Rep36 Understanding Personality Disorder

2.2.3c Socio-economic disadvantage and
personality disorder
Little systematic research has been carried out in
this area but there is an indication that poverty,
unemployment and poor scholastic achievement
are correlated with raised levels of antisocial
activity and personality disorder in particular
individuals. The majority of studies of the
community prevalence of antisocial personality
disorder indicate a clear link with low socio-
economic status (Kohn, Dohrenwend &
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Mirotznik, 1998). The only other personality
disorders considered in this context suggest
obsessive-compulsive personality disorder is
significantly more prevalent in higher socio-
economic groups (Samuels 
et al
., 1994).
2.2.3d Gender and personality disorder
There have been concerns that different
prevalence rates in particular personality
disorders could reflect a gender bias. This could
be due to a combination of three factors:
diagnosis-based bias, biased research samples,
and/or biased assessment tools. Diagnostic bias
is perceived to stem from a gender bias in the
personality disorder constructs, such that to
behave in a stereotypically feminine manner is
associated with a personality disorder diagnosis
(e.g. dependent, histrionic) whereas
stereotypically male behaviour is not (Kaplan,
1983). However, six of the personality disorders
are diagnosed more commonly in males as
opposed to three for females (American
Psychiatric Association, 1994). The purpose of
the classification system is to diagnose
psychopathology accurately, thus there is no
reason to presume men and women would be
equally personality disordered. 
Differences in gender prevalence among the
personality disorders may be more easily
accepted if personality disorders were
conceptualized as extreme, maladaptive forms of
normal personality traits (Corbitt & Widiger,
1995). Should it be true there are personality
disorders with different gender prevalence that
are consistent with the normative differences
between men and women, the diagnosis of these
disorders could still be biased if different
thresholds are used for male stereotyped as
opposed to female stereotyped personality
disorders. However, bias in the application of
diagnostic criteria has the most empirical
support (Widiger, 1998). Clinicians appear to
favour diagnosing female patients with histrionic
personality disorder and males with antisocial
personality disorder, and it was failure to adhere
to diagnostic criteria that was connected to a
misdiagnosis (Widiger, 1998). Clinicians using
unstructured clinical interviews appear to over-
diagnose dependent and histrionic personality
disorders; an unbiased, systematic assessment
appears to reduce the gender bias, but there
continues to be a gender bias with more women
than men meeting criteria for these disorders
(Widiger, 1998). 
It has been suggested that the perception of
gender bias in research into dependent and
histrionic personality disorders reflects the
higher number of women in clinical settings.
However, this gender prevalence may reflect the
fact that, as there were more women at the
clinic, more women suffer from the disorder.
This would be consistent with the prevalence
information available, which suggests that more
women than men have dependent personality
disorder (Reich, 1987). However, an accurate
measure of gender prevalence would require
epidemiological studies that have obtained
representative samples of respective populations,
which have yet to be carried out. 
It has been suggested there are gender biases
within the assessment tools used to measure
personality disorders. Gender bias could occur if
an assessment item scored positively for an
attribute/trait that did not indicate dysfunction
and it applied to one gender more than the
other. This could lead to gender biased false
positive diagnoses of personality disorder. A
study of assessment tools found that there was a
level of gender bias in the assessments and that
this bias was more evident in personality
disorders diagnosed with greater regularity in
men (Lindsay & Widiger, 1995). Therefore,
gender bias may best be addressed through
emphasis upon adherence to the personality
disorder criteria and diagnostic rules and to
construct and apply a set of diagnostic criteria
that minimise false positive and false negative
errors for both men and women.