511958
research-article2013
ISP60710.1177/0020764013511958International Journal of Social PsychiatryFurnham et al.
E CAMDEN SCHIZOPH
Article
The recognition of the personality disorders among young people
International Journal of Social Psychiatry 2014, Vol. 60(7) 681–686 © The Author(s) 2013 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0020764013511958 isp.sagepub.com
Adrian Furnham, Sophie Bates, Ruhina Ladha, Zhen Yi Lee, Chiara Lousley, and Joanna Sigl-Gloecker
Abstract Background: Previous research suggests that mental health literacy regarding the personality disorders is low, with few disorders being recognised. Aims: The current study aimed to examine the effect of a background in psychology as a predictor of knowledge of the personality disorders. Methods: An opportunistic sample of 165 participants (mean age = 30.12 years, standard deviation (SD) = 15.27 years) took part in the study. Participants were instructed to read 10 personality disorder vignettes and other ‘filler’ items and rate each person in terms of how happy, successful at work and good at personal relationships they are, as well as whether they have a psychological problem. Results: Results showed, as predicted, that those with a background in psychology were more accurate at labelling disorders. In addition, laypeople’s mental health literacy was good for identifying the presence of personality disorders, but was considerably poorer when naming them. Conclusion: Recognising that people may have a disorder and having a ‘correct’ or recognised label are not the same thing. Keywords Personality disorders, mental health literacy, adjusted, problems
Introduction The term ‘mental health literacy’ refers to the public understanding of psychiatry (Jorm, 2000), and relates to the capacity of laypeople to recognise and differentiate specific mental disorders, to understand psychiatric terminology and to be aware of possible risk factors as well as sources of help. Several studies have concentrated on examining general public beliefs about and attitudes to mental disorders (Angermeyer & Dietrich, 2006; Chen, Parker, Kua, Jorm, & Loh, 2000). Others have looked at the influence of different demographic characteristics such as age and educational background on the perception of mental disorders (Farrer, Leach, Griffiths, Christensen, & Jorm, 2008; Lauber, Ajdacic-Gross, Fritschi, Stulz, & Rossler, 2005). Further studies have discussed the social stigma associated with psychiatric illness (Corrigan & Penn, 1994), as well as beliefs in the existence of real and fictitious mental disorders (Swami, Persaud, & Furnham, 2011). Most studies have used questionnaires though some have used video clips (Friedman, Oltmanns, & Turkheimer, 2007; Oltmanns, Friedman, Fiedler, & Turkheimer, 2004). Much of this research regarding psychiatric/mental health literacy has focused on schizophrenia and depression. Results of studies investigating these disorders are varied,
but laypeople appear to have considerable difficulty understanding psychiatric terms and ‘correctly’ labelling disorders (Jorm, 2000). However, a recent replication by Furnham, Daoud, and Swami (2009) found that 97% of participants could accurately name depression, 61% recognised schizophrenia but only 39% identified psychopathy. This study is concerned with mental health literacy and the personality disorders as specified by Diagnostic and Statistical Manual of Mental Disorders Fourth Edition, Text Revision (DSM-IV-TR; American Psychiatric Association (APA), 2000). However, the conceptualisation of the personality disorders has come under considerable criticism for many years (Bernstein, Iscan, Maser, & Boards of Directors of the Association for Research in Personality Disorders, 2007; Livesley, Research Department of Clinical, Educational and Health Psychology, University College London, London, UK Corresponding author: Adrian Furnham, Research Department of Clinical, Educational and Health Psychology, University College London, 26 Bedford Way, London WC1H 0AP, UK. Email: [email protected]
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2013) as the various DSM manuals have changed and developed resulting in the latest edition Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-V; APA, 2013). There are also other, related but different, conceptualisations of the personality disorders such as the International Classification of Diseases (ICD)-11 which has also been criticised (Tyrer, Crawford, Mulder, & ICD-11 Working Group for the Revision of Classification of Personality Disorders, 2011). One of the obvious and systemic problems is the reliability of diagnosis leading some clinicians to offering the diagnosis of ‘personality disorder not otherwise specified’ (Verheul, Bartak, & Widiger, 2007). This area is thus full of debate and disagreement among the experts in the field, which may, in part, explain why laypeople are not particularly well informed about these disorders (Widiger, 2011). There have been a few mental health literacy studies in this area, though some concentrating almost exclusively on a specific disorder like psychopathy (antisocial personality disorder; Furnham, Daoud, & Swami, 2009), borderline disorder (Furnham & Dadabhoy, 2012) or the conduct disorders (Furnham & Carter-Leno, 2012). Others have looked at more than one personality disorder, like the study of Furnham, Kirkby, and McClelland (2011) which looked at non-expert’s knowledge of paranoid, narcissistic and obsessive–compulsive disorders. Two more recent studies looked at the ability of laypeople to identify all the disorders (Furnham, Cook, Martin, & Batey, 2011). Furnham, Abajian, and McClelland (2011) found, contrary to predictions, obsessive–compulsive disorder was identified as a personality disorder by only 41% of the participants whereas schizotypal was identified as a disorder by 65% of participants and borderline by 86% of participants. They predicted that a high proportion of participants would be able to recognise that a psychological problem existed, but that a much smaller number would be able to label it correctly – which was also found to be the case. Paranoid personality disorder was correctly identified by 29% of participants and obsessive–compulsive by 25%; but fewer than 10% could correctly identify the remaining disorders. They also found that the likelihood of judging a problem would correlate negatively with how well adjusted the individual in question would be perceived to be. Furnham and Winceslaus (2011) using a similar vignette questionnaire required 223 participants who responded to a questionnaire titled ‘Eccentric people’ which contained vignettes of 10 personality disorders, which they rated, as well as labelled. Participants recognised people with personality disorders as being unhappy, unsuccessful at work and as having poor personal relationships, but did not associate these problems with psychological causes. Rates of ‘correct’ labelling were under 7% for 7/10 personality disorders. Cluster A (apart from paranoid) was commonly labelled as depression or as an autism spectrum disorder.
