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CONTROVERSY ASSOCIATED WITH PERSONALITY AND PARAPHILIC DISORDERS
Between 10% and 20% of the population experience personality disorders. They are difficult to treat as individuals with personality disorders are less likely to seek help than individuals with other mental health disorders. Treatment can be challenging as they do not see their symptoms as painful to themselves or others.
Paraphilic disorders are far more common in men than in women, and generally quite chronic, lasting at least two years. Treatment of these disorders usually involves both psychotherapeutic and pharmacologic treatments.
In this Assignment, you will explore personality and paraphilic disorders in greater detail. You will research potentially controversial elements of the diagnosis and/or treatment and explain ethical and legal considerations when working with these disorders.
TO PREPARE
· Select a specific personality or paraphilic disorder from the
DSM-5-TR to use for this Assignment. – Choose one disorder from the attached PDF documents.
THE ASSIGNMENT
In 3 pages:
· Explain the controversy that surrounds your selected disorder. – Choose one (1) disorder from the attached PDF documents.
· Explain your professional beliefs about this disorder, supporting your rationale with at least three scholarly references from the literature.
· Explain strategies for maintaining the therapeutic relationship with a patient that may present with this disorder.
· Finally, explain ethical and legal considerations related to this disorder that you need to bring to your practice and why they are important.
· At least three scholarly references
· APA 7
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Personality Disorders
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This chapter begins with a general definition of personality 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 norms and expectations of the
individual’s culture, is pervasive and inflexible, has an onset in adolescence or early
adulthood, is stable over time, and leads to distress or impairment.
With any ongoing review process, especially one of this complexity, different viewpoints
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-5 (which were carried over from DSM-IV-
TR), whereas Section III includes the proposed model for personality disorder diagnosis
and conceptualization developed by the DSM-5 Personality and Personality Disorders
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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 others’ 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, criminality, impulsivity, and a failure to learn from experience.
Borderline personality disorder is a pattern of instability in interpersonal
relationships, 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
related to an excessive need to be taken care of.
Obsessive-compulsive personality disorder is a pattern of preoccupation with
orderliness, perfectionism, and control.
Personality change due to another medical condition is a persistent
personality disturbance that is judged to be the direct pathophysiological consequence
of another medical condition (e.g., frontal lobe lesion).
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Other specified personality disorder is a category provided for two situations: 1)
the individual’s personality pattern meets the general 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 disorder, but the
individual is considered to have a personality disorder that is not included in the
DSM-5 classification (e.g., passive-aggressive personality disorder). Unspecified
personality disorder is for presentations in which symptoms characteristic of a
personality disorder are present but there is insufficient information to make a more
specific diagnosis.
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, histrionic, and narcissistic personality disorders. Individuals with these
disorders often appear dramatic, 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 educational situations, has serious limitations and
has not been consistently validated. For instance, two or more disorders from different
clusters, or traits from several of them, can often co-occur and vary in intensity and
pervasiveness.
A review of epidemiological studies from several countries found a median prevalence of
3.6% for disorders in Cluster A, 4.5% for Cluster B, 2.8% for Cluster C, and 10.5% for any
personality disorder (Huang et al. 2009; Morgan and Zimmerman 2018). Prevalence
appears to vary across countries and by ethnicity, raising questions about true cross-
cultural variation and about the impact of diverse definitions and diagnostic instruments
on prevalence assessments (McGilloway et al. 2010; Tyrer et al. 2010).
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
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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 personality
disorders. The DSM-5 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
dimensional models have much in common and together appear to cover the important
areas of personality dysfunction. Their integration, clinical utility, and relationship with the
personality disorder diagnostic categories and various aspects of personality dysfunction
continue to be under active investigation. This includes research on whether the
dimensional model can clarify the cross-cultural prevalence variations seen with the
categorical model (Alarcón et al. 1998; McGilloway et al. 2010; Tyrer et al. 2010).
References: Dimensional Models for Personality Disorders
Alarcón RD, Foulks EF, Vakkur M: Personality Disorders and Culture: Clinical and
Conceptual Interactions. New York, Wiley, 1998
Huang Y, Kotov R, de Girolamo G, et al: DSM-IV personality disorders in the WHO World
Mental Health Surveys. Br J Psychiatry 195(1):46–53, 2009
McGilloway A, Hall RE, Lee T, Bhui KS: A systematic review of personality disorder, race
and ethnicity: prevalence, aetiology and treatment. BMC Psychiatry 10:33, 2010
Morgan TA, Zimmerman M: Epidemiology of personality disorders, in Handbook of
Personality Disorders: Theory, Research, and Treatment, 2nd Edition. Edited by Livesley
WJ, Larstone R. New York, Guilford, 2018, pp 173–196
Tyrer P, Mulder R, Crawford M, et al: Personality disorder: a new global perspective.
World Psychiatry 9(1):56–60, 2010
General Personality Disorder
Criteria
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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 response).
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, occupational, or other important areas of functioning.
D. The pattern is stable and of 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
another 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
environment 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 functional
impairment or subjective distress do they constitute personality disorders. The essential
feature of a personality disorder is an enduring pattern of inner experience and behavior
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that deviates markedly from the norms and expectations of the individual’s culture and is
manifested in at least two of the following areas: cognition, affectivity, interpersonal
functioning, or impulse 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 distress or impairment in social, occupational, or other important
areas of functioning (Criterion 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 attributable 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 distinguished
from characteristics that emerge in response to specific situational stressors or more
transient mental states (e.g., bipolar, depressive, or anxiety disorders; substance
intoxication). 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
interview 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,
supplementary information from other informants may be helpful.
Development 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).
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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
developmental stage or attributable to another mental disorder. It should be recognized
that the traits of a personality 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 features must have been present for at least 1 year. The one
exception to this is antisocial personality disorder, which cannot be diagnosed in
individuals younger than 18 years. Although, 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 personality 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 development 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 medical condition or an unrecognized substance use
disorder.
