Prevalence of Personality Disorders in a General Population Among Men and Women

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1 Article Prevalence of Personality Disorders in a General Population Among Men and Women Psychological Reports 0(0) 1 17! The Author(s) 2017 Reprints and permissions: sagepub.com/journalspermissions.nav DOI: / journals.sagepub.com/home/prx Barbara Gawda Department of Psychology of Emotion & Cognition, University of Maria Curie Sklodowska, Lublin, Poland Katarzyna Czubak Department of Personality, Catholic University of John Paul II, Lublin, Poland Abstract The aim of the present study is to establish the prevalence of personality disorders (PDs) in a healthy (nonclinical) Polish population, to examine sex difference in PDs, and to show the structure of clusters which PDs form with regard to men and women. A large sample of 1460 individuals of age between 18 and 65 years was examined. The Structured Clinical Interview for Axis II was used to obtain information on PDs, the Mini International Neuropsychiatric Interview to obtain information on other disorders, and an interview to record demographic data. Results show that approximately 9% of the sample had at least one PD (the overall rate is 8.9%) and rates on sex differences in PDs are similar to other European and North American countries. The most prevalent PDs are obsessive-compulsive (9.6%), narcissistic (7%), and borderline (7%). Results show the considerable comorbidity of PDs which means that about 9% of the adult population have at least one PD and in fact they display features of many specific PDs. A factor analysis revealed that 12 PDs form different clusters in men and women. Keywords personality disorders, prevalence, nonclinical Polish sample, sex differences, behavioral systems Corresponding Author: Barbara Gawda, Institute of Psychology, Maria Curie Sklodowska University, Plac Litewski 5, Lublin, Poland. bgawda@wp.pl

2 2 Psychological Reports 0(0) Introduction Personality disorders (PDs) are characterized as enduring maladaptive patterns of behavior and experience which involve at least two of four areas: cognitive, affective, interpersonal, and/or control of impulse (American Psychiatric Association, 2000; ICD-10, 1992). Studies on the prevalence of PDs were conducted in clinical and nonclinical samples. Data on the prevalence of PDs in nonclinical community samples report relatively stable rates from about 10% to 15%; e.g., about 14.79% of American adults have at least one PD (Fowler, O Donohue, & Lilenfeld, 2007). The differences between prevalence rates in different countries are dependent on different sampling, instruments used in the studies, and perhaps on some social/cultural aspect (Tyrer et al., 2010). There is still little known on the impact of culture, race, and ethnicity on the etiology and treatment of PDs (McGilloway, Hall, Lee, & Bhui, 2010). This aspect has been overlooked (McGilloway et al., 2010). The types of PDs have been criticized as culturally biased (Bhugra & Bhui, 2001). Some researchers argued that the diagnosis of PDs is a reflection of North American and Western European concepts of personality (Loranger, Janga, & Sartorius, 1997), and behavioral norms may vary from one culture to another. However, there are insufficient studies on the role of culture, ethnicity, and race in diagnosis of PDs (McGilloway et al., 2010). PDs rates for general populations are reported for different countries: Western Europe (2.4%), Colombia (7.9%), Lebanon (6.2%), Mexico (6.1%), Nigeria (2.7%), Republic of China (4.1%), South Africa (6.8%), and USA (7.6%) (Huang et al., 2006). According to the screening questionnaire Structured Clinical Interview for Axis II (SCID-II) in England, Wales and Scotland were shown rate of 10.7% (weighted 4.4%), Cluster C was the most frequent, and the most prevalent was obsessive-compulsive PD (Coid, Yang, Tyrer, Roberts, & Ulrich, 2006; Moran, Rendu, Jenkins, Tylee, & Mann, 2001). Torgersen, Kringlen, and Cramer (2001) reported that PDs range 13.4% in the Norwegian community and the most prevalent was avoidant PD. In Sweden, the most prevalent were narcissistic and obsessivecompulsive PDs (Bodlund, Ekselius, & Lindstrom, 1993) and in Germany, obsessive-compulsive PD too (Maier, Lichtermann, Klingler, Heun, & Hallmayer, 1992). Most data on the PD prevalence come from the USA, e.g., in a study from 1993, the most prevalent PDs were dependent (2% 4%), schizotypal, and antisocial (Kessler et al., 1993). In a student population in the USA from 1997, the most prevalent were histrionic and narcissistic PDs (Lenzenweger, Loranger, Korfine, & Neff, 1997). In 2005, the most prevalent were avoidant, paranoid, and obsessive-compulsive PDs (Zimmerman, Rothschild, & Chelminski, 2005). Samuels et al. (2002) reported that the PD prevalence was 9.0% in the USA community, while Crawford et al. (2005) showed that the prevalence was 15.7%. Other research showed that the PD prevalence rate of USA was 14.8% (based on a random sample) and the most prevalent was the obsessive-compulsive PD (Grant et al., 2004).

