Adult Psychiatric Morbidity Survey: Survey of Mental Health and Wellbeing, England, 2023/4

Personality disorders are described in diagnostic systems as enduring patterns of thoughts, feelings, and behaviours that deviate from cultural expectations, are pervasive and inflexible, and lead to distress or impairment in functioning. How personality disorders are classified, and whether the diagnosis is a valid or helpful way to describe a person’s difficulties, is complex and contested. Nonetheless, the association between meeting diagnostic criteria for personality disorder and substantial long-term distress and health and societal impact, makes investigation of their prevalence a public health concern.

The Structured Clinical Interview for the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) Personality Disorders Questionnaire (SCID-II Q) was used in the self-completion section of the phase one interview, to screen for antisocial personality disorder (ASPD) and borderline personality disorder (BPD) traits. ASPD is defined as a pervasive pattern of disregard for and violation of the rights of others in people aged at least 18, which has persisted since the age of 15. BPD is defined as a pervasive pattern of instability in interpersonal relationships, self-image, and emotional regulation, coupled with marked impulsivity.

Personality disorder (PD) has also been conceptualised under the International Classification of Diseases (ICD-11) as a unitary syndrome, characterised by core interpersonal dysfunction and the presence of a range of other traits. The Standardised Assessment of Personality: Abbreviated Scale (SAPAS) was therefore also used on APMS to screen for ‘general PD traits’. A positive screen indicated that someone may have sufficient relevant traits to warrant further investigation.

• One adult in fifty reported ASPD traits. 2.0% of adults aged 18 and over screened positive for ASPD on the SCID-II Q. Men (2.9%) were more likely than women (1.2%) to screen positive for ASPD.
• Nearly one adult in fifty reported BPD traits. 1.9% of adults aged 16 and over screened positive for BPD on the SCID-II Q. Women were more likely to screen positive for BPD (2.5%) than men (1.3%).
• One adult in seven reported general PD traits. 14.9% of adults screened positive for general PD traits using the SAPAS. Prevalence was similar for men (14.0%) and women (15.6%).
• The general population prevalence of ASPD, BPD and general PD traits remained stable over time. The proportion of 18 to 64 year olds screening positive for ASPD remained fairly stable between 2014 and 2023/4. The proportion of 16 to 64 year olds screening positive for BPD also remained stable, as did the proportion of all adults (16 and over) with general PD traits.
• People reporting PD traits often experienced socioeconomic adversity. Screening positive for ASPD, BPD and general PD traits were all more common among people struggling with debt or who were unemployed.
• PD traits were common in people with depression or an anxiety disorder. Over a third of adults (37.6%) with a common mental health condition screened positive for general PD traits, compared with 8.7% of adults without a common mental health condition.
• Within the general population, a minority of people reporting PD traits received mental health treatment. About two thirds of adults screening positive for ASPD (62.1%) or general personality disorder traits (66.1%) and half of those who screened positive for BPD (47.8%) were not receiving any treatment for a mental or emotional problem or disorder.
• For those who did receive treatment, this was more likely to consist of medication rather than psychological therapy. People screening positive for ASPD, BPD and general PD traits, were all about twice as likely to be in receipt of mental health medication than psychological therapy.

Personality disorders are described in international diagnostic systems as a group of mental health conditions characterised by enduring patterns of thoughts, feelings, and behaviours that deviate significantly from cultural expectations, are pervasive and inflexible, and lead to distress or impairment in social, occupational, or other areas of functioning. People receiving a diagnosis of personality disorder often experience stigma within the healthcare system (Foye et al. 2022). It has been argued that the diagnostic construct itself contributes to this stigma and causes harm (Watts 2019). Nonetheless, the association between meeting diagnostic criteria for personality disorders, and substantial long-term distress, health and societal impacts, makes investigation of their prevalence and associations a public health concern.

People meeting diagnostic criteria for personality disorder (PD) often experience enduring difficulties in relationships with others (Skodol et al. 2005). Along with substantial social difficulties (Moran et al. 2016; Yang et al. 2010), people meeting diagnostic criteria for PD also experience poor general health and reduced life expectancy (Ekselius 2018). It has been argued that antisocial personality disorder (ASPD) and borderline personality disorder (BPD) are types of PD with particular relevance to society and the health service (Coid et al. 2006). This is because meeting diagnostic criteria for either condition is associated with substantial health and economic burden on affected individuals, their families and wider society (Coid et al. 2009).

