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Ahmadi N, Rashidpour P, Mohammadi M, Aardeshirpay J, Abouzari H, Mirzaei M, et al . Prevalence of Personality Disorders among Males and Females between the Ages of 15 and 65 in Yazd in 2017. JSBCH 2023; 7 (2) :1107-1117
URL: http://sbrh.ssu.ac.ir/article-1-231-en.html
Prevalence of Personality Disorders among Males and Females between the Ages of 15 and 65 in Yazd in 2017
Nastaran Ahmadi1 , Parvaneh Rashidpour2 , Mohammadreza Mohammadi3 , Javad Aardeshirpay4 , Hosein Abouzari2 , Masoud Mirzaei5 , Amir Houshang Mehrparvar6 , Fatemeh Rismanian Yazdi4 , Mohammadhadi Farahzadi * 7
1- Cardiovascular Research Center, Non-communicable Diseases Research Institute, Shahid Sadoughi University of Medical Sciences, Yazd, Iran
2- Department of psychiatry, Reserch center of addiction and behavioral sciences,Shahid Sadoughi, University of medical sciences,Yazd,Iran.
3- Psychiatry and Psychology Research Center, Roozbeh Hospital, Tehran University of Medical Sciences, Tehran, Iran.
4- Faculty of Education and Psychology, Yazd University, Yazd, Iran
5- Yazd Cardiovascular Research Center, Shahid Sadoughi University of Medical Sciences, Yazd, Iran.
6- Department of Occupational Medicine, School of Medicine, Shahid Sadoughi University of Medical Sciences, Yazd, Iran.
7- Department of psychiatry, Research Center of Addiction and Behavioral Sciences, Shahid Sadoughi University of Medical Sciences,Yazd,Iran , h.farahzadi@ssu.ac.ir
Keywords: Prevalence, Personality Disorders, Personality Tests, Iran
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Prevalence of Personality Disorders among Males and Females between the Ages of 15 and 65 in Yazd in 2017
Nastaran Ahmadi a , Parvaneh Rashidpour b , Mohammadreza Mohammadi c , Javad Aardeshirpay d ,
Hosein Abouzari b , Masoud Mirzaei e   , Amir Houshang Mehrparvar f   , Fatemeh Rismanian Yazdi d , Mohammadhadi Farahzadi b *

a Cardiovascular Research Center, Non-communicable Diseases Research Institute, Shahid Sadoughi University of Medical Sciences, Yazd, Iran
b Department of psychiatry, Research center of addiction and behavioral sciences, Shahid Sadoughi, University of medical sciences, Yazd, Iran
c Psychiatry and Psychology Research Center, Roozbeh Hospital, Tehran University of Medical Sciences, Tehran, Iran.
d Faculty of Education and Psychology, Yazd University, Yazd, Iran.
e Yazd Cardiovascular Research Center, Shahid Sadoughi University of Medical Sciences, Yazd, Iran.
f Department of Occupational Medicine, School of Medicine, Shahid Sadoughi University of Medical Sciences,
Yazd, Iran.
A R T I C L E I N F O A B S T R A C T
ORIGINAL ARTICLE
Background: Personality disorder is a type of mental disorder in which a rigid and unhealthy pattern of thinking, functioning, and behaving may be seen. A person with a personality disorder has trouble perceiving and relating to situations and people. Limited research has been done on the prevalence of personality disorders in Iran. This study aims at investigating the prevalence of personality disorders among males and females between the ages 15 and 65 in Yazd, Iran.
Methods: The dataset for this cross-sectional study was extracted from a dataset of a national survey conducted on personality disorders of Iranians. The contents relevant to Yazd City were included here with a sample of 1827 people. Among the participants, 852 males and 975 females answered the personality disorders questionnaire (MILON).
Results: Findings indicated that except histrionic and narcissistic patterns, the high rate of the rest of patterns was greater among females, which indicated that in most cases females significantly suffered higher clinical-related personality disorders. Moreover, personality disorders were more prevalent among females (29.8) compared to males (24.3).
Conclusion: This area requires extensive investigation. More evidence is needed regarding the differential impact of personality disorders regarding men and women in other areas of Iran.