Culture-Related Diagnostic Issues
Core aspects of personality like emotion regulation and interpersonal functioning are
influenced by culture, which also provides means of protection and assimilation and norms
for acceptance and denunciation of specific behaviors and personality traits (Ronningstam
et al. 2018). Judgments about personality functioning must take into account the
individual’s ethnic, cultural, and social background. Personality disorders should not be
confused with problems associated with acculturation following migration or with the
expression of habits, customs, or religious and political values based on the individual’s
cultural background or context. Behavioral patterns that appear to be rigid and
dysfunctional aspects of personality disorder may reflect instead adaptive responses to
cultural constraints (Balaratnasingam and Janca 2017; Fang et al. 2016; Ronningstam et al.
2018; Ryder et al. 2014). For example, reliance on an abusive relationship in a small
community where divorce is proscribed may not reflect pathological dependence;
conscientious political protest that puts friends and family members at risk with authorities
or in conflict with legal norms does not necessarily reflect pathological callousness (Ryder
et al. 2014). There are marked variations in the recognition and diagnosis of personality
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disorders across cultural, ethnic, and racialized groups (Alarcón et al. 1998; McGilloway et
al. 2010; Tyrer et al. 2010). Accuracy of diagnosis can be enhanced by attention to
culturally patterned conceptions of self and attachment, assessment biases resulting from
clinicians’ own cultural backgrounds or use of diagnostic instruments that are not normed
to the population being assessed, and the impact of social determinants such as poverty,
acculturative stress, racism, and discrimination on feelings, cognitions, and
behaviors (Iacovino et al. 2014; Raza et al. 2014; Ryder et al. 2014). It is useful for the
clinician, especially when evaluating someone from a different background, to obtain
additional information from informants who are familiar with the person’s cultural
background.
Sex- and Gender-Related Diagnostic Issues
Certain personality disorders (e.g., antisocial personality disorder) are diagnosed more
frequently in men. Others (e.g., borderline, histrionic, and dependent personality
disorders) are diagnosed more frequently in women; however, in the case of borderline
personality disorder, this may be due to higher help-seeking among women. Nonetheless,
clinicians must be cautious not to overdiagnose or underdiagnose certain personality
disorders in women or in men because of social stereotypes about typical gender roles and
behaviors. There is currently insufficient evidence on differences between cis- and
transgender individuals with respect to the epidemiology or clinical presentations of
personality disorders to draw meaningful conclusions.
Differential Diagnosis
Other mental disorders and personality traits
Many of the specific criteria for the personality 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 the 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 persistent 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
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disorder with schizophrenia; avoidant personality disorder with social anxiety disorder)
based on phenomenological or biological 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 psychotic 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 psychotic 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 personality disorders during an episode of a
depressive disorder or an anxiety disorder, because these conditions may have cross-
sectional symptom features that mimic personality traits and may make 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 important not to make a personality
disorder diagnosis based solely on behaviors that are consequences of substance
intoxication or withdrawal or that are associated with activities in the service of sustaining
substance use (e.g., antisocial behavior).
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Personality change due to another medical condition
When enduring changes in personality 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.
References: General Personality Disorder
Alarcón RD, Foulks EF, Vakkur M: Personality Disorders and Culture: Clinical and
Conceptual Interactions. New York, Wiley, 1998
Balaratnasingam S, Janca A: Culture and personality disorder: a focus on indigenous
Australians. Curr Opin Psychiatry 30(1):31–35, 2017
Fang K, Friedlander M, Pieterse AL: Contributions of acculturation, enculturation,
discrimination, and personality traits to social anxiety among Chinese immigrants: a
context-specific assessment. Culture Divers Ethnic Minor Psychol 22(1):58–68, 2016
Iacovino JM, Jackson JJ, Oltmanns TF: The relative impact of socioeconomic status and
childhood trauma on Black-White differences in paranoid personality disorder symptoms.
J Abnorm Psychol 123(1):225–230, 2014
McGilloway A, Hall RE, Lee T, Bhui KS: A systematic review of personality disorder, race
and ethnicity: prevalence, aetiology and treatment. BMC Psychiatry 10:33, 2010
Raza GT, DeMarce JM, Lash SJ, Parker JD: Paranoid personality disorder in the United
States: the role of race, illicit drug use, and income. J Ethn Subst Abuse 13(3):247–257,
2014
Ronningstam EF, Keng S-L, Ridolfi ME et al. Cultural aspects in symptomatology,
assessment, and treatment of personality disorders. Curr Psychiatry Rep 20(4):22, 2018
29582187
Ryder AG, Dere J, Sun J, Chentsova-Dutton YE: The cultural shaping of personality
disorder, in APA Handbook of Multicultural Psychology. Edited by Leong FTL, Comas-
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(F60.0)
Diaz L, Hall GCN, et al. Washington, DC, American Psychological Association, 2014, pp
307–328
Tyrer P, Mulder R, Crawford M, et al: Personality disorder: a new global perspective.
World Psychiatry 9(1):56–60, 2010
Cluster A Personality Disorders
Paranoid Personality Disorder
Diagnostic Criteria
A. A pervasive distrust and suspiciousness of others such that their motives are
interpreted as malevolent, beginning by early adulthood and present in a variety
of contexts, 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 others and is quick to react angrily or to counterattack.
7. Has recurrent suspicions, without justification, regarding fidelity of spouse
or sexual partner.
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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 A1). 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
hostile intentions (Criterion A2). Any perceived deviation from trustworthiness or loyalty
serves to support their underlying assumptions. They are so amazed when a friend or
associate shows loyalty that they cannot trust or believe it. If they get into trouble, they
expect 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 disorder
may misinterpret an honest mistake by a store clerk as a deliberate attempt to shortchange,
or view a casual humorous remark by a coworker as a serious character attack.