3 Gawda and Czubak 3 PDs are known in most cultures around the world; however, the degree to which cultural context influences PDs is not fully described, and only limited data are available in transcultural comparisons (Calliess, Sieberer, Machleidt, & Ziegenbein, 2008). For instance, prevalence for antisocial PD in Taiwan is 0.2% while in the USA is about 3%. It is not evident whether these data present real prevalence of antisocial PD in Taiwan or common tendency to negate the antisocial behavior (Calliess et al., 2008). The antisocial PD prevalence in China compared to Western countries is usually reported as low, and some PDs such as avoidant, dependent, and borderline are not specified in the Chinese Classification of Mental Disorders (Tang & Huang, 1995). In India, no avoidant PD and no borderline PD in Kenya were diagnosed (Loranger et al., 1997). Interestingly, the prevalence of borderline PD is worldwide the highest, except in Kenya, and in general, this prevalence rose in the last 30 years (Loranger et al., 1994). Meta-analysis showed the small but significantly lower prevalence of PDs among black as compared to white populations (McGilloway et al., 2010). There was no significant difference in the prevalence between Asian and white populations, and that Hispanics were more likely to be diagnosed with borderline PD; however, this was not significant (McGilloway et al., 2010). In Great Britain, there were no differences in PDs between black and white populations (Coid et al., 2006). Although the occurrence of antisocial PD is principally independent of the socioeconomic status, it is thought to be associated with individualism/collectivism; in collectivistic cultures, crime rates and APD are lower than in individualistic cultures (Cooke & Michie, 1999). Other findings documented that people from the Middle East and Eastern Europe can appear as more secretive or distrustful to an outsider which may be attributed to Cluster C of PDs (Calliess et al., 2008). Furthermore, typify patterns of histrionic PD as hyperemotionality, seductiveness, charm, somatization, and the tendency to dramatize may cause risk of misdiagnosis of individuals from the Mediterranean area as displaying histrionic PD (Castaneda & Franco, 1985). Spaniards tend to be unwilling to adjust to social standards which may be interpreted as histrionic features (Calliess et al., 2008). Similarly with narcissistic PD, Southern European or Latin American people may be misdiagnosed as narcissistic (Loranger et al., 1994). Asians and Phillipinos more frequently than Europeans or North Americans express shy, being afraid, and passive which may be interpreted as avoidant or dependent PDs traits (Calliess et al., 2008). Likewise, immigrants from foreign countries may be perceived as hostile and cold which reflects some schizoid patterns (Calliess et al., 2008). The main personality dimensions taken into consideration by cultural psychiatrists are individualism versus collectivism, dependence versus independence, and idiocentricism versus allocentricism (Calliess et al., 2008). With regard to the cultural aspect of PD assessment, Alarcon (1996) criticized that only a small part of suggestions on transcultural aspects of PDs made by experts was included in the DSM-IV, and important aspects such as self-image and adjustment were not sufficiently taken into consideration.