Keywords: Prevalence, Personality Disorders, Personality Tests, Iran.

Article History:
Received: 14 Sep 2023
Revised: 01 Nov 2023
Accepted: 08 Nov 2023

*Corresponding Author:
Mohammadhadi Farahzadi
Email:
h.farahzadi@ssu.ac.ir
Tel: +98 9133513197

Citation:
Ahmadi N, Rashidpour P, Mohammadi M, Aardeshirpay J, Abouzari H, Mirzaei M, et al. Prevalence of Personality Disorders among Males and Females between the Ages of 15 and 65 in Yazd in 2017. Journal of Social Behavior and Community Health (JSBCH). 2023; 7(2): 1107-1117.


Introduction
Iran is one of the largest developing countries in the world with a population of over 80. There are great experiences concerning mental health improvement and care programs, such as significant and valuable accomplishments in integration of mental health care with primary mental health care systems. One of the most consequential and important bases in the process of accurate planning is correct estimation of costs and needs and preparation of epidemiological data evaluation systems regarding the prevalence of various disorders (Shirzadi et al., 2019). Personality disorders (PD) are considered as one of the most common psychiatric disorders. Although it often remains unknown in normal situations, studies have shown that the disorder is common and associated with significant complications (Tyrer et al., 2010). PDs constitute an important part of mental health burden of the disease (Van der Boom et al., 2022). PDs are psychological disorders characterized by unhealthy patterns of feelings, thoughts, communication and perceptions (Scheffers et al., 2019). The outcomes are delusions as well as problems with conforming to social norms and values. They are among the most common forms and models of health care. PD is often associated with poor health status, poor quality of life (QoL), and early mortality (Ekselius, 2018).
The Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5) lists 10 PDs in its new classification. DSM-5 categorizes these 10 types of personality disorders into 3 clusters , cluster A (paranoid, schizoid, schizotypal), cluster B (antisocial personality, borderline personality, histrionic personality, narcissistic personality) and cluster C (Obsessive-compulsive personality, dependent personality, avoidant personality) (Baljé etal., 2023). Based on the current evidence and classification, about 6% of the world populations suffer from PD, and there was no difference among the countries about the incidence of the disease (Volkert, Gablonski & Rabung, 2018). Women tend to have more personality disorders compared with men. For instance, men are more likely to have narcissistic, antisocial, passive-aggressive, obsessive-compulsive, or schizotypal personality disorders. The results of a study in Tehran showed the prevalence of the disorders as the following; dependent personality disorders was 1.1%, dramatic, 35.4%, schizoid , 1.7%, avoidant, 0.4%, depressed, 6.9%, narcissistic, 4.3%, obsessive, 6.15%, and negative, 0/9% (Farnoush, Hosseinaei & Bahrami, 2016). Moreover, the results of the reseach by Fatehizadeh et al. (2007 demonstrated that the prevalence of antisocial PD symptoms was 0.08%, narcissistic, 9.1%, demonstrative, 6.4%, and borderline disorder was 0.08%. On the other hand, borderline, avoidant, depressive, dependent and paranoid disorders were more common in women. In the last 5 decades, PD was recognized as a type of mental disorder. PDs are more common in groups: single people, low socio-economic classes, and city center residents (Torgersen, Kringlen & Cramer, 2001). .There has been no comprehensive and precise study regarding the prevalence of all PDs in such a wide range of age groups as 15-65in Iran; they are either focused on specific PDs such as borderline (Mohammadi, Shamohammadi & Salmanian, 2014), or epidemiology of psychiatric disorders (Mohammadi et al., 2017). Previous population-based surveys in Iran have reported the prevalence of psychiatric disorders as 10.8%–23.8% (Noorbala et al., 2017; Mohammadi et al., 2004). Before 1960s, PDs other than antisocial personality disorder were not considered significant and had no significant diagnostic value. Comorbidity of personality disorder with other psychiatric disorders has been shown to have a significant impact on their outcomes, and may be treated with specific treatment (Tkachenko et al., 2020).
 The etiology of PDs is influenced by environmental and genetic factors which is complicated (Mariz, Cruz & Moreira, 2022). Clinical symptoms are different between various types of PDs; the most current element is associated with the inability to create and maintain healthy and good interpersonal relationships. This part has negative effects on the interaction between health-care and psychologist professionals and people who suffer from PD (Winsper, 2018). The current concept of PD, as reflected in the newly proposed ICD-11, is a subsequent description based on the severity of functional impairment rather than the type of clinical presentation, or the existence of discrete disease entities classified in previous classification systems (Watts, 2019). What needs to be affirmed is that PDs negatively affect both the clinical manifestations of other medical problems and their outcome, and the combined effects of having PD reduce life expectancy (Dixon-Gordon et al. 2015). According to the national census of 2016, Yazd is a province located in the center of Iran with a total population of 1074428 people: 889583 urban residents and 184829 rural people, and 16 nomadic people (Afzali et al., 2015). So far, no comprehensive study has been conducted at the provincial level to investigate the epidemiology of personality disorders from adolescence to old age. Hence, according to the importance of personality disorders, the prevalence of personality disorders needs to be investigated to a greater extent to plan treatment approaches and preventive measures. Therefore, the present study investigates the prevalence of personality disorders among both genders aged between 15 and 65 in Yazd Province of Iran.

