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Personality Disorder – Smart Essays

Personality Disorder#

T h is C h s p te r b e g i n s with a general definition of personaliiy disorder that applies to each of the 10 specific personality disorders. A personality disorder is an enduring pattern of inner experience and behavior that deviates markedly from the expectations of the in­ dividual’s culture, is pervasive and inflexible, has an onset in adolescence or early adult­ hood, is stable over time, and leads to distress or impairment.

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With any ongoing review process, especially one of this complexity, different view­ points emerge, and an effort was made to accommodate them. Thus, personality disorders are included in both Sections II and III. The material in Section II represents an update of text associated with the same criteria found in DSM-IV-TR, whereas Section III includes the proposed research model for personality disorder diagnosis and conceptualization de­ veloped by the DSM-5 Personality and Personality Disorders Work Group. As this field evolves, it is hoped that both versions will serve clinical practice and research initiatives, respectively.

The following personality disorders are included in this chapter.

• Paranoid personality disorder is a pattern of distrust and suspiciousness such that oth­ ers’ motives are interpreted as malevolent.

• Schizoid personality disorder is a pattern of detachment from social relationships and a restricted range of emotional expression.

• Schizotypal personality disorder is a pattern of acute discomfort in close relationships, cognitive or perceptual distortions, and eccentricities of behavior.

• Antisocial personality disorder is a pattern of disregard for, and violation of, the rights of others.

• Borderline personality disorder is a pattern of instability in interpersonal relation­ ships, self-image, and affects, and marked impulsivity.

• Histrionic personality disorder is a pattern of excessive emotionality and attention seeking.

• Narcissistic personality disorder is a pattern of grandiosity, need for admiration, and lack of empathy.

• Avoidant personality disorder is a pattern of social inhibition, feelings of inadequacy, and hypersensitivity to negative evaluation.

• Dependent personality disorder is a pattern of submissive and clinging behavior re­ lated to an excessive need to be taken care of.

• Obsessive-compulsive personality disorder is a pattern of preoccupation with order­ liness, perfectionism, and control.

• Personality change due to another medical condition is a persistent personality dis­ turbance that is judged to be due to the direct physiological effects of a medical condi­ tion (e.g., frontal lobe lesion).

• Other specified personality disorder and unspecified personality disorder is a cate­ gory provided for two situations: 1) the individual’s personality pattern meets the gen­ eral criteria for a personality disorder, and traits of several different personality disorders are present, but the criteria for any specific personality disorder are not met;

or 2) the individual’s personality pattern meets the general criteria for a personality dis­ order, but the individual is considered to have a personality disorder that is not in­ cluded in the DSM-5 classification (e.g., passive-aggressive personality disorder).

The personality disorders are grouped into three clusters based on descriptive similarities. Cluster A includes paranoid, schizoid, and schizotypal personality disorders. Individuals with these disorders often appear odd or eccentric. Cluster B includes antisocial, borderline, histri­ onic, and narcissistic personality disorders. Individuals with these disorders often appear dra­ matic, emotional, or erratic. Cluster C includes avoidant, dependent, and obsessive- compulsive personality disorders. Individuals with these disorders often appear anxious or fearful. It should be noted that this clustering system, although useful in some research and ed­ ucational situations, has serious limitations and has not been consistently validated.

Moreover, individuals frequently present with co-occurring personality disorders from different clusters. Prevalence estimates for the different clusters suggest 5.7% for dis­ orders in Cluster A, 1.5% for disorders in Cluster B, 6.0% for disorders in Cluster C, and 9.1% for any personality disorder, indicating frequent co-occurrence of disorders from dif­ ferent clusters. Data from the 2001-2002 National Epidemiologic Survey on Alcohol and Related Conditions suggest that approximately 15% of U.S. adults have at least one per­ sonality disorder.

Dimensional Models for Personality Disorders The diagnostic approach used in this manual represents the categorical perspective that personality disorders are qualitatively distinct clinical syndromes. An alternative to the categorical approach is the dimensional perspective that personality disorders represent maladaptive variants of personality traits that merge imperceptibly into normality and into one another. See Section III for a full description of a dimensional model for person­ ality disorders. The DSM-IV personality disorder clusters (i.e., odd-eccentric, dramatic­ emotional, and anxious-fearful) may also be viewed as dimensions representing spectra of personality dysfunction on a continuum with other mental disorders. The alternative di­ mensional models have much in common and together appear to cover the important ar­ eas of personality dysfunction. Their integration, clinical utility, and relationship with the personality disorder diagnostic categories and various aspects of personality dysfunction are under active investigation.

General Personality Disorder Criteria A. An enduring pattern of inner experience and behavior that deviates markedly from the

expectations of the individual’s culture. This pattern is manifested in two (or more) of the following areas: 1. Cognition (i.e., ways of perceiving and interpreting self, other people, and events). 2. Affectivity (i.e., the range, intensity, lability, and appropriateness of emotional re­

sponse). 3. Interpersonal functioning. 4. Impulse control.

B. The enduring pattern is inflexible and pervasive across a broad range of personal and social situations.

C. The enduring pattern leads to clinically significant distress or impairment in social, oc­ cupational, or other important areas of functioning.

D. The pattern is stable and cf long duration, and Its onset can be traced back at least to adolescence or early adulthood.

E. The enduring pattern is not better explained as a manifestation or consequence of an­ other mental disorder.

F. The enduring pattern is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition (e.g., head trauma).

Diagnostic Features Personality traits are enduring patterns of perceiving, relating to, and thinking about the en­ vironment and oneself that are exhibited in a wide range of social and personal contexts. Only when personality traits are inflexible and maladaptive and cause significant func­ tional impairment or subjective distress do they constitute personality disorders. The essen­ tial feature of a personality disorder is an enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual’s culture and is manifested in at least two of the following areas: cognition, affectivity, interpersonal functioning, or im­ pulse control (Criterion A). This enduring pattern is inflexible and pervasive across a broad range of personal and social situations (Criterion B) and leads to clinically significant dis­ tress or impairment in social, occupational, or other important areas of functioning (Crite­ rion C). The pattern is stable and of long duration, and its onset can be traced back at least to adolescence or early adulthood (Criterion D). The pattern is not better explained as a manifestation or consequence of another mental disorder (Criterion E) and is not attribut­ able to the physiological effects of a substance (e.g., a drug of abuse, a medication, exposure to a toxin) or another medical condition (e.g., head trauma) (Criterion F). Specific diagnostic criteria are also provided for each of the personality disorders included in this chapter.

The diagnosis of personality disorders requires an evaluation of the individual’s long­ term patterns of functioning, and the particular personality features must be evident by early adulthood. The personality traits that define these disorders must also be distin­ guished from characteristics that emerge in response to specific situational stressors or more transient mental states (e.g., bipolar, depressive, or anxiety disorders; substance in­ toxication). The clinician should assess the stability of personality traits over time and across different situations. Although a single interview with the individual is sometimes sufficient for making the diagnosis, it is often necessary to conduct more than one inter­ view and to space these over time. Assessment can also be complicated by the fact that the characteristics that define a personality disorder may not be considered problematic by the individual (i.e., the traits are often ego-syntonic). To help overcome this difficulty, sup­ plementary information from other informants may be helpful.

Deveiopment and Course The features of a personality disorder usually become recognizable during adolescence or early adult life. By definition, a personality disorder is an enduring pattern of thinking, feeling, and behaving that is relatively stable over time. Some types of personality disorder (notably, antisocial and borderline personality disorders) tend to become less evident or to remit with age, whereas this appears to be less true for some other types (e.g., obsessive- compulsive and schizotypal personality disorders).

Personality disorder categories may be applied with children or adolescents in those relatively unusual instances in which the individual’s particular maladaptive personality traits appear to be pervasive, persistent, and unlikely to be limited to a particular devel­ opmental stage or another mental disorder. It should be recognized that the traits of a per­ sonality disorder that appear in childhood will often not persist unchanged into adult life. For a personality disorder to be diagnosed in an individual younger than 18 years, the fea­ tures must have been present for at least 1 year. The one exception to this is antisocial per-

sonality disorder, which cannot be diagnosed in individuals younger than 18 years. Al­ though, by definition, a personality disorder requires an onset no later than early adulthood, individuals may not come to clinical attention until relatively late in life. A per­ sonality disorder may be exacerbated following the loss of significant supporting persons (e.g., a spouse) or previously stabilizing social situations (e.g., a job). However, the devel­ opment of a change in personality in middle adulthood or later life warrants a thorough evaluation to determine the possible presence of a personality change due to another med­ ical condition or an unrecognized substance use disorder.

Culture-Related Diagnostic Issues Judgments about personality functioning must take into account the individual’s ethnic, cul­ tural, and social background. Personality disorders should not be confused with problems as­ sociated with acculturation following immigration or with the expression of habits, customs, or religious and political values professed by the individual’s culture of origin. It is useful for the clinician, especially when evaluating someone from a different background, to obtain ad­ ditional information from informants who are familiar with the person’s cultural background.

Gender-Related Diagnostic Issues Certain personality disorders (e.g., antisocial personality disorder) are diagnosed more frequently in males. Others (e.g., borderline, histrionic, and dependent personality disor­ ders) are diagnosed more frequently in females. Although these differences in prevalence probably reflect real gender differences in the presence of such patterns, clinicians must be cautious not to overdiagnose or underdiagnose certain personality disorders in females or in males because of social stereotypes about typical gender roles and behaviors.

Differential Diagnosis Other mental disorders and personality traits. Many of the specific criteria for the per­ sonality disorders describe features (e.g., suspiciousness, dependency, insensitivity) that are also characteristic of episodes of other mental disorders. A personality disorder should be diagnosed only when ihe defining characteristics appeared before early adulthood, are typical of the individual’s long-term functioning, and do not occur exclusively during an episode of another mental disorder. It may be particularly difficult (and not particularly useful) to distinguish personality disorders from persistent mental disorders such as per­ sistent depressive disorder that have an early onset and an enduring, relatively stable course. Some personality disorders may have a “spectrum” relationship to other mental disorders (e.g., schizotypal personality disorder with schizophrenia; avoidant personality disorder with social anxiety disorder [social phobia]) based on phenomenological or bio­ logical similarities or familial aggregation.

Personality disorders must be distinguished from personality traits that do not reach the threshold for a personality disorder. Personality traits are diagnosed as a personality disorder only when they are inflexible, maladaptive, and persisting and cause significant functional impairment or subjective distress. Psychotic disorders. For the three personality disorders that may be related to the psy­ chotic disorders (i.e., paranoid, schizoid, and schizotypal), there is an exclusion criterion stating that the pattern of behavior must not have occurred exclusively during the course of schizophrenia, a bipolar or depressive disorder with psychotic features, or another psy­ chotic disorder. When an individual has a persistent mental disorder (e.g., schizophrenia) that was preceded by a preexisting personality disorder, the personality disorder should also be recorded, followed by “premorbid” in parentheses. Anxiety and depressive disorders. The clinician must be cautious in diagnosing per­ sonality disorders during an episode of a depressive disorder or an anxiety disorder, be-

cause these conditions may have cross-sectional symptom features that mimic personality traits and may m^ke it more difficult to evaluate retrospectively the individual’s long-term patterns of functioning. Posttraumatic stress disorder. When personality changes emerge and persist after an individual has been exposed to extreme stress, a diagnosis of posttraumatic stress disorder should be considered. Substance use disorders. When an individual has a substance use disorder, it is impor­ tant not to make a personality disorder diagnosis based solely on behaviors that are con­ sequences of substance intoxication or withdrawal or that are associated with activities in the service of sustaining substance use (e.g., antisocial behavior). Personality change due to another medical condition. When enduring changes in per­ sonality arise as a result of the physiological effects of another medical condition (e.g., brain tumor), a diagnosis of personality change due to another medical condition should be considered.

Cluster A Personality Disorders

Paranoid Personality Disorder Diagnostic Criteria 301.0 (F60.0) A. A pervasive distrust and suspiciousness of others such that their nfiotives are inter­

preted as malevolent, beginning by early adulthood and present in a variety of con­ texts, as indicated by four (or more) of the following: 1. Suspects, without sufficient basis, that others are exploiting, harming, or deceiving

him or her. 2. Is preoccupied with unjustified doubts about the loyalty or trustworthiness of friends

or associates. 3. Is reluctant to confide in others because of unwarranted fear that the information

will be used maliciously against him or her. 4. Reads hidden demeaning or threatening meanings into benign remarks or events. 5. Persistently bears grudges (i.e., is unforgiving of insults, injuries, or slights). 6. Perceives attacks on his or her character or reputation that are not apparent to oth­

ers and is quick to react angrily or to counterattack. 7. Has recurrent suspicions, without justification, regarding fidelity of spouse or sexual

partner. B. Does not occur exclusively during the course of schizophrenia, a bipolar disorder or

depressive disorder with psychotic features, or another psychotic disorder and is not attributable to the physiological effects of another medical condition.

Note: If criteria are met prior to the onset of schizophrenia, add “premorbid,” i.e., “paranoid personality disorder (premorbid).”

Diagnostic Features The essential feature of paranoid personality disorder is a pattern of pervasive distrust and suspiciousness of others such that their motives are interpreted as malevolent. This pattern begins by early adulthood and is present in a variety of contexts.

Individuals with this disorder assume that other people will exploit, harm, or deceive them, even if no evidence exists to support this expectation (Criterion Al). They suspect on the basis of little or no evidence that others are plotting against them and may attack them suddenly, at any time and without reason. They often feel that they have been deeply and irreversibly injured by another person or persons even when there is no objective evidence for this. They are preoccupied with unjustified doubts about the loyalty or trustworthiness of their friends and associates, whose actions are minutely scrutinized for evidence of hos­ tile intentions (Criterion A2). Any perceived deviation from trustworthiness or loyalty serves to support their underlying assumptions. They are so amazed when a friend or as­ sociate shows loyalty that they cannot trust or believe it. If they get into trouble, they ex­ pect that friends and associates will either attack or ignore them.