4 4 Psychological Reports 0(0) Data on sex differences in the prevalence of PDs are inconsistent, sometimes sex differences are not reported, e.g., Crawford et al. (2005), whereas other researchers show differences in the specific PDs and in the clusters of PDs among men and women. Corbitt and Widiger (1995) found that men are diagnosed more often with schizoid and antisocial PDs, while women are diagnosed with dependent, borderline, and histrionic PDs. Cluster A disorders, which fall in the schizophrenic spectrum, are more common in men (Paris, 2004). Schizotypal PD (average 3.9%) is significantly greater among men (4.2%) than women (3.7%) (Pulay et al., 2009). Cluster A differences are caused by the schizoid PD which is more frequent in men. The results for Cluster B (dramatic) are also different between men and women because of the presence of antisocial PD which is much more common in men. The prevalence of APD is relatively stable at about 2%: about 3% among men and 1% 2% among women in the USA (American Psychiatric Association, 2000). Borderline PD is more common in women (Paris, 2004); however, not every study reports significant differences in rate of borderline PD among men (5.9%) and women (6.2%) (Grant et al., 2008). Cluster C anxious disorders are equally distributed among men and women; however, dependent PD is more prevalent in women and obsessive-compulsive PD is more common in men (American Psychiatric Association, 2000; Paris, 2004). The sex differences in the prevalence of PDs seem to be constant across countries. Researchers argued that gender differences in normal personality traits could affect gender differences found in the prevalence of PDs (Klonsky, Jane, Turkheimer, & Oltmanns, 2002). Even some critics state that the differential prevalence of PDs among men and women may be a function of gender biases (Jane, Oltmanns, South, & Turkheimer, 2007). In contrast to the culture-relativistic position of cultural psychiatry, there are studies which show a culture-independent applicability of the construct of Axis II of the DSM-IV (Yang, McCrea, & Costa, 2000). Due to the relatively constant rates of PDs in community population, researchers suggest that PDs should be analyzed in terms of their neurobiological determinants (Buss, 2009). The evolutionary perspective assumes that PDs traits can be conceptualized as stable evolutionary strategies which respond to environment and social interactions (Buss, 2009). Personality traits reflect differences in the effectiveness with which people adopt different strategies in complex social interactions. Sociality is a major cause of personality variation; the complex combination of selective pressures accounts for the strategic mix of heritability and environment in human personality development (Figueredo, Hammond, & McKiernan, 2006). From evolutionary perspective also, emotions and dysfunctional emotions incorporated in PDs play an adaptive role, e.g., depression may be an integral part of adaptive syndrome, it facilitates disengagement (Nesse, 1998). Emotional impairments are present in every PD; however, they manifest themselves differently. For instance, in borderline PD, emotional instability may be an adaptive strategy to increase quick responses in dangerous situations

5 Gawda and Czubak 5 (Molina et al., 2009). Similarly, other PDs can be conceptualized as a stable strategy adopted to deal with painful situations (Molina et al., 2009). Hypotheses Taking into account the abovementioned concerns, the study was conducted on large community sample. The first aim of our study was to establish the prevalence of PDs in a Polish sample. The second aim was to examine sex differences in the prevalence of PDs. Basing on the abovementioned literature, we hypothesize that the prevalence of PDs will rate similarly to the other European and North American countries and that sex differences in PDs will be as in those countries. We also assume that obsessive-compulsive PD will be the most prevalent in the community sample. This is potentially associated with the influence of modern society on human personality development and formations of its pathological patterns. The social requirements and expectations for the individual have increased enormously in modern countries; thus, identity and adjustment of the individual has influenced this and can lead to changes of mood, instability, and so on which may be attributed to a PD (Paris, 2004). Method Participants A sample of 2500 individuals was selected from a general healthy nonclinical population in Poland aged between 18 to 65 years on the basis of random selection (the cluster