Compliments are often misinterpreted (e.g., a compliment on a new acquisition is
misinterpreted as a criticism for selfishness; a compliment on an accomplishment is
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misinterpreted 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
fidelity of their spouse or partner.
Paranoid personality disorder should not be diagnosed if the pattern of behavior occurs
exclusively during the course of schizophrenia, a bipolar disorder or depressive disorder
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
Individuals with paranoid personality disorder are generally difficult to get along with and
often have problems with close relationships. Their excessive suspiciousness and hostility
may be expressed in overt argumentativeness, in recurrent complaining, or by hostile
aloofness. They 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 need to
have a high degree of control over those around them. They are often rigid, critical of
others, and unable to collaborate, although they have great difficulty accepting criticism
themselves. They may blame others for their own shortcomings. Because of their quickness
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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.
Prevalence
The estimated prevalence of paranoid personality based on a probability subsample from
Part II of the National Comorbidity Survey Replication was 2.3% (Lenzenweger et al.
2007). The prevalence of paranoid personality disorder in the National Epidemiologic
Survey on Alcohol and Related Conditions was 4.4% (Grant et al. 2004). A review of six
epidemiological studies (four in the United States) found a median prevalence of 3.2%
(Morgan and Zimmerman 2018). In forensic settings, the estimated prevalence may be as
high as 23% (Ullrich et al. 2008).
Development and Course
Paranoid personality disorder may be first apparent in childhood and adolescence with
solitariness, poor peer relationships, social anxiety, underachievement in school, and
interpersonal hypersensitivity. Adolescent onset of paranoid personality disorder is
associated with a prior history of childhood maltreatment, externalizing symptoms,
bullying of peers, and adult appearance of interpersonal aggression (Johnson et al. 2000;
Natsuaki et al. 2009).
Risk and Prognostic Factors
Environmental
Exposure to social stressors such as socioeconomic inequality, marginalization, and racism
is associated with decreased trust, which in some cases is adaptive. The combination of
social stress and childhood maltreatment accounts for the increased prevalence of paranoid
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symptoms in social groups facing racial discrimination (Iacovino et al. 2014). Both
longitudinal (Natsuaki et al. 2009) and cross-sectional studies confirm that childhood
trauma is a risk factor for paranoid personality disorder (Lee 2017).
Genetic and physiological
There is some evidence for an increased prevalence of paranoid personality disorder in
relatives of probands with schizophrenia and for a more specific familial relationship with
delusional disorder, persecutory type (Kendler et al. 1985).
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. Migrants, members of socially oppressed ethnic and racialized populations, and
other groups facing social adversity, racism, and discrimination may display guarded or
defensive behaviors because of unfamiliarity (e.g., language barriers or lack of knowledge of
rules and regulations) or in response to the neglect, hostility, or indifference of the majority
society (Iacovino et al. 2014; Raza et al. 2014). Some cultural groups develop low
generalized trust, especially of outgroup members, which may lead to behaviors that can be
misjudged as paranoid. These include guardedness, limited outward emotionality,
cognitive rigidity, social distance, and hostility or defensiveness in situations experienced
as unfair or discriminatory (Combs et al. 2002; Mosley et al. 2017; van der Linden 2017;
Van Hoorn 2015; Whaley 2004). These behaviors can, in turn, generate anger and
frustration in others, including clinicians, thus setting up a vicious cycle of mutual mistrust,
which should not be confused with paranoid traits or paranoid personality
disorder (Ahmed et al. 2017; Isbell et al. 2020).
Sex- and Gender-Related Diagnostic Issues
While paranoid personality disorder was found to be more common in men than in women
in a meta-analysis relying on clinical and community samples (Lynam and Widiger 2007),
the National Epidemiologic Survey on Alcohol and Related Conditions found it to be more
common in women (Grant et al. 2004).
Differential Diagnosis
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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 disorder 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 a direct physiological
consequence of another medical condition.
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 distinguished 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 personality disorder also includes symptoms such as
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magical thinking, unusual perceptual experiences, 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 associated with pervasive suspiciousness, and
borderline personality disorder exhibits higher levels of impulsivity and self-destructive
behavior. 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, maladaptive,
and persisting and cause significant functional impairment or subjective distress.
Comorbidity
Particularly in response to stress, individuals with this disorder may experience very brief
psychotic episodes (lasting minutes to hours). In some instances, paranoid personality
disorder may appear as the premorbid antecedent of delusional disorder or schizophrenia.
Individuals with paranoid personality disorder may develop major depressive disorder and
may be at increased risk for agoraphobia and obsessive-compulsive disorder. Alcohol and
other substance use disorders frequently occur. The most common co-occurring
personality disorders appear to be schizotypal, schizoid, narcissistic, avoidant, and
borderline.
References: Paranoid Personality Disorder
Ahmed S, Lee S, Shommu N, et al: Experiences of communication barriers between
physicians and immigrant patients: a systematic review and thematic synthesis. Patient
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Experience Journal 4:122–140, 2017
Combs DR, Penn DL, Fenigstein A: Ethnic differences in subclinical paranoia: an
expansion of norms of the Paranoia Scale. Cultur Divers Ethnic Minor Psychol 8(3):248–
256, 2002
Grant BF, Hasin DS, Stinson FS, et al: Prevalence, correlates, and disability of personality
disorders in the United States: results from the National Epidemiologic Survey on Alcohol
and Related Conditions. J Clin Psychiatry 65(7):948–958, 2004
Iacovino JM, Jackson JJ, Oltmanns TF: The relative impact of socioeconomic status and
childhood trauma on black-white differences in paranoid personality disorder symptoms.
