The prevalence of DSM-IV personality disorders in psychiatric outpatients
Abstract
OBJECTIVE: The largest clinical epidemiological surveys of personality disorders have been based on unstructured clinical evaluations. However, several recent studies have questioned the accuracy and thoroughness of clinical diagnostic interviews; consequently, clinical epidemiological studies, like community-based studies, should be based on standardized evaluations. The Rhode Island Methods to Improve Diagnostic Assessment and Services project is one of the largest clinical epidemiological studies to use semistructured interviews to assess a wide range of psychiatric disorders conducted in general clinical outpatient practice. In the present report, the authors examined the frequency of DSM-IV personality disorders in a patient group and the comorbidity among them. METHOD: Eight hundred fifty-nine psychiatric outpatients were interviewed with the Structured Interview for DSM-IV Personality upon presentation for treatment. RESULTS: Slightly less than one-third of the patients were diagnosed with one of the 10 official DSM-IV personality disorders (N=270, 31.4%). When the patients with personality disorder not otherwise specified were included, the rate of any personality disorder increased to almost half of the group (N=391, 45.5%). The majority of patients meeting criteria for one of the specific personality disorders were diagnosed with more than one. Avoidant, borderline, and obsessive-compulsive personality disorder were the most frequent specific diagnoses. CONCLUSIONS: Personality disorders, as a group, are among the most frequent disorders treated by psychiatrists. They should be evaluated in all psychiatric patients because their presence can influence the course and treatment of the axis I disorder that patients typically identify as their chief complaint.
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O'Connor (2005) found evidence for a four-factor structure of DSM PDs generally consistent with general personality dimensions, with NPD forming part of an antagonism factor comprising narcissistic, antisocial, histrionic, and paranoid PDs.
“In these analyses, NPD formed part of an antagonism factor comprising narcissistic, antisocial, histrionic, and paranoid PDs (see Zimmerman et al. 2005).”
From Controversies in Narcissism (2017) · cites this paper as Zimmerman et al. 2005
Longitudinal studies show that the association between marital discord and depressive symptoms is bidirectional, but with a stronger time-lagged association of marital discord predicting depressive symptoms than vice-versa.
“Longitudinal studies show that this association is bidirectional, 241,242 but with a stronger time-lagged association of marital discord predicting depressive symptoms than viceversa. 243”
From Time for united action on depression: a Lancet–World Psychiatric Association Commission (2022) · cites this paper as [241]
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Shame regulation in personality pathology.
Schoenleber, M. L., & Berenbaum, H. (2011) · Journal of Abnormal Psychology · doi:10.1037/a0025281 · Cited by 149 · see citing works
Asherson, P., Young, A., Eich-Höchli, D., Moran, P., Porsdal, V., & Deberdt, W. (2014) · Current Medical Research and Opinion · doi:10.1185/03007995.2014.915800 · Cited by 138 · see citing works
Stein, M. B., Pinsker-Aspen, J. H., & Hilsenroth, M. J. (2007) · Journal of Personality Assessment · doi:10.1080/00223890709336838 · Cited by 120 · see citing works
Pincus, A. L. (2011) · Personality Disorders Theory Research and Treatment · doi:10.1037/a0021191 · Cited by 117 · see citing works
Schizotypal Personality Disorder
Chemerinski, E., Triebwasser, J., Roussos, P., & Siever, L. J. (2012) · Journal of Personality Disorders · doi:10.1521/pedi_2012_26_053 · Cited by 117 · see citing works
Burden and Support Needs of Carers of Persons with Borderline Personality Disorder
Bailey, R. C., & Grenyer, B. F. S. (2013) · Harvard Review of Psychiatry · doi:10.1097/hrp.0b013e3182a75c2c · Cited by 116 · see citing works
“Interestingly, the majority of identified carers in the included studies have been parents (and specifically mothers) to female daughters with BPD.”
BackgroundInfluentialPersonality disorder symptoms and marital functioning.
South, S. C., Turkheimer, E. N., & Oltmanns, T. F. (2008) · Journal of Consulting and Clinical Psychology · doi:10.1037/a0013346 · Cited by 115 · see citing works
“In practice, there is a great deal of comorbidity among the PDs ( Zimmerman, Rothschild, & Chelminski, 2005 ) and between PDs and normal personality (O’Connor, 2002).”