Methods
The dataset for this cross-sectional study was extracted from a dataset regarding a national survey conducted on PDs of Iranians. The contents relevant to Yazd City were included with a sample of 1827 people. This study was funded by the National Institute of Medical Research Development (NIMAD).
1827 people in Yazd were selected using a multi-cluster sampling method. . Among the participants, 852 males and 975 females answered the Personality Disorders Questionnaire (MILON). The inclusion criteria were being Iranian and living in Yazd province for at least one year. The exclusion criteria were having severe physical and mental illnesses.
Trained psychologists were sent to the participants' home, the research project was explained, and
the participants' consent was obtained. Then, psychologists received demographic information, and in the end, participants completed the Millon questionnaire.
Milon's Multiaxial Clinical Questionnaire - Third Edition (MCMI-III): Milon's questionnaire is a self-report scale used by mental health professionals for clinical decision making and diagnosis of people with a particular disorder, or the presence of a specific psychological feature in the subject. The MCMI questionnaire has 175 true-false items, and includes 1) clinical personality patterns, 2) variability indices, 3) clinical syndrome, 4) severe clinical syndrome, and 5) severe personality pathology, which is in accordance with Milon's theory. The age range for the test is 18 or older. Sharifi (2006) standardized the third version of Milon's test in Isfahan. The reliability of this questionnaire by test-retest method ranged from 0.82 to 0.90 and its alpha coefficient ranged from 0.66 to 0.90 (Ball et al., 2004; Golomb et al., 1995). In the study by Farnoush et al. (2016), the reliability of the test was calculated through internal consistency, and Cronbach's alpha of the scales was obtained in the range of 0.85 to 0.97. In addition, Chegini, Delavar and Gharai (2012) tested the reliability of this questionnaire by test-retest method in the patient group (0.793-0.795), and in the non-patient group (0.795-0.972), and the reliability by Cronbach's alpha method was also obtained (0.33-0.78.
Participants signed consent forms. All the information in this research was kept confidential. The study’s protocols were accepted and approved by NIMAD’s ethics committee (ethical code: IR .NIMAD .REC. 1395 .001).
To investigate and analyze data, software packages SPSS Ver. 16 and Crosstabs with descriptive statistics (frequency and percent) were used to determine the prevalence of PD.

Results
In general, the valid data of 1827 participants were analyzed (852 males and 975 females). The report is provided in terms of the subjects having normal, border, and high rates of disorder. The prevalence of clinical personality patterns is presented separately for males and females in Table 1.
 