Clusters B and C (apart from obsessive–compulsive) were commonly labelled as ‘Low self-esteem’. Their history of psychological education and illness were positively correlated with correct recognition of 70% and 60% of the personality disorders, respectively. This study was specifically concerned with whether those with an education in psychology and psychiatry would recognise (and correctly label) the disorders more easily. Four hypotheses were tested. The first was that participants would fail to ‘correctly name’ most of the 10 personality disorders described in the vignettes: that is, their technical vocabulary would be very limited (Furnham, al., 2011; Furnham, Cook, et al., 2011; Abajian, et Furnham, Kirkby, et al., 2011). The second was that paranoid, obsessive–compulsive and narcissistic personality disorders would be correctly identified over and above the other personality disorders. This was because laypeople are more exposed to terms relating to these three disorders in everyday life (Furnham, Cook, et al., 2011; Furnham, Kirkby, et al., 2011). The third hypothesis was that those participants who had studied psychology at any time in their lives would have significantly higher rates of correct identification than those who had not studied psychology. This was because those who studied psychology were more likely to have encountered terms relating to the 10 personality disorders. Fourth, it was hypothesised that there would be significantly different adjustment scores between the three clusters. This was because some personality disorders could seem more detrimental to the success and happiness of the individuals described than others.
Method Participants An opportunity sample of 165 people took part in the study (106 females and 59 males). In order to obtain a representative sample, participants were recruited from various sources, for example, work colleagues, university students and personal contacts. The mean age of the sample was 30.12 years (standard deviation (SD) = 15.27 years), and the range was 18–75 years. A total of 46 participants had previously studied psychology, 119 had not. None were working clinical psychologists or therapists of any kind. Participants were randomly presented with one of the three questionnaires: A (n = 55), B (n = 51) or C (n = 59). The three groups did not differ in terms of gender, age and education.
Stimuli and apparatus Participants were presented with one of three questionnaires with the same format. Each questionnaire related to one cluster of personality disorders – A, B and C. Each questionnaire contained three or four target vignettes (depending on
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Furnham et al. cluster), which each described an individual with a different personality disorder. Thus, cluster A questionnaires contained three vignettes of this kind, cluster B contained four and cluster C had three. These target vignettes were adapted from three textbooks – Nevid, Rathus, and Green (1997), Seligman, Walker, and Rosenhan (2001) and Spitzer, Gibbon, Skodol, Williams, and First (1994). These questionnaires have been used in previous research in the area (Furnham, Abajian, et al., 2011; Furnham, Cook, et al., 2011; Furnham, Kirkby, et al., 2011 Furnham & Winceslaus, 2011). In addition, each questionnaire also had the same five ‘dummy’ vignettes, written to match the style of the target vignettes. All the vignettes were around 100–200 words and clearly phrased. Following each vignette were three questions relating to how happy participants believed the individuals described to be and how successful at work and in personal relationships these individuals were. These were rated on a scale from 1 to 8, where 1 indicated not at all and 8 indicated very. Then, there was a question asking participants to indicate whether the character described in a vignette had a psychological problem or not. Finally, if the participants had indicated that the character described had a problem, they were asked to name it.
Procedure Ethical permission was sought and granted. Participants were given as much time as they needed to complete the anonymous questionnaire, and demographic information was also taken. They took around 30 minutes to complete the questionnaire.
Results Adjustment score analysis The Likert ratings of overall happiness, successfulness at work and ability in personal relationships were totalled and averaged to give a composite score of each participant’s assessment of adjustment for each target vignette. These adjustment scores were then totalled and averaged across the 10 personality disorder vignettes, giving mean adjustment scores for each disorder with a range of 1–8. A higher mean indicates greater ratings of adjustment. These are shown below in Table 1. It can be seen from Table 1 that the vignette describing paranoid personality disorder was believed to be the best adjusted in life (mean (M) = 4.58, SD = 1.43), closely followed by dependent (M = 4.26, SD = 1.35). Conversely, the borderline personality disorder vignette was perceived to be the least well adjusted in life (M = 2.04, SD = 0.91). Overall, the ratings of adjustment were poor for all the disorders, the highest rating being 4.58. Average adjustment scores were calculated for each cluster of personality disorders by averaging the individual
Table 1. Mean adjustment scores for the 10 personality disorders. Personality disorder
Mean
Standard deviation
Schizotypal Paranoid Schizoid Antisocial Borderline Histrionic Narcissistic Avoidant Dependent Obsessive–compulsive
3.48 4.58 3.21 2.14 2.04 2.89 3.21 3.27 4.26 4.02
1.42 1.43 1.04 1.01 0.91 1.35 1.36 0.98 1.35 1.15
Table 2. Mean adjustment scores for each cluster of personality disorders. Cluster
Mean
Standard deviation
A B C
3.75 2.57 3.87
0.89 0.90 0.89
adjustment scores of personality disorders in each cluster. These can be seen in Table 2 below. A one-way analysis of variance (ANOVA) was conducted to assess whether these means were significantly different from one another: F(2, 162) = 34.07, p < .001. A post hoc Ryan–Einot–Gabriel–Welsch Q (REGW-Q) procedure was carried to out to enable multiple comparisons. It was found that the mean adjustment score for cluster B was significantly lower from those of clusters A and C, but those two were not significantly different from one another (p > .05).