Triebwasser, J., Chemerinski, E., Roussos, P., & Siever, L. J. (2012) · Journal of Personality Disorders · doi:10.1521/pedi_2012_26_055 · Cited by 113 · see citing works
Abbass, A., Sheldon, A., Gyra, J., & Kalpin, A. (2008) · Journal of Nervous & Mental Disease · doi:10.1097/nmd.0b013e3181662ff0 · Cited by 112 · see citing works
“These 3 diagnoses were also the most common found in a recent study of PD incidence in psychi- atric outpatients (Zimmerman et al., 2005).”
A systematic review of personality disorders and health outcomes.
Dixon–Gordon, K. L., Whalen, D. J., Layden, B. K., & Chapman, A. L. (2015) · Canadian Psychology/Psychologie canadienne · doi:10.1037/cap0000024 · Cited by 112 · see citing works
Avoidant Personality Disorder: a Current Review
Weinbrecht, A., Schulze, L., Boettcher, J., & Renneberg, B. (2016) · Current Psychiatry Reports · doi:10.1007/s11920-016-0665-6 · Cited by 110 · see citing works
Triebwasser, J., Chemerinski, E., Roussos, P., & Siever, L. J. (2012) · Journal of Personality Disorders · doi:10.1521/pedi.2012.26.6.919 · Cited by 106 · see citing works
Personality Disorders in DSM-5: Emerging Research on the Alternative Model
Morey, L. C., Benson, K. T., Busch, A., & Skodol, A. E. (2015) · Current Psychiatry Reports · doi:10.1007/s11920-015-0558-0 · Cited by 106 · see citing works
Supporting a Person With Personality Disorder: A Study of Carer Burden and Well-Being
Bailey, R. C., & Grenyer, B. F. S. (2014) · Journal of Personality Disorders · doi:10.1521/pedi_2014_28_136 · Cited by 101 · see citing works
Christensen, T. B., Eikenaes, I., Hummelen, B., Pedersen, G., Nysæter, T., Bender, D., Skodol, A., & Selvik, S. G. (2020) · Personality disorders · doi:10.1037/per0000352 · Cited by 91 · see citing works
Cognitive analytic therapy for personality disorder: randomised controlled trial
Clarke, S., Thomas, P., & James, K. (2013) · British Journal of Psychiatry · doi:10.1192/bjp.bp.112.108670 · Cited by 94 · see citing works
“Moreover, outcome trials have focused predominantly on borderline personality disorder, 4,5 despite the fact that this accounts for only 10% of diagnoses, 6 and empirically validated interventions for this group are complex 7,8 and of long duration.”
BackgroundZimmermann, J., Benecke, C., Bender, D. S., Skodol, A. E., Schauenburg, H., Cierpka, M., & Leising, D. (2013) · Journal of Personality Assessment · doi:10.1080/00223891.2013.852563 · Cited by 98 · see citing works
“It should be noted, however, that the specific PD categories that were missing in our sample are rarely found in most clinical samples (e.g., Zimmerman et al., 2005), making our sample rather typical in this regard.”
BackgroundPrevalence and treatment of narcissistic personality disorder in the community: a systematic review
Dhawan, N., Kunik, M. E., Oldham, J., & Coverdale, J. (2010) · Comprehensive Psychiatry · doi:10.1016/j.comppsych.2009.09.003 · Cited by 95 · see citing works
“7% [72-75].”
Huprich, S. K., Bornstein, R. F., & Schmitt, T. A. (2011) · Journal of Personality Disorders · doi:10.1521/pedi.2011.25.5.557 · Cited by 94 · see citing works
“73, 1354–1362. Sass, D. A., & Schmitt, T. A. (2010). A comparative investigation of rotation methods within exploratory factor analysis.”
MethodInfluentialBeck, E., Bo, S., Jørgensen, M. S., Gondan, M., Poulsen, S., Storebø, O. J., Fjellerad Andersen, C., Folmo, E., Sharp, C., Pedersen, J., et al. (2020) · Journal of Child Psychology and Psychiatry · doi:10.1111/jcpp.13152 · Cited by 93 · see citing works
Borderline Personality Disorder and Bipolar Disorder
Paris, J., & Black, D. W. (2015) · The Journal of Nervous and Mental Disease · doi:10.1097/nmd.0000000000000225 · Cited by 95 · see citing works
“PDs are frequent in the community but especially common in inpatient and clinic settings (Lenzenweger et al., 2007; Zimmerman et al., 2005).”