sampling technique). A Wald Wolfowitz test was used to verify a randomness of the sample, the test confirmed the randomness of the sample at p ¼.05. Participants completed the phase I questionnaires (I stage the screening procedure). Many persons were not included in the main investigation (II stage) because they did not give their consent to finish phase I of the study, they were medically ill or psychiatrically ill, they had language/speech or other problems, or they refused to the interview during the phase II of the study. In sum, a sample of 1460 persons completed the phase II interview (they were interviewed with the SCID-II). Participants were excluded after the screening procedure if they had been diagnosed of any other mental disorders. Diagnosis of PDs through the DSM-IV requires that PD patterns are not caused by psychotic, medical, or other mental disorders. In fact, it is obviously known that PDs co-occur with many other disorders. To respect the DSM-IV diagnostic criteria, we exclude people with high scores in the Mini International Neuropsychiatric Interview (M.I.N.I.) which means people with psychotic disorders, major depressive disorder, manic episodes, alcohol dependent, substance dependent, and with any brain damage. The inclusion criteria were age between 18 and 65, absence of pharmacological treatment for at least one month, absence of other

6 6 Psychological Reports 0(0) psychiatric disorders such as psychotic disorders (interviewed with M.I.N.I. Sheehan et al., 1998), and absence of acute neurological and somatic disorders. All of the participants were Caucasian as regards ethnicity. They were in almost equal proportions of men and women. They reported that their socio-economic status was in majority middle (low: 3.8%, middle 80.2%, high: 16%). Measures Structured Clinical Interview for Personality Disorder Testing for axis II of DSM-IV (SCID- II) (First, Gibbon, Spitzer, Williams, & Benjamin, 1997). It is a standardized tool which allows for the diagnosis of 10 PDs in accordance with DSM-IV, plus two additional disorders. The psychometric parameters of this tool are appropriate (First et al., 1997). The Polish adaptation of SCID-II edited by Zawadzki, Popiel, and Praglowska (First et al., 2010) has good reliability; a Cronbach s alpha is in the range between.72 and.81 for different PDs subscales. We used the Polish version of the SCID-II, translated and adapted to the Polish language. This is an official standard adaptation of the SCID-II (First et al., 2010). The 12 scales of the PDs were used in the study. We used SCID-II for DSM-IV because this research was started in 2012 when the DSM-V was not yet available (American Psychiatric Association, 2013). The variables were categorical when estimating the prevalence rates, and numeric when factor analysis was conducted. The Mini International Neuropsychiatric Interview. M.I.N.I. is a short diagnostic structured interview developed for DSM-IV and ICD-10 (Sheehan et al., 1998). It assesses the following disorders: Major Depressive Disorder, Dysthymia, Suicidality, Manic episode, Panic disorder, Agoraphobia, Social Phobia, Obsessive-compulsive disorder, Post-traumatic stress disorder, Alcohol dependence, Substance dependence, Psychotic disorders, Anorexia nervosa, Bulimia, Generalized anxiety disorder, and Antisocial PD (Sheehan et al., 1998). The research supported the inter-rater reliability, reliability, and validity of MINI (Sheehan et al., 1997). This technique has been used in order to exclude individuals with psychotic disorders, alcohol and substance dependence, major depressive disorder, and manic episodes. In this way, we followed the diagnostic criteria for PDs of the DSM-IV, especially E criterion which states that the enduring pattern is not better accounted for as a manifestation or consequence of another mental disorders, and the F criterion the enduring pattern is not due to the direct physiological effects of a substance or a general medical condition (e.g., head trauma) (American Psychiatric Association, 2000, p. 276). Procedure Participants gave their written consent to participation in the study according to the guidelines approved by the local ethic committee. The study consisted of two