Prevalence of clinical personality patterns among male and female Table 1.
Clinical personality pattern (male) Clinical personality pattern (female)
Percent Frequency Percent Frequency
99.2 845 98.1 956 Normal Schizoid
0.8 7 1.5 16 Border
- - 0.3 3 High
98.5 839 98.8 963 Normal Avoidant
1.5 13 0.9 9 Border
- - 0.3 3 High
94 801 86.2 840 Normal Depressive
3.4 29 7 68 Border
2.6 22 6.9 67 High
99.2 845 95.7 933 Normal Dependent
0.5 4 2.8 27 Border
0.4 3 1.5 15 High
60.9 519 80.8 788 Normal Histrionic
26.4 225 10.7 104 Border.
12.7 108 8.5 83 High
96.4 821 94.9 925 Normal Narcissistic
3.2 27 4.9 48 Border
0.5 4 0.2 2 High
99.6 849 100 975 Normal Antisocial
0.2 2 - - Border
0.1 1 - - High
97.7 832 98.7 962 Normal Aggressive
2.3 20 1.2 12 Border
- - 0.1 1 High
64.9 553 77.4 755 Normal Compulsive
25 213 6.2 60 Border
10.1 86 16.4 160 High
97.3 829 93.2 909 Normal Negativistic
2.6 22 6.3 61 Border
0.1 1 0.5 5 High
98 835 97.3 949 Normal Self-defeating
2 17 2.3 22 Border
- - 0.4 4 High
42.3 360 52.1 508 Normal Clinical personality pattern
34.7 296 18.4 179 Border
23 196 29.5 288 High
 
 
as can be seen from Table 1, except the histrionic and narcissistic patterns, the high rate of the rest of patterns was greater among females, indicating that in most cases, females suffered higher clinical-related personality disorders. Interestingly, antisocial PD is the only variable which is neither border nor high among females. The most prevalent disorder among females is compulsive one.
The prevalence of severe personality pathology including schizotypal, borderline, and paranoid separately for females and males is presented in Table 2.
 
Table 2. Prevalence of Severe personality pathology among male and female
Severe personality pathology (male) Severe personality pathology (female)
Percent Frequency Percent Frequency
98.6 840 99.4 969 Normal Schizotypal
1.4 12 0.5 5 Border
- - 0.1 1 High
98 835 98.3 958 Normal Borderline
1.6 14 1.2 12 Border
0.4 3 0.5 5 High
99.5 848 99.4 969 Normal Paranoid
0.5 4 0.5 5 Border
- - 0.1 1 High
97.2 828 97.6 952 Normal Severe personality pathology
2.5 21 1.7 17 Border
0.4 3 0.6 6 High
 
As can be seen from Table 2, similar to clinical personality patterns, females have significantly higher severe personality disorders. Moreover, the borderline is the most prevalent disorder among females.
Table 3 demonstrates the prevalence of personality disorders-relevant clinical disorders among males and females.
 
Table 3. Prevalence of clinical syndromes among males and females
Clinical syndromes (male) Clinical syndromes (female)
97.4 830 97 946 Normal Anxiety
1.3 11 2.1 20 Border
1.3 11 0.9 9 High
98.1 836 97.6 952 Normal Somatoform
1.6 14 1.9 19 Border
0.2 2 0.4 4 High
98.5 839 99.9 974 Normal Bipolar, manic disorder
0.9 8 0.1 1 Border
0.6 5 - - High
97.2 828 95.3 929 Normal Dysthymia
1.6 14 2.3 22 Border
1.2 10 2.5 24 High
99.6 849 99.9 974 Normal Alcohol  dependence
0.4 3 0.1 1 Border
- - - - High
98.8 842 99.9 974 Normal Drug  dependence
0.8 7 0.1 1 Border
0.4 3 - - High
98.8 842 99 965 Normal Post-traumatic stress disorder
1.1 9 0.7 7 Border
0.1 1 0.3 3 High
93.2 794 93.1 908 Normal Clinical syndromes
3.8 32 4 39 Border
3.1 26 2.9 28 High
 
As can be seen from Table 3, other than bipolar, manic disorder, and drug dependence, the rest of PDs related to clinical syndromes were more prevalent among females. It is noteworthy to mention that dysthymia was the most prevalent disorder among others. Table 4 provides the prevalence of personality disorders in clinical syndromes among males and females
 
