ONSET AND CLINICAL COURSE
Personality disorders are relatively common, occurring in 10% to 13% of the general population. Incidence is even higher for people in lower socioeconomic groups and unsta-ble or disadvantaged populations. Fifteen percent of all psy-chiatric inpatients have a primary diagnosis of a personality disorder. Forty percent to 45% of those with a primary diag-nosis of major mental illness also have a coexisting person-ality disorder that significantly complicates treatment. In mental health outpatient settings, the incidence of personal-ity disorder is 30% to 50% (Svrakic & Cloninger, 2005). Clients with personality disorders have a higher death rate, especially as a result of suicide; they also have higher rates of suicide attempts, accidents, and emergency department visits and increased rates of separation, divorce, and involve-ment in legal proceedings regarding child custody (Svrakic Cloninger, 2005). Personality disorders have been corre-lated highly with criminal behavior (70% to 85% of crimi-nals have personality disorders), alcoholism (60% to 70% of alcoholics have personality disorders), and drug abuse (70% to 90% of those who abuse drugs have personality disor-ders; Svrakic & Cloninger, 2005).
People with personality disorders often are described as “treatment resistant.” This is not surprising, considering that personality characteristics and behavioral patterns are deeply ingrained. It is difficult to change one’s personality; if such changes occur, they evolve slowly. The slow course of treatment can be very frustrating for family, friends, and health-care providers.
Another barrier to treatment is that many clients with personality disorders do not perceive their dysfunctional or maladaptive behaviors as a problem; indeed, sometimes these behaviors are a source of pride. For example, a bellig-erent or aggressive person may perceive himself or herself as having a strong personality and being someone who can’t be taken advantage of or pushed around. Clients with person-ality disorders frequently fail to understand the need to change their behavior and may view changes as a threat.
The difficulties associated with personality disorders persist throughout young and middle adulthood but tend to diminish in the 40s and 50s. Those with antisocial per-sonality disorder are less likely to engage in criminal behavior, although problems with substance abuse and disregard for the feelings of others persist. Clients with borderline personality disorder tend to demonstrate decreased impulsive behavior, increased adaptive behav-ior, and more stable relationships by 50 years of age. This increased stability and improved behavior can occur even without treatment. Some personality disorders, such as schizoid, schizotypal, paranoid, avoidant, and obsessive– compulsive, tend to remain consistent throughout life.