Individuals with paranoid personality disorder are reluctant to confide in or become close to others because they fear that the information they share will be used against them (Criterion A3). They may refuse to answer personal questions, saying that the information is “nobody’s business.” They read hidden meanings that are demeaning and threatening into benign remarks or events (Criterion A4). For example, an individual with this disor­ der may misinterpret an honest mistake by a store clerk as a deliberate attempt to short­ change, or view a casual humorous remark by a co-worker as a serious character attack. Compliments are often misinterpreted (e.g., a compliment on a new acquisition is mis­ interpreted as a criticism for selfishness; a compliment on an accomplishment is misinter­ preted as an attempt to coerce more and better performance). They may view an offer of help as a criticism that they are not doing well enough on their own.

Individuals with this disorder persistently bear grudges and are unwilling to forgive the insults, injuries, or slights that they think they have received (Criterion A5). Minor slights arouse major hostility, and the hostile feelings persist for a long time. Because they are constantly vigilant to the harmful intentions of others, they very often feel that their character or reputation has been attacked or that they have been slighted in some other way. They are quick to counterattack and react with anger to perceived insults (Criterion A6). Individuals with this disorder may be pathologically jealous, often suspecting that their spouse or sexual partner is unfaithful without any adequate justification (Criterion A7). They may gather trivial and circumstantial “evidence” to support their jealous beliefs. They want to maintain complete control of intimate relationships to avoid being betrayed and may constantly question and challenge the whereabouts, actions, intentions, and fi­ delity of their spouse or partner.

Paranoid personality disorder should not be diagnosed if the pattern of behavior oc­ curs exclusively during the course of schizophrenia, a bipolar disorder or depressive dis­ order with psychotic features, or another psychotic disorder, or if it is attributable to the physiological effects of a neurological (e.g., temporal lobe epilepsy) or another medical condition (Criterion B).

Associated Features Supporting Diagnosis Individuals with paranoid personality disorder are generally difficult to get along with and often have problems with close relationships. Their excessive suspiciousness and hos­ tility may be expressed in overt argumentativeness, in recurrent complaining, or by quiet, apparently hostile aloofness. Because they are hypervigilant for potential threats, they may act in a guarded, secretive, or devious manner and appear to be “cold” and lacking in tender feelings. Although they may appear to be objective, rational, and unemotional, they more often display a labile range of affect, with hostile, stubborn, and sarcastic expressions predominating. Their combative and suspicious nature may elicit a hostile response in others, which then serves to confirm their original expectations.

Because individuals with paranoid personality disorder lack trust in others, they have an excessive need to be self-sufficient and a strong sense of autonomy. They also need to

have a high degree of control over those around them. They are often rigid, critical of oth­ ers, and unable to collaborate, although they have great difficulty accepting criticism them­ selves. They may blame others for their own shortcomings. Because of their quickness to counterattack in response to the threats they perceive around them, they may be litigious and frequently become involved in legal disputes. Individuals with this disorder seek to confirm their preconceived negative notions regarding people or situations they encounter, attributing malevolent motivations to others that are projections of their own fears. They may exhibit thinly hidden, unrealistic grandiose fantasies, are often attuned to issues of power and rank, and tend to develop negative stereotypes of others, particularly those from population groups distinct from their own. Attracted by simplistic formulations of the world, they are often wary of ambiguous situations. They may be perceived as “fanatics” and form tightly knit “cults” or groups with others who share their paranoid belief systems.

Particularly in response to stress, individuals with this disorder may experience very brief psychotic episodes (lasting minutes to hours). In some instances, paranoid personal­ ity disorder may appear as the premorbid antecedent of delusional disorder or schizo­ phrenia. Individuals with paranoid personality disorder may develop major depressive disorder and may be at increased risk for agoraphobia and obsessive-compulsive dis­ order. Alcohol and other substance use disorders frequently occur. The most common co­ occurring personality disorders appear to be schizotypal, schizoid, narcissistic, avoidant, and borderline.

Prevalence A prevalence estimate for paranoid personality based on a probability subsample from Part II of the National Comorbidity Survey Replication suggests a prevalence of 2.3%, while the National Epidemiologic Survey on Alcohol and Related Conditions data suggest a prevalence of paranoid personality disorder of 4.4%.

Development and Course Paranoid personality disorder may be first apparent in childhood and adolescence with solitariness, poor peer relationships, social anxiety, underachievement in school, hyper­ sensitivity, peculiar thoughts and language, and idiosyncratic fantasies. These children may appear to be “odd” or “eccentric” and attract teasing. In clinical samples, this disorder appears to be more commonly diagnosed in males.

Risk and Prognostic Factors Genetic and physiological. There is some evidence for an increased prevalence of par­ anoid personality disorder in relatives of probands with schizophrenia and for a more spe­ cific familial relationship with delusional disorder, persecutory type.

Culture-Related Diagnostic Issues Some behaviors that are influenced by sociocultural contexts or specific life circumstances may be erroneously labeled paranoid and may even be reinforced by the process of clinical evaluation. Members of minority groups, immigrants, political and economic refugees, or individuals of different ethnic backgrounds may display guarded or defensive behaviors because of unfamiliarity (e.g., language barriers or lack of knowledge of rules and regula­ tions) or in response to the perceived neglect or indifference of the majority society. These behaviors can, in turn, generate anger and frustration in those who deal with these indi­ viduals, thus setting up a vicious cycle of mutual mistrust, which should not be confused with paranoid personality disorder. Some ethnic groups also display culturally related be­ haviors that can be misinterpreted as paranoid.

Differential Diagnosis Other mental disorders with psychotic symptoms. Paranoid personality disorder can be distinguished from delusional disorder, persecutory type; schizophrenia; and a bipolar or depressive disorder with psychotic features because these disorders are all characterized by a period of persistent psychotic symptoms (e.g., delusions and hallucinations). For an additional diagnosis of paranoid personality disorder to be given, the personality disorder must have been present before the onset of psychotic symptoms and must persist when the psychotic symptoms are in remission. When an individual has another persistent mental disorder (e.g., schizophrenia) that was preceded by paranoid personality disorder, paranoid personality dis­ order should also be recorded, followed by “premorbid” in parentheses. Personality change due to another medical condition. Paranoid personality disorder must be distinguished from personality change due to another medical condition, in which the traits that emerge are attributable to the direct effects of another medical condi­ tion on the central nervous system. Substance use disorders. Paranoid personality disorder must be distinguished from symptoms that may develop in association with persistent substance use. Paranoid traits associated with physical handicaps. The disorder must also be distin­ guished from paranoid traits associated with the development of physical handicaps (e.g., a hearing impairment). Other personality disorders and personality traits. Other personality disorders may be confused with paranoid personality disorder because they have certain features in common. It is therefore important to distinguish among these disorders based on differences in their characteristic features. However, if an individual has personality features that meet criteria for one or more personality disorders in addition to paranoid personality disorder, all can be diagnosed. Paranoid personality disorder and schizotypal personality disorder share the traits of suspiciousness, interpersonal aloofness, and paranoid ideation, but schizotypal per­ sonality disorder also includes symptoms such as magical thinking, unusual perceptual ex­ periences, and odd thinking and speech. Individuals with behaviors that meet criteria for schizoid personality disorder are often perceived as strange, eccentric, cold, and aloof, but they do not usually have prominent paranoid ideation. The tendency of individuals with paranoid personality disorder to react to minor stimuli with anger is also seen in borderline and histrionic personality disorders. However, these disorders are not necessarily associ­ ated with pervasive suspiciousness. People with avoidant personality disorder may also be reluctant to confide in others, but more from fear of being embarrassed or found inadequate than from fear of others’ malicious intent. Although antisocial behavior may be present in some individuals with paranoid personality disorder, it is not usually motivated by a desire for personal gain or to exploit others as in antisocial personality disorder, but rather is more often attributable to a desire for revenge. Individuals with narcissistic personality disorder may occasionally display suspiciousness, social withdrawal, or alienation, but this derives primarily from fears of having their imperfections or flaws revealed.

Paranoid traits may be adaptive, particularly in threatening environments. Paranoid personality disorder should be diagnosed only when these traits are inflexible, maladap­ tive, and persisting and cause significant functional impairment or subjective distress.

Schizoid Personality Disorder Diagnostic Criteria 301.20 (F60.1) A. A pervasive pattern of detachment from social relationships and a restricted range of

expression of emotions in interpersonal settings, beginning by early adulthood and present in a variety of contexts, as indicated by four (or more) of the following:

1. Neither desires nor enjoys close relationships, including being part of a family. 2. Almost always chooses solitary activities. 3. Has little, if any, interest in having sexual experiences with another person. 4. Tal<es pleasure in few, if any, activities. 5. Lacks close friends or confidants other than first-degree relatives. 6. Appears indifferent to the praise or criticism of others. 7. Shows emotional coldness, detachment, or flattened affectivity.

B. Does not occur exclusively during the course of schizophrenia, a bipolar disorder or depressive disorder with psychotic features, another psychotic disorder, or autism spectrum disorder and is not attributable to the physiological effects of another medical condition.

Note: If criteria are met prior to the onset of schizophrenia, add “premorbid,” i.e., “schiz­ oid personality disorder (premorbid).”

Diagnostic Features The essential feature of schizoid personality disorder is a pervasive pattern of detachment from social relationships and a restricted range of expression of emotions in interpersonal settings. This pattern begins by early adulthood and is present in a variety of contexts.

Individuals with schizoid personality disorder appear to lack a desire for intimacy, seem indifferent to opportunities to develop close relationships, and do not seem to derive much satisfaction from being part of a family or other social group (Criterion Al). They prefer spending time by themselves, rather than being with other people. They often ap­ pear to be socially isolated or “loners” and almost always choose solitary activities or hob­ bies that do not include interaction with others (Criterion A2). They prefer mechanical or abstract tasks, such as computer or mathematical games. They may have very little interest in having sexual experiences with another person (Criterion A3) and take pleasure in few, if any, activities (Criterion A4). There is usually a reduced experience of pleasure from sen­ sory, bodily, or interpersonal experiences, such as walking on a beach at sunset or having sex. These individuals have no close friends or confidants, except possibly a first-degree relative (Criterion A5).

Individuals with schizoid personality disorder often seem indifferent to the approval or criticism of others and do not appear to be bothered by what others may think of them (Criterion A6). They may be oblivious to the normal subtleties of social interaction and of­ ten do not respond appropriately to social cues so that they seem socially inept or super­ ficial and self-absorbed. They usually display a “bland” exterior without visible emotional reactivity and rarely reciprocate gestures or facial expressions, such as smiles or nods (Cri­ terion A7). They claim that they rarely experience strong emotions such as anger and joy. They often display a constricted affect and appear cold and aloof. However, in those very unusual circumstances in which these individuals become at least temporarily comfort­ able in revealing themselves, they may acknowledge having painful feelings, particularly related to social interactions.

Schizoid personality disorder should not be diagnosed if the pattern of behavior occurs exclusively during the course of schizophrenia, a bipolar or depressive disorder with psy­ chotic features, another psychotic disorder, or autism spectrum disorder, or if it is attrib­ utable to the physiological effects of a neurological (e.g., temporal lobe epilepsy) or another medical condition (Criterion B).

Associated Features Supporting Diagnosis Individuals with schizoid personality disorder may have particular difficulty expressing anger, even in response to direct provocation, which contributes to the impression that

they lack emotion. Their lives sometimes seem directionless, and they may appear to “drift” in their goals. Such individuals often react passively to adverse circumstances and have difficulty responding appropriately to important life events. Because of their lack of social skills and lack of desire for sexual experiences, individuals with this disorder have few friendships, date infrequently, and often do not marry. Occupational functioning may be impaired, particularly if interpersonal involvement is required, but individuals with this disorder may do well when they work under conditions of social isolation. Particu­ larly in response to stress, individuals with this disorder may experience very brief psy­ chotic episodes (lasting minutes to hours). In some instances, schizoid personality disorder may appear as the premorbid antecedent of delusional disorder or schizophre­ nia. Individuals with this disorder may sometimes develop major depressive disorder. Schizoid personality disorder most often co-occurs with schizotypal, paranoid, and avoid­ ant personality disorders.

Prevalence Schizoid personality disorder is uncommon in clinical settings. A prevalence estimate for schizoid personality based on a probability subsample from Part II of the National Co­ morbidity Survey Replication suggests a prevalence of 4.9%. Data from the 2001-2002 National Epidemiologic Survey on Alcohol and Related Conditions suggest a prevalence of 3.1%.

Development and Course Schizoid personality disorder may be first apparent in childhood and adolescence with solitariness, poor peer relationships, and underachievement in school, which mark these children or adolescents as different and make them subject to teasing.

Risk and Prognostic Factors Genetic and physiological. Schizoid personality disorder may have increased preva­ lence in the relatives of individuals with schizophrenia or schizotypal personality disorder.

Culture-Related Diagnostic issues Individuals from a variety of cultural backgrounds sometimes exhibit defensive behaviors and inteφersonal styles that may be erroneously labeled as “schizoid.” For example, those who have moved from rural to metropolitan environments may react with “emotional freezing” that may last for several months and manifest as solitary activities, constricted affect, and other deficits in communication. Immigrants from other countries are some­ times mistakenly perceived as cold, hostile, or indifferent.

Gender-Related Diagnostic issues Schizoid personality disorder is diagnosed slightly more often in males and may cause more impairment in them.

Differential Diagnosis Other mental disorders with psychotic symptoms. Schizoid personality disorder can be distinguished from delusional disorder, schizophrenia, and a bipolar or depressive dis­ order with psychotic features because these disorders are all characterized by a period of persistent psychotic symptoms (e.g., delusions and hallucinations). To give an additional diagnosis of schizoid personality disorder, the personality disorder must have been present before the onset of psychotic symptoms and must persist when the psychotic symptoms

are in remission. When an individual has a persistent psychotic disorder (e.g., schizophre­ nia) that was preceded by schizoid personality disorder, schizoid personality disorder should also be recorded, followed by “premorbid” in parentheses. Autism spectrum disorder. There may be great difficulty differentiating individuals with schizoid personality disorder from those with milder forms of autism spectrum disorder, which may be differentiated by more severely impaired social interaction and stereotyped behaviors and interests. Personality change due to another medical condition. Schizoid personality disorder must be distinguished from personality change due to another medical condition, in which the traits that emerge are attributable to the effects of another medical condition on the central nervous system. Substance use disorders. Schizoid personality disorder must also be distinguished from symptoms that may develop in association with persistent substance use. Other personality disorders and personality traits. Other personality disorders may be confused with schizoid personality disorder because they have certain features in com­ mon. It is, therefore, important to distinguish among these disorders based on differences in their characteristic features. However, if an individual has personality features that meet criteria for one or more personality disorders in addition to schizoid personality dis­ order, all can be diagnosed. Although characteristics of social isolation and restricted af- fectivity are common to schizoid, schizotypal, and paranoid personality disorders, schizoid personality disorder can be distinguished from schizotypal personality disorder by the lack of cognitive and perceptual distortions and from paranoid personality disorder by the lack of suspiciousness and paranoid ideation. The social isolation of schizoid per­ sonality disorder can be distinguished from that of avoidant personality disorder, which is attributable to fear of being embarrassed or found inadequate and excessive anticipation of rejection. In contrast, people with schizoid personality disorder have a more pervasive detachment and limited desire for social intimacy. Individuals with obsessive-compulsive personality disorder may also show an apparent social detachment stemming from devo­ tion to work and discomfort with emotions, but they do have an underlying capacity for intimacy.

