Personality Disorders are among the least understood of the recognized psychological disorders. Unfortunately they are also the most common severe mental disorders. Their severity is compounded because personality disordered persons often have other medical or mental illnesses. More specifically, people suffering from personality disorders are more likely than the general population to also suffer from a history of alcohol and/or substance abuse (Bowden-Jones, et. al., 2004; Morganstern & Miller, 1997; Thuo, et. al. 2008; Volkan, 1994.), sexual dysfunction (Bogaerts, et. al., 2006; Maina, et. al. 2007; Neeleman, 2007; Hill, Habermann, Berner, & Briken, P. 2006), generalized anxiety disorder (Brooks, Baltazar, & Munjack, 1989; Hansen, et. al., 2007; Massion, et. al., 2002; Mavissakalian, et. al., 1995), bipolar disorder (George, et. al., 2003; Maina, Albert, Pessina, & Bogetto, 2007; Wilson, et. al., 2007), body-dysmorphic disorder (Semiz, et. al. 2008), obsessive-compulsive disorder (Hansen, et. al., 2007; Maina, Albert, Pessina, & Bogetto, 2007), depressive disorder (Wilson, et. al, 2007), post-partum depression (Akman, Uguz, & Kaya, 2007), eating disorders (Godt, 2002; Marañon, Echeburúa, & Grijalvo, 2004; Sansone, Levitt, & Sansone, 2005), post-traumatic stress disorder (Bollinger, et. al., 2000; Johnson, Sheahan, & Chard,  2003; Mclean & Gallop, 2003), self-mutilation (Andover, et. al., 2005; Dulit, et. al., 1994; Paris, 2005; Rollinick, 2001) and suicidal thoughts or acts (Pompili, Ruberto, Girardi, & Tatarelli, 2004).

Other maladaptive social consequences of personality disorders include decreased academic performance (King, 2000), domestic violence1 (Berger-Jackson, 2003), child molestation and sexual offense (Bogaerts, et. al., 2008; Dudeck, et. al., 2007), incarceration (Lindsay, et. al., 2006; Narisco, 2007), poor work habits and performance (Furnham, 2007; Kyrios, et. al. 2007; Lynch & Horton, 2004), and pathological gambling (Bagby, et. al. 2008; Samuels, et. al., 1994).
People diagnosed with one personality disorder often suffer from other personality disorders. In one study the majority of patients meeting criteria for a diagnosis of a personality disorders also were diagnosed with an additional personality disorder. The most prevalent personality disorders for the first diagnosis were avoidant, borderline, and obsessive-compulsive personality disorders. The authors suggest that patients suffering from personality disorders should be evaluated for additional personality disorders because their presence can influence the course and treatment (Zimmerman, Rothschild, & Chelminski, 2005).

One of the most interesting things about personality disorders is that people around the one with disorder will be more distressed then the person manifesting the disorder. This distress may even be worse when the people close to the personality-disordered person are knowledgeable about the disorder (Hoffman, et. al., 2003; Scheirs & Bok, 2007). This fits in with many of our ideas about bizarre behaviors – they seem strange to us, but not the person exhibiting them.

Prevalence

Understanding personality disorders is important, as the prevalence of these disorders is quite high. For instance, a recent study found that 44% of volunteers for biomedical research studies suffered from a personality disorder (Bunce, et. al. 2005). Nevertheless the prevalence of personality disorders reported in the research is somewhat variable depending on the milieu and populations studied.

A good example of this variability can be seen in two studies conducted by the same first author. Moran et. al. (2000) examined the prevalence of personality disorder along with its relationship to sociodemographic status and common mental disorders in 300 primary care patients in the U.K.. They found a diagnosis of personality disorder in 24% of patients in the study. These personality-disordered patients were more likely to have past and present psychiatric problems, to be single, and to present to the surgery on an emergency basis when compared to non-personality disordered patients. Patients with cluster B personality disorders were particularly associated with psychiatric problems. The authors concluded that there is a high prevalence rate of personality disorders in the primary care setting and that this represents a significant source of burden.

However, two years later the same author reported relatively low rates for cluster B personality disorders in a similar population. Moran & Mann (2002) examined 303 primary care patients in southeast England for cluster B personality disorders. Using standardized assessment instruments they identified just 13 patients with personality disorders or a prevalence of 4% in their sample. The authors concluded that among primary care patients, cluster B personality disorders were uncommon.

Another study from a nearby geographical area, but situated in a community mental health clinic demonstrated much higher prevalence of personality disorders among their patients. This team of researchers from South London assessed personality disorders, as well as psychotic and affective disorders in their patient population. They found 52% of their patients met the criteria for one or more personality disorders, while 67 % of patients had a psychotic illness and 23 % had a diagnosis of a depressive disorder. Non-psychotic patients seen by nursing staff had extremely high rates of personality disorder, when compared to patients seen by psychiatrists and psychologists (Keown, Holloway, & Kuipers, 2002).