Table 4. Prevalence of severe clinical syndromes among males and females
Severe clinical syndromes (males) Severe clinical syndromes (females)
98.1 836 98.7 962 Normal Thought  disorder
1.9 16 1.1 11 Border
- - 0.2 2 High
99.9 851 99.5 970 Normal Major  depression
0.1 1 0.5 5 Border
- - - - High
99.8 850 99.7 972 Normal Delusional  disorder
0.1 1 0.2 2 Border
0.1 1 0.1 1 High
98 835 98.2 957 Normal Severe clinical syndromes
1.9 16 1.5 15 Border
0.1 1 0.3 3 High
 
As can be seen from Table 4, both females and males have shown no high rates of major depression, and they have been equal in delusional disorder. However, females showed higher rates of thought disorder and severe clinical syndrome in general. Figures 1 and 2 depict the prevalence of PDs among females and males, respectively.

Discussion
The present study investigated PDs in Yazd Province of Iran. Using MCMI-III which was distributed among a sample composed of 1827 participants (852 males and 975 females); it was found that the prevalence of personality disorders was much higher among females compared to that of males. This finding was consistent with Sepehri et al.'s research conducted in Tabriz city (Sepehri et al., 2017). Nevertheless, histrionic and narcissistic patterns were higher among males. The results of this research were in line with the research by Fatehizadeh et al. (2016) in Isfahan metropolis, and also the research by Farnoosh et al. (2007) in Tehran. Narcissistic personality disorder (NPD) is usually characterized by an absence of empathy for others, and also fickle and brittle self-esteem, which makes peoples with NPD seek attention and approval (Esmaeilian et al., 2022; Nenadic et al., 2015). The prevalence of NPD in the population ranged from 0% to 6.2%, and 50% to 75% of the affected individuals were males (Schulze et al., 2013). Several factors such as childhood trauma, heredity, age, and culture have been shown to influence the development of NPD (Andrews-Hanna et al., 2010). Recent studies revealed that with the quick development of China's social economy, the surface of narcissism in the younger group of people is increasing too fast (Svob et al. 2016). Another study predicted that if a society becomes more narcissistic and has less empathy, this will lead into a higher amount of anxiety, crime, and depression (Rubinov & Sporns, 2010).
Generally, epidemiological perusals have shown different rates of PDs; some reports suggested similar total rates between both genders (Bangash, 2020; Volkert, Gablonski & Rabung, 2018). On the other hand, other studies pointed to higher rates of PDs in men. Regarding the prevalence of PDs such as borderline, the result of previous research has shown that a higher ratio of women suffered from a borderline personality disorder compared to men; however, recent research has not found any differences in prevalence by gender (Golomb et al., 1995). Moreover, gender differences in borderline personality disorder (BPD) may not exist regarding certain types of self-destructive behaviors, such as levels of psychological distress at clinical presentation or self-cutting. Nonetheless, current evidence suggested that there were considerable gender differences in (BPD) regarding personality traits, treatment utilization, and Axis I and II comorbidity. According to personality characteristics, men with BPD are less likely to show explosive temperament and lower levels of novelty seeking than women with BPD (Yang et al., 2021). Some studies  reported that women diagnosed with BPD usually faced childhood trauma or adversity, sexual abuse, environmental risk factors, childhood illnesses, parental loss, child abuse, and neglect (McKay et al., 2022; Yen et al., 2021).
In contrast with findings of this study, Golomb et al., (1995) reported that based on Hamilton's
17-item depression questionnaire, the scores were obtained for 108 men with an average age of 39.28 and 208 women with an average age of
39.11 = respectively (standard deviation = 3.8) and (Standard deviation = 6.9). It was more likely for men to meet the criteria of antisocial, obsessive-compulsive, and narcissistic PDs in comparison to women according to the modified personality diagnosis questionnaire, and for obsessive-compulsive personality disorders and narcissistic according to the interview named Structured Clinical Interview for DSM-III-R Personality Disorders (SCID-II). Accordingly, Paris (2004) discovered that antisocial disorder mostly happened with men, and BPD was more prevalent with women. He found that these differences were not fictitious, but reflected gender differences in personality which underlined Axis II diagnoses. Engemann et al. (2021) observed a relationship between cardiac parasympathetic activity and antisocial behavior in men.
In a big sample of 1460 people from Poland who were 18 to 65, noticeable differences were found in the prevalence of PDs between women and men. Depressive, obsessive-compulsive, dependent, borderline, and avoidant PDs were more likely to happen among women, while schizoid, antisocial, and schizotypal PDs were more likely to happen among men (Gawda & Czubak, 2017). In a study investigating samples of BPD patients, Vatheuer et al. (2021) found no increased aggression among male patients, indicating that BPD decreases gender differences typically found in the general population. However, neurobiological studies comparing BPD patients with healthy sex-matched individuals revealed several interesting gender differences. On the one hand, there were well-replicated results regarding the reduction of hippocampal and amygdala gray matter volumes in female patients with BPD, whereas these results were not similar in male BPD patients. On the other hand, only male patients with BPD had reduced striatal activity during the time of an aggression task; this showed a more severe
deficit in central serotonergic response, reduced anterior cingulate cortex gray matter volume, and increased putamen gray matter volume. These neurobiological results concentrated on the real importance of impulsivity for aggression in male patients with BPD (Mancke, Bertsch & Herpertz, 2015; Vatheuer et al., 2021).
Similarly, Sansone and Sansone (2011), Mattingley et al. (2022) argued that male patients with BPD might have substance use disorders, while female patients with BPD might have mood, anxiety, eating, and PTSD or post-traumatic stress disorders (Amad et al., 2019). Concerning the coexistence of second axis, there were more male patients with BPD than females regarding antisocial personality disorder (Moreira et al., 2022). Finally, regarding treatment, men with BPD might have treatment histories associated with substance abuse, while women might have treatment histories characterized by more psychotherapy and pharmacotherapy.
This was the first study on epidemiological survey regarding PDs among males and females in Yazd province; however, its generalization to the whole country of Iran should be done with caution.