Awareness of a psychological problem Results showed that 67% of participants correctly perceived the presence of a psychological problem in the cluster A target vignettes, 62% in the cluster B vignettes and 57% in the cluster C vignettes. To examine these results more closely, Table 3 below shows the percentages of participants who correctly stated that there was a psychological problem present in the target vignettes for each personality disorder. A higher percentage indicates a higher rate of correct identification. Table 3 shows that participants were most successful at correctly perceiving a psychological problem present in the borderline personality disorder vignette (88%). This was closely followed by the schizoid vignette (80%). Less than half of the participants identified a problem in the narcissistic vignette (46%) and the dependent vignette (44%). Over half of participants correctly ascertained the presence
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Table 3. Percentages of participants that identified the ‘presence of’ a psychological problem in target vignettes. Personality disorder
Percentage that correctly answered ‘yes’
Schizotypal Paranoid Schizoid Antisocial Borderline Histrionic Narcissistic Avoidant Dependent Obsessive–compulsive
66 56 80 57 88 55 46 63 44 64
Table 4. Percentages of participants that ‘correctly labelled’ the personality disorders present in target vignettes. Personality disorder
Percentage correctly identified
Schizotypal Paranoid Schizoid Antisocial Borderline Histrionic Narcissistic Avoidant Dependent Obsessive–compulsive
0 44.8 2.5 3 3 7 19 0 1 23
correctly naming the psychological problem being 44.8%, in the case of the paranoid vignette. A total of 23% of participants correctly labelled obsessive–compulsive personality disorder in its vignette, with 19% identifying narcissistic personality disorder. Yet only 3% of participants correctly named antisocial and borderline personality disorder. Moreover, none of the participants correctly labelled either schizotypal or avoidant personality disorder, and only 1% correctly identified dependent personality disorder in its vignette. In total, 14.5% of participants correctly named cluster A personality disorders, 6% correctly identified cluster B disorders and 8.5% correctly labelled cluster C disorders. A Cochran’s Q test was conducted to assess how successful participants were at naming the psychological problem being described. It showed that there was a highly significant difference in the proportion of correctly naming the psychological problem that was being described between the personality disorder vignettes – Q(9) = 85.31, p < .001. While participants were quite successful at identifying the presence of a psychological problem in the target vignettes, they were much less successful at being able to name the relevant personality disorders. The largest percentage discrepancy was present in the borderline personality disorder vignette − 85%, followed by the schizoid vignette at 77%. The smallest discrepancy was in the paranoid vignette, at 11.5%, and was followed by a 27% discrepancy in the narcissistic vignette.
Psychology and non-psychology comparison of a psychological problem in 8 out of the 10 personality disorder vignettes. In order to assess whether these percentages were significantly different from one another, a non-parametric test was conducted for several related samples, assuming independent groups as opposed to repeated measures. As a binary measure was being analysed (i.e. no = 0 and yes = 1), the Cochran’s Q test showed that there was a significant difference in the proportions of successful identification of a psychological problem being described, between the personality disorder vignettes – Q(9) = 35.42, p < .001.
Rates of correct identification Participants’ responses were only marked as ‘correct’ if they explicitly named the personality disorder. ‘Attention seeking’ is a diagnostic criterion for histrionic personality disorder, for example, but responses such as this, which did not specifically label the vignette as ‘histrionic’ were marked as incorrect. Table 4 above shows how successful naming was for each target vignette respectively. As predicted, participants performed very poorly on this question, with the highest percentage of participants
Both psychology and non-psychology participants were most successful at naming the paranoid (65% and 25%, respectively), narcissistic (26% and 11%, respectively) and obsessive–compulsive (22% and 24%, respectively) personality disorders. However, non-psychology participants could not correctly identify 6 out of the 10 disorders, as compared to 3 in the case of the psychology participants. Both non-psychology and psychology participants had similar, relatively high rates of identification for the obsessive–compulsive vignette. No participants correctly labelled either schizotypal or avoidant personality disorder. A one-tailed (due to directional hypothesis) independent samples t-test was conducted on this data and showed that those who had studied psychology at any point in their life were significantly better at correctly naming the 10 personality disorders than those who had not studied psychology – t(163) = 3.45, p < .001.