Using data from the 2001-2002 National Epidemiologic Survey on Alcohol and Related Conditions, Grant et. al. (2004) report that 14.79% of adults in the United States (approximately 30.8 million people) met the criterion for diagnosis of at least one personality disorder. The study did not include diagnoses for borderline, schizotypal and narcissistic personality disorders, which would have likely increased the incidence of personality order diagnoses. Of the personality disorders studied the most prevalent disorder was obsessive-compulsive personality disorder (7.9%), followed by paranoid personality disorder (4.4%), antisocial personality disorder (3.6%), schizoid personality disorder (3.1%), avoidant personality disorder (2.4%), histrionic personality disorder (1.8%), and dependent personality disorder (0.5%). Women had a significantly higher risk of avoidant, dependent, and paranoid personality disorders while men were at greater risk for antisocial personality disorder. No gender differences were seen for risk of obsessive-compulsive, schizoid, or histrionic personality disorders. Other risk factors for the personality disorders studied included being Native American, black, young adulthood, low socioeconomic status, and not having a significant other. Avoidant, dependent, schizoid, paranoid, and antisocial personality disorders were significant predictors of disability, while obsessive-compulsive personality disorder had an inconsistent relationship to disability. Individuals with histrionic personality disorder did not have any disability when compared with those without the disorder.

Bowden-Jones, et. al. (2004) found 37% of substance abusers and 53% of alcohol abusers in their sample also suffered from a personality disorder.

It is estimated that up to 50% of prisoners in the United States have antisocial personality disorder. This is likely due to the fact that behavioral characteristics associated with antisocial personality disorder, such as substance abuse, aggression, violence and vagrancy, are often related to criminal behavior. (Lindsay, et. al. 2006). In the U.K. the number of prisoners with antisocial personality disorder is 26%, less than the prevalence rates in the U.S., but still a substantial number (Hobson & Shine, 1998).

Clinical History & Treatment

Personality typically refers to those aspects of a person’s character that are not transient, i.e. ‘traits’, and opposed to ‘states’. According to Millon, Blaneyu, & Davis (1999):

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. (pg. 510)

From this definition of personality the expectation is that traits associated with personality disorders would be stable over time. Recent studies support this idea (McGlashan, et. al. 2005). Therefore we can understand personality disorders (PDs) to be long-term, maladaptive patterns that pervade all aspects of a person’s life. These patterns include problems related to: perception (viewing and understanding the external world), ability to regulate emotions, high levels of anxiety, and poor impulse control. These patterns can lead to significant costs to both the person suffering from a personality disorder and the society he or she functions within. These costs, include lost productivity, increased interaction with law enforcement, imprisonment, a pattern of hospitalization, significant unhappiness, and suicide.

Personality disorders are notoriously difficult to treat. Long-term intensive psychotherapy has been shown to be effective for some personality-disordered patients  (Bond, & Perry, 2004, 2006; Chatham, 1989). As Chatham puts it in regards to patients with borderline personality disorder;

I have observed that towards the end of the change process, patients often realize with surprise that early in psychotherapy certain things upset or traumatized them strongly enough to trigger various degrees of aberrant behavior. Basically, genuine improvement in borderline patients can begin only when primitive defenses and internalized pathological object relations have been uncovered and discarded. The patients must recognize that they can get on in the world without this pathology, because they now have moved forward in psychological development. But to get to this point sometimes requires a very long period of intensive psychotherapy (1989, p. 420).

According to Kernberg (1985), for this long-term intensive psychotherapy to be effective for people suffering from borderline personality disorders (or low ego strength – a defining characteristic of most personality disorders) the psychotherapy needs to be conducted by a skilled therapist who is in control of his or her own hostility and is not narcissistic. Therefore, while long-term psychotherapy for personality disorders is recommended there are may barriers to this type of treatment.  Even if patients could afford and tolerate or afford this kind of treatment, finding the right therapist is crucial for a positive treatment prognosis. Short-term and supportive psychotherapy doesn’t seem to work as well as long-term intensive psychotherapy (Hoglend, 1993; Kernberg, 1985). Caligor, Kernberg, & Clarkin (2007) report on a transference-based object relations psychotherapy specifically designed for the treatment of personality disorders that appears to be effective.

