Personality disorders: Prevalence and demography at a psychiatric outpatient in North India

Abstract

Background: Even though personality disorders are common among psychiatric populations, the data from India on their prevalence and demography are sparse.

Aim: To profile the prevalence and demography of personality disorders in North India.

Methods: The retrospective study was based on patients attending the outpatient of a general hospital psychiatric centre in North India between June 1996 and June 2006. The specified data were collected from the case records of those receiving a primary or comorbid ICD-10 diagnosis of a personality disorder.

Results: Personality disorders had a prevalence of 1.07%, with a preponderance of those aged 21–40 years (69.4%), men (64.9%), employed and students (37.3% and 32.8% respectively), unmarried (56%), graduates and undergraduates (27.6% each), and referred by the family (68.7%). The most common personality disorders were anxious-avoidant and borderline. Compared with the anxious-avoidant group, the borderline group was younger (mean age 24.44 vs 29.66 years) and had a preponderance of females (60% vs 27.1%).

Conclusion: The prevalence of personality disorders among the psychiatric outpatients was low compared to most of the research literature reporting clinically diagnosed personality disorders. The differences between the borderline and anxious-avoidant personality disorder subjects were largely explained by interrelated demographic variables.

Keywords

epidemiology general hospital outpatients personality disorder prevalence psychiatric disorder

Introduction

The personality consists of temperament, character and psyche, each of which may have multiple dimensions (Svrakic and Cloninger, 2005). However, personality disorders (PDs) are studied as discrete psychopathological entities or clinical categories. The ICD-10 lists 10 PDs and in the diagnostic guidelines describes these as comprising deeply ingrained and enduring behaviour patterns that manifest as inflexible responses to a broad range of personal and social situations and represent either extreme or significant deviations from the way the average individual in that culture perceives, thinks, feels and, particularly, relates to others (World Health Organization, 1992). Such behaviour patterns tend to be stable and encompass multiple domains of behaviour and psychological functioning. They are frequently, but not always, associated with various degrees of subjective distress and problems in social functioning and performance.

A study of PDs is justified for several reasons. They are common across countries and their presence influences the outcome of comorbid psychiatric disorders (Reich and Green, 1991). The present research was prompted by the fact that data from India on prevalence and demography of PDs is sparse. This paper reports on a retrospective study of the prevalence and demography of PDs at a hospital in North India.

Methodology

The study was carried out at the Postgraduate Institute of Medical Education and Research, Chandigarh, a multi-speciality teaching hospital providing services to a major area of North India. The service users have a population base of approximately 40 million people with a broadly similar North Indian culture and a full range of socio-economic variation. They come from the states of Punjab, Haryana, Himachal Pradesh, and parts of Uttar Pradesh, Rajasthan and, Jammu and Kashmir. The hospital serves as the first and direct contact for almost a third of the patients for all services including psychiatric services.

The department of psychiatry receives patients seeking treatment on referral from self, family members, and other medical and non-medical agencies from within or outside the institute. As per the local cultural norm, and encouraged by the department, in almost all the cases/visits close relatives/family members accompany the subjects, which ensures/enhances the reliability and adequacy of the information obtained. All registrants are initially assessed by a psychiatric social worker (including sociodemographic and referral details) and a trained psychiatrist (who briefly records the history, examination and differential/diagnosis; institutes an interim management plan including referrals, investigations, medications and other psychosocial interventions; and offers an appointment for a detailed diagnostic assessment). The detailed assessment by a trainee psychiatrist includes a clinical interview with the patient and the accompanying person/s. The trainee discusses his assessment with a consultant psychiatrist who independently re-evaluates the case. In the case of a discrepancy between the information recorded earlier and that elicited at the assessment, the trainee and the consultant discuss the issue with the psychiatrist/s who evaluated the case and recorded the findings earlier. On rare occasions, if a consensus is not reached, the final diagnosis recorded is the one given by the consultant, listing the reasons to justify it. Each case is thus evaluated at three levels independently and is discussed and followed up as required, before the diagnosis and management plan is finalized. As a matter of department policy, all diagnoses are made as per the ICD-10, copies of which are routinely available and are used to describe the diagnoses by ICD name and code. The case records are maintained with relevant details being recorded at each follow-up. Periodically the progress is reviewed and if needed, the diagnoses and the management plan are revised. All adult cases (age 16 years and over) undergoing a detailed outpatient assessment or admitted to the ward directly are entered in an ‘adult case-work-up register’, assigning a ‘psychiatry number’ and listing name, age, gender and contact/address details and the final ICD-10 diagnoses.