Discussion These results showed a marked discrepancy between how successful participants were at perceiving the presence of
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Furnham et al. a problem in the target vignettes and correctly identifying it. Participants were considerably more successful at stating there was a problem present than being able to actually name it using the ‘accepted’ psychiatric terms. For example, although a substantial proportion of participants (88%) were able to perceive the presence of a psychological problem in the borderline personality disorder vignette, only 3% were able to ‘correctly’ label it as such. Therefore, it could be that laypeople have reasonably good psychiatric literacy in terms of being aware of problematic behaviours and characteristics but are poor in their knowledge of psychiatric terminology. This is consistent with results found by Furnham, Abajian, et al. (2011), Furnham, Cook, et al. (2011), Furnham, Kirkby, et al. (2011) and Furnham and Winceslaus (2011). This has important implications for how mental health literacy is assessed. Certainly, knowledge of the ‘technical terminology’ seems less important than the recognition of the symptoms as reflecting poor adjustment. Added to this, it should be noted that there is considerable debate about the classification and reliable diagnosis of many of the personality disorders. Participants were most successful at perceiving problems in, and identifying, cluster A personality disorders. However, it should be noted that cluster A contained paranoid personality disorder, which was by far the best identified disorder, thus skewing the rate of correct identification for cluster A. Furnham, Abajian, et al. (2011) suggested that this finding could be because of differences in terms of prevalence regarding the personality disorders and the clusters they fall in. Research has found cluster A to be the most prevalent out of the three (Coid, Yang, Tyrer, Roberts, & Ullrich, 2006; Huang et al., 2009), indicating a higher likelihood of coming into contact with cluster A disorders, either through others or oneself. The current study found that two cluster A disorders were in the top three of those most successfully recognised as a psychological problem (schizoid and schizotypal). Therefore, people may have been more familiar with the characteristics and behaviours associated with cluster A disorders due to greater exposure to them. In relation to the second hypothesis, the current study was strongly in line with previous research (Furnham, Abajian, et al., 2011; Furnham & Winceslaus, 2011), replicating results and finding that only paranoid (44.8% correct), obsessive–compulsive (23%) and narcissistic (19%) personality disorders had rates of identification over 10%, while nobody correctly labelled avoidant and schizotypal personality disorders. This could be because of the frequency of terms relating to these disorders appearing in the media and everyday life. For example, the term ‘OCD’ is often used by laypeople when referring to a person with ‘obsessive’ tendencies, such as arranging things in order repeatedly or frequently washing their hands. ‘Paranoid’ is an often repeated term
in the media when discussing conspiracy theories and ‘narcissist’ is also commonly used, in relation to people who are perceived to be highly self-absorbed. However, ‘avoidant’ and ‘schizotypal’ are very rarely heard in the media and in everyday life. Participants who studied psychology at any time in their lives were more likely to have encountered terms relating to the 10 personality disorders and were thus better at ‘correctly labelling’ the target vignettes than participants who had not studied psychology. However, it was found that neither psychology nor non-psychology participants correctly named avoidant and schizotypal personality disorders. Nonetheless, psychology participants were vastly better at correctly identifying all but two of the remaining disorders. It was found that participants believed cluster B disordered individuals to be significantly less well adjusted than clusters A and C disordered individuals. This is likely to be because, by definition, people with cluster B disorders are ‘emotional’ and ‘erratic’, thus leading them to be less emotionally stable than people with cluster A or C disorders. This, in turn, explains why they may be unhappier – because they may be more prone to sudden changeability in mood. They could be less successful in work because of an inability to focus, and they may be less able in personal relationships due to their unpredictability. One limitation of the current study is that written vignettes were used. Levels of psychiatric literacy may differ when observing a person as opposed to reading about them. This aspect of the methodology could be improved in future research by using more realistic presentation devices. Two studies using 30-second video clips of people found ‘Laypersons can make accurate judgements regarding some personality characteristics associated with personality disorders, even on the basis of minimal information’ (Oltmanns et al., 2004). It would also have been advantageous to have a bigger and more representative sample as well as ‘alternative/equivalent’ vignettes for each disorder to ensure reliability. This study used reasonably small, opportunistic sample of people mainly from London, although it should be pointed out that no professionals, like clinical psychologist or psychiatrists, took part. However, the sample did tend to have better educated young people who may therefore have higher mental health literacy although this speculation is worthy of further study. It would also have benefitted from knowing more about each participant, particularly the precise nature of their education, interest and experience of psychology, therapy and therapists. This study therefore requires replication on a bigger, more representative sample. Funding This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.
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References American Psychiatric Association (APA). (2000). Diagnostic and statistical manual of mental disorders (DSM-IV-TR) (4th ed., text rev.). Washington, DC: Author. American Psychiatric Association (APA). (2013). Diagnostic and statistical manual of mental disorders (DSM-V) (5th ed.). Washington, DC: Author. Angermeyer, M. C., & Dietrich, S. (2006). Public beliefs about and attitudes towards people with mental illness: A review of population studies. Acta Psychiatrica Scandinavica, 113, 163–179. Bernstein, D. P., Iscan, C., Maser, J., & Boards of Directors of the Association for Research in Personality Disorders. (2007). Opinions of personality disorder experts regarding the DSM-IV personality disorders classification system. Journal of Personality Disorders, 21, 536–551. Chen, H., Parker, G., Kua, J., Jorm, A., & Loh, J. (2000). Mental health literacy in Singapore. Annals of the Academy of Medicine Singapore, 29, 467–473. Coid, J., Yang, M., Tyrer, P., Roberts, A., & Ullrich, S. (2006). Prevalence and correlates of personality disorder in Great Britain. British Journal of Psychiatry, 188, 423–431. Corrigan, P. W., & Penn, D. L. (1994). Lessons from social psychology on discrediting psychiatric stigma. American Psychologist, 54, 765–776. Farrer, L., Leach, L., Griffiths, K. M., Christensen, H., & Jorm, A. F. (2008). Age differences in mental health literacy. BMC Public Health, 8, 125. Friedman, J., Oltmanns, T., & Turkheimer, E. (2007). Interpersonal perception and personality disorders. Journal of Research in Personality, 41, 667–688. Furnham, A., Abajian, N., & McClelland, A. (2011). Psychiatric literacy and the personality disorders. Psychiatry Research, 189, 110–114. Furnham, A., & Carter-Leno, V. (2012). Psychiatric literacy and the conduct disorders. Research in Developmental Disabilities, 33, 24–31. Furnham, A., Cook, R., Martin, N., & Batey, M. (2011). Mental health literacy among university students. Journal of Public Mental Health, 10, 198–210. Furnham, A., & Dadabhoy, J. (2012). Beliefs about causes, behavioural manifestations a treatment of borderline personality disorder. Psychiatry Research, 197, 307–313. Furnham, A., Daoud, J., & Swami, V. (2009). ‘How to spot a psychopath’. Lay theories of psychopathy. Social Psychiatry and Psychiatric Epidemiology, 44, 464–472.
