The prevalence of personality disorders in contemporary society depends on the validity of the classification system and diagnostic instruments used to establish the presence of a disorder. As we have discussed, there are problems with classification and nosology that make estimates of prevalence only approximate. Millon and Davis (1996) write: "No other area in the study of psychopathology is fraught with more controversy than the personality disorders" (p. 485). Nevertheless, epi-demiological surveys do shed some light and provide some empirical evidence about the prevalence of personality disorders in the population. The most often cited study on the prevalence of personality disorders in the United States is by Weissman (1993) who found that approximately one out of 10 people fulfill the criteria for a personality disorder. Merikangas and Weissman (1986) found that approximately half of those receiving mental health treatment also suffered from a personality disorder. The Weissman study remains the most comprehensive report on the prevalence of personality disorders but was based on DSM-III and as Mattia and Zimmerman point out: "No epidemiological survey of the full range of personality disorders has been conducted in the post DSM-III era" (2001, p. 107). Further studies are warranted; the Merikangas and Weissman studies have illuminated the problem of quantifying the extent of personality disorders in the general and clinical population and will guide future research.
The finding that about half of those receiving mental health treatment are compromised in their personality functioning, enough to warrant a personality disorder diagnosis, underscores the importance of acknowledging the contribution of personality to relational disturbances such as marital dysfunction, spousal abuse, domestic violence, child abuse, as well as the most common clinical syndromes such as anxiety, depression, eating disorders, and addictions. The prevalence rates for personality disorders vary greatly. In a review of six studies, Mattia and Zimmerman (2001) found that the rates documented ranged from as low as 6.7% to as high as 33.3%. These findings are suggestive of a greater problem than is being acknowledged. There are few epidemiological studies that have investigated the prevalence of childhood and adolescent personality disorders. Bernstein et al. (1993) indicate that the rate of personality disorders between the ages of 9 and 19 is "high." They found that approximately 31% suffer from moderate personality disturbance and 17% can be classified as severe. In contrast, Lewinsohn, Rohde, Seeley, and Klein (1997), using a different methodology, only report 3.3% rate of prevalence in young adults; the discrepancy seems to be due to methodological and measurement issues but is useful in pointing the way for further studies.
Are we underestimating the prevalence of personality disorders? What does seem evident from clinical practice, although undocumented by empirical findings, is the increasing number of children, adolescents, and adults who are entering treatment with signs of personality dysfunction. This may be disguised because of a tendency for clinicians to use diagnostic nomenclature that is less pathology oriented and "more hopeful" in terms of prognosis. Many clinicians still believe that personality dysfunction is beyond the realm of treatment and will avoid it in favor of a less stigmatizing Axis I disorder. The presence of multiple co-occurring clinical syndromes is often a sign that personality dysfunction is at the root of the problem but may be obscured by the complex interrelationship of these clinical and relational disorders, and an unwillingness to address the personality component. With regards to childhood and adolescent personality disorders, P. F. Kernberg, Weiner, and Bardenstein (2000) write: "when PDs are looked for in children and adolescents, their prevalence can be considerable" (p. 4). Further, they state in their book Personality Disorders in Children and Adolescents: "Our purpose is to present the mounting and compelling evidence for the presence of PDs in children and adolescents so that they will be more readily recognized and treated" (p. ix).
Are we witnessing signs of an epidemic in process? If clinical, sociocultural, and political indices are accurate, we may be entering an unprecedented era for
Prevalence of Personality Disorders in Contemporary Society 11
individual and social pathology caused by economic pressure, racism, and cultural fragmentation (West, 2001), which might be a harbinger for an epidemic in personality dysfunction. Cultural, political, and economic factors are putting undue strain on family and social institutions that were once able to mitigate some of the impact of increased anxiety from rapid cultural change and fragmentation that spawn social pathologies and promote personality dysfunction in individuals and families. In clinical settings, we see more and more severe cases of personality disorder at younger ages, along with fewer resources from the community with which to handle these, magnified by destabilization of the family. More and more, families are left without the necessary support to deal with disturbances in their family members. This is particularly evident to clinicians who have tried to find an appropriate hospital for a personality disturbed patient that will keep the patient more than a few days before returning the patient to the community and to a family ill-equipped to deal with the burden of acute episodes and chronic care. As more and more families are being forced into harsher economic conditions and poverty, the likelihood that there will be an epidemic in personality disorders is not far fetched. This may be especially true for groups that have already been marginalized by racism and economic disadvantage (West, 2001). West writes:
The collapse of meaning in life—the eclipse of hope and absence of love of self and others, the breakdown of family and neighborhood bonds—leads to the social dera-cination and cultural denudement of urban dwellers, especially children. We have created rootless, dangling people with little link to the supportive networks—family, friends, school—that sustain some sense of purpose in life. We have witnessed the collapse of the spiritual communities that in the past helped Americans face despair, disease, and death that transmit through the generations dignity and decency, excellence and elegance. (p. 10)
West (2001) is concerned that unless there is significant attention paid to the problems of racism, sociocultural marginalization, and downward mobility of many groups in American society, the foundation of democracy will be threatened. There is no research that has investigated the presence of personality dysfunction in minority populations but it is clear that African American males as a group are experiencing severe stress to their personality systems.