7 Gawda and Czubak 7 stages: stage I a screening stage (use of M.I.N.I. and demographic data questionnaire) and stage II (PD assessment with use of the Polish version of SCID-II). All interviews were conducted face-to-face by the trained graduate psychologists. Inter-rate reliability between interviewers was assessed by computing a W-Kendall. Reliability for the interviewers was good enough; W-Kendall ¼.99, p <.001. The prevalence rates for specific PDs were calculated as the percentage of people who have obtained the scores above the thresholds (cut-off points) according to the SCID-II. The overall rates of the prevalence of PDs in the population were estimated as the weighted percentage of all PDs including the co-occurrence of PDs. We have taken into account the cooccurrence of PDs because it was common that an individual had high scores (above the threshold) in two, three, or more PDs (Lenzenweger, 2008). We found three main groups of the co-occurred PDs. We calculated the mean percentage for each of the groups of the co-occurring PDs. These three means were then summed up together to obtain the overall score. Results The purpose of this study was to establish the prevalence of PDs in the general population and then to examine sex differences in PDs. Additionally, we want to show whether the PDs form the same three clusters as in the DSM-IV between men and women. That is why we aim to compare the putative similarities between PDs rates and clusters with other studies from literature. Prevalence was estimated by calculating the occurrence percentage for the whole sample and for women and men separately. We found PDs rates at about 8.9% which means that about 9% of general population displays at least one PD. The most prevalent PDs in the Polish population are obsessivecompulsive (9.66%), narcissistic (7.05%), and borderline (7.35%) (see Table 1). The less prevalent PDs are antisocial (1.62%), histrionic (1.15%), and schizoid and schizotypal (2.10% and 2.13%, respectively). The results are presented in Table 1. Significant differences in the prevalence of PDs between men and women were found. Avoidant, dependent, obsessive-compulsive, depressive, and borderline PDs are more common among women, whereas antisocial, schizotypal and schizoid PDs are more common among men. An additionally conducted factor analysis revealed that 12 PDs form three main factors (these three clusters explain in sum about 60% of variance, Kaiser-Meyer-Olkin Measure of Sampling Adequacy ¼.886, Bartlett s test of sphericity: ¼ ; p <.001). The three PDs factors in men differ from the three PDs factors in women, and furthermore, these three main factors are different than those from the DSM s. In men, the largest factor (factor no 1) comprises six PDs such as avoidant, dependent, obsessive-compulsive, passiveaggressive, histrionic, and borderline. It is partly similar to Cluster C anxiousfearful disorders and Cluster B dramatic disorders. Factor 2 contains

8 8 Psychological Reports 0(0) Table 1. Prevalence of PDs in a Polish community sample (n ¼ 1460). Personality disorders M (for PDs traits S.E. Women (n ¼ 760) % Men (n ¼ 700) % F (1,1458) % with at least one PD Avoidant * 3.60 Dependent ** 4.49 Obsessive-compulsive , * 9.66 Passive-aggressive Depressive ** 4.27 Paranoid Schizotypal ** 2.13 Schizoid ** 2.10 Histrionic Narcissistic Borderline *** 7.35 Antisocial ** 1.62 Total weighted % 8.9 M: means; S.E.: standard errors; PD: personality disorders. The bold items indicate the highest percent. *p <.05, **p <.01, ***p <.001 paranoid, schizotypal, and schizoid PDs which is identical to Cluster A from DSM-IV. And factor 3 comprises antisocial and narcissistic PDs which are similar to Cluster B (see Table 2). Three different factors were identified in women. Factor 1 was mostly loaded by five PDs such as avoidant, dependent, passive-aggressive, depressive, and borderline which is similar to Cluster C from the DSM-IV. Factor 2 was mostly found with histrionic and narcissistic PDs which is similar to Cluster B dramatic PDs. Factor 3 was loaded by antisocial and schizoid PDs traits (see Table 3). Discussion We examined a large nonclinical sample in four years. We conclude that PDs are prevalent at a similar level as in North American and other European countries; the overall rate is about 9%. Although this is the first study on a Polish community and there are little data to refer to from other Central European countries, the presented results are in line with previous data reporting that the community prevalence of PDs range from 3% to 10% (de Girolamo & Dotto, 2000; Grant et al., 2008). It supports the statement that PDs have relatively consistent rates in community samples (Fowler et al., 2007). Our findings on