Furnham, A., Kirkby, V., & McClelland, A. (2011). Non-expert’s theories of three major personality disorders. Personality and Mental Health, 5, 43–56. Furnham, A., & Winceslaus, J. (2011). Psychiatric literacy and the personality disorders. Psychopathology, 45, 29–41. Huang, Y., Kotov, R., de Girolamo, G., Preti, A., Angermeyer, M., Benjet, C., … Kessler, R. C. (2009). DSM-IV personality disorders in the WHO Mental Health Surveys. British Journal of Psychiatry, 195, 46–53. Jorm, A. F. (2000). Mental health literacy: Public knowledge and beliefs about mental disorders. British Journal of Psychiatry, 177, 396–401. Lauber, C., Ajdacic-Gross, V., Fritschi, N., Stulz, N., & Rossler, W. (2005). Mental health literacy in an educational elite – An online survey among university students. BMC Public Health, 5, 44. Livesley, J. (2013). The DSM-5 personality disorder proposal and the future directions in the diagnostic classification of personality disorder. Psychopathy, 46, 207–216. Nevid, J. S., Rathus, S. A., & Green, B. (1997). Abnormal psychology in a changing world (3rd ed.). New York, NY: Prentice Hall. Oltmanns, T., Friedman, J., Fiedler, E., & Turkheimer, E. (2004). Perceptions of people with personality disorders based on thin slices of behaviour. Journal of Research in Personality, 38, 216–229. Seligman, M.E.P., Walker, E., & Rosenhan, D.L. (2001). Abnormal Psychology (4th ed.). New York: W.W. Norton. Spitzer, R., Gibbon, M., Skodol, A., Williams, J., & First, M. (1994). DSM-IV case book. Washington, DC: American Psychiatric Press. Swami, V., Persaud, R., & Furnham, A. (2011). The recognition of mental health disorders and its association with psychiatric scepticism, knowledge of psychiatry, and the Big Five personality factors: An investigation using the overclaiming technique. Social Psychiatry and Psychiatric Epidemiology, 46, 181–189. Tyrer, P., Crawford, M., Mulder, R., & ICD-11 Working Group for the Revision of Classification of Personality Disorders. (2011). Reclassifying personality disorders. Lancet, 377, 1814–1815. Verheul, R., Bartak, A., & Widiger, T. (2007). Prevalence and construct validity of personality disorder not otherwise specified. Journal of Personality Disorders, 21, 359–370. Widiger, T. (2011). The DSM-5 dimensional model of personality disorder: Rationale and empirical support. Journal of Personality Disorders, 25, 222–234.
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research-article2013
ISP60710.1177/0020764013511958International Journal of Social PsychiatryFurnham et al.
E CAMDEN SCHIZOPH
Article
The recognition of the personality disorders among young people
International Journal of Social Psychiatry 2014, Vol. 60(7) 681–686 © The Author(s) 2013 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0020764013511958 isp.sagepub.com
Adrian Furnham, Sophie Bates, Ruhina Ladha, Zhen Yi Lee, Chiara Lousley, and Joanna Sigl-Gloecker
Abstract Background: Previous research suggests that mental health literacy regarding the personality disorders is low, with few disorders being recognised. Aims: The current study aimed to examine the effect of a background in psychology as a predictor of knowledge of the personality disorders. Methods: An opportunistic sample of 165 participants (mean age = 30.12 years, standard deviation (SD) = 15.27 years) took part in the study. Participants were instructed to read 10 personality disorder vignettes and other ‘filler’ items and rate each person in terms of how happy, successful at work and good at personal relationships they are, as well as whether they have a psychological problem. Results: Results showed, as predicted, that those with a background in psychology were more accurate at labelling disorders. In addition, laypeople’s mental health literacy was good for identifying the presence of personality disorders, but was considerably poorer when naming them. Conclusion: Recognising that people may have a disorder and having a ‘correct’ or recognised label are not the same thing. Keywords Personality disorders, mental health literacy, adjusted, problems
Introduction The term ‘mental health literacy’ refers to the public understanding of psychiatry (Jorm, 2000), and relates to the capacity of laypeople to recognise and differentiate specific mental disorders, to understand psychiatric terminology and to be aware of possible risk factors as well as sources of help. Several studies have concentrated on examining general public beliefs about and attitudes to mental disorders (Angermeyer & Dietrich, 2006; Chen, Parker, Kua, Jorm, & Loh, 2000). Others have looked at the influence of different demographic characteristics such as age and educational background on the perception of mental disorders (Farrer, Leach, Griffiths, Christensen, & Jorm, 2008; Lauber, Ajdacic-Gross, Fritschi, Stulz, & Rossler, 2005). Further studies have discussed the social stigma associated with psychiatric illness (Corrigan & Penn, 1994), as well as beliefs in the existence of real and fictitious mental disorders (Swami, Persaud, & Furnham, 2011). Most studies have used questionnaires though some have used video clips (Friedman, Oltmanns, & Turkheimer, 2007; Oltmanns, Friedman, Fiedler, & Turkheimer, 2004). Much of this research regarding psychiatric/mental health literacy has focused on schizophrenia and depression. Results of studies investigating these disorders are varied,
but laypeople appear to have considerable difficulty understanding psychiatric terms and ‘correctly’ labelling disorders (Jorm, 2000). However, a recent replication by Furnham, Daoud, and Swami (2009) found that 97% of participants could accurately name depression, 61% recognised schizophrenia but only 39% identified psychopathy. This study is concerned with mental health literacy and the personality disorders as specified by Diagnostic and Statistical Manual of Mental Disorders Fourth Edition, Text Revision (DSM-IV-TR; American Psychiatric Association (APA), 2000). However, the conceptualisation of the personality disorders has come under considerable criticism for many years (Bernstein, Iscan, Maser, & Boards of Directors of the Association for Research in Personality Disorders, 2007; Livesley, Research Department of Clinical, Educational and Health Psychology, University College London, London, UK Corresponding author: Adrian Furnham, Research Department of Clinical, Educational and Health Psychology, University College London, 26 Bedford Way, London WC1H 0AP, UK. Email: [email protected]