The total impact of personality disorders (PDs) on the individual, family, and society is substantial. Ruegg and Francis (1995) nicely summarized the impact:
PDs are associated with crime, substance abuse, disability, increased need for medical care, suicide attempts, self-injurious behavior, assaults, delayed recovery from Axis I and medical illness, institutionalization, underachievement, underemployment, family disruption, child abuse and neglect, homelessness, illegitimacy, poverty, STDs, misdiagnosis and mistreatment of medical and psychiatric disorder, malpractice suits, medical and judicial recidivism, dissatisfaction with and disruption of psychiatric treatment settings, and dependency on public support. (pp. 16-17)
"As economic conditions worsen and the trend toward family breakdown continues, we can predict an increase in the incidence of personality disorder" (Magnavita, 1997). This development underscores the urgency of developing the science of personality, obtaining epidemiological findings concerning the prevalence, developing cogent theoretical models, and effective treatment interventions for this under served population. According to P. F. Kernberg et al. (2000): "Personality disorders (PDs) historically have received less attention from clinicians and researchers than other psychiatric disorders such as depression and schizophrenia" (p. 3).
Along with a discussion of the prevalence of personality disorders, we should also consider the associated topic of comorbidity: the co-occurrence of more than one clinical disorder. Dolan-Sewell, Krueger, and Shea (2001) believe there are inherent problems with the concept of comorbidity when applied to mental disorders. "Although the use of the term 'comorbidity' to refer to covariation among disorders is common, our understanding of mental disorders has not yet reached the level described as truly 'distinct' " (p. 85). Comorbidity reflects the use of the dominant medical model to conceptualize mental disorders and may not be as useful as it is with medical illness where two or more separate disease entities often co-exist. The relationship among personality disorders and clinical syndromes is not so clear and might not be separable. Personality disorders represent a dysfunction of the individual and family personality system and thus lead to the expression of clinical disturbances and relational dysfunction (Magnavita, 1997, 2000, in press). Dissecting psychopathological conditions into various syndromes may mean losing sight of the goal of treating the personality system of the individual, the family, and the broader ecosystem in which they function.
Regardless of the controversy, using the current dominant diagnostic system of classification (DSM), there is increasing empirical evidence of the likelihood that a personality disorder diagnosis suggests that another clinical disorder will also be present and that it will likely be the reason for treatment. Tyrer, Gunderson, Lyons, and Tohen (1997) in their review of the literature found some of the following associated comorbid conditions: Borderline PD and Depression; Depressive PD and Depression; Avoidant PD and Generalized Social Phobia: Cluster B PDs and Psychoactive Substance Abuse; Cluster B and C PDs and Eating Disorders, and Somatoform Disorders; Cluster C PDs and Anxiety Disorders and Hypochondriasis; and finally Cluster A PDs and Schizophrenia. Looking at this phenomenon of co-occurring disorders from another perspective suggests that 79% of those diagnosed with a personality disorder will also fulfill criteria for an Axis I disorder (Fabrega, Ulrich, Pilkonis, & Messich, 1992).
Relevance of Identifying Co-Occurring Disorders for Clinical Practice
Co-occurring disorders are not exhibited by chance but emerge out of the personality configuration of the patient's total ecological system from the microscopic level to the macroscopic level of analysis. The clinical syndrome, relational dysfunction, and personality characteristics and organization of each patient cannot be viewed separately. For example, we know that marital dissatisfaction is a cause of depression in women and that the personality characteristics and organization of a woman will influence how this complex constellation is handled. A woman with histrionic features may act out by having an affair and causing a marital showdown; a woman with obsessive features may become more perfectionistic and drive her spouse away; a woman with borderline features may become more self-destructive, increasing parasuicidal behavior such as cutting her arms; a dependent woman might triangulate a child by encouraging school phobia as she herself becomes increasingly agoraphobic. Millon (1999) has termed his model of treatment personality-guided therapy, which is an apt and useful description for how all therapy, regardless of the presenting complaint or treatment focus, should be conducted. The personality system, the central organizing system of a person, should be the cornerstone of treatment. Much of psychotherapy is concerned with pattern recognition, so that using personality as the central organizing system allows us to see patterns that are interconnected and, once discovered, are more readily restructured or modified. We next focus our attention on the causes of personality disorders.
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