Individuals who are “loners” may display personality traits that might be considered schizoid. Only when these traits are inflexible and maladaptive and cause significant func­ tional impairment or subjective distress do they constitute schizoid personality disorder.

Schizotypal Personality Disorder Diagnostic Criteria 301.22 (F21) A. A pervasive pattern of social and interpersonal deficits marked by acute discomfort

with, and reduced capacity for, close relationships as well as by cognitive or perceptual distortions and eccentricities of behavior, beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following: 1. Ideas of reference (excluding delusions of reference). 2. Odd beliefs or magical thinking that influences behavior and is inconsistent with

subcultural norms (e.g., superstitiousness, belief in clairvoyance, telepathy, or “sixth sense”: in children and adolescents, bizarre fantasies or preoccupations).

3. Unusual perceptual experiences, including bodily illusions. 4. Odd thinking and speech (e.g., vague, circumstantial, metaphorical, overelaborate,

or stereotyped). 5. Suspiciousness or paranoid ideation.

6. Inappropriate or constricted affect. 7. Behavior or appearance that is odd, eccentric, or peculiar. 8. Lack of close friends or confidants other than first-degree relatives. 9. Excessive social anxiety that does not diminish with familiarity and tends to be as­

sociated with paranoid fears rather than negative judgments about self. B. Does not occur exclusively during the course of schizophrenia, a bipolar disorder or

depressive disorder with psychotic features, another psychotic disorder, or autism spectrum disorder.

Note: If criteria are met prior to the onset of schizophrenia, add “premorbid,” e.g., “schizo­ typal personality disorder (premorbid).”

Diagnostic Features The essential feature of schizotypal personality disorder is a pervasive pattern of social and interpersonal deficits marked by acute discomfort with, and reduced capacity for, close relationships as well as by cognitive or perceptual distortions and eccentricities of be­ havior. This pattern begins by early adulthood and is present in a variety of contexts.

Individuals with schizotypal personality disorder often have ideas of reference (i.e., in­ correct interpretations of casual incidents and external events as having a particular and unusual meaning specifically for the person) (Criterion Al). These should be distin­ guished from delusions of reference, in which the beliefs are held with delusional convic­ tion. These individuals may be superstitious or preoccupied with paranormal phenomena that are outside the norms of their subculture (Criterion A2). They may feel that they have special powers to sense events before they happen or to read others’ thoughts. They may believe that they have magical control over others, which can be implemented directly (e.g., believing that their spouse’s taking the dog out for a walk is the direct result of think­ ing an hour earlier it should be done) or indirectly through compliance with magical rit­ uals (e.g., walking past a specific object three times to avoid a certain harmful outcome). Perceptual alterations may be present (e.g., sensing that another person is present or hear­ ing a voice murmuring his or her name) (Criterion A3). Their speech may include unusual or idiosyncratic phrasing and construction. It is often loose, digressive, or vague, but with­ out actual derailment or incoherence (Criterion A4). Responses can be either overly con­ crete or overly abstract, and words or concepts are sometimes applied in unusual ways (e.g., the individual may state that he or she was not “talkable” at work).

Individuals with this disorder are often suspicious and may have paranoid ideation (e.g., believing their colleagues at work are intent on undermining their reputation with the boss) (Criterion A5). They are usually not able to negotiate the full range of affects and interpersonal cuing required for successful relationships and thus often appear to interact with others in an inappropriate, stiff, or constricted fashion (Criterion A6). These individ­ uals are often considered to be odd or eccentric because of unusual mannerisms, an often unkempt manner of dress that does not quite “fit together,” and inattention to the usual social conventions (e.g., the individual may avoid eye contact, wear clothes that are ink stained and ill-fitting, and be unable to join in the give-and-take banter of co-workers) (Criterion A7).

Individuals with schizotypal personality disorder experience interpersonal related­ ness as problematic and are uncomfortable relating to other people. Although they may express unhappiness about their lack of relationships, their behavior suggests a decreased desire for intimate contacts. As a result, they usually have no or few close friends or con­ fidants other than a first-degree relative (Criterion A8). They are anxious in social situa­ tions, particularly those involving unfamiliar people (Criterion A9). They will interact with other individuals when they have to but prefer to keep to themselves because they feel that they are different and just do not “fit in.” Their social anxiety does not easily abate.

even when they spend more time in the setting or become more familiar with the other people, because t̂ heir anxiety tends to be associated with suspiciousness regarding others’ motivations. For example, when attending a dinner party, the individual with schizotypal personality disorder will not become more relaxed as time goes on, but rather may become increasingly tense and suspicious.

Schizotypal personality disorder should not be diagnosed if the pattern of behavior oc­ curs exclusively during the course of schizophrenia, a bipolar or depressive disorder with psychotic features, another psychotic disorder, or autism spectrum disorder (Criterion B).

Associated Features Supporting Diagnosis Individuals with schizotypal personality disorder often seek treatment for the associated symptoms of anxiety or depression rather than for the personality disorder features per se. Particularly in response to stress, individuals with this disorder may experience transient psychotic episodes (lasting minutes to hours), although they usually are insufficient in du­ ration to warrant an additional diagnosis such as brief psychotic disorder or schizophreni­ form disorder. In some cases, clinically significant psychotic symptoms may develop that meet criteria for brief psychotic disorder, schizophreniform disorder, delusional disorder, or schizophrenia. Over half may have a history of at least one major depressive episode. From 30% to 50% of individuals diagnosed with this disorder have a concurrent diagnosis of major depressive disorder when admitted to a clinical setting. There is considerable co­ occurrence with schizoid, paranoid, avoidant, and borderline personality disorders.

Prevalence In community studies of schizotypal personality disorder, reported rates range from 0.6% in Norwegian samples to 4.6% in a U.S. community sample. The prevalence of schizotypal personality disorder in clinical populations seems to be infrequent (0%-1.9%), with a higher estimated prevalence in the general population (3.9%) found in the National Epi­ demiologic Survey on Alcohol and Related Conditions.

Development and Course Schizotypal personality disorder has a relatively stable course, with only a small propor­ tion of individuals going on to develop schizophrenia or another psychotic disorder. Schizotypal personality disorder may be first apparent in childhood and adolescence with solitariness, poor peer relationships, social anxiety, underachievement in school, hyper­ sensitivity, peculiar thoughts and language, and bizarre fantasies. These children may ap­ pear “odd” or “eccentric” and attract teasing.

Risk and Prognostic Factors Genetic and physiological. Schizotypal personality disorder appears to aggregate fa­ milially and is more prevalent among the first-degree biological relatives of individuals with schizophrenia than among the general population. There may also be a modest in­ crease in schizophrenia and other psychotic disorders in the relatives of probands with schizotypal personality disorder.

Cultural-Related Diagnostic issues Cognitive and perceptual distortions must be evaluated in the context of the individual’s cultural milieu. Pervasive culturally determined characteristics, particularly those regard­ ing religious beliefs and rituals, can appear to be schizotypal to the uninformed outsider (e.g., voodoo, speaking in tongues, life beyond death, shamanism, mind reading, sixth sense, evil eye, magical beliefs related to health and illness).

Gender-Related Diagnostic Issues Schizotypal personality disorder may be slightly more common in males.

Differential Diagnosis Other mental disorders with psychotic symptoms. Schizotypal personality disorder can be distinguished from delusional disorder, schizophrenia, and a bipolar or depressive disorder with psychotic features because these disorders are all characterized by a period of persistent psychotic symptoms (e.g., delusions and hallucinations). To give an addi­ tional diagnosis of schizotypal personality disorder, the personality disorder must have been present before the onset of psychotic symptoms and persist when the psychotic symptoms are in remission. When an individual has a persistent psychotic disorder (e.g., schizophrenia) that was preceded by schizotypal personality disorder, schizotypal per­ sonality disorder should also be recorded, followed by “premorbid” in parentheses.

Neurodevelopmental disorders. There may be great difficulty differentiating children with schizotypal personality disorder from the heterogeneous group of solitary, odd chil­ dren whose behavior is characterized by marked social isolation, eccentricity, or peculiar­ ities of language and whose diagnoses would probably include milder forms of autism spectrum disorder or language communication disorders. Communication disorders may be differentiated by the primacy and severity of the disorder in language and by the char­ acteristic features of impaired language found in a specialized language assessment. Milder forms of autism spectrum disorder are differentiated by the even greater lack of so­ cial awareness and emotional reciprocity and stereotyped behaviors and interests.

Personality change due to another medical condition. Schizotypal personality disor­ der must be distinguished from personality change due to another medical condition, in which the traits that emerge are attributable to the effects of another medical condition on the central nervous system.

Substance use disorders. Schizotypal personality disorder must also be distinguished from symptoms that may develop in association with persistent substance use.

Other personality disorders and personality traits. Other personality disorders may be confused with schizotypal personality disorder because they have certain features in common. It is, therefore, important to distinguish among these disorders based on differ­ ences in their characteristic features. However, if an individual has personality features that meet criteria for one or more personality disorders in addition to schizotypal person­ ality disorder, all can be diagnosed. Although paranoid and schizoid personality disor­ ders may also be characterized by social detachment and restricted affect, schizotypal personality disorder can be distinguished from these two diagnoses by the presence of cognitive or perceptual distortions and marked eccentricity or oddness. Close relation­ ships are limited in both schizotypal personality disorder and avoidant personality dis­ order; however, in avoidant personality disorder an active desire for relationships is constrained by a fear of rejection, whereas in schizotypal personality disorder there is a lack of desire for relationships and persistent detachment. Individuals with narcissistic personality disorder may also display suspiciousness, social withdrawal, or alienation, but in narcissistic personality disorder these qualities derive primarily from fears of hav­ ing imperfections or flaws revealed. Individuals with borderline personality disorder may also have transient, psychotic-like symptoms, but these are usually more closely related to affective shifts in response to stress (e.g., intense anger, anxiety, disappointment) and are usually more dissociative (e.g., derealization, depersonalization). In contrast, individuals with schizotypal personality disorder are more likely to have enduring psychotic-like symp­ toms that may worsen under stress but are less likely to be invariably associated with pro­ nounced affective symptoms. Although social isolation may occur in borderline personality

disorder, it is usually secondary to repeated interpersonal failures due to angry outbursts and frequent mood shifts, rather than a result of a persistent lack of social contacts and de­ sire for intimacy. Furthermore, individuals with schizotypal personality disorder do not usually demonstrate the impulsive or manipulative behaviors of the individual with bor­ derline personality disorder. However, there is a high rate of co-occurrence between the two disorders, so that making such distinctions is not always feasible. Schizotypal features during adolescence may be reflective of transient emotional turmoil, rather than an endur­ ing personality disorder.

Cluster B Personality Disorders

Antisocial Personality Disorder Diagnostic Criteria 301.7 (F60.2) A. A pervasive pattern of disregard for and violation of the rights of others, occurring since

age 15 years, as indicated by three (or more) of the following: 1. Failure to conform to social norms with respect to lawful behaviors, as indicated by

repeatedly performing acts that are grounds for arrest. 2. Deceitfulness, as indicated by repeated lying, use of aliases, or conning others for

personal profit or pleasure. 3. Impulsivity or failure to plan ahead. 4. Irritability and aggressiveness, as indicated by repeated physical fights or assaults. 5. Reckless disregard for safety of self or others. 6. Consistent irresponsibility, as indicated by repeated failure to sustain consistent

work behavior or honor financial obligations. 7. Lack of remorse, as indicated by being indifferent to or rationalizing having hurt,

mistreated, or stolen from another. B. The individual is at least age 18 years. C. There is evidence of conduct disorder with onset before age 15 years. D. The occurrence of antisocial behavior is not exclusively during the course of schizo­

phrenia or bipolar disorder.

Diagnostic Features The essential feature of antisocial personality disorder is a pervasive pattern of disregard for, and violation of, the rights of others that begins in childhood or early adolescence and continues into adulthood. This pattern has also been referred to as psychopathy, sociopathy, or dyssocial personality disorder. Because deceit and manipulation are central features of an­ tisocial personality disorder, it may be especially helpful to integrate information acquired from systematic clinical assessment with information collected from collateral sources.

For this diagnosis to be given, the individual must be at least age 18 years (Criterion B) and must have had a history of some symptoms of conduct disorder before age 15 years (Criterion C). Conduct disorder involves a repetitive and persistent pattern of behavior in which the basic rights of others or major age-appropriate societal norms or rules are vio­ lated. The specific behaviors characteristic of conduct disorder fall into one of four cate­ gories: aggression to people and animals, destruction of property, deceitfulness or theft, or serious violation of rules.

The pattern of antisocial behavior continues into adulthood. Individuals with antiso­ cial personality disorder fail to conform to social norms with respect to lawful behavior (Criterion Al). They may repeatedly perform acts that are grounds for arrest (whether they are arrested or not), such as destroying property, harassing others, stealing, or pur­ suing illegal occupations. Persons with this disorder disregard the wishes, rights, or feel­ ings of others. They are frequently deceitful and manipulative in order to gain personal profit or pleasure (e.g., to obtain money, sex, or power) (Criterion A2). They may repeat­ edly lie, use an alias, con others, or malinger. A pattern of impulsivity may be manifested by a failure to plan ahead (Criterion A3). Decisions are made on the spur of the moment, without forethought and without consideration for the consequences to self or others; this may lead to sudden changes of jobs, residences, or relationships. Individuals with antiso­ cial personality disorder tend to be irritable and aggressive and may repeatedly get into physical fights or commit acts of physical assault (including spouse beating or child beat­ ing) (Criterion A4). (Aggressive acts that are required to defend oneself or someone else are not considered to be evidence for this item.) These individuals also display a reckless disregard for the safety of themselves or others (Criterion A5). This may be evidenced in their driving behavior (i.e., recurrent speeding, driving while intoxicated, multiple acci­ dents). They may engage in sexual behavior or substance use that has a high risk for harm­ ful consequences. They may neglect or fail to care for a child in a way that puts the child in danger.