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2013) as the various DSM manuals have changed and developed resulting in the latest edition Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-V; APA, 2013). There are also other, related but different, conceptualisations of the personality disorders such as the International Classification of Diseases (ICD)-11 which has also been criticised (Tyrer, Crawford, Mulder, & ICD-11 Working Group for the Revision of Classification of Personality Disorders, 2011). One of the obvious and systemic problems is the reliability of diagnosis leading some clinicians to offering the diagnosis of ‘personality disorder not otherwise specified’ (Verheul, Bartak, & Widiger, 2007). This area is thus full of debate and disagreement among the experts in the field, which may, in part, explain why laypeople are not particularly well informed about these disorders (Widiger, 2011). There have been a few mental health literacy studies in this area, though some concentrating almost exclusively on a specific disorder like psychopathy (antisocial personality disorder; Furnham, Daoud, & Swami, 2009), borderline disorder (Furnham & Dadabhoy, 2012) or the conduct disorders (Furnham & Carter-Leno, 2012). Others have looked at more than one personality disorder, like the study of Furnham, Kirkby, and McClelland (2011) which looked at non-expert’s knowledge of paranoid, narcissistic and obsessive–compulsive disorders. Two more recent studies looked at the ability of laypeople to identify all the disorders (Furnham, Cook, Martin, & Batey, 2011). Furnham, Abajian, and McClelland (2011) found, contrary to predictions, obsessive–compulsive disorder was identified as a personality disorder by only 41% of the participants whereas schizotypal was identified as a disorder by 65% of participants and borderline by 86% of participants. They predicted that a high proportion of participants would be able to recognise that a psychological problem existed, but that a much smaller number would be able to label it correctly – which was also found to be the case. Paranoid personality disorder was correctly identified by 29% of participants and obsessive–compulsive by 25%; but fewer than 10% could correctly identify the remaining disorders. They also found that the likelihood of judging a problem would correlate negatively with how well adjusted the individual in question would be perceived to be. Furnham and Winceslaus (2011) using a similar vignette questionnaire required 223 participants who responded to a questionnaire titled ‘Eccentric people’ which contained vignettes of 10 personality disorders, which they rated, as well as labelled. Participants recognised people with personality disorders as being unhappy, unsuccessful at work and as having poor personal relationships, but did not associate these problems with psychological causes. Rates of ‘correct’ labelling were under 7% for 7/10 personality disorders. Cluster A (apart from paranoid) was commonly labelled as depression or as an autism spectrum disorder.
Clusters B and C (apart from obsessive–compulsive) were commonly labelled as ‘Low self-esteem’. Their history of psychological education and illness were positively correlated with correct recognition of 70% and 60% of the personality disorders, respectively. This study was specifically concerned with whether those with an education in psychology and psychiatry would recognise (and correctly label) the disorders more easily. Four hypotheses were tested. The first was that participants would fail to ‘correctly name’ most of the 10 personality disorders described in the vignettes: that is, their technical vocabulary would be very limited (Furnham, al., 2011; Furnham, Cook, et al., 2011; Abajian, et Furnham, Kirkby, et al., 2011). The second was that paranoid, obsessive–compulsive and narcissistic personality disorders would be correctly identified over and above the other personality disorders. This was because laypeople are more exposed to terms relating to these three disorders in everyday life (Furnham, Cook, et al., 2011; Furnham, Kirkby, et al., 2011). The third hypothesis was that those participants who had studied psychology at any time in their lives would have significantly higher rates of correct identification than those who had not studied psychology. This was because those who studied psychology were more likely to have encountered terms relating to the 10 personality disorders. Fourth, it was hypothesised that there would be significantly different adjustment scores between the three clusters. This was because some personality disorders could seem more detrimental to the success and happiness of the individuals described than others.
Method Participants An opportunity sample of 165 people took part in the study (106 females and 59 males). In order to obtain a representative sample, participants were recruited from various sources, for example, work colleagues, university students and personal contacts. The mean age of the sample was 30.12 years (standard deviation (SD) = 15.27 years), and the range was 18–75 years. A total of 46 participants had previously studied psychology, 119 had not. None were working clinical psychologists or therapists of any kind. Participants were randomly presented with one of the three questionnaires: A (n = 55), B (n = 51) or C (n = 59). The three groups did not differ in terms of gender, age and education.
Stimuli and apparatus Participants were presented with one of three questionnaires with the same format. Each questionnaire related to one cluster of personality disorders – A, B and C. Each questionnaire contained three or four target vignettes (depending on
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Furnham et al. cluster), which each described an individual with a different personality disorder. Thus, cluster A questionnaires contained three vignettes of this kind, cluster B contained four and cluster C had three. These target vignettes were adapted from three textbooks – Nevid, Rathus, and Green (1997), Seligman, Walker, and Rosenhan (2001) and Spitzer, Gibbon, Skodol, Williams, and First (1994). These questionnaires have been used in previous research in the area (Furnham, Abajian, et al., 2011; Furnham, Cook, et al., 2011; Furnham, Kirkby, et al., 2011 Furnham & Winceslaus, 2011). In addition, each questionnaire also had the same five ‘dummy’ vignettes, written to match the style of the target vignettes. All the vignettes were around 100–200 words and clearly phrased. Following each vignette were three questions relating to how happy participants believed the individuals described to be and how successful at work and in personal relationships these individuals were. These were rated on a scale from 1 to 8, where 1 indicated not at all and 8 indicated very. Then, there was a question asking participants to indicate whether the character described in a vignette had a psychological problem or not. Finally, if the participants had indicated that the character described had a problem, they were asked to name it.