People who meet diagnostic criteria for PD often also experience mood and anxiety disorders (Grant et al. 2005; Leichsenring et al. 2023, Shah et al. 2023). However, research shows that, even after accounting for the effects of concurrent mood and anxiety disorder, screening positive for PD is an independent risk factor for poor future mental health and serious relational difficulties (Moran et al. 2016). Therefore, mapping the prevalence and correlates of PD traits among the general population may help to identify a subsection who are at particularly high risk of future health problems.

Antisocial personality disorder (ASPD)

The diagnostic criteria for ASPD describe a pattern of impulsive, aggressive and irresponsible behaviour, and a disregard for the rights of others, emerging in childhood or early adolescence (Goldstein et al. 2006). The diagnostic criteria have been criticised as difficult to distinguish from general antisocial behaviour, and hence in danger of being over-applied to individuals in the criminal justice system, alongside the broader issues of the medicalisation of criminality, stigma, and potential neglect of the role of social structures (Pickersgill 2009; Jones 2023; Wayland et al. 2013). Conversely, the UK National Offender Personality Disorder Pathway for offenders deemed likely to have a personality disorder, has enabled access to psychological formulation and interventions for thousands of prisoners (Vamvakas et al. 2024, Skett and Lewis 2019). About half of the offenders accessing the Pathway are likely to meet diagnostic criteria for ASPD (Bali et al. 2023).

In general population studies, meeting diagnostic criteria for ASPD is associated with increased morbidity and mortality due, among other things, to increased rates of injury from assaults, alcohol and drug use, suicidal behaviour, and road accidents (Krasnova et al. 2019; Shepherd and Farrington 2003; Ullrich and Coid 2009), along with increased deaths from health conditions such as chronic lower respiratory disease and cancer (Krasnova et al. 2019).

In the general population, the estimated prevalence of ASPD varies with diagnostic classification system, method of assessment and place (for example, the rate is higher in urban than rural areas (Coid et al. 2006)). Despite these differences, there is similarity in the estimates generated by community surveys of PD based on full clinical assessment: 0.7% of 18 to 65 year olds in Oslo, Norway (Torgersen et al. 2001), 0.6% in the US (Lenzenweger et al. 2007), and 0.3% in England (McManus et al. 2009). Compared with women, men are more likely to meet diagnostic criteria for ASPD. People meeting criteria for ASPD have often grown up in families where parenting was characterised by conflict and inconsistency, with care sometimes transferred to outside agencies (Holmes et al. 2001; Black et al. 1995). There is a strong association with experiences of emotional, sexual and physical abuse in childhood (DeLisi et al. 2019; Schorr et al. 2021). Meeting diagnostic criteria for ASPD is associated with multiple medical and social problems, including low educational attainment, substance misuse, self-harm and crime (Moran et al. 2001; Moran et al. 2016).

While the diagnosis of ASPD is conceptually distinct from general antisocial behaviour, Diagnostic and Statistical Manual of Mental Disorders (DSM-IV and 5) (APA 1994; 2013) criteria require childhood antisocial behaviour (to the level of conduct disorder) for the full diagnosis in adulthood. The evidence for working with children and young people who are at risk, and their families, points to the potential value of preventative measures (National Institute for Health and Care Excellence (NICE) 2013). Criminality is strongly associated with, but not essential for, the diagnosis of ASPD, which includes a broad range of antisocial behaviours and personality traits. The prevalence of ASPD among prisoners is very high: 63% of male remand prisoners and 49% of male sentenced prisoners were assessed to have ASPD (Singleton et al. 1998). In the general population, 36.9% of people who have been in prison screen positive for ASPD, which is ten times higher than the rest of the population (Bebbington et al. 2021). People meeting diagnostic criteria for the disorder account for a disproportionately large proportion of crime and violence committed.

The extended harm and costs associated with meeting diagnostic criteria for ASPD include high levels of personal injury and financial damage to victims, as well as increased costs of policing, and the impact on the criminal justice system and prison services (Welsh et al. 2008). Additional costs linked to ASPD include increased use of healthcare, lost employment opportunities, and family breakdown.

Despite the societal and personal impacts, there is limited evidence of effective treatments for people meeting diagnostic criteria for ASPD (van den Bosch et al. 2018). NICE guidelines outline treatment options, focusing on treatment for any comorbid disorders and psychological interventions such as group-based cognitive and behavioural therapies and alcohol or substance use therapy. NICE recommends that pharmacological interventions should not be routinely used for the treatment of ASPD or its associated behaviours. Where they are used for comorbid conditions, it is recommended that attention is paid to levels of adherence and risks of misuse or overdose (NICE 2013). More recent research has shown that Mentalisation-Based Treatment may be an effective intervention for individuals with antisocial personality disorder within forensic populations (Fonagy et al. 2025).