Individuals with antisocial personality disorder also tend to be consistently and ex­ tremely irresponsible (Criterion A6). Irresponsible work behavior may be indicated by sig­ nificant periods of unemployment despite available job opportunities, or by abandonment of several jobs without a realistic plan for getting another job. There may also be a pattern of repeated absences from work that are not explained by illness either in themselves or in their family. Financial irresponsibility is indicated by acts such as defaulting on debts, fail­ ing to provide child support, or failing to support other dependents on a regular basis. In­ dividuals with antisocial personality disorder show little remorse for the consequences of their acts (Criterion A7). They may be indifferent to, or provide a superficial rationaliza­ tion for, having hurt, mistreated, or stolen from someone (e.g., ‘Tife’s unfair,” “losers de­ serve to lose”). These individuals may blame the victims for being foolish, helpless, or deserving their fate (e.g., “he had it coming anyway”); they may minimize the harmful consequences of their actions; or they may simply indicate complete indifference. They generally fail to compensate or make amends for their behavior. They may believe that everyone is out to “help number one” and that one should stop at nothing to avoid being pushed around.

The antisocial behavior must not occur exclusively during the course of schizophrenia or bipolar disorder (Criterion D).

Associated Features Supporting Diagnosis Individuals with antisocial personality disorder frequently lack empathy and tend to be callous, cynical, and contemptuous of the feelings, rights, and sufferings of others. They may have an inflated and arrogant self-appraisal (e.g., feel that ordinary work is beneath them or lack a realistic concern about their current problems or their future) and may be excessively opinionated, self-assured, or cocky. They may display a glib, superficial charm and can be quite voluble and verbally facile (e.g., using technical terms or jargon that might impress someone who is unfamiliar with the topic). Lack of empathy, inflated self­ appraisal, and superficial charm are features that have been commonly included in tradi­ tional conceptions of psychopathy that may be particularly distinguishing of the disorder and more predictive of recidivism in prison or forensic settings, where criminal, delin­ quent, or aggressive acts are likely to be nonspecific. These individuals may also be irre­ sponsible and exploitative in their sexual relationships. They may have a history of many

sexual partners and may never have sustained a monogamous relationship. They may be irresponsible as parents, as evidenced by malnutrition of a child, an illness in the child re­ sulting from a aèk of minimal hygiene, a child’s dependence on neighbors or nonresident relatives for food or shelter, a failure to arrange for a caretaker for a young child when the individual is away from home, or repeated squandering of money required for household necessities. These individuals may receive dishonorable discharges from the armed ser­ vices, may fail to be self-supporting, may become impoverished or even homeless, or may spend many years in penal institutions. Individuals with antisocial personality disorder are more likely than people in the general population to die prematurely by violent means (e.g., suicide, accidents, homicides).

Individuals with antisocial personality disorder may also experience dysphoria, in­ cluding complaints of tension, inability to tolerate boredom, and depressed mood. They may have associated anxiety disorders, depressive disorders, substance use disorders, so­ matic symptom disorder, gambling disorder, and other disorders of impulse control. In­ dividuals with antisocial personality disorder also often have personality features that meet criteria for other personality disorders, particularly borderline, histrionic, and nar­ cissistic personality disorders. The likelihood of developing antisocial personality disor­ der in adult life is increased if the individual experienced childhood onset of conduct disorder (before age 10 years) and accompanying attention-deficit/hyperactivity disorder. Child abuse or neglect, unstable or erratic parenting, or inconsistent parental discipline may increase the likelihood that conduct disorder will evolve into antisocial personality disorder.

Prevalence Twelve-month prevalence rates of antisocial personality disorder, using criteria from pre­ vious DSMs, are between 0.2% and 3.3%. The highest prevalence of antisocial personality disorder (greater than 70%) is among most severe samples of males with alcohol use dis­ order and from substance abuse clinics, prisons, or other forensic settings. Prevalence is higher in samples affected by adverse socioeconomic (i.e., poverty) or sociocultural (i.e., migration) factors.

Development and Course Antisocial personality disorder has a chronic course but may become less evident or remit as the individual grows older, particularly by the fourth decade of life. Although this re­ mission tends to be particularly evident with respect to engaging in criminal behavior, there is likely to be a decrease in the full spectrum of antisocial behaviors and substance use. By definition, antisocial personality cannot be diagnosed before age 18 years.

Risk and Prognostic Factors Genetic and physiological. Antisocial personality disorder is more common among the first-degree biological relatives of those with the disorder than in the general population. The risk to biological relatives of females with the disorder tends to be higher than the risk to biological relatives of males with the disorder. Biological relatives of individuals with this disorder are also at increased risk for somatic symptom disorder and substance use disorders. Within a family that has a member with antisocial personality disorder, males more often have antisocial personality disorder and substance use disorders, whereas fe­ males more often have somatic symptom disorder. However, in such families, there is an increase in prevalence of all of these disorders in both males and females compared with the general population. Adoption studies indicate that both genetic and environmental factors contribute to the risk of developing antisocial personality disorder. Both adopted and biological children of parents with antisocial personality disorder have an increased

risk of developing antisocial personality disorder, somatic symptom disorder, and sub­ stance use disorders. Adopted-away children resemble their biological parents more than their adoptive parents, but the adoptive family environment influences the risk of devel­ oping a personality disorder and related psychopathology.

Culture-Related Diagnostic issues Antisocial personality disorder appears to be associated with low socioeconomic status and urban settings. Concerns have been raised that the diagnosis may at times be misap­ plied to individuals in settings in which seemingly antisocial behavior may be part of a protective survival strategy. In assessing antisocial traits, it is helpful for the clinician to consider the social and economic context in which the behaviors occur.

Gender-Related Diagnostic issues Antisocial personality disorder is much more common in males than in females. There has been some concern that antisocial personality disorder may be underdiagnosed in fe­ males, particularly because of the emphasis on aggressive items in the definition of con­ duct disorder.

Differential Diagnosis The diagnosis of antisocial personality disorder is not given to individuals younger than 18 years and is given only if there is a history of some symptoms of conduct disorder be­ fore age 15 years. For individuals older than 18 years, a diagnosis of conduct disorder is given only if the criteria for antisocial personality disorder are not met. Substance use disorders. When antisocial behavior in an adult is associated with a substance use disorder, the diagnosis of antisocial personality disorder is not made unless the signs of antisocial personality disorder were also present in childhood and have con­ tinued into adulthood. When substance use and antisocial behavior both began in childhood and continued into adulthood, both a substance use disorder and antisocial personality disorder should be diagnosed if the criteria for both are met, even though some antisocial acts may be a consequence of the substance use disorder (e.g., illegal selling of drugs, thefts to obtain money for drugs). Schizophrenia and bipolar disorders. Antisocial behavior that occurs exclusively dur­ ing the course of schizophrenia or a bipolar disorder should not be diagnosed as antisocial personality disorder. Other personality disorders. Other personality disorders may be confused with antiso­ cial personality disorder because they have certain features in common. It is therefore im­ portant to distinguish among these disorders based on differences in their characteristic features. However, if an individual has personality features that meet criteria for one or more personality disorders in addition to antisocial personality disorder, all can be diag­ nosed. Individuals with antisocial personality disorder and narcissistic personality disor­ der share a tendency to be tough-minded, glib, superficial, exploitative, and lack empathy. However, narcissistic personality disorder does not include characteristics of impulsivity, aggression, and deceit. In addition, individuals with antisocial personality disorder may not be as needy of the admiration and envy of others, and persons with narcissistic per­ sonality disorder usually lack the history of conduct disorder in childhood or criminal behavior in adulthood. Individuals with antisocial personality disorder and histrionic personality disorder share a tendency to be impulsive, superficial, excitement seeking, reckless, seductive, and manipulative, but persons with histrionic personality disorder tend to be more exaggerated in their emotions and do not characteristically engage in an­ tisocial behaviors. Individuals with histrionic and borderline personality disorders are

manipulative to gain nurturance, whereas those with antisocial personality disorder are manipulative to gain profit, power, or some other material gratification. Individuals with antisocial personality disorder tend to be less emotionally unstable and more aggressive than those with borderline personality disorder. Although antisocial behavior may be present in some individuals with paranoid personality disorder, it is not usually moti­ vated by a desire for personal gain or to exploit others as in antisocial personality disorder, but rather is more often attributable to a desire for revenge. Criminal behavior not associated with a personality disorder. Antisocial personality disorder must be distinguished from criminal behavior undertaken for gain that is not ac­ companied by the personality features characteristic of this disorder. Only when antisocial personality traits are inflexible, maladaptive, and persistent and cause significant func­ tional impairment or subjective distress do they constitute antisocial personality disorder.

Borderline Personality Disorder Diagnostic Criteria 301.83 (F60.3) A pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity, beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following: 1. Frantic efforts to avoid real or imagined abandonment. (Note: Do not include suicidal

or self-mutilating behavior covered in Criterion 5.) 2. A pattern of unstable and intense interpersonal relationships characterized by alternat­

ing between extremes of idealization and devaluation. 3. Identity disturbance: markedly and persistently unstable self-image or sense of self. 4. Impulsivity in at least two areas that are potentially self-damaging (e.g., spending, sex,

substance abuse, reckless driving, binge eating). (Note: Do not include suicidal or self- mutilating behavior covered in Criterion 5.)

5. Recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior. 6. Affective instability due to a marked reactivity of mood (e.g., intense episodic dysphoria,

irritability, or anxiety usually lasting a few hours and only rarely more than a few days). 7. Chronic feelings of emptiness. 8. Inappropriate, intense anger or difficulty controlling anger (e.g., frequent displays of

temper, constant anger, recurrent physical fights). 9. Transient, stress-related paranoid ideation or severe dissociative symptoms._______

Diagnostic Features The essential feature of borderline personality disorder is a pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity that begins by early adulthood and is present in a variety of contexts.

Individuals with borderline personality disorder make frantic efforts to avoid real or imagined abandonment (Criterion 1). The perception of impending separation or rejection, or the loss of external structure, can lead to profound changes in self-image, affect, cognition, and behavior. These individuals are very sensitive to environmental circumstances. They ex­ perience intense abandonment fears and inappropriate anger even when faced with a real­ istic time-limited separation or when there are unavoidable changes in plans (e.g., sudden despair in reaction to a clinician’s announcing the end of the hour; panic or fury when some­ one important to them is just a few minutes late or must cancel an appointment). They may believe that this “abandonment” implies they are “bad.” These abandonment fears are re­ lated to an intolerance of being alone and a need to have other people with them. Their frantic

efforts to avoid abandonment may include impulsive actions such as self-mutilating or sui­ cidal behaviors, which are described separately in Criterion 5.

Individuals with borderline personality disorder have a pattern of unstable and intense relationships (Criterion 2). They may idealize potential caregivers or lovers at the first or second meeting, demand to spend a lot of time together, and share the most intimate details early in a relationship. However, they may switch quickly from idealizing other people to devaluing them, feeling that the other person does not care enough, does not give enough, or is not “there” enough. These individuals can empathize with and nurture other people, but only with the expectation that the other person will “be there” in return to meet their own needs on demand. These individuals are prone to sudden and dramatic shifts in their view of others, who may alternatively be seen as beneficent supports or as cruelly punitive. Such shifts often reflect disillusionment with a caregiver whose nurturing qualities had been idealized or whose rejection or abandonment is expected.

There may be an identity disturbance characterized by markedly and persistently un­ stable self-image or sense of self (Criterion 3). There are sudden and dramatic shifts in self­ image, characterized by shifting goals, values, and vocational aspirations. There may be sudden changes in opinions and plans about career, sexual identity, values, and types of friends. These individuals may suddenly change from the role of a needy supplicant for help to that of a righteous avenger of past mistreatment. Although they usually have a self­ image that is based on being bad or evil, individuals with this disorder may at times have feelings that they do not exist at all. Such experiences usually occur in situations in which the individual feels a lack of a meaningful relationship, nurturing, and support. These in­ dividuals may show worse performance in unstructured work or school situations.

Individuals with borderline personality disorder display impulsivity in at least two areas that are potentially self-damaging (Criterion 4). They may gamble, spend money irrespon­ sibly, binge eat, abuse substances, engage in unsafe sex, or drive recklessly. Individuals with this disorder display recurrent suicidal behavior, gestures, or threats, or self-mutilat­ ing behavior (Criterion 5). Completed suicide occurs in 8%-10% of such individuals, and self-mutilative acts (e.g., cutting or burning) and suicide threats and attempts are very common. Recurrent suicidality is often the reason that these individuals present for help. These self-destructive acts are usually precipitated by threats of separation or rejection or by expectations that the individual assumes increased responsibility. Self-mutilation may occur during dissociative experiences and often brings relief by reaffirming the ability to feel or by expiating the individual’s sense of being evil.

Individuals with borderline personality disorder may display affective instability that is due to a marked reactivity of mood (e.g., intense episodic dysphoria, irritability, or anx­ iety usually lasting a few hours and only rarely more than a few days) (Criterion 6). The basic dysphoric mood of those with borderline personality disorder is often disrupted by periods of anger, panic, or despair and is rarely relieved by periods of well-being or satis­ faction. These episodes may reflect the individual’s extreme reactivity to interpersonal stresses. Individuals with borderline personality disorder may be troubled by chronic feel­ ings of emptiness (Criterion 7). Easily bored, they may constantly seek something to do. Individuals with this disorder frequently express inappropriate, intense anger or have dif­ ficulty controlling their anger (Criterion 8). They may display extreme sarcasm, enduring bitterness, or verbal outbursts. The anger is often elicited when a caregiver or lover is seen as neglectful, withholding, uncaring, or abandoning. Such expressions of anger are often followed by shame and guilt and contribute to the feeling they have of being evil. During periods of extreme stress, transient paranoid ideation or dissociative symptoms (e.g., de­ personalization) may occur (Criterion 9), but these are generally of insufficient severity or duration to warrant an additional diagnosis. These episodes occur most frequently in re­ sponse to a real or imagined abandonment. Symptoms tend to be transient, lasting min­ utes or hours. The real or perceived return of the caregiver’s nurturance may result in a remission of symptoms.