9 Gawda and Czubak 9 Table 2. Factor analysis for PDs traits in men (n ¼ 700). Personality disorders Factor 1 Factor 2 Factor 3 Avoidant Dependent Obsessive-compulsive Passive-aggressive Depressive Paranoid Schizotypal Schizoid Histrionic Narcissistic Borderline Antisocial PD: personality disorders. The bold items indicate the highest factor loadings. Table 3. Factor analysis for PDs traits in women (n ¼ 1460). Personality disorders Factor 1 Factor 2 Factor 3 Avoidant Dependent Obsessive-compulsive Passive-aggressive Depressive Paranoid Schizotypal Schizoid Histrionic Narcissistic Borderline Antisocial PD: personality disorders. The bold items indicate the highest factor loadings. sex differences in the prevalence of PDs are also similar to those presented in the literature. Antisocial, schizotypal, and schizoid PDs are more common among men (Corbitt & Widiger, 1995; Paris, 2004), whereas avoidant, dependent, depressive, and borderline PDs are all more common among women (American Psychiatric Association, 2000; Fowler et al., 2007; Grant et al.,

10 10 Psychological Reports 0(0) 2008; Paris, 2004). Then, our results are consistent with the data which reports that one of the most prevalent PDs is obsessive-compulsive, especially in Germany, Great Britain, Norway, Sweden, and in the USA (Grant et al., 2004; Torgersen et al., 2001). The high prevalence of obsessive-compulsive PD is potentially due to the social requirements and expectations for the individual which have been rising in modern societies (Paris, 2004). It is possible that identity and adjustment of the individual is influenced by these requirements and lead to changes of mood, instability, and attribute to some PDs traits (Paris, 2004). Modern societies demand a high measure of responsibility and perfection and require people to create and arrange their social roles. This may evoke inner conflicts, experience of being maladjusted and form background for PD behavior, e.g., cultural components of Japan is perfectionism, carefulness, and orderliness (Chang, 1995). Similar patterns are observed in European societies (Calliess et al., 2008). These cultural patterns may influence an increase of obsessive-compulsive traits of PD. That is why the increased anxious-fearful PDs (Cluster C) are reported here and in other European and North American countries (Bodlund et al., 1993; Coid et al., 2006; Maier et al., 1992). Likewise, this may refer to the found high prevalence of borderline PD which has been reported as worldwide the highest (Loranger et al., 1997). High rate for narcissistic PD is also consistent with worldwide tendency of increasing of subclinical narcissism and narcissistic traits (MacDonald, 2014). Researchers stated that narcissism reached epidemic proportions (MacDonald, 2014; Twenge & Campbell, 2009). The high prevalence of narcissistic PD may also reflect some cultural aspect of Polish community as the higher average score on covert narcissism has been found in Polish sample in comparison to Dutch sample (Zondag, Van Halen, & Wojtkowiak, 2009). As the categorical diagnosis based on binary choice through DSM-IV was criticized in much previous research (Grant et al., 2004; Tyrer et al., 2010), we focused on PDs traits as dimensional variables at the second stage of our analyses. Furthermore, there are more aspects of the DSM-IV which have been criticized. Although reports show that 3% 10% of adult populations in various countries of the world have a PD, only a minority of these display a severe PD (Tyrer et al., 2010). It means that severity of PDs is not considered in the DSM- IV classification which has been criticized. Next, this classification generates comorbidity of several PDs across different clusters (Tyrer et al., 2010). Thus, the assessment of PDs means that a person displays the different PDs traits. PD patterns partly overlap which is unhelpful. Then, the frequent use of PD not otherwise specified documents that this classification is unhelpful (Bernstein, Iscan, & Maser, 2007). Thus, researchers suggest dimensional approach to PDs instead of categorical typical to DSM-IV. These ideas have been considered in the DSM-V (Moran, Rooney, Tyrer, & Coid, 2016). In such a situation, we aimed to demonstrate whether PDs clusters are similar in men and women. We expected that this analysis helps to understand the mechanism of the