J Abnorm Psychol 123(1):225–230, 2014
Isbell LM, Tager J, Beals K, Liu G: Emotionally evocative patients in the emergency
department: a mixed methods investigation of providers’ reported emotions and
implications for patient safety. BMJ Qual Saf 29(10):1–2, 2020
Johnson JP, Cohen E, Smailes S, et al: Adolescent personality disorders associated with
violence and criminal behavior during adolescence and early adulthood. Am J Psychiatry
157(9):1406–1412, 2000
Kendler KS, Masterson CC, Davis KL: Psychiatric illness in first-degree relatives of
patients with paranoid psychosis, schizophrenia and medical illness. Br J Psychiatry
147:524–531, 1985
Lee R: Mistrustful and misunderstood: a review of paranoid personality disorder. Curr
Behav Neurosci Rep 4:151–165, 2017
Lenzenweger MF, Lane MC, Loranger AW, Kessler RC: DSM-IV personality disorders in
the National Comorbidity Survey Replication. Biol Psychiatry 62(6):553–564, 2007
Lynam DR, Widiger TA: Using a general model of personality to understand sex
differences in the personality disorders. J Pers Disord 21(6):583–602, 2007 18072861
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(F60.1)
Morgan TA, Zimmerman M: Epidemiology of personality disorders, in Handbook of
Personality Disorders: Theory, Research, and Treatment, 2nd Edition. Edited by Livesley
WJ, Larstone R. New York, Guilford, 2018, pp 173–196
Mosley DV, Owen KH, Rostosky SS, Reese RJ: Contextualizing behaviors associated with
paranoia: perspectives of black men. Psychology of Men & Masculinity 18(2):165–175,
2017
Natsuaki MN, Cicchetti D, Rogosch FA: Examining the developmental history of child
maltreatment, peer relations, and externalizing problems among adolescents with
symptoms of paranoid personality disorder. Dev Psychopathol 21(4):1181–1193, 2009
Raza GT, DeMarce JM, Lash SJ, Parker JD: Paranoid personality disorder in the United
States: the role of race, illicit drug use, and income. J Ethn Subst Abuse 13(3):247–257,
2014
Ullrich S, Deasy D, Smith J, et al: Detecting personality disorders in the prison population
of England and Wales: comparing case identification using the SCID-II Screen and the
SCID-II Clinical Interview. Journal of Forensic Psychiatry & Psychology 19(3):301–322,
2008
van der Linden M, Hooghe M, de Vroome T, Van Laar C: Extending trust to immigrants:
generalized trust, cross-group friendship and anti-immigrant sentiments in 21 European
societies. PLoS One 12(5):e0177369, 2017
Van Hoorn A: Individualist–collectivist culture and trust radius: a multilevel approach.
Journal of Cross-Cultural Psychology 46(2):269–276, 2015
Whaley AL: Ethnicity/race, paranoia, and hospitalization for mental health problems
among men. Am J Public Health 94(1):78–81, 2004
Schizoid Personality Disorder
Diagnostic Criteria
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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. Takes 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., “schizoid 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 A1). They prefer
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spending time by themselves, rather than being with other people. They often appear to be
socially isolated or “loners” and almost always choose solitary activities or hobbies 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
sensory, 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
often do not respond appropriately to social cues so that they seem socially inept or
superficial 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 (Criterion 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
comfortable 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
psychotic features, another psychotic disorder, or autism spectrum 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
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
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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.
Prevalence
Schizoid personality disorder is uncommon in clinical settings. The estimated prevalence of
schizoid personality disorder based on a probability subsample from Part II of the National
Comorbidity Survey Replication was 4.9% (Lenzenweger et al. 2007). The prevalence of
schizoid personality disorder in the National Epidemiologic Survey on Alcohol and Related
Conditions was 3.1% (Grant et al. 2004). A review of six epidemiological studies (four in
the United States) found a median prevalence of 1.3% (Morgan and Zimmerman 2018).
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 prevalence 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 interpersonal 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
sometimes mistakenly perceived as cold, hostile, or indifferent, which may be a response to
social ostracism from the host society.
Sex- and Gender-Related Diagnostic Issues
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While some research suggests that schizoid personality disorder may be more common in
men (Furnham and Trickey 2011), other research suggests that there is no gender
difference in prevalence (Grant et al. 2004; Lenzenweger et al. 2007).
Differential Diagnosis
Other mental disorders with psychotic symptoms
Schizoid 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 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., schizophrenia) 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 individuals with autism spectrum disorder, particularly with milder forms of either
disorder, as both include a seeming indifference to companionship with others (Gadow
2013; Hopwood and Thomas 2012). However, autism spectrum disorder may be
differentiated by 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 a direct physiological
consequence of another medical condition.
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
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Other personality disorders may be confused with schizoid 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 schizoid personality disorder, all can be diagnosed. Although characteristics
of social isolation and restricted affectivity 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 personality 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 devotion to work and discomfort with
emotions, but they do have an underlying capacity for intimacy.
Individuals who are “loners” or quite introverted may display personality traits that might
be considered schizoid, consistent with the broader conceptualization of schizoid
personality disorder as a disorder defined by pathological
introversion/detachment (Samuel and Widiger 2008). Only when these traits are inflexible
and maladaptive and cause significant functional impairment or subjective distress do they
constitute schizoid personality disorder.
Comorbidity
Particularly in response to stress, individuals with this disorder may experience very brief
psychotic episodes (lasting minutes to hours). In some instances, schizoid personality
disorder may appear as the premorbid antecedent of delusional disorder or schizophrenia.
Individuals with this disorder may sometimes develop major depressive disorder. Schizoid
personality disorder most often co-occurs with schizotypal, paranoid, and avoidant
personality disorders.