Associated Features Supporting Diagnosis Individuals with borderline personality disorder may have a pattern of undermining themselves at the moment a goal is about to be realized (e.g., dropping out of school just before graduation; regressing severely after a discussion of how well therapy is going; de­ stroying a good relationship just when it is clear that the relationship could last). Some in­ dividuals develop psychotic-like symptoms (e.g., hallucinations, body-image distortions, ideas of reference, hypnagogic phenomena) during times of stress. Individuals with this disorder may feel more secure with transitional objects (i.e., a pet or inanimate possession) than in interpersonal relationships. Premature death from suicide may occur in individu­ als with this disorder, especially in those with co-occurring depressive disorders or sub­ stance use disorders. Physical handicaps may result from self-inflicted abuse behaviors or failed suicide attempts. Recurrent job losses, interrupted education, and separation or di­ vorce are common. Physical and sexual abuse, neglect, hostile conflict, and early parental loss are more common in the childhood histories of those with borderline personality dis­ order. Common co-occurring disorders include depressive and bipolar disorders, sub­ stance use disorders, eating disorders (notably bulimia nervosa), posttraumatic stress disorder, and attention-deficit/hyperactivity disorder. Borderline personahty disorder also frequently co-occurs with the other personality disorders.

Prevalence The median population prevalence of borderline personality disorder is estimated to be 1.6% but may be as high as 5.9%. The prevalence of borderline personality disorder is about 6% in primary care settings, about 10% among individuals seen in outpatient mental health clinics, and about 20% among psychiatric inpatients. The prevalence of borderline personality disorder may decrease in older age groups.

Development and Course There is considerable variability in the course of borderline personahty disorder. The most common pattern is one of chronic instability in early adulthood, with episodes of serious affective and impulsive dyscontrol and high levels of use of health and mental health re­ sources. The impairment from the disorder and the risk of suicide are greatest in the young-adult years and gradually wane with advancing age. Although the tendency to­ ward intense emotions, impulsivity, and intensity in relationships is often lifelong, indi­ viduals who engage in therapeutic intervention often show improvement beginning sometime during the first year. During their 30s and 40s, the majority of individuals with this disorder attain greater stability in their relationships and vocational functioning. Fol­ low-up studies of individuals identified through outpatient mental health clinics indicate that after about 10 years, as many as half of the individuals no longer have a pattern of be­ havior that meets full criteria for borderline personality disorder.

Risk and Prognostic Factors Genetic and physiological. Borderline personality disorder is about five times more common among first-degree biological relatives of those with the disorder than in the gen­ eral population. There is also an increased familial risk for substance use disorders, anti­ social personality disorder, and depressive or bipolar disorders.

Culture-Related Diagnostic Issues The pattern of behavior seen in borderline personality disorder has been identified in many settings around the world. Adolescents and young adults with identity problems (especially when accompanied by substance use) may transiently display behaviors that misleadingly

give the impression of borderline personality disorder. Such situations are characterized by emotional instability, “existential” dilemmas, uncertainty, anxiety-provoking choices, con­ flicts about sexual orientation, and competing social pressures to decide on careers.

Gender-Related Diagnostic issues Borderline personality disorder is diagnosed predominantly (about 75%) in females.

Differential Diagnosis Depressive and bipolar disorders. Borderline personality disorder often co-occurs with depressive or bipolar disorders, and when criteria for both are met, both may be diagnosed. Because the cross-sectional presentation of borderline personality disorder can be mimicked by an episode of depressive or bipolar disorder, the clinician should avoid giving an addi­ tional diagnosis of borderline personality disorder based only on cross-sectional presenta­ tion without having documented that the pattern of behavior had an early onset and a long­ standing course. Other personality disorders. Other personality disorders may be confused with border­ line personality disorder because they have certain features in common. It is therefore im­ portant to distinguish among these disorders based on differences in their characteristic features. However, if an individual has personality features that meet criteria for one or more personality disorders in addition to borderline personality disorder, all can be diag­ nosed. Although histrionic personality disorder can also be characterized by attention seek­ ing, manipulative behavior, and rapidly shifting emotions, borderline personality disorder is distinguished by self-destructiveness, angry disruptions in close relationships, and chronic feelings of deep emptiness and loneliness. Paranoid ideas or illusions may be pres­ ent in both borderline personality disorder and schizotypal personality disorder, but these symptoms are more transient, interpersonally reactive, and responsive to external structur­ ing in borderline personality disorder. Although paranoid personality disorder and narcis­ sistic personality disorder may also be characterized by an angry reaction to minor stimuli, the relative stability of self-image, as well as the relative lack of self-destructiveness, impul- sivity, and abandonment concerns, distinguishes these disorders from borderline person­ ality disorder. Although antisocial personality disorder and borderline personality disorder are both characterized by manipulative behavior, individuals with antisocial personality disorder are manipulative to gain profit, power, or some other material gratification, whereas the goal in borderline personality disorder is directed more toward gaining the con­ cern of caretakers. Both dependent personality disorder and borderline personality disorder are characterized by fear of abandonment; however, the individual with borderline person­ ality disorder reacts to abandonment with feelings of emotional emptiness, rage, and de­ mands, whereas the individual with dependent personality disorder reacts with increasing appeasement and submissiveness and urgently seeks a replacement relationship to provide caregiving and support. Borderline personality disorder can further be distinguished from dependent personality disorder by the typical pattern of unstable and intense relationships. Personality change due to another medical condition. Borderline personality disor­ der must be distinguished from personality change due to another medical condition, in which the traits that emerge are attributable to the effects of another medical condition on the central nervous system. Substance use disorders. Borderline personality disorder must also be distinguished from symptoms that may develop in association with persistent substance use. Identity problems. Borderline personality disorder should be distinguished from an identity problem, which is reserved for identity concerns related to a developmental phase (e.g., adolescence) and does not qualify as a mental disorder.

Histrionic Personality Disorder Diagnostic Criteria 301.50 (F60.4) A pervasive pattern of excessive emotionality and attention seeking, beginning by early adult­ hood and present in a variety of contexts, as indicated by five (or more) of the following: 1. Is uncomfortable in situations in which he or she is not the center of attention. 2. Interaction with others is often characterized by inappropriate sexually seductive or

provocative behavior. 3. Displays rapidly shifting and shallow expression of emotions. 4. Consistently uses physical appearance to draw attention to self. 5. Has a style of speech that is excessively impressionistic and lacking in detail. 6. Shows self-dramatization, theatricality, and exaggerated expression of emotion. 7. Is suggestible (i.e., easily influenced by others or circumstances). 8. Considers relationships to be more intimate than they actually are.

Diagnostic Features The essential feature of histrionic personality disorder is pervasive and excessive emotion­ ality and attention-seeking behavior. This pattern begins by early adulthood and is pres­ ent in a variety of contexts.

Individuals with histrionic personality disorder are uncomfortable or feel unappreci­ ated when they are not the center of attention (Criterion 1). Often lively and dramatic, they tend to draw attention to themselves and may initially charm new acquaintances by their enthusiasm, apparent openness, or flirtatiousness. These qualities wear thin, however, as these individuals continually demand to be the center of attention. They commandeer the role of “the life of the party.” If they are not the center of attention, they may do something dramatic (e.g., make up stories, create a scene) to draw the focus of attention to themselves. This need is often apparent in their behavior with a clinician (e.g., being flattering, bring­ ing gifts, providing dramatic descriptions of physical and psychological symptoms that are replaced by new symptoms each visit).

The appearance and behavior of individuals with this disorder are often inappropri­ ately sexually provocative or seductive (Criterion 2). This behavior not only is directed to­ ward persons in whom the individual has a sexual or romantic interest but also occurs in a wide variety of social, occupational, and professional relationships beyond what is ap­ propriate for the social context. Emotional expression may be shallow and rapidly shifting (Criterion 3). Individuals with this disorder consistently use physical appearance to draw attention to themselves (Criterion 4). They are overly concerned with impressing others by their appearance and expend an excessive amount of time, energy, and money on clothes and grooming. They may “fish for compliments” regarding appearance and may be easily and excessively upset by a critical conunent about how they look or by a photograph that they regard as unflattering.

These individuals have a style of speech that is excessively impressionistic and lacking in detail (Criterion 5). Strong opinions are expressed with dramatic flair, but underlying reasons are usually vague and diffuse, without supporting facts and details. For example, an individual with histrionic personality disorder may comment that a certain individual is a wonderful human being, yet be unable to provide any specific examples of good qual­ ities to support this opinion. Individuals with this disorder are characterized by self­ dramatization, theatricality, and an exaggerated expression of emotion (Criterion 6). They may embarrass friends and acquaintances by an excessive public display of emotions (e.g., embracing casual acquaintances with excessive ardor, sobbing uncontrollably on minor

sentimental occasions, having temper tantrums). However, their emotions often seem to be turned on and off too quickly to be deeply felt, which may lead others to accuse the in­ dividual of faking these feelings.

Individuals with histrionic personality disorder have a high degree of suggestibility (Cri­ terion 7). Their opinions and feelings are easily influenced by others and by current fads. They may be overly trusting, especially of strong authority figures whom they see as mag­ ically solving their problems. They have a tendency to play hunches and to adopt convic­ tions quickly. Individuals with this disorder often consider relationships more intimate than they actually are, describing almost every acquaintance as “my dear, dear friend” or referring to physicians met only once or twice under professional circumstances by their first names (Criterion 8).

Associated Features Supporting Diagnosis Individuals with histrionic personality disorder may have difficulty achieving emotional in­ timacy in romantic or sexual relationships. Without being aware of it, they often act out a role (e.g., “victim” or “princess”) in their relationships to others. They may seek to control their partner through emotional manipulation or seductiveness on one level, while display­ ing a marked dependency on them at another level. Individuals with this disorder often have impaired relationships with same-sex friends because their sexually provocative inter­ personal style may seem a threat to their friends’ relationships. These individuals may also alienate friends with demands for constant attention. They often become depressed and up­ set when they are not the center of attention. They may crave novelty, stimulation, and ex­ citement and have a tendency to become bored with their usual routine. These individuals are often intolerant of, or frustrated by, situations that involve delayed gratification, and their actions are often directed at obtaining immediate satisfaction. Although they often ini­ tiate a job or project with great enthusiasm, their interest may lag quickly. Longer-term re­ lationships may be neglected to make way for the excitement of new relationships.

The actual risk of suicide is not known, but clinical experience suggests that individu­ als with this disorder are at increased risk for suicidal gestures and threats to get attention and coerce better caregiving. Histrionic personality disorder has been associated with higher rates of somatic symptom disorder, conversion disorder (functional neurological symptom disorder), and major depressive disorder. Borderline, narcissistic, antisocial, and dependent personality disorders often co-occur.

Prevalence Data from the 2001-2002 National Epidemiologic Survey on Alcohol and Related Condi­ tions suggest a prevalence of histrionic personality of 1.84%.

Culture-Related Diagnostic Issues Norms for interpersonal behavior, personal appearance, and emotional expressiveness vary widely across cultures, genders, and age groups. Before considering the various traits (e.g., emotionality, seductiveness, dramatic interpersonal style, novelty seeking, sociabil­ ity, charm, impressionability, a tendency to somatization) to be evidence of histrionic per­ sonality disorder, it is important to evaluate whether they cause clinically significant impairment or distress.

Gender-Related Diagnostic Issues In clinical settings, this disorder has been diagnosed more frequently in females; however, the sex ratio is not significantly different from the sex ratio of females within the respective clinical setting. In contrast, some studies using structured assessments report similar prev­ alence rates among males and females.

Differential Diagnosis Other personality disorders and personality traits. Other personality disorders may be confused with histrionic personality disorder because they have certain features in common. It is therefore important to distinguish among these disorders based on differ­ ences in their characteristic features. However, if an individual has personality features that meet criteria for one or more personality disorders in addition to histrionic personal­ ity disorder, all can be diagnosed. Although borderline personality disorder can also be characterized by attention seeking, manipulative behavior, and rapidly shifting emotions, it is distinguished by self-destructiveness, angry disruptions in close relationships, and chronic feelings of deep emptiness and identity disturbance. Individuals with antisocial personality disorder and histrionic personality disorder share a tendency to be impulsive, superficial, excitement seeking, reckless, seductive, and manipulative, but persons with histrionic personality disorder tend to be more exaggerated in their emotions and do not characteristically engage in antisocial behaviors. Individuals with histrionic personality disorder are manipulative to gain nurturance, whereas those with antisocial personality disorder are manipulative to gain profit, power, or some other material gratification. Al­ though individuals with narcissistic personality disorder also crave attention from others, they usually want praise for their ‘”superiority,” whereas individuals with histrionic per­ sonality disorder are willing to be viewed as fragile or dependent if this is instrumental in getting attention. Individuals with narcissistic personality disorder may exaggerate the intimacy of their relationships with other people, but they are more apt to emphasize the “VIP” status or wealth of their friends. In dependent personality disorder, the individual is excessively dependent on others for praise and guidance, but is without the flamboyant, exaggerated, emotional features of individuals with histrionic personality disorder.

Many individuals may display histrionic personality traits. Only when these traits are inflexible, maladaptive, and persisting and cause significant functional impairment or subjective distress do they constitute histrionic personality disorder. Personality change due to another medical condition. Histrionic personality disorder must be distinguished from personality change due to another medical condition, in which the traits that emerge are attributable to the effects of another medical condition on the central nervous system. Substance use disorders. The disorder must also be distinguished from sjonptoms that may develop in association with persistent substance use.

Narcissistic Personality Disorder Diagnostic Criteria 301.81 (F60.81) A pervasive pattern of grandiosity (in fantasy or behavior), need for admiration, and lack of empathy, beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following: 1. Has a grandiose sense of self-importance (e.g., exaggerates achievements and talents,

expects to be recognized as superior without commensurate achievements). 2. Is preoccupied with fantasies of unlimited success, power, brilliance, beauty, or ideal

love. 3. Believes that he or she is “special” and unique and can only be understood by, or

should associate with, other special or high-status people (or institutions). 4. Requires excessive admiration. 5. Has a sense of entitlement (i.e., unreasonable expectations of especially favorable

treatment or automatic compliance with his or her expectations).