BackgroundGilbert, F., & Daffern, M. (2011) · Psychology of Violence · doi:10.1037/a0024089 · Cited by 91 · see citing works
“In both forensic and nonforensic populations, research suggests that the most common pattern observed is one of high comorbidity, both within and across the three DSM–IV–TR clusters (Zimmerman, 2005).”
BackgroundLaporte, L., Paris, J., Guttman, H. A., & Russell, J. A. (2011) · Journal of Personality Disorders · doi:10.1521/pedi.2011.25.4.448 · Cited by 89 · see citing works
The relationship between avoidant personality disorder and social phobia
Hummelen, B., Wilberg, T., Pedersen, G., & Karterud, S. (2007) · Comprehensive Psychiatry · doi:10.1016/j.comppsych.2007.03.004 · Cited by 88 · see citing works
“The few DSM-IV studies that have reported on the overlap between SP and APD found the prevalence of SP within APD to range from 31% to 86% [6,28-30].”
BackgroundDiagnosing borderline personality disorder
Biskin, R. S., & Paris, J. (2012) · Canadian Medical Association Journal · doi:10.1503/cmaj.090618 · Cited by 87 · see citing works
The Case for Shifting Borderline Personality Disorder to Axis I
New, A. S., Triebwasser, J., & Charney, D. S. (2008) · Biological Psychiatry · doi:10.1016/j.biopsych.2008.04.020 · Cited by 84 · see citing works
Clinical Utility of the DSM-5 Alternative Model of Personality Disorders
Bach, B., Markon, K. E., Simonsen, E. H., & Krueger, R. F. (2015) · Journal of Psychiatric Practice · doi:10.1097/01.pra.0000460618.02805.ef · Cited by 90 · see citing works
Kaźmierczak, I., Zajenkowska, A., Rogoza, R., Jonason, P. K., & Ścigała, D. (2023) · PLOS ONE · doi:10.1371/journal.pone.0281046 · Cited by 90 · see citing works
“Furthermore, online participants were higher on depression and anxiety (their mean scores indicate clinical “caseness” using the cut-off of 11 points suggested by Zigmond and Snaith [31] as compared to those who never participated in research before (their mean scores indicate a borderline level for depression and cli…”
ResultInfluentialGood psychiatric management: a review
Gunderson, J. G., Masland, S. R., & Choi-Kain, L. W. (2018) · Current Opinion in Psychology · doi:10.1016/j.copsyc.2017.12.006 · Cited by 87 · see citing works
Narcissistic personality disorder in DSM-5.
Skodol, A. E., Bender, D. S., & Morey, L. C. (2014) · Personality Disorders: Theory, Research, and Treatment · doi:10.1037/per0000023 · Cited by 83 · see citing works
Miller, J. D. (2012) · Journal of Personality · doi:10.1111/j.1467-6494.2012.00773.x · Cited by 83 · see citing works
Pryor, L. R., Miller, J. D., & Gaughan, E. T. (2008) · Journal of Personality Assessment · doi:10.1080/00223890802248893 · Cited by 83 · see citing works
“However, both entitlement scales were also correlated with the other Cluster B PDs and with paranoid PD, which is consistent with the pattern of co-occurrence typically found for these PDs (e.g., Zimmerman et al., 2005).”
BackgroundResultZimmermann, J., Benecke, C., Hörz, S., Rentrop, M., Peham, D., Bock, A., Wallner, T., Schauenburg, H., Frommer, J., Huber, D., et al. (2013) · Diagnostica · doi:10.1026/0012-1924/a000076 · Cited by 82 · see citing works
Therapeutic bond judgments: Congruence and incongruence.
Atzil–Slonim, D., Bar‐Kalifa, E., Rafaeli, E., Lutz, W., Rubel, J. A., Schiefele, A.-K., & Peri, T. (2015) · Journal of Consulting and Clinical Psychology · doi:10.1037/ccp0000015 · Cited by 82 · see citing works
Wright, A. G. C., Zalewski, M., Hallquist, M. N., Hipwell, A. E., & Stepp, S. D. (2016) · Journal of Personality Disorders · doi:10.1521/pedi_2015_29_200 · Cited by 78 · see citing works
“Indeed, BPD significantly covaries with both internalizing and externalizing disorders in epidemiological (Eaton et al., 2011) and clinical samples (Zimmerman et al., 2005) in adulthood.”