References: Schizoid Personality Disorder
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(F21)
Furnham A, Trickey G: Sex differences in the dark side traits. Personality and Individual
Differences 50(4):517–522, 2011
Gadow KD: Association of schizophrenia spectrum disorder and autism spectrum
disorder (ASD) symptoms in children with ASD and clinical controls. Res Dev Disabil
34(4):1289–1299, 2013
Grant BF, Hasin DS, Stinson FS, et al: Prevalence, correlates, and disability of personality
disorders in the United States: results from the National Epidemiologic Survey on Alcohol
and Related Conditions. J Clin Psychiatry 65(7):948–958, 2004
Hopwood CJ, Thomas KM: Paranoid and schizoid personality disorders, in The Oxford
Handbook of Personality Disorders. Edited by Widiger TA. New York, Oxford University
Press, 2012, pp 582–602
Lenzenweger MF, Lane MC, Loranger AW, Kessler RC: DSM-IV personality disorders in
the National Comorbidity Survey Replication. Biol Psychiatry 62(6):553–564, 2007
Morgan TA, Zimmerman M: Epidemiology of personality disorders, in Handbook of
Personality Disorders: Theory, Research, and Treatment, 2nd Edition. Edited by Livesley
WJ, Larstone R. New York, Guilford, 2018, pp 173–196
Samuel DB, Widiger TA: A meta-analytic review of the relationships between the five-
factor model and DSM-IV-TR personality disorders: a facet level analysis. Clin Psychol
Rev 28(8):1326–1342, 2008
Schizotypal Personality Disorder
Diagnostic Criteria
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:
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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 associated 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.,
“schizotypal 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 behavior.
This pattern begins by early adulthood and is present in a variety of contexts.
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Individuals with schizotypal personality disorder often have ideas of reference (i.e.,
incorrect interpretations of casual incidents and external events as having a particular and
unusual meaning specifically for the person) (Criterion A1). These should be distinguished
from delusions of reference, in which the beliefs are held with delusional conviction. 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 thinking an
hour earlier it should be done) or indirectly through compliance with magical rituals (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 hearing a voice
murmuring their name) (Criterion A3). Their speech may include unusual or idiosyncratic
phrasing and construction. It is often loose, digressive, or vague, but without actual
derailment or incoherence (Criterion A4). Responses can be either overly concrete 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
individuals 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 relatedness 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 confidants
other than a first-degree relative (Criterion A8). They are anxious in social situations,
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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 their 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 occurs
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
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.
Prevalence
The estimated prevalence of schizotypal personality disorder based on a probability
subsample from Part II of the National Comorbidity Survey Replication was 3.3%
(Lenzenweger et al. 2007).The prevalence of schizotypal personality disorder in the
National Epidemiologic Survey on Alcohol and Related Conditions data was 3.9% (Pulay et
al. 2009). A review of five epidemiological studies (three in the United States) found a
median prevalence of 0.6% (Morgan and Zimmerman 2018).
Development and Course
Schizotypal personality disorder has a relatively stable course, with only a small proportion
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, hypersensitivity,
peculiar thoughts and language, and bizarre fantasies. These children may appear “odd” or
“eccentric” and attract teasing.
Risk and Prognostic Factors
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Genetic and physiological
Schizotypal personality disorder appears to aggregate familially 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 increase in schizophrenia and other
psychotic disorders in the relatives of probands with schizotypal personality disorder. Twin
studies indicate highly stable genetic factors and rather transient environmental factors for
an increased risk for the schizotypal syndrome (Kendler et al. 2015), and genetic risk
variants for schizophrenia may be linked to schizotypal personality disorder (e.g.,
Hodgkinson et al. 2004; Nyegaard et al. 2010). Neuroimaging studies detect group-level
differences in the size and function of specific brain regions in individuals with schizotypal
personality disorder in comparison with healthy persons, individuals with schizophrenia,
and individuals with other personality disorders (e.g., Fervaha and Remington 2013; Rosell
et al. 2014).
Culture-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
regarding supernatural and religious beliefs and practices (life beyond death, speaking in
tongues, voodoo, shamanism, mind reading, sixth sense, evil eye, magical beliefs related to
health and illness), can appear to be schizotypal to the uninformed clinician. Thus,
observed cross-national and cross-ethnic variations in the prevalence and expression of
schizotypal traits may be a true epidemiological finding or one due to differences in the
cultural acceptance of these experiences (Fonseca-Pedrero et al. 2018; Pulay et al. 2009).
Sex- and Gender-Related Diagnostic Issues
Schizotypal personality disorder appears to be slightly more common in men than in
women (Furnham and Trickey 2011; Pulay et al. 2009).
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
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disorders are all characterized by a period of persistent psychotic symptoms (e.g., delusions
and hallucinations). To give an additional 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 personality 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 children whose behavior is characterized by
marked social isolation, eccentricity, or peculiarities 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 characteristic features of impaired
language found in a specialized language assessment. Milder forms of autism spectrum
disorder are differentiated by the even greater lack of social awareness and emotional
reciprocity and stereotyped behaviors and interests.
Personality change due to another medical condition
Schizotypal personality disorder must be distinguished from personality change due to
another medical condition, in which the traits that emerge are a direct physiological
consequence of another medical condition.
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 differences in their characteristic features. However, if an
individual has personality features that meet criteria for one or more personality disorders
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in addition to schizotypal personality disorder, all can be diagnosed. Although paranoid
and schizoid personality disorders 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 relationships are limited in both schizotypal personality disorder and
avoidant personality disorder; 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 having 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 symptoms that may worsen under stress but are less likely to be
invariably associated with pronounced 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 desire for intimacy. Furthermore, individuals with
schizotypal personality disorder do not usually demonstrate the impulsive or manipulative
behaviors of the individual with borderline 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 enduring personality disorder.
Comorbidity
Particularly in response to stress, individuals with this disorder may experience transient
psychotic episodes (lasting minutes to hours), although they usually are insufficient in
duration to warrant an additional diagnosis such as brief psychotic disorder or
schizophreniform disorder. In some cases, clinically significant psychotic symptoms may
develop that meet criteria for brief psychotic disorder, schizophreniform disorder,
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delusional disorder, or schizophrenia. There is considerable co-occurrence with schizoid,
paranoid, avoidant, and borderline personality disorders.
References: Schizotypal Personality Disorder
Fervaha G, Remington G: Neuroimaging findings in schizotypal personality disorder: a
systematic review. Prog Neuropsychopharmacol Biol Psychiatry 43:96–107, 2013
Fonseca-Pedrero E, Chan RCK, Debbané M, et al: Comparisons of schizotypal traits across
12 countries: results from the International Consortium for Schizotypy Research.