The adult case-work-up registers from June 1996 to June 2006 were scanned to identify cases/psychiatry numbers having PD as a primary or secondary/comorbid diagnosis. The first author studied the available identified case notes for the relevant data using a proforma designed for this study. The demographic profile of the sample was compared to the adult outpatient cases undergoing detailed assessment in 2003, and to an earlier study on PDs carried out at the same centre (Sharan, 2001). The two largest diagnostic subgroups of the sample (anxious-avoidant and borderline PDs) were compared for the demographic profile. The data were analysed using descriptive statistics with SPSS version 11.

Results

PD prevalence

Between June 1996 and June 2006 there were 18,405 detailed adult psychiatric assessments. The registers for January to December 1998 and March to August 2004 covering 2,287 cases were not available. Thus the available database was limited to 16,118 patients (87.57%). Of these, only 173 had received a PD diagnosis giving a prevalence rate of 1.07% . Of these cases, there was detailed data analysis and traceable case notes for just 134 cases (77.01%).

Demography

Table 1 compares the demography of PD cases, adult psychiatric detailed evaluation outpatients, and the PD cases from Sharan’s (2001) study. Compared to the adult psychiatric detailed evaluation outpatients of 2003, the current PD sample had more men (65% vs 51%), never married (56% vs 31%), students (33% vs 11%), post-school educated (69% vs 40%) and nuclear family subjects (69% vs 56%), and fewer re-/married (39.5% vs 63%), housewives (17% vs 38%) and school dropouts (5% vs 25%). Compared to Sharan (2001) there were more never married (56% vs 47%), students (33% vs 0%) and unemployed (10% vs 0), school completers (22% vs 0%) and graduates (28% vs 0), lowest income (61% vs 56%) and nuclear family (69% vs 61) subjects. For all three groups the data for age, income and source of referral were not available in a comparable format. Among the PD sample, the gender differences were significant for occupation (χ ² = 41.929, df = 4) and income (χ ² = 9.428, df = 4) (Table 1).

Table 1.

Demography of personality disorder samples: Study sample vs all adult worked-up outpatient cases in 2003 vs Sharan (2001) study

Study sample (N = 134)Variable	Male (n = 87)	Female (n = 47)	Total		All adult worked-up cases in 2003 (N = 2,082)	Sharan study in 2001 (N = 57)
			N	%	%
Gender
Male			87	64.9	50.9	61.4
Female			47	35.1	49.1	38.6
Age (years)
16–20	13	9	2	16.4	^a	^a
21–40	61	32	93	69.4
41–65	13	6	19	14.2
Marital status
Never married	53	22	75	56.0	31.2	47.4
Re/married	32	21	53	39.5	63	52.6
Widowed/divorced/separated	2	4	6	4.5	5.1	–
Occupation ^b
Employed	40	10	50	37.3	33.2	56.1
Unemployed	14	0	14	10.4	12.5	–
Housewives	0	23	23	17.2	38.1	43.9
Retired	2	0	2	2.2	4.3	–
Students	30	14	44	32.8	11.2	–
Education
Illiterate	1	4	5	3.7	11.7	–
School dropout	5	2	7	5.2	25.0	26.3
Matriculate	21	9	30	22.4	21	–
Undergraduate	27	10	37	27.6	18.2	29.8
Graduate	23	14	37	27.6	16.2	–
Masters	10	8	18	13.4	5.8	43.9
Not known	0	0	0	0	1.6	–
Religion
Hindu	63	30	93	69.4	70.6	73.7
Sikh	21	17	38	28.4	25.0	26.3
Other	3	0	3	2.2	4.4	–
Income (rupees/month)^c
0–749	45	37	82	61.2	^a	56.1
750–5,999	19	4	23	17.2		26.3
≥6,000	23	6	29	21.6		17.5
Family type
Nuclear	55	37	92	68.7	55.8	61.4
Extended	20	8	28	20.9	9.7	22.8
Joint	12	2	14	10.4	34.5	15.8
Referred by
Self	32	10	42	31.3	^a	^a
Relative	37	27	64	47.8
Medical service	18	10	28	20.9

Data not available in comparative format, ^b χ ² = 41.929, df = 4, ^c χ ² 9.428, df = 2 (approximately 45 Indian rupees = US$1)

Gender and prevalence

The more common PDs were anxious-avoidant (44%) and emotionally unstable (25.4%, including borderline 18.7% and impulsive 6.7%); the less common were paranoid (0.7%), dependent (1.5%), unspecified (2.2%), anankastic (4.5%), schizoid, antisocial and others (5.2% each), and histrionic (6%) (Table 2). This gave the following rates of prevalence: anxious-avoidant (0.36%), borderline (0.15%), emotionally unstable – impulsive (0.05%), histrionic (0.049%), schizoid, antisocial and others (0.043% each), and anankastic (0.03%). Emotionally unstable impulsive, anankastic, anxious-avoidant and schizoid PDs showed a preponderance in males, whereas histrionic, emotionally unstable borderline and antisocial PDs showed a preponderance in females.