Scala, J. W., Levy, K. N., Johnson, B. N., Kivity, Y., Ellison, W. D., Pincus, A. L., Wilson, S. J., & Newman, M. G. (2018) · Journal of Personality Disorders · doi:10.1521/pedi.2018.32.supp.36 · Cited by 77 · see citing works
Current understanding of narcissism and narcissistic personality disorder
Yakeley, J. (2018) · BJPsych Advances · doi:10.1192/bja.2018.20 · Cited by 77 · see citing works
The impact of avoidant personality disorder on psychosocial impairment is substantial
Wilberg, T., Karterud, S., Pedersen, G., & Urnes, Ø. (2009) · Nordic Journal of Psychiatry · doi:10.1080/08039480902831322 · Cited by 76 · see citing works
“Narcissistic 3 (3) 8 (3) 1 (0) 1 (1) 4 (4) Antisocial 8 (8) 18 (7) 9 (2) 4 (3) 2 (2)”
Miller, J. D., Hoffman, B. J., Campbell, W. K., & Pilkonis, P. A. (2008) · Comprehensive Psychiatry · doi:10.1016/j.comppsych.2007.08.012 · Cited by 74 · see citing works
“[24] and community samples (median, .05”
Interpersonal Functioning in Obsessive–Compulsive Personality Disorder
Cain, N. M., Ansell, E. B., Simpson, H. B., & Pinto, A. (2014) · Journal of Personality Assessment · doi:10.1080/00223891.2014.934376 · Cited by 76 · see citing works
Paris, J. (2008) · Annual Review of Clinical Psychology · doi:10.1146/annurev.clinpsy.032408.153457 · Cited by 73 · see citing works
Grenyer, B. F. S., Lewis, K. L., Fanaian, M., & Kotzé, B. (2018) · PLoS ONE · doi:10.1371/journal.pone.0206472 · Cited by 71 · see citing works
“People with personality disorders comprise a significant proportion of those presenting to emergency and inpatient mental health units [3, 40].”
BackgroundAlcohol Use Disorder and Antisocial and Borderline Personality Disorders
Helle, A. C. (2019) · Alcohol research · doi:10.35946/arcr.v40.1.05 · Cited by 75 · see citing works
Convergence between DSM-IV-TR and DSM-5 Diagnostic Models for Personality Disorder
Morey, L. C., & Skodol, A. E. (2013) · Journal of Psychiatric Practice · doi:10.1097/01.pra.0000430502.78833.06 · Cited by 72 · see citing works
Borderline Personality Disorder (BPD): In the Midst of Vulnerability, Chaos, and Awe
Kulacaoğlu, F., & Köse, S. (2018) · Brain Sciences · doi:10.3390/brainsci8110201 · Cited by 71 · see citing works
“3% of psychiatric outpatients and 20% of psychiatric inpatients according to the studies in clinical settings [4,8,9].”
BackgroundHummelen, B., Wilberg, T., Pedersen, G., & Karterud, S. (2008) · The Journal of Nervous and Mental Disease · doi:10.1097/nmd.0b013e3181775a4e · Cited by 72 · see citing works
“…in clinical samples range from 5.1% to 16.4% (Alnaes and Torgersen, 1988; Fossati et al., 2000; Oldham et al., 1992; Stuart et al., 1998; Zanarini et al., 1998; Zimmerman et al., 2005) and from 0% to 9.3% in community surveys (Grant et al., 2005; Samuels et al., 2002; Torgersen et al., 2001).”
BackgroundResultInfluentialShort-term group schema therapy for mixed personality disorders: a pilot study
Skewes, S. A., Samson, R. A., Simpson, S. G., & van Vreeswijk, M. (2015) · Frontiers in Psychology · doi:10.3389/fpsyg.2014.01592 · Cited by 70 · see citing works
“Avoidant, borderline, and obsessive-compulsive personality disorders are among the most frequently specified diagnoses (Zimmerman et al., 2005).”