6. Is interpersonally exploitative (i.e., takes advantage of others to achieve his or her own ends).

7. Lacks empathy: is unwilling to recognize or identify with the feelings and needs of others. 8. Is often envious of others or believes that others are envious of him or her. 9. Shows arrogant, haughty behaviors or attitudes.

Diagnostic Features The essential feature of narcissistic personality disorder is a pervasive pattern of grandi­ osity, need for admiration, and lack of empathy that begins by early adulthood and is pres­ ent in a variety of contexts.

Individuals with this disorder have a grandiose sense of self-importance (Criterion 1). They routinely overestimate their abilities and inflate their accomplishments, often appearing boastful and pretentious. They may blithely assume that others attribute the same value to their efforts and may be surprised when the praise they expect and feel they deserve is not forthcoming. Often implicit in the inflated judgments of their own accomplishments is an un­ derestimation (devaluation) of the contributions of others. Individuals with narcissistic per­ sonality disorder are often preoccupied with fantasies of unlimited success, power, brilliance, beauty, or ideal love (Criterion 2). They may ruminate about “‘long overdue” admiration and privilege and compare themselves favorably with famous or privileged people.

Individuals with narcissistic personality disorder believe that they are superior, spe­ cial, or unique and expect others to recognize them as such (Criterion 3). They may feel that they can only be understood by, and should only associate with, other people who are special or of high status and may attribute “unique,” “perfect,” or “gifted” qualities to those with whom they associate. Individuals with this disorder believe that their needs are spe­ cial and beyond the ken of ordinary people. Their own self-esteem is enhanced (i.e., “mir­ rored”) by the idealized value that they assign to those with whom they associate. They are likely to insist on having only the “top” person (doctor, lawyer, hairdresser, instructor) or being affiliated with the “best” institutions but may devalue the credentials of those who dis­ appoint them.

Individuals with this disorder generally require excessive admiration (Criterion 4). Their self-esteem is almost invariably very fragile. Tliey may be preoccupied with how well they are doing and how favorably they are regarded by others. This often takes the form of a need for constant attention and admiration. They may expect their arrival to be greeted with great farifare and are astonished if others do not covet their possessions. They may constantly fish for compliments, often with great charm. A sense of entitlement is evident in these individ­ uals’ unreasonable expectation of especially favorable treatment (Criterion 5). They expect to be catered to and are puzzled or furious when this does not happen. For example, they may assume that they do not have to wait in line and that their priorities are so important that others should defer to them, and then get irritated when others fail to assist “in their very important work.” This sense of entitlement, combined with a lack of sensitivity to the wants and needs of others, may result in the conscious or unwitting exploitation of others (Criterion 6). They expect to be given whatever they want or feel they need, no matter what it might mean to others. For example, these individuals may expect great dedication from others and may overwork them without regard for the impact on their lives. They tend to form friendships or romantic relationships only if the other person seems likely to advance their purposes or otherwise enhance their self-esteem. They often usuφ special privileges and extra resources that they believe they deserve because they are so special.

Individuals with narcissistic personality disorder generally have a lack of empathy and have difficulty recognizing the desires, subjective experiences, and feelings of others (Crite­ rion 7). They may assume that others are totally concerned about their welfare. They tend to discuss their own concerns in inappropriate and lengthy detail, while failing to recognize that others also have feelings and needs. They are often contemptuous and impatient with

others who talk about their own problems and concerns. These individuals may be oblivious to the hurt their remarks may inflict (e.g., exuberantly telling a former lover that “I am now in the relationship of a lifetime!”; boasting of health in front of someone who is sick). When recognized, the needs, desires, or feelings of others are likely to be viewed disparagingly as signs of weakness or vulnerability. Those who relate to individuals with narcissistic person­ ality disorder typically find an emotional coldness and lack of reciprocal interest.

These individuals are often envious of others or believe that oéiers are envious of them (Criterion 8). They may begrudge others their successes or possessions, feeling that they better deserve those achievements, admiration, or privileges. They may harshly devalue the contri­ butions of others, particularly when those individuals have received acknowledgment or praise for their accomplishments. Arrogant, haughty behaviors characterize these individuals; they often display snobbish, disdainful, or patronizing attitudes (Criterion 9). For example, an individual with this disorder may complain about a clumsy waiter’s “rudeness” or “stupidity” or conclude a medical evaluation with a condescending evaluation of the physician.

Associated Features Supporting Diagnosis Vulnerability in self-esteem makes individuals with narcissistic personality disorder very sensitive to “injury” from criticism or defeat. Although they may not show it outwardly, criticism may haunt these individuals and may leave them feeling humiliated, degraded, hollow, and empty. They may react with disdain, rage, or defiant counterattack. Such ex­ periences often lead to social withdrawal or an appearance of humility that may mask and protect the grandiosity. Interpersonal relations are typically impaired because of problems derived from entitlement, the need for admiration, and the relative disregard for the sen­ sitivities of others. Though overweening ambition and confidence may lead to high achievement, performance may be disrupted because of intolerance of criticism or defeat. Sometimes vocational functioning can be very low, reflecting an unwillingness to take a risk in competitive or other situations in which defeat is possible. Sustained feelings of shame or humiliation and the attendant self-criticism may be associated with social with­ drawal, depressed mood, and persistent depressive disorder (dysthymia) or major de­ pressive disorder. In contrast, sustained periods of grandiosity may be associated with a hypomanie mood. Narcissistic personality disorder is also associated with anorexia ner­ vosa and substance use disorders (especially related to cocaine). Histrionic, borderline, antisocial, and paranoid personality disorders may be associated with narcissistic person­ ality disorder.

Prevalence Prevalence estimates for narcissistic personality disorder, based on DSM-IV definitions, range from 0% to 6.2% in community samples.

Development and Course Narcissistic traits may be particularly common in adolescents and do not necessarily in­ dicate that the individual will go on to have narcissistic personality disorder. Individuals with narcissistic personality disorder may have special difficulties adjusting to the onset of physical and occupational limitations that are inherent in the aging process.

Gender-Related Diagnostic Issues Of those diagnosed with narcissistic personality disorder, 50%-75% are male.

Differential Diagnosis Other personality disorders and personality traits. Other personality disorders may be confused with narcissistic personality disorder because they have certain features in

common. It is, therefore, important to distinguish among these disorders based on differ­ ences in their characteristic features. However, if an individual has personality features that meet criteria for one or more personality disorders in addition to narcissistic person­ ality disorder, all can be diagnosed. The most useful feature in discriminating narcissistic personality disorder from histrionic, antisocial, and borderline personality disorders, in which the interactive styles are coquettish, callous, and needy, respectively, is the grandi­ osity characteristic of narcissistic personality disorder. The relative stability of self-image as well as the relative lack of self-destructiveness, impulsivity, and abandonment concerns also help distinguish narcissistic personality disorder from borderline personality disor­ der. Excessive pride in achievements, a relative lack of emotional display, and disdain for others’ sensitivities help distinguish narcissistic personality disorder from histrionic personality disorder. Although individuals with borderline, histrionic, and narcissistic personality disorders may require much attention, those with narcissistic personality dis­ order specifically need that attention to be admiring. Individuals with antisocial and nar­ cissistic personality disorders share a tendency to be tough-minded, glib, superficial, exploitative, and unempathic. However, narcissistic personality disorder does not neces­ sarily include characteristics of impulsivity, aggression, and deceit. In addition, individu­ als with antisocial personality disorder may not be as needy of the admiration and envy of others, and persons with narcissistic personality disorder usually lack the history of con­ duct disorder in childhood or criminal behavior in adulthood. In both narcissistic person­ ality disorder and obsessive-compulsive personality disorder, the individual may profess a commitment to perfectionism and believe that others cannot do things as well. In con­ trast to the accompanying self-criticism of those with obsessive-compulsive personality disorder, individuals with narcissistic personality disorder are more likely to believe that they have achieved perfection. Suspiciousness and social withdrawal usually distinguish those with schizotypal or paranoid personality disorder from those with narcissistic per­ sonality disorder. When these qualities are present in individuals with narcissistic person­ ality disorder, they derive primarily from fears of having imperfections or flaws revealed.

Many highly successful individuals display personality traits that might be considered narcissistic. Only when these traits are inflexible, maladaptive, and persisting and cause significant functional impairment or subjective distress do they constitute narcissistic per­ sonality disorder. Mania or hypomania. Grandiosity may emerge as part of manic or hypomanie episodes, but the association with mood change or functional impairments helps distinguish these episodes from narcissistic personality disorder. Substance use disorders. Narcissistic personality disorder must also be distinguished from symptoms that may develop in association with persistent substance use.

Cluster C Personality Disorders

Avoidant Personality Disorder Diagnostic Criteria 301.82 (F60.6) A pervasive pattern of social inhibition, feelings of inadequacy, and hypersensitivity to neg­ ative evaluation, beginning by early adulthood and present in a variety of contexts, as in­ dicated by four (or more) of the following: 1. Avoids occupational activities that involve significant interpersonal contact because of

fears of criticism, disapproval, or rejection.

2. Is unwilling to get involved with people unless certain of being liked. 3. Shows restraint within intimate relationships because of the fear of being shamed or

ridiculed. ‘ 4. Is preoccupied with being criticized or rejected in social situations. 5. Is inhibited in new interpersonal situations because of feelings of inadequacy. 6. Views self as socially inept, personally unappealing, or inferior to others. 7. Is unusually reluctant to take personal risks or to engage in any new activities because

they may prove embarrassing.

Diagnostic Features The essential feature of avoidant personality disorder is a pervasive pattern of social inhi­ bition, feelings of inadequacy, and hypersensitivity to negative evaluation that begins by early adulthood and is present in a variety of contexts.

Individuals with avoidant personality disorder avoid work activities that involve sig­ nificant interpersonal contact because of fears of criticism, disapproval, or rejection (Cri­ terion 1). Offers of job promotions may be declined because the new responsibilities might result in criticism from co-workers. These individuals avoid making new friends unless they are certain they will be liked and accepted without criticism (Criterion 2). Until they pass stringent tests proving the contrary, other people are assumed to be critical and dis­ approving. Individuals with this disorder will not join in group activities unless there are repeated and generous offers of support and nurturance. Interpersonal intimacy is often difficult for these individuals, although they are able to establish intimate relationships when there is assurance of uncritical acceptance. They may act with restraint, have diffi­ culty talking about themselves, and withhold intimate feelings for fear of being exposed, ridiculed, or shamed (Criterion 3).

Because individuals with this disorder are preoccupied with being criticized or re­ jected in social situations, they may have a markedly low threshold for detecting such re­ actions (Criterion 4). If someone is even slightly disapproving or critical, they may feel extremely hurt. They tend to be shy, quiet, inhibited, and “invisible” because of the fear that any attention would be degrading or rejecting. They expect that no matter what they say, others will see it as “wrong,” and so they may say nothing at all. They react strongly to subtle cues that are suggestive of mockery or derision. Despite their longing to be active participants in social life, they fear placing their welfare in the hands of others. Individuals with avoidant personality disorder are inhibited in new interpersonal situations because they feel inadequate and have low self-esteem (Criterion 5). Doubts concerning social competence and personal appeal become especially manifest in settings involving inter­ actions with strangers. These individuals believe themselves to be socially inept, person­ ally unappealing, or inferior to others (Criterion 6). They are unusually reluctant to take personal risks or to engage in any new activities because these may prove embarrassing (Criterion 7). They are prone to exaggerate the potential dangers of ordinary situations, and a restricted lifestyle may result from their need for certainty and security. Someone with this disorder may cancel a job interview for fear of being embarrassed by not dressing appropriately. Marginal somatic symptoms or other problems may become the reason for avoiding new activities.

Associated Features Supporting Diagnosis Individuals with avoidant personality disorder often vigilantly appraise the movements and expressions of those with whom they come into contact. Their fearful and tense de­ meanor may elicit ridicule and derision from others, which in turn confirms their self­ doubts. These individuals are very anxious about the possibility that they will react to crit­ icism with blushing or crying. They are described by others as being “shy,” “timid,”

“lonely,” and “isolated.” The major problems associated with this disorder occur in social and occupational functioning. The low self-esteem and hypersensitivity to rejection are associated with restricted interpersonal contacts. These individuals may become relatively isolated and usually do not have a large social support network that can help them weather crises. They desire affection and acceptance and may fantasize about idealized relation­ ships with others. The avoidant behaviors can also adversely affect occupational function­ ing because these individuals try to avoid the types of social situations that may be important for meeting the basic demands of the job or for advancement.

Other disorders that are commonly diagnosed with avoidant personality disorder in­ clude depressive, bipolar, and anxiety disorders, especially social anxiety disorder (social phobia). Avoidant personality disorder is often diagnosed with dependent personality disorder, because individuals with avoidant personality disorder become very attached to and dependent on those few other people with whom they are friends. Avoidant per­ sonality disorder also tends to be diagnosed with borderline personality disorder and with the Cluster A personality disorders (i.e., paranoid, schizoid, or schizotypal personality disorders).

Prevalence Data from the 2001-2002 National Epidemiologic Survey on Alcohol and Related Condi­ tions suggest a prevalence of about 2.4% for avoidant personality disorder.

Development and Course The avoidant behavior often starts in infancy or childhood with shyness, isolation, and fear of strangers and new situations. Although shyness in childhood is a common precur­ sor of avoidant personality disorder, in most individuals it tends to gradually dissipate as they get older. In contrast, individuals who go on to develop avoidant personality disor­ der may become increasingly shy and avoidant during adolescence and early adulthood, when social relationships with new people become especially important. There is some evidence that in adults, avoidant personality disorder tends to become less evident or to remit with age. This diagnosis should be used with great caution in children and adoles­ cents, for whom shy and avoidant behavior may be developmentally appropriate.

Culture-Related Diagnostic issues There may be variation in the degree to which different cultural and ethnic groups regard diffidence and avoidance as appropriate. Moreover, avoidant behavior may be the result of problems in acculturation following immigration.