Borderline personality disorder (BPD)

BPD, also unofficially yet frequently referred to in the UK as emotionally unstable personality disorder (EUPD), is defined as a pervasive pattern of instability in interpersonal relationships, self-image, and emotional regulation, coupled with marked impulsivity. People meeting diagnostic criteria for BPD may have severe difficulties with sustaining relationships and experience high rates of self-harm and suicidal behaviour (Paris 2019). It has been argued that the diagnosis of BPD lacks coherence and construct validity (Tyrer 2009; Tyrer et al. 2019), and that it may lead to stigma, testimonial injustice, denial of victimhood and re-traumatisation when applied to trauma survivors (Hartley et al. 2022; Lomani 2022; Watts 2024a; Watts 2024b). While trauma is an important risk factor for developing all types of mental health difficulties, BPD has been found to be three times more strongly associated with a history of childhood trauma than other psychiatric diagnoses, including mood disorders, other personality disorders, and psychosis (Porter et al. 2020). Trauma is more strongly associated with BPD in clinical than in general population samples (Porter et al. 2020). For example, a study in the USA found that 61% of inpatients meeting diagnostic criteria for BPD reported childhood sexual abuse, and 59% reported childhood physical abuse (Zanarini et al. 1997). An evaluation of people given the diagnosis in UK personality disorder services found that 93% reported a history of trauma, most commonly sexual trauma or violence (Barnicot and Crawford 2018). Despite the criticism and debate surrounding the diagnosis, it has been retained in some form in both the DSM and ICD diagnostic systems and is used by NICE in their clinical guidelines (American Psychiatric Association (APA) 2013; NICE 2009; NICE 2015;  World Health Organization (WHO) 2019 ).

The diagnosis has important public health implications. The suicide rate among people meeting diagnostic criteria for BPD is many times higher than in the general population (Chesney et al. 2014). In a case register study of 2,440 individuals diagnosed with a personality disorder in South London, 3% had died within a 5 year period; 62% were from natural causes and 38% were accidental deaths or deaths by suicide (Fok et al. 2014). Alcohol or drug use, physical illness, and impairment in activities of daily living were all independently associated with all-cause mortality. In an overlapping cohort of people with a PD diagnosis, life expectancy was estimated to be 18 years shorter than among the general population (Fok et al. 2012). The majority of patients in these studies were likely to have had a BPD diagnosis, since this is the most common PD diagnosis given by mental health services (Tyrer 2018).

In the general population and clinical samples, BPD traits can be measured from early adolescence onwards (Videler et al. 2019). The fifth version of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) requires symptoms to have been present since late adolescence or early adult life for a diagnosis of BPD to be given (APA 2013). However, controversially, diagnosis from early adolescence has been permitted since the latest DSM revision (Hartley et al. 2022). It has particularly been cautioned that adolescents may meet diagnostic criteria for BPD through impulsivity, emotional instability and self-harm, which represent common adolescent behaviours that overlap with other types of mental health difficulties and neurodiversity (Sharp et al. 2019). Cohort studies have shown that the symptoms associated with BPD fluctuate but generally improve over time, particularly when treated with an effective psychological intervention (Stoffers-Winterling et al. 2022). Among those receiving treatment, one longitudinal study of a clinical cohort reported that 88% of treated patients improved sufficiently not to meet the criteria for BPD ten years after first diagnosis (Zanarini et al. 2006).

As with ASPD, the prevalence of BPD identified through community-based surveys is sensitive to the diagnostic classification system used and the method of assessment. The rates identified have, however, been broadly similar across studies: 0.7% in Oslo, Norway (Torgersen et al. 2001), 1.3% in the US (Lenzenweger et al. 2007), 0.4% in England (McManus et al. 2009), and 1.9% across high income countries (Volkert et al. 2018). In some instances, prevalence has been found to be higher in women than men (Skodol et al. 2005), although this was not the case in APMS 2014 (McManus et al. 2016). Among clinical populations, a higher rate among women is consistently observed. It has been argued this reflects the fact that women are substantially more likely to seek treatment for this condition (Kulacaoglu et al. 2018) or, alternatively, that the diagnosis is a social construction used to pathologise the strategies which some women use to survive and resist oppression and abuse (Shaw and Proctor 2005).