11 Gawda and Czubak 11 differentiation in PDs between men and women. We established that PDs traits did not form the identical three clusters to the clusters in DSM-IV/DSM-V, neither in men nor in women. Three independent PDs clusters identified in men were more clear in terms of the DSM-V clusters. Cluster 1/Factor 1 was similar to the Cluster B dramatic and the Clusters C anxious/fearful disorders. Factor 2 was clearly identical to Cluster A odd/eccentric disorders, and factor 3 comprises PDs from the Cluster B. It reveals that three factors are not independent, PDs are inter-correlated, and there are disorders belonging to different clusters from the DSM-V in one factor. In women, there are no clear clusters as in the DSM-IV/V either; in the Factor 1, there are PDs from B and C clusters. Similarly, Factor 2 comprises disorders from Clusters B, and Factor 3 contains schizoid and antisocial PDs which belong to the different DSM s clusters such as odd/eccentric and dramatic. It suggests that criteria for PDs considerably overlap which was highlighted in the literature (Tyrer et al., 2010). Then, possibly another mechanism regulates the relationship between disorders and behavior in the two sexes. Typical anxious disorders such as dependent, depressive, and obsessive-compulsive are inter-correlated with borderline PD in women, while antisocial is related among women to schizoid PD. The last connection suggests that in women both antisocial and schizoid behaviors are understood as a sign of independence, whereas histrionic disorder is related to narcissistic behavior. Possibly, for women, both histrionic and narcissistic disorders have a common binding mechanism which is low self-esteem. For men, histrionic behavior is clearly linked to anxious-fearful disorders; histrionic behavior is not typical for men. It shows that there are the potential behavioral patterns differentiating men from women. First, this differential prevalence may be a function of gender biases as suggested by Jane et al. (2007). Second, the similarity in our findings to the data from literature on sex differences in PDs suggests culture-independent evolutionary interpretation. If we conceptualize PDs from evolutionary perspective as different strategies to adapt to the complex social interactions (Figueredo et al., 2006), we may interpret our findings on sex differences as a result of differences in adaptation to social roles (Buss, 2009). The human social behavioral system thesis is one of the evolutionary approaches which enables to describe personality pathology. Pathological behavior as the interactions between four behavioral systems: attachment, care-giving, dominance, and sexual (Leedom, 2014). The four human behavioral systems organize information processing, emotions, learning, and goal-directed behavior (Leedom, 2014). The neural basis of these systems is under regulation of and in turn regulates specific hormones (Leedom, 2014, p. 5). Disruption of these systems causes psychopathology. Hence, antisocial PD is linked to a disruption in social reward, empathy, care-giving behavioral system, and excessive dominance behavioral system (Leedom, 2014). Common for men aggressive behavior is comorbid with antisocial tendencies and related to the excessive dominance behavioral system (Johnson, Leedom, & Muhtadie, 2012). In schizoid

12 12 Psychological Reports 0(0) personality, attachment behavioral system is not present. Dependent and borderline PDs more common in women are associated with disorganized emotionality and deficient attachment behavioral system, whereas loss of attachment is related to depressive behavior (Leedom, 2014). Women displayed PDs from Cluster C anxious-fearful and Cluster B dramatic PDs more often. It may be explained in terms of different emotionality in women than in men formed as a result of adaptive behavioral systems. Women are more emotional; they have a tendency toward negative affectivity, more frequently experience fear and higher anxiety than men, use negative strategies for solving problems, have positive attitudes toward anxiety, and use cognitive avoidance (Ben-Zur & Zeidner, 1988; Robichaud & Dugas, 2002). The affect-intensity hypothesis posits that women experience life more intensely and encode emotions better in memory, and the cognitive-style hypothesis posits that women use different strategies for encoding, recalling, as well as generating affective information (Fujita, Diener, & Sandvik, 1991; Seidlitz & Diener, 1998). These affective characteristics are associated with neural mechanisms; more brain regions are correlated with emotional processing, subjective emotional experience, and encoding affective experience in memory in women (Canli, Desmond, Zhao, & Gabrieli, 2002). This may also result in the differences in personality pathology in men and women. Conclusions The evidence on the prevalence of PDs in the community sample of Poland shows that obsessive-compulsive, narcissistic, and borderline are the most prevalent PDs in this population. The overall rates of PDs and rates on sex differences in PDs are similar to those in other European countries and North America. PD traits did not form the identical three clusters