Gender-Related Diagnostic Issues Avoidant personality disorder appears to be equally frequent in males and females.

Differential Diagnosis Anxiety disorders. There appears to be a great deal of overlap between avoidant person­ ality disorder and social anxiety disorder (social phobia), so much so that they may be alternative conceptualizations of the same or similar conditions. Avoidance also character­ izes both avoidant personality disorder and agoraphobia, and they often co-occur. Other personality disorders and personality traits. Other personality disorders may be confused with avoidant personality disorder because they have certain features in com­ mon. It is, therefore, important to distinguish among these disorders based on differences in their characteristic features. However, if an individual has personality features that meet criteria for one or more personality disorders in addition to avoidant personality dis-

order, all can be diagnosed. Both avoidant personality disorder and dependent personal­ ity disorder are characterized by feelings of inadequacy, hypersensitivity to criticism, and a need for reassurance. Although the primary focus of concern in avoidant personality disorder is avoidance of humiliation and rejection, in dependent personality disorder the focus is on being taken care of. However, avoidant personality disorder and dependent personality disorder are particularly likely to co-occur. Like avoidant personality disor­ der, schizoid personality disorder and schizotypal personality disorder are characterized by social isolation. However, individuals with avoidant personality disorder want to have relationships with others and feel their loneliness deeply, whereas those with schizoid or schizotypal personality disorder may be content with and even prefer their social isola­ tion. Paranoid personality disorder and avoidant personality disorder are both character­ ized by a reluctance to confide in others. However, in avoidant personality disorder, this reluctance is attributable more to a fear of being embarrassed or being found inadequate than to a fear of others’ malicious intent.

Many individuals display avoidant personality traits. Only when these traits are in­ flexible, maladaptive, and persisting and cause significant functional impairment or sub­ jective distress do they constitute avoidant personality disorder. Personality change due to another medical condition. Avoidant personality disorder must be distinguished from personality change due to another medical condition, in which the traits that emerge are attributable to the effects of another medical condition on the central nervous system. Substance use disorders. Avoidant personality disorder must also be distinguished from symptoms that may develop in association with persistent substance use.

Dependent Personality Disorder Diagnostic Criteria 301.6(F60.7) A pervasive and excessive need to be taken care of that leads to submissive and clinging behavior and fears of separation, beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following: 1. Has difficulty making everyday decisions without an excessive amount of advice and

reassurance from others. 2. Needs others to assume responsibility for most major areas of his or her life. 3. Has difficulty expressing disagreement with others because of fear of loss of support

or approval. (Note: Do not include realistic fears of retribution.) 4. Has difficulty initiating projects or doing things on his or her own (because of a lack of

self-confidence in judgment or abilities rather than a lack of motivation or energy). 5. Goes to excessive lengths to obtain nurturance and support from others, to the point

of volunteering to do things that are unpleasant. 6. Feels uncomfortable or helpless when alone because of exaggerated fears of being

unable to care for himself or herself. 7. Urgently seeks another relationship as a source of care and support when a close re­

lationship ends. 8. Is unrealistically preoccupied with fears of being left to take care of himself or herself.

Diagnostic Features The essential feature of dependent personality disorder is a pervasive and excessive need to be taken care of that leads to submissive and clinging behavior and fears of separation. This pattern begins by early adulthood and is present in a variety of contexts. The dependent

and submissive behaviors are designed to elicit caregiving and arise from a self-perception of being unable to function adequately without the help of others.

Individuals with dependent personality disorder have great difficulty making every­ day decisions (e.g., what color shirt to wear to work or whether to carry an umbrella) without an excessive amount of advice and reassurance from others (Criterion 1). These individu­ als tend to be passive and to allow other people (often a single other person) to take the ini­ tiative and assume responsibility for most major areas of their lives (Criterion 2). Adults with this disorder typically depend on a parent or spouse to decide where they should live, what kind of job they should have, and which neighbors to befriend. Adolescents with this disorder may allow their parent(s) to decide what they should wear, with whom they should associate, how they should spend their free time, and what school or college they should attend. This need for others to assume responsibility goes beyond age-appro­ priate and situation-appropriate requests for assistance from others (e.g., the specific needs of children, elderly persons, and handicapped persons). Dependent personality dis­ order may occur in an individual who has a serious medical condition or disability, but in such cases the difficulty in taking responsibility must go beyond what would normally be associated with that condition or disability.

Because they fear losing support or approval, individuals with dependent personality disorder often have difficulty expressing disagreement with other individuals, especially those on whom they are dependent (Criterion 3). These individuals feel so unable to func­ tion alone that they will agree with things that they feel are wrong rather than risk losing the help of those to whom they look for guidance. They do not get appropriately angry at others whose support and nurturance they need for fear of alienating them. If the individ­ ual’s concerns regarding the consequences of expressing disagreement are realistic (e.g., realistic fears of retribution from an abusive spouse), the behavior should not be consid­ ered to be evidence of dependent personality disorder.

Individuals with this disorder have difficulty initiating projects or doing things inde­ pendently (Criterion 4). They lack self-confidence and believe that they need help to begin and carry through tasks. They will wait for others to start things because they believe that as a rule others can do them better. These individuals are convinced that they are incapable of functioning independently and present themselves as inept and requiring constant as­ sistance. They are, however, likely to function adequately if given the assurance that some­ one else is supervising and approving. There may be a fear of becoming or appearing to be more competent, because they may believe that this will lead to abandonment. Because they rely on others to handle their problems, they often do not leam the skills of indepen­ dent living, thus perpetuating dependency.

Individuals with dependent personality disorder may go to excessive lengths to obtain nurturance and support from others, even to the point of volunteering for unpleasant tasks if such behavior will bring the care they need (Criterion 5). They are willing to submit to what others want, even if the demands are unreasonable. Their need to maintain an im­ portant bond will often result in imbalanced or distorted relationships. They may make ex­ traordinary self-sacrifices or tolerate verbal, physical, or sexual abuse. (It should be noted that this behavior should be considered evidence of dependent personality disorder only when it can clearly be established that other options are available to the individual.) Indi­ viduals with this disorder feel uncomfortable or helpless when alone, because of their ex­ aggerated fears of being unable to care for themselves (Criterion 6). They will “tag along” with important others just to avoid being alone, even if they are not interested or involved in what is happening.

When a close relationship ends (e.g., a breakup with a lover; the death of a caregiver), in­ dividuals with dependent personality disorder may urgently seek another relationship to provide the care and support they need (Criterion 7). Their belief that they are unable to function in the absence of a close relationship motivates these individuals to become quickly and indiscriminately attached to another individual. Individuals with this disorder are often

preoccupied with fears of being left to care for themselves (Criterion 8). They see themselves as so totally dependent on the advice and help of an important other person that they worry about being abandoned by that person when there are no grounds to justify such fears. To be considered as evidence of this criterion, the fears must be excessive and unrealistic. For ex­ ample, an elderly man with cancer who moves into his son’s household for care is exhibiting dependent behavior that is appropriate given this person’s life circumstances.

Associated Features Supporting Diagnosis Individuals with dependent personality disorder are often characterized by pessimism and self-doubt, tend to belittle their abilities and assets, and may constantly refer to them­ selves as “stupid.” They take criticism and disapproval as proof of their worthlessness and lose faith in themselves. They may seek overprotection and dominance from others. Oc­ cupational functioning may be impaired if independent initiative is required. They may avoid positions of responsibility and become anxious when faced with decisions. Social re­ lations tend to be limited to those few people on whom the individual is dependent. There may be an increased risk of depressive disorders, anxiety disorders, and adjustment dis­ orders. Dependent personality disorder often co-occurs with other personality disorders, especially borderline, avoidant, and histrionic personality disorders. Chronic physical ill­ ness or separation anxiety disorder in childhood or adolescence may predispose the indi­ vidual to the development of this disorder.

Prevalence Data from the 2001-2002 National Epidemiologic Survey on Alcohol and Related Condi­ tions yielded an estimated prevalence of dependent personality disorder of 0.49%, and de­ pendent personality was estimated, based on a probability subsample from Part II of the National Comorbidity Survey Replication, to be 0.6%.

Deveiopment and Course This diagnosis should be used with great caution, if at all, in children and adolescents, for whom dependent behavior may be developmentally appropriate.

Culture-Reiated Diagnostic issues The degree to which dependent behaviors are considered to be appropriate varies sub­ stantially across different age and sociocultural groups. Age and cultural factors need to be considered in evaluating the diagnostic threshold of each criterion. Dependent behav­ ior should be considered characteristic of the disorder only when it is clearly in excess of the individual’s cultural norms or reflects unrealistic concerns. An emphasis on passivity, politeness, and deferential treatment is characteristic of some societies and may be mis­ interpreted as traits of dependent personality disorder. Similarly, societies may differen­ tially foster and discourage dependent behavior in males and females.

Gender-Reiated Diagnostic Issues In clinical settings, dependent personality disorder has been diagnosed more frequently in females, although some studies report similar prevalence rates among males and females.

Differential Diagnosis Other mental disorders and medical conditions. Dependent personality disorder must be distinguished from dependency arising as a consequence of other mental disorders (e.g., depressive disorders, panic disorder, agoraphobia) and as a result of other medical conditions.

Other personality disorders and personality traits. Other personality disorders may be confused with dependent personality disorder because they have certain features in com­ mon. It is therefore important to distinguish among these disorders based on differences in their characteristic features. However, if an individual has personality features that meet cri­ teria for one or more personality disorders in addition to dependent personality disorder, all can be diagnosed. Although many personality disorders are characterized by dependent features, dependent personality disorder can be distinguished by its predominantly submis­ sive, reactive, and clinging behavior. Both dependent personality disorder and borderline personality disorder are characterized by fear of abandonment; however, the individual with borderline personality disorder reacts to abandonment with feelings of emotional emp­ tiness, rage, and demands, whereas the individual with dependent personality disorder re­ acts with increasing appeasement and submissiveness and urgently seeks a replacement relationship to provide caregiving and support. Borderline personality disorder can further be distinguished from dependent personality disorder by a typical pattern of unstable and intense relationships. Individuals with histrionic personality disorder, like those with de­ pendent personality disorder, have a strong need for reassurance and approval and may ap­ pear childlike and clinging. However, unlike dependent personality disorder, which is characterized by self-effacing and docile behavior, histrionic personality disorder is charac­ terized by gregarious flamboyance with active demands for attention. Both dependent personality disorder and avoidant personality disorder are characterized by feelings of in­ adequacy, hypersensitivity to criticism, and a need for reassurance; however, individuals with avoidant personality disorder have such a strong fear of humiliation and rejection that they withdraw until they are certain they will be accepted. In contrast, individuals with de­ pendent personality disorder have a pattern of seeking and maintaining connections to im­ portant others, rather than avoiding and withdrawing from relationships.

Many individuals display dependent personality traits. Orüy when these traits are in­ flexible, maladaptive, and persisting and cause significant functional impairment or sub­ jective distress do they constitute dependent personality disorder. Personality change due to another medical condition. Dependent personality disor­ der must be distinguished from personality change due to another medical condition, in which the traits that emerge are attributable to the effects of another medical condition on the central nervous system. Substance use disorders. Dependent personality disorder must also be distinguished from symptoms that may develop in association with persistent substance use.

Obsessive-Compulsive Personality Disorder Diagnostic Criteria 301.4 (F60.5) A pervasive pattern of preoccupation with orderliness, perfectionism, and mental and in- teφersonal control, at the expense of flexibility, openness, and efficiency, beginning by early adulthood and present in a variety of contexts, as indicated by four (or more) of the following: 1. Is preoccupied with details, rules, lists, order, organization, or schedules to the extent

that the major point of the activity is lost. 2. Shows perfectionism that interferes with task completion (e.g., is unable to complete a

project because his or her own overly strict standards are not met). 3. Is excessively devoted to work and productivity to the exclusion of leisure activities and

friendships (not accounted for by obvious economic necessity). 4. Is overconscientious, scrupulous, and inflexible about matters of morality, ethics, or

values (not accounted for by cultural or religious identification).

5. Is unable to discard worn-out or worthless objects even when they have no sentimental value.

6. Is reluctant to delegate tasks or to work with others unless they submit to exactly his or her way of doing things.

7. Adopts a miserly spending style toward both self and others; money is viewed as something to be hoarded for future catastrophes.

8. Shows rigidity and stubbornness.

Diagnostic Features The essential feature of obsessive-compulsive personality disorder is a preoccupation with orderliness, perfectionism, and mental and interpersonal control, at the expense of flexibility, openness, and efficiency. This pattern begins by early adulthood and is present in a variety of contexts.

Individuals with obsessive-compulsive personality disorder attempt to maintain a sense of control through painstaking attention to rules, trivial details, procedures, lists, schedules, or form to the extent that the major point of the activity is lost (Criterion 1). They are excessively careful and prone to repetition, paying extraordinary attention to detail and repeatedly checking for possible mistakes. They are oblivious to the fact that other people tend to become very annoyed at the delays and inconveniences that result from this behavior. For example, when such individuals misplace a list of things to be done, they will spend an inordinate amount of time looking for the list rather than spending a few moments re-creating it from memory and proceeding to accomplish the tasks. Time is poorly allocated, and the most important tasks are left to the last moment. The perfection­ ism and self-imposed high standards of performance cause significant dysfunction and distress in these individuals. They may become so involved in making every detail of a project absolutely perfect that the project is never finished (Criterion 2). For example, the completion of a written report is delayed by numerous time-consuming rewrites that all come up short of “perfection.” Deadlines are missed, and aspects of the individual’s life that are not the current focus of activity may fall into disarray.

Individuals with obsessive-compulsive personality disorder display excessive devotion to work and productivity to the exclusion of leisure activities and friendships (Criterion 3). This behavior is not accounted for by economic necessity. They often feel that they do not have time to take an evening or a weekend day off to go on an outing or to just relax. They may keep postponing a pleasurable activity, such as a vacation, so that it may never occur. When they do take time for leisure activities or vacations, they are very uncomfortable un­ less they have taken along something to work on so they do not “waste time.” There may be a great concentration on household chores (e.g., repeated excessive cleaning so that “one could eat off the floor”). If they spend time with friends, it is likely to be in some kind of for­ mally organized activity (e.g., sports). Hobbies or recreational activities are approached as serious tasks requiring careful organization and hard work to master. The emphasis is on perfect performance. These individuals turn play into a structured task (e.g., correcting an infant for not putting rings on the post in the right order; telling a toddler to ride his or her tri­ cycle in a straight line; turning a baseball game into a harsh “lesson”).

