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The Prevalence of Personality Disorders in a Community Sample
Svenn Torgersen, PhD;
Einar Kringlen, MD;
Victoria Cramer, PhD
Arch Gen Psychiatry. 2001;58:590-596.
ABSTRACT
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Background To our knowledge, no previous studies of personality disorders (PDs)
in a large representative sample of the common population have been conducted.
Methods A representative sample of 2053 individuals between the ages of 18 and
65 years in Oslo, the capital of Norway, was studied from 1994 to 1997. Information
about PDs was obtained by means of the Structured Interview for DSM-III-R Personality Disorders, in conjunction with an interview recording
demographic data. The subjects were interviewed primarily at home, but in
some instances, also at the clinic.
Results The prevalence of PDs was 13.4% (SE, 0.7). The prevalence rates (SEs)
for specific PDs, irrespective of whether a person had 1 or more PD, were:
paranoid, 2.4% (0.3); schizoid, 1.7% (1.6); schizotypal, 0.6% (0.2); antisocial,
0.7% (0.2); sadistic, 0.2% (0.1); borderline, 0.7% (0.2); histrionic, 2.0%
(0.3); narcissistic, 0.8; (0.2); avoidant, 5.0% (0.5); dependent, 1.5% (0.3);
obsessive-compulsive: 2.0% (0.3); passive-aggressive, 1.7% (0.3); self-defeating,
0.8%, (0.2). The prevalence of PDs was highest among subjects with only a
high school education or less, and living without a partner in the center
of the city.
Conclusions Personality disorders were found to be prevalent, with avoidant, schizoid,
and paranoid PDs more common, and borderline PD less common than what is usually
reported. Personality disorders tend to be more frequent among single individuals
from the lower socioeconomic classes in the center of the city. It is impossible
to determine what is cause and what is consequence from a cross-sectional
study.
INTRODUCTION
IN CONTRAST to symptom disorders, few epidemiological studies of personality
disorders (PDs) have been conducted to establish their prevalence. As the
structured Diagnostic Interview Schedule (DIS)1
contains questions pertaining to the antisocial PD, it has been studied in
epidemiological studies of symptom disorders.2, 3, 4, 5, 6
An attempt has also been made to arrive at estimates of the prevalence of
obsessive-compulsive3 and histrionic7 PDs in such studies. One study has tried to estimate
the frequency of borderline PD using the DIS.8
As to studies of the whole realm of PDs, Table 1 presents an overview of the prevalence of these disorders.
The studies show a wide variation of prevalences of all as well as of the
specific PDs. The prevalence of any PD varies between 5.9 and 22.5, with a
median prevalence of 11.1 and a pooled prevalence of 12.47.
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Table 1. The Prevalence (Percentage) of Personality Disorders in 10
Community Studies*
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The main limitation of the previous studies is that the samples are
not representative of the population at large.
The samples are also small, varying from 133 to 799 individuals, with
a median of 302 individuals. Two studies have simply applied clinical interviews,9, 15 thus obtaining the most deviant prevalence.
Two studies have applied self-report questionnaires.11, 14
Only 6 of the studies have used structured interviews.10, 12, 13, 16, 17, 18
The present study was an attempt to examine a relatively representative,
large sample from the common population. We sought to establish the prevalence
of the specific PDs and study the demographic correlates. From earlier studies,
especially clinical samples, our hypotheses were that women are more likely
to have a borderline, histrionic, or dependent PD, while men are more likely
to have an antisocial, schizoid, or obsessive-compulsive PD. We expected more
PDs among younger individuals, especially higher frequencies of antisocial
and borderline PDs. As is the case with other psychiatric disorders, we believe
that PDs are more common among those with lower socioeconomic status. We chose
education as the best measure because low income is so easily a direct consequence
of psychiatric disabilities. Our hypothesis was that there are more PDs among
those living in the inner city and those living alone. In Norway, as in Scandinavia
generally, many couples live together in stable relationships without being
married. So we must apply the variable "living alone, living together with
a partner," rather than "being married, not being married."
METHODS
SAMPLE
Our point of departure was the National Register of Oslo containing
the names and addresses of all citizens in Oslo. The group aged 18 to 65 years
encompassed 308 237 individuals. From this population, a sample of 3590
individuals was drawn by chance according to a computer program in the national
register. Figure 1 shows the reduction
in the sample of 3590 individuals for various reasons.
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Reduction in the sample size from the original sample to the interviewed
sample. SIDP-R indicates Structured Interview for DSM-III-R Personality
Disorders.