Procedure Ethical permission was sought and granted. Participants were given as much time as they needed to complete the anonymous questionnaire, and demographic information was also taken. They took around 30 minutes to complete the questionnaire.
Results Adjustment score analysis The Likert ratings of overall happiness, successfulness at work and ability in personal relationships were totalled and averaged to give a composite score of each participant’s assessment of adjustment for each target vignette. These adjustment scores were then totalled and averaged across the 10 personality disorder vignettes, giving mean adjustment scores for each disorder with a range of 1–8. A higher mean indicates greater ratings of adjustment. These are shown below in Table 1. It can be seen from Table 1 that the vignette describing paranoid personality disorder was believed to be the best adjusted in life (mean (M) = 4.58, SD = 1.43), closely followed by dependent (M = 4.26, SD = 1.35). Conversely, the borderline personality disorder vignette was perceived to be the least well adjusted in life (M = 2.04, SD = 0.91). Overall, the ratings of adjustment were poor for all the disorders, the highest rating being 4.58. Average adjustment scores were calculated for each cluster of personality disorders by averaging the individual
Table 1. Mean adjustment scores for the 10 personality disorders. Personality disorder
Mean
Standard deviation
Schizotypal Paranoid Schizoid Antisocial Borderline Histrionic Narcissistic Avoidant Dependent Obsessive–compulsive
3.48 4.58 3.21 2.14 2.04 2.89 3.21 3.27 4.26 4.02
1.42 1.43 1.04 1.01 0.91 1.35 1.36 0.98 1.35 1.15
Table 2. Mean adjustment scores for each cluster of personality disorders. Cluster
Mean
Standard deviation
A B C
3.75 2.57 3.87
0.89 0.90 0.89
adjustment scores of personality disorders in each cluster. These can be seen in Table 2 below. A one-way analysis of variance (ANOVA) was conducted to assess whether these means were significantly different from one another: F(2, 162) = 34.07, p < .001. A post hoc Ryan–Einot–Gabriel–Welsch Q (REGW-Q) procedure was carried to out to enable multiple comparisons. It was found that the mean adjustment score for cluster B was significantly lower from those of clusters A and C, but those two were not significantly different from one another (p > .05).
Awareness of a psychological problem Results showed that 67% of participants correctly perceived the presence of a psychological problem in the cluster A target vignettes, 62% in the cluster B vignettes and 57% in the cluster C vignettes. To examine these results more closely, Table 3 below shows the percentages of participants who correctly stated that there was a psychological problem present in the target vignettes for each personality disorder. A higher percentage indicates a higher rate of correct identification. Table 3 shows that participants were most successful at correctly perceiving a psychological problem present in the borderline personality disorder vignette (88%). This was closely followed by the schizoid vignette (80%). Less than half of the participants identified a problem in the narcissistic vignette (46%) and the dependent vignette (44%). Over half of participants correctly ascertained the presence
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Table 3. Percentages of participants that identified the ‘presence of’ a psychological problem in target vignettes. Personality disorder
Percentage that correctly answered ‘yes’
Schizotypal Paranoid Schizoid Antisocial Borderline Histrionic Narcissistic Avoidant Dependent Obsessive–compulsive
66 56 80 57 88 55 46 63 44 64
Table 4. Percentages of participants that ‘correctly labelled’ the personality disorders present in target vignettes. Personality disorder
Percentage correctly identified
Schizotypal Paranoid Schizoid Antisocial Borderline Histrionic Narcissistic Avoidant Dependent Obsessive–compulsive
0 44.8 2.5 3 3 7 19 0 1 23
correctly naming the psychological problem being 44.8%, in the case of the paranoid vignette. A total of 23% of participants correctly labelled obsessive–compulsive personality disorder in its vignette, with 19% identifying narcissistic personality disorder. Yet only 3% of participants correctly named antisocial and borderline personality disorder. Moreover, none of the participants correctly labelled either schizotypal or avoidant personality disorder, and only 1% correctly identified dependent personality disorder in its vignette. In total, 14.5% of participants correctly named cluster A personality disorders, 6% correctly identified cluster B disorders and 8.5% correctly labelled cluster C disorders. A Cochran’s Q test was conducted to assess how successful participants were at naming the psychological problem being described. It showed that there was a highly significant difference in the proportion of correctly naming the psychological problem that was being described between the personality disorder vignettes – Q(9) = 85.31, p < .001. While participants were quite successful at identifying the presence of a psychological problem in the target vignettes, they were much less successful at being able to name the relevant personality disorders. The largest percentage discrepancy was present in the borderline personality disorder vignette − 85%, followed by the schizoid vignette at 77%. The smallest discrepancy was in the paranoid vignette, at 11.5%, and was followed by a 27% discrepancy in the narcissistic vignette.
Psychology and non-psychology comparison of a psychological problem in 8 out of the 10 personality disorder vignettes. In order to assess whether these percentages were significantly different from one another, a non-parametric test was conducted for several related samples, assuming independent groups as opposed to repeated measures. As a binary measure was being analysed (i.e. no = 0 and yes = 1), the Cochran’s Q test showed that there was a significant difference in the proportions of successful identification of a psychological problem being described, between the personality disorder vignettes – Q(9) = 35.42, p < .001.