Schizophr Res 199:128–134, 2018
Furnham A, Trickey G: Sex differences in the dark side traits. Personality and Individual
Differences 50(4):517–522, 2011
Hodgkinson CA, Goldman D, Jaeger J, et al: Disrupted in schizophrenia 1 (DISC1):
association with schizophrenia, schizoaffective disorder, and bipolar disorder. Am J Hum
Genet 75(5):862–872, 2004
Kendler KS, Aggen SH, Neale MC, et al: A longitudinal twin study of cluster A personality
disorders. Psychol Med 45(7):1531–1538, 2015
Lenzenweger MF, Lane MC, Loranger AW, Kessler RC: DSM-IV personality disorders in
the National Comorbidity Survey Replication. Biol Psychiatry 62(6):553–564, 2007
Morgan TA, Zimmerman M: Epidemiology of personality disorders, in Handbook of
Personality Disorders: Theory, Research, and Treatment, 2nd Edition. Edited by Livesley
WJ, Larstone R. New York, Guilford, 2018, pp 173–196
Nyegaard M, Demontis D, Foldager L, et al: CACNA1C (rs1006737) is associated with
schizophrenia. Mol Psychiatry 15(2):119–121, 2010
Pulay AJ, Stinson FS, Dawson DA, et al: Prevalence, correlates, disability, and
comorbidity of DSM-IV schizotypal personality disorder: results from the wave 2 national
epidemiologic survey on alcohol and related conditions. Prim Care Companion J Clin
Psychiatry 11(2):53–67, 2009
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(F60.2)
Rosell DR, Futterman SE, McMaster A, Siever LJ: Schizotypal personality disorder: a
current review. Curr Psychiatry Rep 16(7):452, 2014
Cluster B Personality Disorders
Antisocial Personality Disorder
Diagnostic Criteria
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
schizophrenia or bipolar disorder.
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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 antisocial 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 evidence of conduct disorder with onset 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 violated. The specific
behaviors characteristic of conduct disorder fall into one of four categories: 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 antisocial
personality disorder fail to conform to social norms with respect to lawful behavior
(Criterion A1). They may repeatedly perform acts that are grounds for arrest (whether they
are arrested or not), such as destroying property, harassing others, stealing, or pursuing
illegal occupations. Persons with this disorder disregard the wishes, rights, or feelings 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 repeatedly 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 antisocial
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
beating) (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
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evidenced in their driving behavior (i.e., recurrent speeding, driving while intoxicated,
multiple accidents). They may engage in sexual behavior or substance use that has a high
risk for harmful 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 extremely
irresponsible (Criterion A6). Irresponsible work behavior may be indicated by significant
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,
failing to provide child support, or failing to support other dependents on a regular basis.
Individuals with antisocial personality disorder show little remorse for the consequences of
their acts (Criterion A7). They may be indifferent to, or provide a superficial rationalization
for, having hurt, mistreated, or stolen from someone (e.g., “life’s unfair,” “losers deserve 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
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. Some antisocial individuals 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 traditional conceptions of psychopathy that may be particularly
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distinguishing of the disorder and more predictive of recidivism in prison or forensic
settings, where criminal, delinquent, or aggressive acts are likely to be nonspecific. These
individuals may also be irresponsible 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 resulting from a lack 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 services, 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 individuals in the general
population to die prematurely from natural causes and suicide (Krasnova et al. 2019).
Prevalence
The estimated prevalence of antisocial personality disorder based on a probability
subsample from Part II of the National Comorbidity Survey Replication was 0.6%
(Lenzenweger et al. 2007).The prevalence of antisocial personality disorder in the National
Epidemiologic Survey on Alcohol and Related Conditions data was 3.6% (Grant et al.
2004). A review of seven epidemiological studies (six in the United States) found a median
prevalence of 3.6% (Morgan and Zimmerman 2018). The highest prevalence of antisocial
personality disorder (greater than 70%) is among samples of men with the most severe
alcohol use disorders (Bucholz et al. 2000) and from substance abuse clinics, prisons, or
other forensic settings (Moran et al. 1999). Lifetime prevalence appears to be similar across
non-Latinx White and Black individuals and lower in Latinx and Asian
Americans (Goldstein et al. 2017). Prevalence may be higher in sam ples 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, often by age 40 (Black 2015). Although this remission tends
to be particularly evident with respect to engaging in criminal behavior, there is likely to be
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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
Environmental
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.
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. Biological relatives of individuals
with this disorder are also at increased risk for somatization disorder (a diagnosis that was
replaced in DSM-5 with 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 females more often
have somatization disorder (Javdani et al. 2011).
Culture-Related Diagnostic Issues
Antisocial personality disorder has been associated with low socioeconomic status and
urban settings. The diagnosis may at times be misapplied to individuals in settings in which
seemingly antisocial behavior may be part of a protective survival strategy (e.g., formation
of youth gangs in urban areas with high rates of violence and discrimination). Sociocultural
contexts with high rates of child maltreatment or exposure to violence also tend to have
elevated prevalence of antisocial behaviors, suggesting either a potential risk factor for the
development of antisocial personality disorder or an adverse environment that evokes
reactive and contextual antisocial behaviors that do not represent pervasive and enduring
traits consistent with a personality disorder (Jervis et al. 2014; Kounou et al. 2015; Liu et
al. 2012). In assessing antisocial traits, it is helpful for the clinician to consider the social
and economic context in which the behaviors occur. In the National Epidemiologic Survey
on Alcohol and Related Conditions, prevalence appears to vary across U.S. ethnic and
racialized groups, possibly because of a combination of true prevalence differences,
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measurement artifacts, and the impact of adverse environments that generate behaviors
that resemble those of antisocial personality disorder but are instead reactive and
contextual (Goldstein et al. 2017). Individuals from some socially oppressed groups may be
at higher risk for misdiagnosis or overdiagnosis of antisocial personality disorder because
they are more likely to be misdiagnosed with conduct disorder in adolescence (Baglivio et
al. 2017; Caldwell et al. 2016; Fadus et al. 2020; Mandell et al. 2007; Rousseau et al. 2008),
which is a requirement for a diagnosis of antisocial personality disorder.