BackgroundDifferential Diagnosis of Borderline Personality Disorder
Paris, J. (2018) · Psychiatric Clinics of North America · doi:10.1016/j.psc.2018.07.001 · Cited by 68 · see citing works
Morgan, T. A., Chelminski, I., Young, D., Dalrymple, K. L., & Zimmerman, M. A. (2013) · Journal of Psychiatric Research · doi:10.1016/j.jpsychires.2013.06.009 · Cited by 68 · see citing works
Self-citationBartak, A., Andrea, H., Spreeuwenberg, M. D., Ziegler, U. M., Dekker, J., Rossum, B. V., Hamers, E. F. M., Scholte, W. R., Aerts, J., Busschbach, J. J. V., et al. (2010) · Psychotherapy and Psychosomatics · doi:10.1159/000321999 · Cited by 64 · see citing works
“and are highly prevalent in psychiatric patients (13.0p) [”
BackgroundZimmerman, M. A., Chelminski, I., Young, D., Dalrymple, K. L., & Martinez, J. H. (2013) · Journal of Personality Disorders · doi:10.1521/pedi.2013.27.2.244 · Cited by 65 · see citing works
Self-citationFossati, A., Feeney, J., Pincus, A., Borroni, S., & Maffei, C. (2015) · Psychoanalytic Psychology · doi:10.1037/a0037175 · Cited by 64 · see citing works
Ellison, W. D., & Levy, K. N. (2011) · Psychological Assessment · doi:10.1037/a0026264 · Cited by 64 · see citing works
Trends in Subthreshold Psychiatric Diagnoses for Youth in Community Treatment
Safer, D. J., Rajakannan, T., Burcu, M., & ZITO, J. M. (2014) · JAMA Psychiatry · doi:10.1001/jamapsychiatry.2014.1746 · Cited by 62 · see citing works
Comtois, K., & Carmel, A. (2016) · Journal of Behavioral Health Services & Research · doi:10.1007/s11414-014-9416-9 · Cited by 58 · see citing works
Macdonald, K., Berlow, R., & Thomas, M. L. (2013) · Journal of Affective Disorders · doi:10.1016/j.jad.2013.07.040 · Cited by 56 · see citing works
Scott, L. N., Kim, Y., Nolf, K. A., Hallquist, M. N., Wright, A. G. C., Stepp, S. D., Morse, J. Q., & Pilkonis, P. A. (2013) · Journal of Personality Disorders · doi:10.1521/pedi_2013_27_099 · Cited by 62 · see citing works
“Finally, BPD, ASPD, and AVPD features are prevalent in general psychiatric and forensic settings (Kendall et al., 2009; Zimmerman et al., 2005), and both ASPD and AVPD show high rates of comorbidity with BPD (Grant et al.”
- Authors
- Zimmerman, M., Rothschild, L., & Chelminski, I.
- Affiliations
- Lifespan (US)
- Venue
- American Journal of Psychiatry
- Published
- 2005-10-01
- Volume
- 162
- Issue
- 10
- Pages
- 1911-1918
- ISSN
- 0002-953X (ISSN-L)
- 1535-7228
- OpenAlex
- W2162488020
- Cited by
- 825
- References
- 42
- Citations by year
- 2026: 13 · 2025: 24 · 2024: 17 · 2023: 39 · 2022: 33 · 2021: 51 · 2020: 78 · 2019: 47 · 2018: 48 · 2017: 56 · 2016: 36 · 2015: 50 · 2014: 63 · 2013: 38 · 2012: 60
- FWCI
- 22.37
- Type
- journal article
- Language
- en
- Open access
- closed
- Locations
- American Journal of Psychiatry (publishedVersion)
- PubMed (publishedVersion)
- Funders
- National Institutes of Health (5r29mh048732-05)
- National Institute of Mental Health (MH-56404, MH48732)
- Topics
- Social Sciences › Psychology › Clinical Psychology › Personality Disorders and Psychopathology
- Social Sciences › Psychology › Clinical Psychology › Personality Traits and Psychology
- Health Sciences › Medicine › Psychiatry and Mental health › Bipolar Disorder and Treatment
- Keywords
- personality disorders, DSM-IV personality disorders, prevalence, psychiatric outpatients, comorbidities, avoidant personality disorder, borderline personality disorder, obsessive-compulsive personality disorder, semi-structured interviews, clinical epidemiology
- MeSH terms
- Adult, Ambulatory Care, Mental Disorders, Female, Humans, Male, Personality Disorders, Psychiatric Status Rating Scales, Comorbidity, Prevalence, Diagnostic and Statistical Manual of Mental Disorders
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