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Four of the individuals were deceased, 345 had moved from Oslo, and
548 were not found at the given address. It is possible that these individuals
were not located either because they had provided an incorrect address to
the authorities, or because they had moved to another residence inside or
outside of Oslo without informing the authorities of their new address. As
a result, one fourth of the sample could not be traced.
Of those who were contacted, 51 were either too medically ill, hospitalized
in a medical hospital, or too physically disabled or sensory disabled to participate
in an interview. Thirty-three persons, 5 of whom were hospitalized in a psychiatric
ward, were too emotionally ill to be interviewed. A few others were taken
in at a refugee reception center. Eighty-seven others were unable to be interviewed
because they were unable to speak a Scandinavian language or English, French,
German, or one of the other foreign languages used by the interviewers (including
Asian languages). Altogether, close to 7% of those traced could not be interviewed
for the above-named reasons.
Of those remaining, 18% refused to be interviewed, or they postponed
the interview for too long. All in all, 2066 of a total sample of 3590 were
interviewed. However, among these, it was not possible to establish PD diagnoses
for 13 because of inadequate information. Consequently, the total sample amounted
to 2053 subjects.
In contrast to most studies, we did not select households, but started
with a fixed list of potential subjects. Consequently, we know something about
those who did not participate. More women than men participated (62.7% and
52.7%, respectively). Those aged 40 years or older were included more frequently
than younger individuals (60.8% compared with 55.0%). More subjects living
in the town periphery were included than individuals in the center of the
city (60.5% and 49.0%, respectively). The center of the city was defined as
the 5 regions that meet in the heart of the city, thus constituting the downtown
core of the city. All differences are statistically significant with a  2 test (P< .001). Combined, men aged 40
years or older living in the center of the city participated least often (42.5%),
and women aged 40 or older living on the outskirts of the city participated
most often (68.7%). The reason for the lower rate of participation in the
different demographic groups was not refusal or illness, but incorrect address
and relocation without a new correct address.
INSTRUMENTS
The Structured Interview for DSM-III-R (SIDP-R)
Personality Disorders19 was applied to assess
PDs in the subjects. The interviewers, mainly experienced nurses, but also
medical students and experienced interviewers, were trained by using live
patient interviews and videos of patient interviews throughout a period of
several weeks. All interviews were conducted face-to-face, mostly at home,
but some took place at the psychiatric clinic. The SIDP-R consists of 160
questions grouped under 16 thematic sections, such as "relationships," "emotions,"
and "reactions to stressful situations." At the end of each section is a listing
of relevant DSM-III-R criteria rated from 0 to 2,
with brief descriptions guiding the ratings. Level 0 corresponds with "not
present," and levels 1 and 2, with "present to a moderate degree" and "present
to a severe degree," respectively. A rating of 1 or 2 indicates criterion
fulfilled.
The instructions for the SIDP-R specify a "five-year rule" which means
that behavior typical of the past 5 years was the basis for the ratings. If
an individual's personality changed dramatically during the past few years,
the personality that dominated most of the time during the last 5 years was
considered typical. The PD diagnoses were made without reference to the exclusion
criteria, eg, schizophrenia for schizotypal PD.
The reliability was assessed by means of a rater listening to 40 audiotaped
interviews. The  value for any PD was 0.84. The number of persons with
a specific PD was too small for making any calculation. Instead, intraclass
correlations for the scaled PDs were calculated. The intraclass correlation
for schizoid PD was 0.78; 0.71 for paranoid; 0.92 for schizotypal; 0.78 for
obsessive-compulsive; 0.78 for histrionic; 0.82 for dependent; 0.95 for antisocial;
0.83 for avoidant; 0.89 for borderline; 0.95 for passive-aggressive; 0.87
for sadistic; and 0.85 for self-defeating PD. The median intraclass correlation
was thus 0.83.
STATISTICAL PROCEDURE
The prevalence rates were weighted, taking into account the slight,
although statistically significant, differences between the interviewed sample
and the population at large.
The relationship between PDs and demographic associations was calculated
by means of a logistic regression analysis, in which the discrete demographic
variables (sex, age group, educational level, living in the center/periphery
of the city, living alone/with a partner, married/not married) were independent
variables, and each of the PDs were dependent variables. In this way, odds
ratios with confidence intervals were calculated taking into account possible
correlations between the demographic variables. Multiple regression analysis
was also performed. The independent demographic variables were treated as
semicontinuous where possible, and the dependent variables were PD scales
created by assigning number of criteria fulfilled for the respective PDs.
The  level is 5% if not otherwise stated.