Table 2.

Personality disorders: Type and gender profile

Personality disorder type	Male n = 87		Female n = 47		Total N = 134
	n	%	n	%	N	%
Paranoid	1	1.1	0	0	1	0.7
Schizoid	5	5.7	2	4.3	7	5.2
Antisocial	3	3.4	4	8.5	7	5.2
Emotionally unstable – impulsive	8	9.2	1	2.1	9	6.7
Emotionally unstable – borderline	10	11.5	15	31.9	25	18.7
Histrionic	2	2.3	6	12.8	8	6.0
Anankastic	5	5.7	1	2.1	6	4.5
Anxious-avoidant	43	49.4	16	34.0	59	44.0
Dependent	2	2.3	0	0	2	1.5
Other (e.g. narcissistic, self-defeating)	5	5.7	2	4.3	7	5.2
Unspecified	3	3.4	0	0	3	2.2

Anxious-avoidant vs borderline PDs

The borderline group was younger (mean age 24.44 vs 29.66 years, t = 2.262, p = 0.005) with age range of 16–35 years, compared to 16–60 years for the anxious-avoidant group (Table 3). The borderline group had more women (60% vs 40%, χ ² = 8.153, p = 0.004) and housewives (28% vs 15%), while the anxious-avoidant group had more employed (44% vs 20%) and men (73% vs 40%). The borderline group had more with a lower-income background (80% vs 52.5%), while only the anxious-avoidant group came from a middle-income background (22% vs 0%) (χ ² = 7.906, p = 0.019). The borderline group was more often single (72% vs 56%), and from a nuclear family (84% vs 63%), and less often from an extended family (25% vs 4%). The borderline group came more by family referral (48% vs 32%) and less by self-referral (24% vs 46%).

Table 3.

Anxious-avoidant and borderline personality disorders: Demographic comparison

Variable	Anxious-avoidant n = 59		Borderline n = 25
Age (mean + SD) ^a	29.66 + 5.66		24.44 + 10.90
	n	%	n	%
Age (years)
16–20	6	10.2	6	24
21–40	42	71.2	19	76
41–60	11	18.6	0	0
Gender ^b
Male	43	72.9	10	40
Female	16	27.1	15	60
Education
Illiterate	1	1.7	2	8
Up to middle	3	5.1	0	0
Matriculate/Intermediate	28	47.5	12	48
Graduate/Masters	27	45.8	11	44
Occupation
Employed	26	44.1	5	20
Unemployed	4	6.8	2	8
Housewives	9	15.3	7	28
Retired	0	0	1	4
Students	20	33.9	10	40
Income (rupees/month)^c
0–749	31	52.5	20	80
750–5,999	13	21.7	0	0
≥6,000	15	25.4	5	20
Marital status
Single	33	55.9	18	72
Re/married	23	39.0	6	24
Widowed/separated	3	5.1	1	4
Family type
Nuclear	37	62.7	21	84
Extended	15	25.4	2	4
Joint	7	11.9	2	8
Religion
Hindu	42	71.2	15	60
Sikh	16	27.1	10	40
Christian	1	1.7	0	0
Referred by
Self	27	45.8	6	24
Relative	19	32.2	12	48
Medical service	13	22.0	7	28

t = 2.262, p = 0.005; ^b χ ² = 8.153, p = 0.004; ^c χ ² = 7.906, p = 0.019

Discussion

This was a clinic-based study with a greater possibility of more distressed help-seekers forming the base of the sample population. Although the case notes used were guided by a general psychiatric rather than a PD-specific assessment, the presence of a key informant during the assessment may have enhanced the reliability of the information; an earlier study has shown reliable similarity across the patients’ subjective ratings and the key informants’ objective ratings for assessment of quality of life (Lobana et al., 2001).

PD prevalence

Community-based studies have reported a PD prevalence of 0.01%–2.8% in China, India and Germany, using unstructured clinical interviews with the patients and informants (Cheung, 1991; Dilling et al., 1989; Sethi et al., 1972) and of 2.4%–9.1% in Western Europe, Columbia and the USA (Huang et al., 2009; Lenzenweger et al., 2007) using the International Personality Disorder Examination (IPDE) (Loranger et al., 1991). In psychiatric outpatients, the rates have varied from 5% with alcohol misuse (Allan, 1991) to 47% with substance dependence (Ross et al., 1988) and up to 81% with any axis-I disorder (Alnaes and Torgersen, 1988). In psychiatric inpatients, the comparative rates were 18.3%–20% in Australia and Kenya (Jackson et al., 1991; Thuo et al., 2008).