General personality disorder traits

The classification of personality disorder remains hotly debated. Arguments against the categorical classification include the fact that there is substantial co-morbidity between subtypes of personality disorder, and that, to be considered to relate to ‘personality’, diagnostic criteria should relate to personality traits that can be observed on a continuum within the general population. A large amount of empirical evidence supports the view that dimensional assessment of personality traits - which are normative in their central tendency and atypical/problematic in their extremes - has robust construct validity across both clinical and non-clinical samples. Yet, there has been considerable resistance to the adoption of a dimensional classification of personality disorder, due to concerns about its clinical utility and ease of application (Livesley 2007). Increasingly, however, it has been proposed that PD should be classified as a unitary disorder, characterised by core interpersonal dysfunction (of varying degrees of severity), accompanied by the presence of a range of adaptive and maladaptive traits (Tyrer et al. 2015). This view has become embedded in the WHO ICD-11 classification of PD. Additionally, the classification of ICD-11 PD relies primarily on a general definition of PD, and reduces the importance of subclassification by particular “types” or “domains” of PD. In light of these developments, in APMS 2014 a general PD traits screen was added to the assessment battery. This set of screening questions (SAPAS) was retained in APMS 2023/4.

In this chapter, prevalence of screening positive for ASPD, BPD and for ‘general personality disorder’ traits (as screened for using the SAPAS) are presented for the adult population living in private households in England. Associations with age, gender, ethnicity, employment status, problem debt, area-level deprivation and region are examined. Comorbidities with physical and mental health conditions are presented, as well as levels of mental health service use and treatment among people screening positive.

Antisocial and borderline personality disorder

As in APMS 2014, the measures used to screen for ASPD and BPD in APMS 2023/4 relate to DSM-IV criteria. This is to enable changes over time to be assessed across the APMS series. DSM-5 was released shortly after APMS 2014 fieldwork was carried out and introduced an Alternative Model for Personality Disorders. However, the ten personality disorder subtypes and their criteria remained unchanged between the DSM-IV and the DSM-5.

DSM-IV and DSM-5 define a personality disorder as ‘an enduring pattern of inner experience and behaviour that deviates markedly from the expectations of the individual’s culture, is pervasive and inflexible, has an onset in adolescence or early adulthood, is stable over time, and leads to distress or impairment’. DSM-IV and DSM-5 identify ten types of personality disorder grouped into three clusters (APA 1994; 2013):

• Cluster A includes the ‘odd or eccentric’ types
• Cluster B disorders are the ‘dramatic, emotional or erratic’ types, and
• Cluster C is the ‘anxious-fearful’ group. 

ASPD and BPD are both cluster B disorders. The other ‘dramatic, emotional or erratic’ types (narcissistic and histrionic) yielded no positive cases when assessed in APMS 2000 and were not included in subsequent surveys.

ASPD

DSM-IV characterises ASPD as a pervasive pattern of disregard for and violation of the rights of others that has persisted in the individual since the age of 15 or earlier, as indicated by three (or more) of seven criteria:

• Failure to conform to social norms
• Irresponsibility
• Deceitfulness
• Indifference to the welfare of others
• Recklessness
• Failure to plan ahead
• Irritability and aggressiveness (Millon and Davis 1993). 

A feature of ASPD in the DSM-IV is that it requires the individual to meet diagnostic criteria in childhood (presence of conduct disorder before age 15) as well as adulthood. Because particular behaviours must have persisted beyond the age of 18, people younger than this cannot be given the diagnosis. For this reason, participants aged 16 or 17 were excluded from the base for the ASPD analysis.

BPD

According to the DSM-IV diagnostic criteria for BPD, the key features are instability of interpersonal relationships, self-image and mood, combined with marked impulsivity, beginning by early adulthood. It is indicated by five (or more) of the following criteria:

• Frantic efforts to avoid real or imagined abandonment
• Pattern of unstable and intense personal relationships
• Unstable self-image
• Impulsivity in more than one way that is self-damaging (e.g. spending, sex, substance abuse, binge eating, reckless driving)
• Suicidal or self-harming behaviour
• Affective instability
• Chronic feelings of emptiness
• Anger
• Paranoid thoughts or severe dissociative symptoms (quasi-psychotic). 

Unlike ASPD, a DSM-IV diagnosis of BPD is possible before the age of 18, and the BPD analysis therefore included all APMS participants aged 16 and over.

Assessment

Previous surveys have covered all ten types of personality disorder, including APMS 2000 which used the full Structured Clinical Interview for DSM-IV Personality Disorders (SCID-II) in phase two (First et al. 1997; Singleton et al. 2002). However, population surveys of mental disorder often limit the assessment of personality disorder to briefer screening assessments because fully structured interviews are time-consuming. APMS 2007 covered ASPD and BPD in the phase one and two interviews, but not other PD. This was made possible by the modular structure of the SCID-II interview which covers each PD subtype separately. As in APMS 2014, APMS 2023/4 did not include the SCID-II at phase two, but rather screened for BPD and ASPD based only on phase one self-report data using the SCID-II Q. The prevalence figures presented in this chapter are therefore not comparable with the two-phase prevalence figures in the 2007 report due to this change in methods. APMS 2014 and 2023/4 also screened for general PD traits, using the SAPAS.