Individuals with obsessive-compulsive personality disorder may be excessively con­ scientious, scrupulous, and inflexible about matters of morality, ethics, or values (Crite­ rion 4). They may force themselves and others to follow rigid moral principles and very strict standards of performance. They may also be mercilessly self-critical about their own mistakes. Individuals with this disorder are rigidly deferential to authority and rules and insist on quite literal compliance, with no rule bending for extenuating circumstances. For example, the individual will not lend a quarter to a friend who needs one to make a tele­ phone call because “neither a borrower nor a lender be” or because it would be “bad” for

the person’s character. These qualities should not be accounted for by the individual’s cul­ tural or religious identification.

Individuals with this disorder may be unable to discard worn-out or worthless objects, even when they have no sentimental value (Criterion 5). Often these individuals will ad­ mit to being “pack rats.” They regard discarding objects as wasteful because “you never know when you might need something” and will become upset if someone tries to get rid of the things they have saved. Their spouses or roommates may complain about the amount of space taken up by old parts, magazines, broken appliances, and so on.

Individuals with obsessive-compulsive personality disorder are reluctant to delegate tasks or to work with others (Criterion 6). They stubbornly and unreasonably insist that everything be done their way and that people conform to their way of doing things. They often give very detailed instructions about how things should be done (e.g., there is one and only one way to mow the lawn, wash the dishes, build a doghouse) and are surprised and irritated if others suggest creative alternatives. At other times they may reject offers of help even when behind schedule because they believe no one else can do it right.

Individuals with this disorder may be miserly and stingy and maintain a standard of living far below what they can afford, believing that spending must be tightly controlled to provide for future catastrophes (Criterion 7). Obsessive-compulsive personality disorder is characterized by rigidity and stubbornness (Criterion 8). Individuals with this disorder are so concerned about having things done the one “correct” way that they have trouble going along with anyone else’s ideas. These individuals plan ahead in meticulous detail and are unwilling to consider changes. Totally wrapped up in their own perspective, they have difficulty acknowledging the viewpoints of others. Friends and colleagues may be­ come frustrated by this constant rigidity. Even when individuals with obsessive-compul­ sive personality disorder recognize that it may be in their interest to compromise, they may stubbornly refuse to do so, arguing that it is “the principle of the thing.”

Associated Features Supporting Diagnosis When rules and established procedures do not dictate the correct answer, decision making may become a time-consuming, often painful process. Individuals with obsessive- compulsive personality disorder may have such difficulty deciding which tasks take pri­ ority or what is the best way of doing some particular task that they may never get started on anything. They are prone to become upset or angry in situations in which they are not able to maintain control of their physical or interpersonal environment, although the an­ ger is typically not expressed directly. For example, an individual may be angry when ser­ vice in a restaurant is poor, but instead of complaining to the management, the individual ruminates about how much to leave as a tip. C3n other occasions, anger may be expressed with righteous indignation over a seemingly minor matter. Individuals with this disorder may be especially attentive to their relative status in dominance-submission relationships and may display excessive deference to an authority they respect and excessive resistance to authority they do not respect.

Individuals with this disorder usually express affection in a highly controlled or stilted fashion and may be very uncomfortable in the presence of others who are emotionally ex­ pressive. Their everyday relationships have a formal and serious quality, and they may be stiff in situations in which others would smile and be happy (e.g., greeting a lover at the airport). They carefully hold themselves back until they are sure that whatever they say will be perfect. They may be preoccupied with logic and intellect, and intolerant of affec­ tive behavior in others. They often have difficulty expressing tender feelings, rarely pay­ ing compliments. Individuals with this disorder may experience occupational difficulties and distress, particularly when confronted with new situations that demand flexibility and compromise.

Individuals with anxiety disorders, including generalized anxiety disorder, social anx­ iety disorder (social phobia), and specific phobias, and obsessive-compulsive disorder (OCD)

have an increased likelihood of having a personality disturbance that meets criteria for ob- sessive-compulçive personality disorder. Even so, it appears that the majority of individ­ uals with OCD do not have a pattern of behavior that meets criteria for this personality disorder. Many of the features of obsessive-compulsive personality disorder overlap with “type A” personality characteristics (e.g., preoccupation with work, competitiveness, time urgency), and these features may be present in people at risk for myocardial infarction. There may be an association between obsessive-compulsive personality disorder and de­ pressive and bipolar disorders and eating disorders.

Prevalence Obsessive-compulsive personality disorder is one of the most prevalent personality dis­ orders in the general population, with estimated prevalence ranging from 2.1% to 7.9%.

Culture-Related Diagnostic Issues In assessing an individual for obsessive-compulsive personality disorder, the clinician should not include those behaviors that reflect habits, customs, or interpersonal styles that are culturally sanctioned by the individual’s reference group. Certain cultures place sub­ stantial emphasis on work and productivity; the resulting behaviors in members of those societies need not be considered indications of obsessive-compulsive personality disorder.

Gender-Related Diagnostic Issues In systematic studies, obsessive-compulsive personality disorder appears to be diagnosed about twice as often among males.

Differential Diagnosis Obsessive-compulsive disorder. Despite the similarity in names, OCD is usually easily distinguished from obsessive-compulsive personality disorder by the presence of true ob­ sessions and compulsions in OCD. When criteria for both obsessive-compulsive person­ ality disorder and OCD are met, both diagnoses should be recorded.

Hoarding disorder. A diagnosis of hoarding disorder should be considered especially when hoarding is extreme (e.g., accumulated stacks of worthless objects present a fire haz­ ard and make it difficult for others to walk through the house). When criteria for both ob­ sessive-compulsive personality disorder and hoarding disorder are met, both diagnoses should be recorded.

Other personality disorders and personality traits. Other personality disorders may be confused with obsessive-compulsive personality disorder because they have certain features in common. It is, therefore, important to distinguish among these disorders based on differences in their characteristic features. However, if an individual has personality features that meet criteria for one or more personality disorders in addition to obsessive- compulsive personality disorder, all can be diagnosed. Individuals with narcissistic per­ sonality disorder may also profess a commitment to perfectionism and believe that others cannot do things as well, but these individuals are more likely to believe that they have achieved perfection, whereas those with obsessive-compulsive personahty disorder are usually self-critical. Individuals with narcissistic or antisocial personality disorder lack generosity but will indulge themselves, whereas those with obsessive-compulsive person­ ality disorder adopt a miserly spending style toward both self and others. Both schizoid personality disorder and obsessive-compulsive personality disorder may be characterized by an apparent formality and social detachment. In obsessive-compulsive personality dis­ order, this stems from discomfort with emotions and excessive devotion to work, whereas in schizoid personality disorder there is a fundamental lack of capacity for intimacy.

Obsessive-compulsive personality traits in moderation may be especially adaptive, par­ ticularly in situations that reward high performance. Only when these traits are inflexible, maladaptive, and persisting and cause significant functional impairment or subjective dis­ tress do they constitute obsessive-compulsive personality disorder. Personality change due to another medical condition. Obsessive-compulsive person­ ality disorder must be distinguished from personality change due to another medical con­ dition, in which the traits emerge attributable to the effects of another medical condition on the central nervous system. Substance use disorders. Obsessive-compulsive personality disorder must also be dis­ tinguished from symptoms that may develop in association with persistent substance use.

Other Personality Disorders

Personality Change Due to Another Medical Condition

Diagnostic Criteria 310.1 (F07.0) A. A persistent personality disturbance that represents a change fronn the individual’s pre­

vious characteristic personality pattern. Note: In children, the disturbance involves a marked deviation from normal devel­ opment or a significant change in the child’s usual behavior patterns, lasting at least 1 year.

B. There is evidence from the history, physical examination, or laboratory findings that the disturbance is the direct pathophysiological consequence of another medical condition.

C. The disturbance is not better explained by another mental disorder (including another mental disorder due to another medical condition).

D. The disturbance does not occur exclusively during the course of a delirium. E. The disturbance causes clinically significant distress or impairment in social, occupa­

tional, or other important areas of functioning. Specify whether:

Labile type: If the predominant feature is affective lability. Disinhibited type: If the predominant feature is poor impulse control as evidenced by sexual indiscretions, etc. Aggressive type: If the predominant feature is aggressive behavior. Apathetic type: If the predominant feature is marked apathy and indifference. Paranoid type: If the predominant feature is suspiciousness or paranoid ideation. Other type: If the presentation is not characterized by any of the above subtypes. Combined type: If more than one feature predominates in the clinical picture. Unspecified type

Coding note: Include the name of the other medical condition (e.g., 310.1 [F07.0] person­ ality change due to temporal lobe epilepsy). The other medical condition should be coded and listed separately immediately before the personality disorder due to another medical condition (e.g., 345.40 [G40.209] temporal lobe epilepsy; 310.1 [F07.0] personality change due to temporal lobe epilepsy).

Subtypes The particular {Personality change can be specified by indicating the symptom presenta­ tion that predominates in the clinical presentation.

Diagnostic Features The essential feature of a personality change due to another medical condition is a persis­ tent personality disturbance that is judged to be due to the direct pathophysiological ef­ fects of a medical condition. The personality disturbance represents a change from the individual’s previous characteristic personality pattern. In children, this condition may be manifested as a marked deviation from normal development rather than as a change in a stable personality pattern (Criterion A). There must be evidence from the history, physical examination, or laboratory findings that the personality change is the direct physiological consequence of another medical condition (Criterion B). The diagnosis is not given if the disturbance is better explained by another mental disorder (Criterion C). The diagnosis is not given if the disturbance occurs exclusively during the course of a delirium (Criterion D). The disturbance must also cause clinically significant distress or impairment in social, occupational, or other important areas of functioning (Criterion E).

Common manifestations of the personality change include affective instability, poor impulse control, outbursts of aggression or rage grossly out of proportion to any precipi­ tating psychosocial stressor, marked apathy, suspiciousness, or paranoid ideation. The phenomenology of the change is indicated using the subtypes listed in the criteria set. An individual with the disorder is often characterized by others as “not himself [or herself].” Although it shares the term “personality” with the other personality disorders, this diag­ nosis is distinct by virtue of its specific etiology, different phenomenology, and more vari­ able onset and course.

The clinical presentation in a given individual may depend on the nature and localiza­ tion of the pathological process. For example, injury to the frontal lobes may yield symp­ toms such as lack of judgment or foresight, facetiousness, disinhibition, and euphoria. Right hemisphere strokes have often been shown to evoke personality changes in asso­ ciation with unilateral spatial neglect, anosognosia (i.e., inability of the individual to recognize a bodily or functional deficit, such as the existence of hemiparesis), motor im- persistence, and other neurological deficits.

Associated Features Supporting Diagnosis A variety of neurological and other medical conditions may cause personality changes, including central nervous system neoplasms, head trauma, cerebrovascular disease, Huntington’s disease, epilepsy, infectious conditions with central nervous system in­ volvement (e.g., HIV), endocrine conditions (e.g., hypothyroidism, hypo- and hyperadre- nocorticism), and autoimmune conditions with central nervous system involvement (e.g., systemic lupus erythematosus). The associated physical examination findings, laboratory findings, and patterns of prevalence and onset reflect those of the neurological or other medical condition involved.

Differentiai Diagnosis Chronic medical conditions associated with pain and disability. Chronic medical con­ ditions associated with pain and disability can also be associated with changes in person­ ality. The diagnosis of personality change due to another medical condition is given only if a direct pathophysiological mechanism can be established. This diagnosis is not given if the change is due to a behavioral or psychological adjustment or response to another med­ ical condition (e.g., dependent behaviors that result from a need for the assistance of others following a severe head trauma, cardiovascular disease, or dementia).

Delirium or major neurocognitive disorder. Personality change is a frequently associated feature of a delirium or major neurocognitive disorder. A separate diagnosis of personal­ ity change due to another medical condition is not given if the change occurs exclusively during the course of a delirium. However, the diagnosis of personality change due to an­ other medical condition may be given in addition to the diagnosis of major neurocognitive disorder if the personality change is a prominent part of the clinical presentation. Another mental disorder due to another medical condition. The diagnosis of person­ ality change due to another medical condition is not given if the disturbance is better ex­ plained by another mental disorder due to another medical condition (e.g., depressive disorder due to brain tumor). Substance use disorders. Personality changes may also occur in the context of substance use disorders, especially if the disorder is long-standing. The clinician should inquire carefully about the nature and extent of substance use. If the clinician wishes to indicate an etiological re­ lationship between the personality change and substance use, the unspecified category for the specific substance (e.g., unspecified stimulant-related disorder) can be used. Other mental disorders. Marked personality changes may also be an associated feature of other mental disorders (e.g., schizophrenia; delusional disorder; depressive and bipolar disorders; other specified and unspecified disruptive behavior, impulse-control, and con­ duct disorders; panic disorder). However, in these disorders, no specific physiological fac­ tor is judged to be etiologically related to the personality change. Other personality disorders. Personality change due to another medical condition can be distinguished from a personality disorder by the requirement for a clinically significant change from baseline personality functioning and the presence of a specific etiological medical condition.

Other Specified Personality Disorder 301.89 (F60.89)

This category applies to presentations in wliich symptoms characteristic of a personality disorder that cause clinically significant distress or impairment in social, occupational, or other important areas of functioning predominate but do not meet the full criteria for any of the disorders in the personality disorders diagnostic class. The other specified personality disorder category is used in situations in which the clinician chooses to communicate the specific reason that the presentation does not meet the criteria for any specific personality disorder. This is done by recording “other specified personality disorder” followed by the specific reason (e.g., “mixed personality features”).

Unspecified Personality Disorder 301.9 (F60.9)

This category applies to presentations in which symptoms characteristic of a personality disorder that cause clinically significant distress or impairment in social, occupational, or other important areas of functioning predominate but do not meet the full criteria for any of the disorders in the personality disorders diagnostic class. The unspecified personality disorder category is used in situations in which the clinician chooses not to specify the rea­ son that the criteria are not met for a specific personality disorder, and includes presenta­ tions in which there is insufficient information to make a more specific diagnosis.

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