as in the DSM-IV/DSM-V among men and women. It suggests a difference of mechanism underlying personality pathology in men and women which has been explained in terms of a cultureindependent evolutionary approach. And it shows that diagnostic criteria for PDs overlap causing problems in the differentiation of specific PDs and consequently in treatment (Chiesa, Fonagy, Holmes, Drahorad, & Harrison-Hall, 2002; Mulder, 2002). Possibly, the current effort to identify the core features of PDs and the use of four independent factors of PDs will help more in the assessment of PDs than DSM-IV classification (Tyrer et al., 2010). The alternative model of PDs proposed in the DSM-V attempts to introduce structured and multidimensional definition of PDs seems to be promising (Moran et al., 2016). Limitations The overestimation (or incorrect estimation) of PDs in our study is possible. A first potential cause of the incorrect estimation is the lack of Polish normative data of PDs by the SCID-II. This is the first study on the prevalence of PDs in

13 Gawda and Czubak 13 Poland with use of the SCID-II and as we do not have Polish normative data, we used the APA thresholds (cut-off points) to establish PDs. The second potential cause of overestimation (or incorrect estimation) of PDs is considerable cooccurrence of PDs. Although we try to find the way of estimation including co-occurrence of PDs, much more associations between PDs than those we have taken into account may exist. For instance, scores under cut-off points of one PD may interact with other PDs. In general, this is serious problem in many studies focusing on the estimation of the prevalence of PDs. We realize that it is impossible to consider all associations between PDs and that this is potentially the main cause of the overestimation of some PDs in populations. Future directions Suggestion for future research is to replicate the current data with use of the DSM-V tool and to establish the core PDs traits which do not overlap. We realize that now the main problem of the assessment of PDs is co-occurrence of PDs, and thus determining the independent patterns of PDs is crucial. Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. Funding The author(s) received no financial support for the research, authorship, and/or publication of this article. References Alarcon, R. (1996). Personality disorders and culture in DSM-IV: A critique. Journal of Personality Disorder, 10, American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (DSM-4 th ed.). Washington, DC: American Psychiatric Press. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders -5th edition. Washington, DC: Author. Ben-Zur, H., & Zeidner, M. (1988). Sex differences in anxiety, curiosity, and anger: A cross-cultural study. Sex Roles, 19, Bernstein, D. P., Iscan, C., & Maser, J. (2007). Opinions of personality disorder experts regarding the DSM-IV personality d disorders classification. Journal of Personality Disorders, 21, Bhugra, D., & Bhui, K. (2001). Cross-cultural psychiatry: A practical guide. London, England: Arnold. Bodlund, O., Ekselius, L., & Lindstro m, E. (1993). Personality traits and disorders among psychiatric outpatients and normal subjects on the basis of the SCID screen questionnaire. Nordic Journal of Psychiatry, 47,

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17 Gawda and Czubak 17 Tyrer, P., Mulder, R., Crawford, M., Newton-Howes, G., Simonsen, E., & Ndetei, D. (2010). Personality disorder: A new global perspective. World Psychiatry, 9, Yang, J., McCrea, R. R., & Costa, P. T. (2000). The cross-cultural generalizability of Axis-II construct: An evaluation of two personality disorder assessment instruments in the People s Republic of China. Journal of Personality Disorders, 14, Zimmerman, M., Rothschild, L., & Chelminski, I. (2005). The prevalence of DSM-IV personality disorders in psychiatric outpatients. American Journal of Psychiatry, 162, Zondag, H. J., Van Halen, C., & Wojtkowiak, J. (2009). Overt and covert narcissism in Poland and The Netherland. Psychological Reports, 104(3), Author Biographies Barbara Gawda is an associative Professor in Psychology at the University of Maria Curie- Sklodowska in Lublin, Poland. She received her PhD in Psychology in 1998 from the University of Maria Curie-Sklodowska. Her publications are focused on personality disorders, emotions and motivation, psycholinguistics. She has published many scientific articles and books. Katarzyna Czubak is an assistant at the Catholic University of John Paul II in Lublin, Poland. She received her PhD in Psychology in 2016 from University of Maria Curie-Sklodowska.