A positive screen for personality disorder only indicates that someone may have sufficient traits to warrant further and fuller investigation. Screened positive prevalence estimates are usually higher than the true prevalence of a disorder. It should also be noted that the term ‘screened’ is used as a convention and does not indicate that the screening tests used in the survey are used as part of a national screening programme.

Screening positive for ASPD or BPD on the SCID-II Q

As in previous years, the SCID-II screening questionnaire (SCID-II Q) was included in phase one in the self-completion section of the interview. In 2023/4, all personality disorder questions were asked of participants of all ages (in 2014, the SCID-II Q was asked of participants aged between 16 and 64). 

The ASPD module covered childhood conduct disorder and adult antisocial personality, as a diagnosis of ASPD requires both to be present. The questions used to screen for these disorders are listed in the questionnaire in Appendix C. Each question asked the participant to indicate whether they had a particular personality characteristic, for example: ‘Are you the kind of person who…’. All questions had three response categories: ‘yes’, ‘no’, and ‘don’t know/does not apply’. A score of one was given for each item where the participant answered ‘yes’.

Screening positive for general personality disorder traits using the SAPAS

In APMS 2014, the Standardised Assessment of Personality: Abbreviated Scale (SAPAS) (Moran et al. 2003) was added to assess for the likely presence of general PD traits from any of the three DSM clusters.

The SAPAS was chosen on the grounds that it was, at that time, the best performing rapid screen for PD (Germans et al. 2012) and has been validated for use in general population samples (Fok et al. 2015).

Each of the eight questions on the SAPAS asked participants to indicate whether they had a particular personality characteristic, for example ‘Are you normally an impulsive sort of person?’ Participants could answer either ‘yes’ or ‘no’. A score of one was given for each item for which the participant responded ‘yes’, generating a score of 0–8. Those scoring four or more, were defined as screening positive for general PD traits. This cut-point was chosen as it provides the best balance between sensitivity and specificity in a general population sample (Fok et al. 2015). Participants with more than two SAPAS items missing were not given a SAPAS score.

In summary, in this chapter:

• A positive screen for ASPD or BPD draws on the phase one SCID-II screening questionnaire (SCID-II Q).
• A positive screen for general personality disorder traits draws on the phase one SAPAS.

Screening positive for ASPD and BPD, by age and gender

2.0% of adults aged 18 and over screened positive for ASPD on the SCID-II Q. If everyone in the population had been screened, it is likely that between 1.7% and 2.5% of those aged 18 and over would have screened positive (95% confidence interval (CI)). This equates to about 950 thousand adults living in England meeting the diagnostic criteria for ASPD.

The prevalence of ASPD was higher among men (2.9%, 95% CI 2.3, 3.7) than women (1.2%, CI 0.8, 1.8). Screening positive for ASPD was associated with age. Prevalence was highest among those aged 25 to 34 (2.8%, CI 1.7, 4.6), 35 to 44 (3.5%, CI 2.2, 5.5) and 45 to 54 (2.4%, CI 1.5, 3.7), and lowest among younger (1.3%, CI 0.8, 2.1, of 18 to 24 year olds) and older age groups (between 1.2%, CI 0.7, 2.1, of 65 to 74 year olds, and 0.3%, CI 0.1, 1.2, of those aged 75+). This pattern was evident among both men and women.

1.9% of adults aged 16 and over screened positive for BPD on the SCID-II Q. If everyone in the population had been screened, it is likely that between 1.5% and 2.5% of adults would have screened positive (95% CI). This equates to about 900 thousand adults living in England meeting diagnostic criteria for BPD.

The proportion screening positive for BPD was 2.5% among women (CI 1.9, 3.3) and 1.3% among men (CI 0.8, 2.1). Prevalence was highest among 16 to 24 year olds (6.1%, CI 3.8, 9.6) and decreased with age.

For more information: Table 8.1 and Table A1 for confidence intervals

Screening positive for general PD traits, by age and gender

The SAPAS classified one in seven adults (14.9%, 95% CI 13.6, 16.2) as screening positive for ‘general PD traits’. This equates to about 6.9 million adults living in England screening positive for general PD traits.