Sex- and Gender-Related Diagnostic Issues
Antisocial personality disorder is three times as common in men than in women (Compton
et al. 2005). Women with antisocial personality disorder are more likely to have
experienced childhood and adult adverse experiences such as sexual abuse compared with
men (Alegria et al. 2013). Clinical presentation may vary, with men more often presenting
with irritability/aggression and reckless disregard for the safety of others compared with
women (Alegria et al. 2013). Comorbid substance use disorders are more common in men,
while comorbid mood and anxiety disorders are more common in women (Alegria et al.
2013).There has been some concern that antisocial personality disorder may be
underdiagnosed in females, particularly because of the emphasis on aggressive items in the
definition of conduct disorder (Alegria et al. 2013; Paris et al. 2013).
Differential Diagnosis
The diagnosis of antisocial personality disorder is not given to individuals younger than 18
years and is given only if there is evidence of conduct disorder before 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 continued 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
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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 during 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 antisocial 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
antisocial personality disorder, all can be diagnosed. Individuals with antisocial personality
disorder and narcissistic personality disorder 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 personality 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 antisocial 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 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.
Criminal behavior not associated with a mental disorder
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Antisocial personality disorder must be distinguished from antisocial behavior not due to a
mental disorder, for example, criminal behavior undertaken for gain that is not
accompanied by the personality features characteristic of this disorder. In these cases, the
condition adult antisocial behavior may be coded (see “Other Conditions That May Be a
Focus of Clinical Attention”).
Comorbidity
Individuals with antisocial personality disorder may also experience dysphoria, including
complaints of tension, inability to tolerate boredom, and depressed mood. They may have
associated anxiety disorders, mood disorders, substance use disorders, somatic symptom
disorder, and gambling disorder. Individuals with antisocial personality disorder also often
have personality features that meet criteria for other personality disorders, particularly
borderline, histrionic, and narcissistic personality disorders. The likelihood of developing
antisocial personality disorder in adult life is increased if the individual experienced
childhood onset of conduct disorder (before age 10 years) and accompanying attention-
deficit/hyperactivity disorder.
References: Antisocial Personality Disorder
Alegria AA, Blanco C, Petry NM, et al: Sex differences in antisocial personality disorder:
results from the National Epidemiological Survey on Alcohol and Related Conditions.
Personal Disord 4(3):214–222, 2013
Baglivio MT, Wolff KT, Piquero AR, et al: Racial/ethnic disproportionality in psychiatric
diagnoses and treatment in a sample of serious juvenile offenders. J Youth Adolesc
46(7):1424–1451, 2017
Black DW: The natural history of antisocial personality disorder. Can J Psychiatry
60(7):309–314, 2015
Bucholz KK, Hesselbrock VM, Heath AC, et al: A latent class analysis of antisocial
personality disorder symptom data from a multi-centre family study of alcoholism.
Addiction 95(4):553–567, 2000
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Caldwell CH, Assari S, Breland-Noble AM: The epidemiology of mental disorders in
African American children and adolescents, in Handbook of Mental Health in African
American Youth. Edited by Breland-Noble AM, Al-Mateen CS, Singh NN. Cham,
Switzerland, Springer, 2016, pp 3–20
Compton WM, Conway KP, Stinson FS, et al: Prevalence, correlates, and comorbidity of
DSM-IV antisocial personality syndromes and alcohol and specific drug use disorders in
the United States: results from the National Epidemiologic Survey on Alcohol and Related
Conditions. J Clin Psychiatry 66(6):677–685, 2005
Fadus MC, Ginsburg KR, Sobowale K, et al: Unconscious bias and the diagnosis of
disruptive behavior disorders and ADHD in African American and Hispanic youth. Acad
Psychiatry 44(1):95–102, 2020
Goldstein RB, Chou SP, Saha TD, et al: The epidemiology of antisocial behavioral
syndromes in adulthood: results from the National Epidemiologic Survey on Alcohol and
Related Conditions–III. J Clin Psychiatry 78(1):90–98, 2017
Grant BF, Stinson FS, Dawson DA, et al: Co-occurrence of 12-month alcohol and drug use
disorders and personality disorders in the United States: results from the National
Epidemiologic Survey on Alcohol and Related Conditions. Arch Gen Psychiatry
61(4):361–368, 2004
Javdani S, Sadeh N, Verona E: Expanding our lens: female pathways to antisocial
behavior in adolescence and adulthood. Clin Psychol Rev 31(8):1324–1348, 2011
Jervis LL, Spicer P, Belcourt A, et al: The social construction of violence among Northern
Plains tribal members with antisocial personality disorder and alcohol use disorder.
