Today I am going to blog about personality disorders, which clinically may be one of the most divisive diagnoses; both for patients and staff. In my experience, some patients can feel stigmatised by the diagnosis and some staff can develop malignant alienation; as outlined by Watts and Morgan in the paper with the subheading ‘Dangers for patients who are hard to like’ (Watts 1994).
There are however groups of people championing people with ‘personality disorder’ and the Mental Elf has collaborated with the British and Irish Group for the Study of Personality Disorder (BIGSPD) and launched a series of short videos sharing highlights from their 2025 conference in Liverpool. This community of professionals are interested in widening the understanding of ‘personality disorder’ and complex emotional and relational needs.
It therefore feels timely to share this paper published in December 2025 in Lancet Psychiatry, which looks at the global epidemiology of ‘personality disorder’ and the results may not be exactly what you expect!
Shahid et al completed a global systematic review and meta-regression of population-based surveys in relation to any of the potential diagnostic ‘personality disorders’ within DSM or ICD-10. The paper looks at the prevalence, mortality, and diagnostic stability of ‘personality disorders’ using population-representative data across high income countries (HICs) and low to middle income countries (LMIC).
Explore the ‘personality disorders’ videos recorded at the 2025 BIGSPD conference in Liverpool.
Methods
PRISMA and GATHER guidelines were followed in relation to paper selection. Papers were identified between the years of 1980 and 2024, looking for cross-sectional or longitudinal studies in peer-reviewed journals reporting prevalence or mortality associated with any ‘personality disorder’. Papers were excluded if they relied on self-reports or non-representative samples.
Study quality was assessed using the Joanna Briggs Institute critical appraisal tools. Meta-regression analyses were completed to estimate the prevalence and standardised mortality ratios associated with ‘personality disorder’.
Results
60 studies across 28 countries were identified, representing 139,373 individuals for prevalence and 392,420 individuals for mortality.
Prevalence
- HICs 5.2% (95% uncertainty interval 3.7 to 7.3).
- LMICs 4.1% (95% uncertainty interval 2.8 to 6.0) p=0.013.
Although, note the overlapping 95% uncertainty intervals implying the true result could be anywhere within that range.
- Prevalence was significantly higher among men compared to women (p<0.0001) and in younger than older age (p<0.0001).
- Diagnostic criteria and interviewer qualifications influenced prevalence estimates, with use of ICD-10 being associated with lower prevalence than DSM, and administration by mental health professionals overestimating prevalence when compared to what were described as ‘experienced clinicians’.
Mortality
- ‘Personality disorders’ were associated with elevated mortality, with inpatients showing the highest risk (standardized mortality ratio [SMR] of 4.7).
- Outpatients had lower mortality risk (SMR of 1.8), while combined inpatient and outpatient samples had an SMR of 2.2.
- Mortality risk decreased with age and was higher among men than women.
Diagnostic stability
- ‘Personality disorders’ showed moderate diagnostic stability, with rates ranging from 34.1% to 73% depending on follow-up duration (the shorter the duration the higher the stability).
- Stability tended to decline over longer periods, potentially reflecting symptom improvement over time.
Between-study heterogeneity was very high for prevalence (I2=98·8%) and mortality (I2=99·4%) and study quality assessment indicated that 59 studies were of high quality, with only one study of moderate quality. In addition, publication bias was identified in prevalence analyses.
Personality disorders are more common in higher income countries than low and middle income countries.
Conclusions
The authors concluded that:
Personality disorder is common, associated with premature mortality, and diagnostically stable, yet remains excluded from the Global Burden of Diseases, Injuries, and Risk Factors Study.
We provide a comprehensive synthesis of personality disorder epidemiology, offering the foundation needed to inform future global estimates and policy responses.
Strengths and limitations
This paper does reflect a very comprehensive view of global data in relation to ‘personality disorder’; however this has flagged some problems with the available evidence base:
- No eligible data was identified after 2014, which reduced the timeliness of finding.
- There is limited data from LMICs which restricts the generalisability of findings.
- Publication bias was detected in prevalence analyses, potentially inflating pooled prevalence estimates.
- Excess mortality data was scarce, with most of these in HICs.
- Diagnostic stability data were limited to clinical samples, which may overrepresent severe cases.
- Significant heterogeneity related to study design, diagnostic methods and sample characteristics.
To try and minimise the impact of the data set, the study did have robust criteria, and included a wide range of countries and sets a good benchmark in which to further develop research.
Significant heterogeneity was found in the studies, limiting the reliability of results.
Implications for practice
This study provides a comprehensive review of ‘personality disorder’ epidemiology to date, revealing its significant prevalence, diagnostic stability, and association with elevated mortality although caveated with a range of data limitations.
Within clinical services it wouldn’t be unusual for staff to surmise that borderline personality disorder (BPD) is more common in females and antisocial personality disorder is more common in men, however in these community-based studies the sex differences are minimal and this needs to be considered in day to day practice.
The authors have highlighted that the prevalence rates of personality disorder identified in this study are similar to the global point prevalence identified for anxiety in the Global Burden of Disease study 2021 and higher than depressive disorder (2.9%). However, personality disorder does not seem to get as much ‘airtime’ as the other conditions and indeed isn’t included within the GBD studies or evident in public health initiatives and service planning. Does this come back to stigma and malignant alienation except at a much wider scale?
The findings highlight the need for improved data collection, global recognition, and tailored mental health services to address the burden of personality disorders effectively.
Future research should focus on underrepresented regions, adopt dimensional diagnostic frameworks, and explore age-specific patterns of remission and stability.
The findings highlight the need for improved data collection, global recognition, and tailored mental health services to address the burden of personality disorders effectively.
Statement of interests
Dr Kirsten Lawson has no conflict of interests to declare. AI was not used in the development of this blog.
Edited by
Dr Simon Bradstreet.
Links
Primary paper
Shadid, J., Ferrari, A.J., Bach, B., Sellbom, M., Sharp, C., Hutsebaut, J., d’Huart, D., Santomauro, D.F., & Chanen, A. (2025) The global epidemiology of personality disorder: a systematic review and meta-regression. The Lancet Psychiatry 2025 12(12) 932 – 946
Other references
Watts, D & Morgan, G. (1994). Malignant alienation. Dangers for patients who are hard to like. The British Journal of Psychiatry 1994 164(1) 11–15