The proportion screening positive for general PD traits was similar for men (14.0%, CI 12.1, 16.2) and women (15.6%, CI 13.9, 17.4). The likelihood of screening positive for general PD traits declined with age from 26.4% (CI 21.2, 32.4) of those aged 16 to 24 to 5.6% (CI 4.1, 7.6) of those aged 75 and over. The pattern of association between screening positive and age was different for men and women. In women, the decline was more pronounced: 35.3% (CI 26.8, 44.7) of those aged 16 to 24 screened positive for general PD traits, compared with 22.9% (CI 18.3, 28.2) of women aged 25 to 34 and 5.8% (CI 3.6, 9.3) of women aged 75 or over.

For more information: Table 8.3 and Table A1 for confidence intervals

Screening positive for ASPD, BPD and general PD traits, 2014 and 2023/4

Note that the trend data analyses were carried out by sex (male and female) rather than gender (men and women) to allow for comparison with 2014. See How to interpret the findings for information on how changes over time were assessed.

The proportion screening positive for ASPD among adults aged 18 to 64 appeared to remain stable: 3.3% (95% CI 2.8, 4.0) in 2014 and 2.4% (CI 1.9, 3.1) in 2023/4 with confidence intervals overlapping slightly. 

The proportion of adults aged 16 to 64 screening positive for BPD has remained stable: 2.4% (CI 2.0, 2.9) in 2014 and 2.5% (CI 1.9, 3.2) in 2023/4.

For more information: Table 8.2 and Table B1 for confidence intervals

The proportion of adults aged 16 or over screening positive for general PD traits has also remained stable over time (13.7%, CI 12.7, 14.6 in 2014,14.9% CI 13.6, 16.2 in 2023/4).

For more information: Table 8.4 and Table B2 for confidence intervals

ASPD and BPD screens by general PD traits screen

Among people screening positive on the SAPAS for general PD traits (at a cut point of 4), a minority also met the criteria for ASPD or BPD. 12.0% of those who screened positive for general PD traits also screened positive for BPD, and 7.3% screened positive for ASPD.  

For more information: Table 8.5

Screening positive for PD by other characteristics

Ethnic group

The age-standardised proportion screening positive for ASPD varied by ethnic group. The prevalence was highest among White British (2.1%, 95% CI 1.6, 2.7) and White other adults (2.9%, CI 1.4, 5.9). 1.5% of Black/Black British adults screened positive (CI 0.3, 7.8) and 1.5% in those from Mixed/multiple/other groups (CI 0.5, 4.7), while no Asian participants in the sample screened positive for ASPD. It should be noted that the confidence intervals for some estimates were wide and overlapping, so apparent differences between ethnic groups should be treated with caution.

The age-standardised proportion of screening positive for BPD also varied by ethnic group. The prevalence was highest among White British (2.3%, CI 1.7, 3.1) and those of Mixed/multiple/other ethnicity (3.7%, CI 1.0, 13.2), and lowest among those in the Asian/Asian British (0.6%, CI 0.2, 1.7) and White other (0.6%, CI 0.1, 2.3) groups.

For more information: Tables 8.6 and Table A2 for confidence intervals

Screening positive for general personality disorder traits was associated with ethnic group in age-standardised analyses, with adults from a Mixed/multiple/other group being most likely to screen positive for general personality disorder traits (23.5%, CI 14.7, 35.2) and Asian/Asian British adults being least likely (7.9%, CI 5.4, 11.4).

For more information: Tables 8.7 and Table A2 for confidence intervals

Employment status

Employment status was associated with all age-standardised measures of PD among adults of working age (16 to 64).

Those who were unemployed were more likely to screen positive for ASPD (8.6%), BPD (8.4%) and general personality disorder traits (36.5%).

For more information: Table 8.8 and Table 8.9

Problem debt

In age-standardised analyses, being seriously behind with debt repayments or having utilities cut off was associated with greater likelihood of screening positive for ASPD, BPD and general personality disorder traits. See the APMS 2023/4 Methods documentation for more information on how problem debt was derived.

Adults who reported experiencing problem debt were more than twice as likely to screen positive for ASPD (4.6%), BPD (5.2%) and general personality disorder traits (28.1%) than those without problem debt (1.7%, 1.6% and 13.6%, respectively).

For more information: Table 8.10 and Table 8.11

Area-level deprivation

Age-standardised prevalence of screening positive for ASPD and BPD was not significantly associated with living in a more or less deprived neighbourhood.

An association, however, was significant for general personality disorder traits. 19.9% of adults living in the most deprived IMD quintile screened positive for general personality disorder traits, compared with 12.7% of those living in the least deprived quintile.

For more information: Table 8.12 and Table 8.13

Region

The age-standardised proportion of adults screening positive for ASPD and BPD did not significantly vary by region.