Rates of correct identification Participants’ responses were only marked as ‘correct’ if they explicitly named the personality disorder. ‘Attention seeking’ is a diagnostic criterion for histrionic personality disorder, for example, but responses such as this, which did not specifically label the vignette as ‘histrionic’ were marked as incorrect. Table 4 above shows how successful naming was for each target vignette respectively. As predicted, participants performed very poorly on this question, with the highest percentage of participants
Both psychology and non-psychology participants were most successful at naming the paranoid (65% and 25%, respectively), narcissistic (26% and 11%, respectively) and obsessive–compulsive (22% and 24%, respectively) personality disorders. However, non-psychology participants could not correctly identify 6 out of the 10 disorders, as compared to 3 in the case of the psychology participants. Both non-psychology and psychology participants had similar, relatively high rates of identification for the obsessive–compulsive vignette. No participants correctly labelled either schizotypal or avoidant personality disorder. A one-tailed (due to directional hypothesis) independent samples t-test was conducted on this data and showed that those who had studied psychology at any point in their life were significantly better at correctly naming the 10 personality disorders than those who had not studied psychology – t(163) = 3.45, p < .001.
Discussion These results showed a marked discrepancy between how successful participants were at perceiving the presence of
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Furnham et al. a problem in the target vignettes and correctly identifying it. Participants were considerably more successful at stating there was a problem present than being able to actually name it using the ‘accepted’ psychiatric terms. For example, although a substantial proportion of participants (88%) were able to perceive the presence of a psychological problem in the borderline personality disorder vignette, only 3% were able to ‘correctly’ label it as such. Therefore, it could be that laypeople have reasonably good psychiatric literacy in terms of being aware of problematic behaviours and characteristics but are poor in their knowledge of psychiatric terminology. This is consistent with results found by Furnham, Abajian, et al. (2011), Furnham, Cook, et al. (2011), Furnham, Kirkby, et al. (2011) and Furnham and Winceslaus (2011). This has important implications for how mental health literacy is assessed. Certainly, knowledge of the ‘technical terminology’ seems less important than the recognition of the symptoms as reflecting poor adjustment. Added to this, it should be noted that there is considerable debate about the classification and reliable diagnosis of many of the personality disorders. Participants were most successful at perceiving problems in, and identifying, cluster A personality disorders. However, it should be noted that cluster A contained paranoid personality disorder, which was by far the best identified disorder, thus skewing the rate of correct identification for cluster A. Furnham, Abajian, et al. (2011) suggested that this finding could be because of differences in terms of prevalence regarding the personality disorders and the clusters they fall in. Research has found cluster A to be the most prevalent out of the three (Coid, Yang, Tyrer, Roberts, & Ullrich, 2006; Huang et al., 2009), indicating a higher likelihood of coming into contact with cluster A disorders, either through others or oneself. The current study found that two cluster A disorders were in the top three of those most successfully recognised as a psychological problem (schizoid and schizotypal). Therefore, people may have been more familiar with the characteristics and behaviours associated with cluster A disorders due to greater exposure to them. In relation to the second hypothesis, the current study was strongly in line with previous research (Furnham, Abajian, et al., 2011; Furnham & Winceslaus, 2011), replicating results and finding that only paranoid (44.8% correct), obsessive–compulsive (23%) and narcissistic (19%) personality disorders had rates of identification over 10%, while nobody correctly labelled avoidant and schizotypal personality disorders. This could be because of the frequency of terms relating to these disorders appearing in the media and everyday life. For example, the term ‘OCD’ is often used by laypeople when referring to a person with ‘obsessive’ tendencies, such as arranging things in order repeatedly or frequently washing their hands. ‘Paranoid’ is an often repeated term
in the media when discussing conspiracy theories and ‘narcissist’ is also commonly used, in relation to people who are perceived to be highly self-absorbed. However, ‘avoidant’ and ‘schizotypal’ are very rarely heard in the media and in everyday life. Participants who studied psychology at any time in their lives were more likely to have encountered terms relating to the 10 personality disorders and were thus better at ‘correctly labelling’ the target vignettes than participants who had not studied psychology. However, it was found that neither psychology nor non-psychology participants correctly named avoidant and schizotypal personality disorders. Nonetheless, psychology participants were vastly better at correctly identifying all but two of the remaining disorders. It was found that participants believed cluster B disordered individuals to be significantly less well adjusted than clusters A and C disordered individuals. This is likely to be because, by definition, people with cluster B disorders are ‘emotional’ and ‘erratic’, thus leading them to be less emotionally stable than people with cluster A or C disorders. This, in turn, explains why they may be unhappier – because they may be more prone to sudden changeability in mood. They could be less successful in work because of an inability to focus, and they may be less able in personal relationships due to their unpredictability. One limitation of the current study is that written vignettes were used. Levels of psychiatric literacy may differ when observing a person as opposed to reading about them. This aspect of the methodology could be improved in future research by using more realistic presentation devices. Two studies using 30-second video clips of people found ‘Laypersons can make accurate judgements regarding some personality characteristics associated with personality disorders, even on the basis of minimal information’ (Oltmanns et al., 2004). It would also have been advantageous to have a bigger and more representative sample as well as ‘alternative/equivalent’ vignettes for each disorder to ensure reliability. This study used reasonably small, opportunistic sample of people mainly from London, although it should be pointed out that no professionals, like clinical psychologist or psychiatrists, took part. However, the sample did tend to have better educated young people who may therefore have higher mental health literacy although this speculation is worthy of further study. It would also have benefitted from knowing more about each participant, particularly the precise nature of their education, interest and experience of psychology, therapy and therapists. This study therefore requires replication on a bigger, more representative sample. Funding This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.
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