Newer kinds of therapeutic techniques such as Cognitive-Behavior therapy and Dialectic Behavior Therapy (DBT) that was specifically designed to treat personality disorders show promise in effectively treating personality disorders2 (Davidson, et. al., 2007; Fruzzetti, 2002; Linehan, 1993; Linehan, et. al., 2007; Lynch, et. al., 2007; Salsman & Linehan, 2006; Sperry, 2006). Some question the long-term efficacy of these treatments, which seem to be measuring rather simple outcomes when compared to long-term psychodynamic treatment (Kernberg, 1985). Indeed, some research suggests that Cognitive-Behavior therapy works less well for personality disorders than for other types of mental problems (Luk, et. al., 1991). Another study indicates that the psychodynamic approaches may yield better long-term therapeutic results than Cognitive-Behavioral therapy with personality disordered patients (Leichsenring & Leibing, 2003). Nevertheless, Cognitive-Behavior therapy and Dialectic Behavior Therapy have shown efficacy in reducing acting out behaviors such as suicide attempts while being accessible (Davidson, et. al., 2006; Linehan, et. al., 2007). In fact, in one study the four major approaches to treating borderline personality disorders were all found to be successful in reducing behavioral acting out and affective instability, while not eliminating the underlying personality disorder (Lopez, et. al., 2007).

One of the dirty secrets of the psychotherapy profession is that many if not most therapists either consciously or unconsciously screen out patients with personality disorders (Hartman, 1999), or take on a ‘removed’ scientific attitude towards them (Davidtz, 2008). A UK study found that registered mental health nurses perceived patients with a diagnosis of borderline personality disorder more negatively than patients with a diagnosis of schizophrenia. Patients diagnosed with borderline personality disorder were perceived as more dangerous and were subject to more social rejection than those with a diagnosis of schizophrenia (Markham, 2003). Rothschild and Rand (2006) make the case that psychotherapists take on the emotional states of their patients through unconscious mirroring. This can cause vicarious trauma for psychotherapists, especially when they are unaware of their autonomic arousal. Since personality disordered patients have much more unstable emotional states it stands to reason that the psychotherapist will take on a much greater burden and a higher level of vicarious trauma when working with this patient population. As Fonagy says:

Why are these patients designated as difficult? Part of the difficulty undoubtedly arises out of the obligation we quickly feel as clinicians to enact that which is projected onto us. We are forced to be as our patients wish us to be, because we sense that without this, prolonged contact with us might be intolerable. They behave “unreasonably” toward us to elicit the reaction that they require, one which confirms for them that they have successfully externalized the alien part of the self. Because we try not to react in these directions in response to mild provocation, we unwittingly force our patients to become “more difficult.” They get under our skin and eventually discover what will make us react with anger, or what will cause us to neglect them, reject them, or feel excited by them, in all instances forgoing our therapeutic identity. (Fonagy, 1998, p. 1)

Indeed, we find that psychotherapists report personality-disordered patients as their most difficult (Davidtz, 2008). This is not only true in individual therapy but for group therapy as well (Liebenberg, 1990; Roth, Stone, & Kibel, 1990). Psychotherapists quickly learn that the amount of progress these patients make in therapy is disproportional to the amount of distress they inflict on the therapist. This sentiment has been born out on research studies that have shown that patients with personality disorders may have a propensity to engage in litigation with their therapist (Gutheil, 2005; Gutheil & Alexander, 1992), or their workplace (McDonald, 2002). This makes sense when examining the relationship between personality disorder-related phenomena such as suicide attempts and memories of child abuse which produce a good deal of the litigation directed towards mental health professionals (Gutheil, 2004). In the defense of psychotherapists, many are not trained to treat people with personality disorders, or only offer therapies that clearly do not work with these kinds of patients. In this way the screening of personality-disordered patients is justified as being better for both the therapist and the patient.

There are currently no drugs that directly treat personality disorders. Instead a number of different kinds of drugs are used to treat the symptoms associated with the personality disorder (Quante, et. al., 2008).

The onset of personality disorders is usually in adolescents or early adulthood. However, a careful observer may be able to identify children who are likely to express these disorders later on. People who suffer from personality disorders, particularly Hysteric, Borderline, or Paranoid, end up with a greater chance of being hospitalized throughout their lives. This is due to a good deal of a suicidal behaviors, depression, alcohol/drug abuse, obsessive compulsive behaviors, eating disorders, domestic violence and other types of drama which are co-morbid with these personality disorders.

Next – Origins & Neurobiology of Personality Disorders

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1. Interestingly enough it seems that being a victim of domestic violence rather than the perpetrator is not related to having a personality disorder. In fact, some personality disorders may be inversely related to being the victim of domestic violence (Manelski, 2005).

2. DBT combines Cognitive Behavior Therapy with mindfulness techniques from Buddhist psychology.