Screening positive for general personality disorder traits was, however, associated with region. Adults living in the North East (21.4%), East of England (18.8%) and the North West (18.2%) were the most likely to screen positive, and those living in the South West (9.5%) were the least.

For more information: Table 8.14 and Table 8.15

Comorbidity

Physical health conditions

• Adults with a limiting physical health condition (3.1%) were more likely than those without (1.4%) to screen positive for ASPD in age-standardised analyses.
• Adults with a limiting physical health condition (3.6%) were more likely than those without (1.3%) to screen positive for BPD.
• Adults with a limiting physical health condition (23.1%) were more likely than those without (10.8%) to screen positive for general personality disorder traits.

For more information: Table 8.16 and Table 8.17

Common mental health conditions

Participants with a common mental health condition (CMHC) were more likely than those without to screen positive on each PD measure.

• 4.9% of adults with a CMHC screened positive for ASPD, compared with 1.2% of those without a CMHC.
• 7.5% of participants with a CMHC screened positive for BPD, compared with 0.2% of those without a CMHC.
• Adults with a CMHC were also more likely than those without to screen positive for general PD traits (37.6%, compared with 8.7%).

For more information: Table 8.16 and Table 8.17

Self-diagnosis and professional diagnosis of PD

Participants were shown a list of mental health conditions and asked whether they thought that they had ever had any of them. The list included ‘a personality disorder’. Those who reported that they thought that they have had a personality disorder were asked if this had been diagnosed by a professional, and if so, whether the condition had been present in the past 12 months.

• 1.2% of adults overall reported that they thought they had had a personality disorder at some point. 0.9% of adults reported that they had been professionally diagnosed with a personality disorder and 0.8% of adults reported having a diagnosed personality disorder present in the past 12 months.

• 8.3% of adults who screened positive for ASPD reported that they thought they had had a personality disorder at some point, 7.7% reported that this had been diagnosed by a professional, and 6.6% reported that the disorder had been present in the past 12 months.

• 13.9% of adults who screened positive for BPD reported that they thought they had had a personality disorder at some point, 10.5% reported that this had been diagnosed by a professional, and 10.5% reported that the disorder had been present in the past 12 months.

• Among adults who screened positive for general PD traits, 5.0% thought that they had had a personality disorder, 3.7% reported that this had been diagnosed by a professional, and 3.5% reported that the disorder had been present in the past 12 months. 

For more information: Table 8.18

Treatment

Treatment and service use

Participants were asked about different types of mental health treatment and service use. These included current psychotropic medication or psychological therapy for any mental or emotional problem (not necessarily related to personality disorder traits). Participants were also asked about their use of a range of health, community and day care services over the past year.

About two thirds of adults who screened positive for ASPD (62.1%) or general personality disorder traits (66.1%), and half of those who screened positive for BPD (47.8%), were not receiving any treatment for an emotional problem or disorder around the time of the interview. Those with a positive screen for ASPD and BPD were twice as likely to be in receipt of medication (31.7% and 43.8%, respectively) than psychological therapy (15.8% and 21.6%, respectively). Similarly, adults screening positive for general PD traits on the SAPAS were more likely to be in receipt of medication (28.2%) than psychological therapy (12.1%).

About one in four adults (26.3%) who screened positive for ASPD and 59.5% of those who screened positive for BPD had used health care services for a mental health related reason in the past year. This was one in three (32.1%) among adults with a positive screen for general PD traits, and one in ten (9.8%) of those screening negative for general PD traits.

Community care services were used in the past year by one in three of those meeting BPD criteria (33.2%), one in five of those meeting ASPD criteria (20.2%) and one in six (15.6%) of those with general PD traits.

For more information: Table 8.19 and Table 8.20

Psychotropic medication

Participants were asked which (if any) psychotropic medications they were taking for a mental health reason (not necessarily for symptoms related to personality disorder). Overall, 12.5% of all adults were taking some form of psychotropic medication, with the most common medication types being those primarily used to treat depression (11.7%) and anxiety (10.7%). See Chapter 2 Mental health treatment and service use for more details.

The most common medications taken among those screening positive for ASPD or BPD, were those used to treat depression (29.2% and 41.5%, respectively) and anxiety (23.7% and 38.6%, respectively). These were also the most commonly used psychotropic medications used by those who screened negative for ASPD (11.5% and 10.5%, respectively) and BPD (11.0% and 10.0%, respectively).

The pattern was similar among those screening positive for general personality disorder traits, with about one in four taking medication used to treat depression (26.7%) or anxiety (23.5%).