RESULTS
The unweighted prevalence rate of any PD in the present sample was 13.1%
in general, 14.6% among women, and 13.7% among men (Table 2). The weighted prevalence is slightly higher at 13.4% (Table 2). Generally, there was very little
difference between the unweighted and weighted percentages because our sample
was fairly representative of the population at large. The most prevalent PD
was avoidant PD (5.0%), followed by paranoid (2.2% and 2.4%, unweighted and
weighted, respectively), histrionic, and obsessive-compulsive (both 1.9%-2.0%).
The rarest disorders were sadistic (0.2%), schizotypal (0.6%), antisocial
(0.6%-0.7%), and borderline PDs (0.7%). The fearful cluster is very common
(9.2%-9.4%), while the other 2 clusters are only one third as prevalent. Statistically,
antisocial, passive aggressive, and obsessive-compulsive PDs are significantly
more common among men. Also, schizoid PD is twice as common among men, but
this is not statistically significant. Borderline, histrionic, dependent,
and self-defeating PDs are twice as common among women as among men; however,
the differences are not statistically significant.
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Table 2. Total Unweighted and Weighted Prevalences of Personality Disorders
(Percentages) for Men and Women
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The mean number of PD diagnoses among those with a PD was 1.48. Seventy-one
percent of those with PD had only 1, 18.6% had 2, 5.2% had 3, 3.3% had 4,
1.1% had 5, 0.4% had 6, and 0.4% had 7 diagnoses.
Table 3 presents the increased
risk of different PDs in various demographic groups. As logistic regression
is applied, the possible correlations between the different demographic variables
are taken into account.
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Table 3. Demographic Associations With Personality Disorders*
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It is observed that although the prevalence of PDs in general and the
prevalence of the different clusters are the same in men and women, there
is a sex difference in terms of the specific type of disorders. Men are more
often schizoid and passive-aggressive, while women are more often histrionic
and dependent.
Personality disorders are diagnosed most frequently in those older than
49 years, which is particularly so for the eccentric cluster.
Those with a high school education or less are more likely to have a
PD, especially of the eccentric type. This is in particular the case for paranoid
and avoidant PDs. Interestingly, obsessive-compulsive PD is more frequent
in subjects with higher education (ie, a college/university education) compared
with those with less education.
Living in the center of the city is related to having a PD. Again, this
relationship is most often observed for the eccentric cluster, in particular
paranoid and schizotypal PDs. Histrionic and passive-aggressive PDs are also
relatively more prevalent in the center of the city.
Living without a partner is related to having a PD and to having eccentric
and dramatic PDs. In addition, living without a partner is related to the
paranoid, schizoid, antisocial, borderline, and self-defeating PDs.
Table 4 presents the statistically
significant standardized ß weight's from multiple regression analyses
in which PD scales are applied by adding the criteria. Age and education are
treated as continuous variables. The Enter method was applied. All results
from the logistic regression analyses are confirmed, with the exception of
the relationship between PDs generally and younger age, more individuals with
passive-aggressive PD in the city center, and more women with histrionic PD.
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Table 4. Statistically Significant Demographic Associations to Personality
Disorders Based on Multiple Regression Analysis, Standardized ß Weights,
and Multiple Regression Correlations
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In addition, a number of other relationships appeared in the multiple
regression analysis. Antisocial, sadistic, narcissistic, obsessive-compulsive,
eccentric, and dramatic traits were related to being male, while self-defeating
traits were related to being female. Antisocial, sadistic, borderline, passive-aggressive,
and dramatic traits are correlated with younger age. Schizoid, schizotypal,
antisocial, sadistic, borderline, dependent, self-defeating, dramatic, and
fearful traits are related to less education. Schizoid, borderline, narcissistic,
obsessive-compulsive, self-defeating, and dramatic traits are more often observed
in the center of the city. Schizoid and obsessive-compulsive traits are more
often found among those not married. Schizotypal, histrionic, narcissistic,
dependent, passive-aggressive, and fearful traits are more often found among
those living without a partner.
COMMENT
Having more than 1 PD diagnosis is common. Our mean number of 1.48 diagnoses
among those with a PD is slightly lower than what is observed in clinical
populations.20, 21
The observed prevalence of any PDs in the present study is almost exactly
the same as the prevalence in the pooled data from earlier studies (Table 1). The prevalence of avoidant, paranoid,
and schizoid PDs is considerably higher in this study compared with previous
ones (Table 1), whereas the rate
of borderline PD is relatively low. Only the Swedish14
and German13 studies show a somewhat similar
pattern, with a high prevalence of paranoid and avoidant PDs. It is not clear
whether these observations reflect an improved sampling by our study, or national
character traits that may be shared with other Scandinavians and Northern
Europeans. Studies of patient populations in Norway have demonstrated a high
prevalence of avoidant and paranoid PDs when compared with, for instance,
American studies.22, 23
According to a Norwegian twin study,24
avoidant, paranoid, and schizoid PDs seem to be less genetically influenced
than other PDs. It may be that some cultural factors are responsible for the
development of these disorders in Norway, with the consequence that they seem
to be both more prevalent and more environmentally determined.
