Are Personality Disorders Assessed in Young People?

To the Editor: Personality disorders are highly prevalent, disabling, and costly. Decades of research suggest that they commonly emerge in childhood and adolescence, demonstrate early stability, and, critically, respond well to early treatment and prevention efforts (1). It is vital that early-onset personality disorders are properly identified, as accurate diagnosis is essential for implementation of effective interventions.

Despite consistent empirical support for the validity of pediatric personality disorders, there are indications that practitioners resist personality disorder assessment in young people. Yet aside from several practitioner surveys (e.g., reference 2), large-scale data are lacking on the extent of this underdiagnosis. We therefore analyzed responses from a large national survey of university students who reported whether they had been diagnosed previously with a mental illness by a health professional. We compared those reports with the prevalence of personality disorder diagnoses ascertained with structured interviews in a university student subsample of the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) (3).

The Healthy Minds Study (4) included 113,515 students from 105 U.S. universities who provided complete histories of psychiatric diagnoses. As shown in Table 1, about one in 200 Healthy Minds Study students was diagnosed with any personality disorder, and rates of individual personality disorders were as low as one in 10,000. By comparison, more than five in 100 respondents had been diagnosed with major depressive disorder. The discrepancy in prevalence between personality disorder and depression was even more pronounced in the Healthy Minds Study treatment-seeking subsample.

The comparison of the “true” disorder rates from the NESARC with the “diagnosed” rates from the Healthy Minds Study illustrates that the vast majority of young people who have a personality disorder are undiagnosed. The true versus diagnosed prevalence rates differ by a factor of approximately 40 for personality disorders, compared with a factor of 1.3 for major depression.

We caution that our contrasts rely on patients’ reports of diagnoses, which may be imperfect proxies of true assessment results. Also, the lion’s share of research on pediatric personality disorders has targeted borderline personality disorder, but we could not evaluate the underdiagnosis of borderline personality disorder because it was not surveyed in the NESARC university subsample. With those caveats in mind, we conclude that practitioners are not assessing or treating personality disorders prior to adulthood, despite a clear need for early intervention. Given the data supporting the concurrent and prognostic importance of personality disorder diagnoses in youths, clinicians arguably should assess them.