For more information: Table 8.21 and Table 8.22

The concept, measurement and diagnosis of personality disorder are contested. The epidemiological data generated from this survey has limitations, chiefly in terms of the reliance on being self-reported and cross-sectional. Further, how one interprets screening positive for personality disorder on any of the measures is a matter for debate. It has been noted, with concern in some quarters, that the introduction of a general personality disorder descriptor alongside dimensionality in ICD-11, will greatly increase the numbers of people deemed to be meeting diagnostic criteria (Tyrer et al. 2014; Watts 2019). In line with this, 14.9% of the sample screened positive for general personality disorder traits, while screening positive for ASPD (2.0%) and BPD (1.9%) was considerably less likely.

Diagnostic criteria for BPD and general PD traits overlap with, and hence are more likely to be endorsed by, people with complex PTSD or by people who are autistic (WHO 2019; Lai and Baron-Cohen 2015). This potentially contributes to diagnostic overshadowing (where a healthcare professional misattributes the symptoms of one condition to another that has previously been diagnosed). Those in this sample with physical health conditions or other common mental health conditions (like depression or an anxiety disorder), were more than twice as likely to screen positive for PD as those without a physical or common mental health condition. Although some caution is warranted as the numbers of people who screened positive for ASPD (117) and BPD (99) in this survey were relatively small, several clear public health implications of screening positive on the personality disorder measures are evident.

People screening positive for PD often experience socioeconomic adversity. Those reporting personality disorder traits were more likely to not be in employment, to be seriously behind with debt repayments or have had their utilities cut off, or (for those with general PD traits) to live in more deprived neighbourhoods, compared with those who did not screen positively for personality disorder. Screening positive for ASPD was more common in men than women and among non-British white adults, while adults from a Mixed/multiple/other ethnic group were particularly likely to screen positive for general personality disorder traits.

Screening positive for PD is associated with younger age and being a woman. In keeping with other research (Newton-Howes et al. 2015; Zanarini et al. 2003), general PD traits (as measured by the SAPAS) were associated with age. Prevalence was higher in younger age groups than older: in particular, one in three (35.3%) women 16 to 24 screened positive for general PD traits. Further, 9.8% of women aged 16 to 24 met diagnostic criteria for BPD according to the SCID-II Q. The very high identified prevalence of general PD traits in young women is noteworthy. It is known that this is one of the highest risk demographic groups for experiencing psychological distress (Alonso et al. 2004). However, the association with this demographic is also consistent with feminist critiques of the diagnosis which view it as a means to pathologise the responses of young women to oppression (Shaw and Proctor 2005).

Likelihood of meeting diagnostic criteria for PD may decrease over time. Stability within the individual has been a defining feature of both the ICD-10 (WHO 1992) and DSM definitions of personality disorder (NICE 2009). The cross-sectional association with age in APMS data is therefore intriguing as it raises a prospective research question about whether the diagnostic criteria for personality disorder truly persist across the life course. ICD-11 indicates that the likelihood of meeting diagnostic criteria for PD may decrease over time, and the diagnosis should be regarded only as ‘relatively’ stable after early adulthood. Certainly, there is evidence of fluctuation over time in the presence of criteria within individuals (Livesley et al. 1992), and the course of the disorder is susceptible to treatment (Marcus et al. 2006; Storebø et al. 2020). Moreover, clinical trials have shown that some psychological therapies can be effective in the treatment of borderline personality disorders (Storebø et al. 2020), although the results of pharmacological trials have been less conclusive (Paris 2008).

Most people screening positive for personality disorder in the APMS sample were not receiving treatment for any kind of mental or emotional problem. Of those that were receiving treatment, twice as many cited medication than psychological therapies, which may reflect treatment of comorbid conditions. This is despite NICE guidelines recommending psychological therapies as the first line of treatment. NICE quality standards for both people with BPD or ASPD include being offered a choice of psychological therapies (NICE 2015). As noted previously, the sample size and cross-sectional nature of these data, alongside the limitations of self-reported screening tools and the debate around the diagnostic constructs, require us to treat these findings with some caution. Nevertheless, they suggest that improvements in treatment and service provision may be required to achieve satisfactory levels of therapeutic help for people meeting diagnostic criteria for personality disorder as recommended by NICE.  

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Please cite this chapter as:

Clery, E., David, M., Cretch, E., Morris, S., Barnicot, K., Coid, J., McManus, S., & Moran, P. (2025). Personality disorder. In Morris, S., Hill, S., Brugha, T., McManus, S. (Eds.). Adult Psychiatric Morbidity Survey: Survey of Mental Health and Wellbeing, England, 2023/4. NHS England.