Our finding that schizoid, antisocial, narcissistic and obsessive-compulsive
PDs and/or traits are more often observed among men, and histrionic, avoidant,
and dependent features are more often found among women has also been reported
in earlier studies.10, 25 As in
the present study, these researchers did not find that borderline PD was related
to the sex of the subject. Most clinical studies do. In fact, we found that
borderline PD was twice as frequent among women; however, the low number of
subjects with borderline PD made it very difficult to reach statistical significance.
Furthermore, it is possible that being female and having borderline features
interact to make the person more likely to seek treatment.
Earlier studies10, 25 have
also observed that those with antisocial, borderline, and passive-aggressive
traits were younger, and those with schizoid features were older. No other
study has found that schizotypal, avoidant, and obsessive-compulsive PDs and
traits are more frequent in older age.
No other epidemiological study has investigated whether those with PDs
or PD traits more often live alone. In Norway, this is significant because
many couples live together in stable relationships without being married;
however, if one considers marital status (single, married, divorced, separated,
widowed), one may make a comparison with previous studies. Earlier studies
have shown that those with borderline PD were more often single, those with
antisocial PD were more often divorced, those with passive-aggressive PD were
more often not married, and those with a PD were more often separated at the
time of the interview.10 The present study
showed that those with these PDs and traits more often lived without a partner.
Educational level has seldom been related to the prevalence of PDs.
Reich et al11 found no demographic connection
to PDs in general. Nor did Nestad et al7 find
any demographic correlations to histrionic PD.
No other study of PDs has investigated the difference between those
living in the city center as opposed to living on the outskirts. Lewis and
Booth,26 however, found that greater London
had a higher prevalence of psychiatric morbidity than average. The same authors27 found the highest General Health Questionnaire scores
in those living in built-up urban areas. A somewhat lower score was observed
among those in urban areas with "access to gardens or open spaces." The lowest
score was found among those living in country areas. Sex, age, marital status,
and social class were all controlled for in the study.
The fact that more psychiatric disorders are found in the center of
cities has been known since the 1930s.28 The
reason for this is not easy to determine. Two hypotheses have been popular.
The drift hypothesis states that those with emotional problems drift to the
center, maybe to live anonymously; and the stress hypothesis maintains that
there is more emotional hardship in the city center.29
Which hypothesis is more correct has not yet been decided. Our results cannot
be explained by socioeconomic status. The city center has both poorer and
more prosperous areas, as has the periphery. Furthermore, we controlled for
demographic variables. The population density is higher in the city center.
There are 6292 people per square kilometer living in the center of the city,
compared with 2912 people per square kilometer living in the periphery. In
fact, 5 of 6 of the most densely populated areas in the city (which consists
of a total of 25 areas) lie in the center. Anomie as a consequence of population
density has been a popular explanation.29
Our study has several limitations. Although our sample is more representative
than earlier studies of PDs, we did not succeed in obtaining exactly the same
proportion of the population in all demographic strata. However, we controlled
for the sampling bias and obtained slightly higher prevalence rates.
In conclusion, PDs are relatively prevalent. Nearly 1 in 7 individuals
in the Oslo catchment area was identified as meeting criteria for such a disorder.
Age, education, area of living, and life situation seem to correlate with
PDs and traits.
Whether the demographic associations are causes or consequences, and
to what extent there are cohort effects taking place, can only be answered
by future, prospective longitudinal studies of large community samples.
AUTHOR INFORMATION
Accepted for publication January 23, 2000.
This study was supported by a grant from the Norwegian Council for Mental
Health, Oslo, and the Foundation for Health and Rehabilitation, Oslo.
From Center of Research in Clinical Psychology, Department of Psychology
(Dr Torgersen), and the Department of Psychiatry, Oslo University, Oslo, Norway
(Dr Kringlen); and Diakonhjemmet Hospital, Oslo (Drs Kringlen and Cramer).
Corresponding author and reprints: Svenn Torgersen, PhD, Department
of Psychology, Oslo University, PO Box 1039, Blindern, N-0315 Oslo, Norway
(e-mail: Svenn.Torgersen{at}psykologi.uio.no).
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Epidemiology, public health and the problem of personality disorder
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Prevalence and correlates of personality disorders in a community sample
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