Conclusion
There are gender differences regarding PDs in Yazd Province of Iran. Gender differences in all types of PDs mirror gender differences regarding normal personality characteristics. Men have a tendency to score higher on narcissistic and histrionic traits, while women scored higher on characteristics such as being schizoid, avoidant, depressive, dependent, aggressive, compulsive, negativistic and self-defeating; this was while females were reported to be less antisocial in this study. The results of psychometric studies have shown a systematic gender bias in DSM-IV-TR diagnostic criteria for PDs. This field needs more expansive investigation. More evidence is needed regarding the differential effect of personality disorders of male and female patients in other areas of Iran. This research showed a good perspective on the prevalence of PDs in Yazd province, which had not been conducted with such comprehensiveness. The results of this research can be helpful in mental health education programs for prevention and treatment. It is also proposed to undertake studies on the causes of women's more PDs in communities and cultures such as Iran.

Acknowledgments
The authors would like to thank all the participants, clinical experts, clinicians, research assistants, and students who contributed to the process of data collection.

Conflict of Interest
The authors declare that the text is completely original and that there are no conflicts of interest in it.

Funding
This study was supported by the national institute for medical research development (NIMAD). Informed consent was obtained from all the individual adult participants included in the study. We the authors are grateful to the NIMAD (National Institute for Medical Research Development) for financial funding the research reported here with. Grant number: 940906. We the authors are also grateful thankful to the PPRCT (Psychiatry and Psychology Research Center) for a timely travel grant to assist the later stages of the project.

Ethical Considerations
I testify on behalf of all co-authors that our article: This material has not been published in whole or in part elsewhere. The manuscript is not currently being considered for publication in another journal, and all authors have been personally and actively involved in substantive work leading to the manuscript and will hold themselves jointly and individually responsible for its content.

Code of Ethics
IR.NIMAD.REC.1395.001

Authors’ contributions
N. A, P. R, was involved with methodology; A, did data collection; M. R. M, J; Adid the writing; H. A, M. M, were involved with original draft; A. M, F. M, did data analysis; M. F, did the supervision; N. A, M. R. M, Formal Analysis, Writing – Review and Editing, Supervision. All the authors read and approved the final manuscript and were responsible for any question related to the article.

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Type of Study: Original Article | Subject: Psychology
Received: 2023/10/14 | Accepted: 2023/11/8 | Published: 2023/11/20
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