In contrast, the psychiatric outpatient PD prevalence in the present study was low at 1.07%. The reason for this could be the use of ICD-10-based general psychiatric evaluation rather than a PD-specific assessment instrument. An earlier study at the centre using IPDE in psychiatric outpatients obtained a high rate of PD despite a low correspondence between the clinical and IPDE diagnoses (11% vs 33.8%) (Sharan, 2001).

The wide discrepancy between research instrument and clinical PD diagnoses is attributed to the fact that while the research instruments depend on answers to direct questions, the clinicians depend on historical accounts and direct observation (Westen, 1997; Westen and Arkowitz-Westen, 1998). Also implicated are the clinicians’ attitudes of considering the PDs as stigmatizing, as value judgments rather than real diagnoses, and as being harder to manage when clinically diagnosed than when diagnosed by instrument (Tyrer, 2008).

Finally, the use of instruments resembling the clinical decision-making process (Q-sort) results in quite a high agreement between clinicians’ and instrument-based PD diagnoses (Westen and Shedler, 1999a, 1999b).

Demography

The typical subject was a 29-year-old male (65%), never married (56%), employed (37%) or student (33%), undergraduate or graduate (27.6% each), from a nuclear family (69%), with lower income (61%) and referred by the family (48%). The finding of a typical subject being a young adult is similar to a community study from Germany (Maier et al., 1992) but contrasts with the mean age of 45.8 years reported in a community study from the USA (Reich et al., 1989). The finding of male preponderance among the PD cases compares well with a similar study from the same centre (65% vs 61.4%; Sharan, 2001) and a World Health Organization multicentre study (odds ratio (OR) of 2.5 for males) (Huang et al., 2009), but contrasts with men accounting for 51% of the general psychiatric outpatients and a preponderance of females among PD cases reported from the UK (Coid et al., 2006) and Norway (Torgersen et al., 2001).

The finding of 56% and 3% subjects being never married and divorced or separated, respectively, are in contrast to 28.1%, 47.8% and 14.4% PD subjects being single, married and divorced, respectively, in a community sample in the UK (Coid et al., 2006). The marital profile of the present sample must be seen in the context of the mean age of 29 years and the cultural norm of almost universal marriage by the age of 35, and the rarity of separation and divorce in comparison to the West (Khandelwal et al., 2004).

The finding of 61.2% subjects with a monthly income of < 749 rupees (45 Indian rupees = US$1) is similar to that for the patients in the general psychiatric clinic and another PD study from the centre (56.1%; Sharan, 2001). This is in contrast to 42.3% in full-time work and 38% economically inactive subjects in a community sample in the UK (Coid et al., 2006). The only significant gender differences for occupation and income were accounted for by the fact that most women were non-earning housewives. The finding of 68.7% subjects belonging to nuclear families was similar to the general psychiatry outpatients and to the earlier study (61.4%; Sharan, 2001). In the present sample, 48% of cases being referred by family could be due to problems in interpersonal functioning; 31% of cases being self-referred could be due the subjective distress caused by anxious-avoidant and borderline PDs; there was no literature found to support this speculation.

Types of PD

The finding of anxious-avoidant (0.36%) and borderline (0.15%) PDs being the most common is similar to that of the earlier study at the same centre; however, in that study the application of IPDE led to the emergence of emotionally unstable (impulsive and borderline) being the most common PD (Sharan, 2001). The finding of anxious-avoidant as the most common PD is similar to an outpatient- and SIPD-based study from Norway (Torgersen et al., 2001); however, the prevalence was much lower and similar to that of an IPDE-based study from the USA, which reported anxious-avoidant as third most common (Loranger et al., 1991).

The finding of borderline as the second most common PD is similar to that of a community-based study from the USA (Moldin et al., 1994), although these findings are in contrast to two IPDE-based community studies from the USA reporting 0%–0.5% of borderline PD (Lenzenweger et al., 1997; Samuels et al., 2002). In the present study, compared to anxious-avoidant, the borderline PD subjects were significantly younger and more often female. These findings have literature support in borderline PD being reported more commonly among women, unmarried or widowed subjects, especially in the 19–34 year age group (Swartz et al., 1990), and borderline PD subjects more likely being women aged 30–39 years compared to anxious-avoidant PD subjects being men or women over 50 (Torgersen et al., 2001).

The borderline PD subjects having a lower income was mainly because 60% of them were young women who were students, unemployed or housewives.

Conclusions

Studying outpatients may have increased the greater possibility of having more distressed help-seekers in the sample. Another limitation was the use of a retrospective review of case notes based on routine clinical interviews guided by a general psychiatric, rather than a PD-specific instrument-based assessment. Despite these limitations, this study provides prevalence and demographic data on PDs in a clinic-based sample from India. The sample had a PD prevalence of 1.07% and contained more students or unemployed single young men. Borderline and anxious-avoidant PDs had significant demographic differences. These results reflect the target populations for further PD research in India.

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