Transcult Psychiatry 51(1):23–46, 2014
Kounou KB, Dogbe Foli AA, Djassoa G, et al: Childhood maltreatment and personality
disorders in patients with a major depressive disorder: a comparative study between
France and Togo. Transcult Psychiatry 52(5):681–699, 2015
Krasnova A, Eaton WW, Samuels JF: Antisocial personality and risks of cause-specific
mortality: results from the Epidemiologic Catchment Area study with 27 years of follow-
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(F60.3)
up. Soc Psychiatry Psychiatr Epidemiol 54(5):617–625, 2019
Lenzenweger MF, Lane MC, Loranger AW, Kessler RC: DSM-IV personality disorders in
the National Comorbidity Survey Replication. Biol Psychiatry 62(6):553–564, 2007
Liu N, Zhang Y, Brady HJ, et al: Relation between childhood maltreatment and severe
intrafamilial male-perpetrated physical violence in Chinese community: the mediating
role of borderline and antisocial personality disorder features. Aggress Behav 38(1):64–
76, 2012
Mandell DS, Ittenbach RF, Levy SE, Pinto-Martin JA: Disparities in diagnoses received
prior to a diagnosis of autism spectrum disorder. J Autism Dev Disord 37(9):1795–1802,
2007 17160456
Moran P: The epidemiology of antisocial personality disorder. Soc Psychiatry Psychiatr
Epidemiol 34(5):231–242, 1999
Morgan TA, Zimmerman M: Epidemiology of personality disorders, in Handbook of
Personality Disorders: Theory, Research, and Treatment, 2nd Edition. Edited by Livesley
WJ, Larstone R. New York, Guilford, 2018, pp 173–196
Paris J, Chenard-Poirier M-P, Biskin R: Antisocial and borderline personality disorders
revisited. Compr Psychiatry 54(4):321–325, 2013
Rousseau C, Hassan G, Measham T, Lashley M: Prevalence and correlates of conduct
disorder and problem behavior in Caribbean and Filipino immigrant adolescents. Eur
Child Adolesc Psychiatry 17(5):264–273, 2008
Borderline Personality Disorder
Diagnostic Criteria
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:
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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
alternating 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 experience intense abandonment fears and inappropriate anger even
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when faced with a realistic 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 someone 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 related 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 suicidal behaviors, which are described separately in
Criterion 5 (see also “Association With Suicidal Thoughts or Behavior”).
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 unstable
self-image or sense of self (Criterion 3). There are sudden and dramatic shifts in self-image
(e.g., suddenly changing 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 the
feeling of being bad or evil, individuals with this disorder may at times have feelings that
they do not exist at all. This can be both painful and frightening to those with this disorder.
Such experiences usually occur in situations in which the individual feels a lack of a
meaningful relationship, nurturing, and support. These individuals may show worse
performance in unstructured work or school situations. This lack of a full and enduring
identity makes it difficult for the individual with borderline personality disorder to identify
maladaptive patterns of behavior and can lead to repetitive patterns of troubled
relationships.
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Individuals with borderline personality disorder display impulsivity in at least two areas
that are potentially self-damaging (Criterion 4). They may gamble, spend money
irresponsibly, binge eat, abuse substances, engage in unsafe sex, or drive recklessly.
Individuals with this disorder display recurrent suicidal behavior, gestures, or threats, or
self-mutilating behavior (Criterion 5). Recurrent suicidal thoughts or behavior are 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
assume increased responsibility. Self-mutilative acts (e.g., cutting or burning) are very
common and may occur during periods in which the individual is experiencing dissociative
symptoms. These acts often bring relief by reaffirming the individual’s 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 anxiety
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 satisfaction.
These episodes may reflect the individual’s extreme reactivity to interpersonal stresses.
Individuals with borderline personality disorder may be troubled by chronic feelings of
emptiness, which can co-occur with painful feelings of aloneness (Criterion 7). Easily
bored, they may frequently seek excitement to avoid their feelings of emptiness.
Individuals with this disorder frequently express inappropriate, intense anger or have
difficulty 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., depersonalization) may occur (Criterion 9), but these are generally of insufficient
severity or duration to warrant an additional diagnosis. These episodes occur most
frequently in response to a real or imagined abandonment. Symptoms tend to be transient,
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lasting minutes or hours. The real or perceived return of the caregiver’s nurturance may
result in a remission of symptoms.
Associated Features
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;
destroying a good relationship just when it is clear that the relationship could last). Some
individuals 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 individuals
with borderline personality disorder, especially in those with co-occurring depressive
disorders or substance use disorders. However, deaths from other causes. such as accidents
or illness, are more than twice as common as deaths by suicide in individuals with
borderline personality disorder (Temes et al. 2019). Physical handicaps may result from
self-inflicted abuse behaviors or failed suicide attempts. Recurrent job losses, interrupted
education, and separation or divorce 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 disorder.
Prevalence
The estimated prevalence of borderline personality disorder based on a probability
subsample from Part II of the National Comorbidity Survey Replication was 1.4%
(Lenzenweger et al. 2007). The prevalence of borderline personality disorder in the
National Epidemiologic Survey on Alcohol and Related Conditions data was 5.9% (Grant et
al. 2008). A review of seven epidemiological studies (six in the United States) found a
median prevalence of 2.7% (Morgan and Zimmerman 2018). The prevalence of borderline
personality disorder is about 6% in primary care settings (Gross et al. 2002), about 10%
among individuals seen in outpatient mental health clinics, and about 20% among
psychiatric inpatients (Widiger and Frances 1989; Zimmerman et al. 2017).
Development and Course
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Borderline personality disorder has typically been thought of as an adult-onset disorder.
However, it has been found in treatment settings that symptoms in adolescents as young as
age 12 or 13 years can meet full criteria for the disorder (Ha et al. 2014; Kaess et al. 2013;
Zanarini et al. 2017). It is not yet known what percentage of adults first entering treatment
actually have such an early onset of borderline personality disorder.
Borderline personality disorder has long been thought of as a disorder with a poor
symptomatic course, which tended to lessen in severity as those with borderline personality
disorder entered their 30s and 40s. However, prospective follow-up studies have found
that stable remissions of 1–8 years are very common (Gunderson et al. 2011; Zanarini et al.
2012). Impulsive symptoms of borderline personality disorder remit the most rapidly,
while affective symptoms remit at a substantially slower rate (Zanarini et al. 2016). In
contrast, recovery from borderline personality disorder (i.e., concurrent symptomatic
remission and good psychosocial functioning) is more difficult to achieve and less stable
over time (Zanarini et al. 2012). Lack of recovery is associated with supporting oneself on
disability benefits and suffering from poor physical health (Keuroghlian et al. 2013).
Risk and Prognostic Factors
Environmental
Borderline personality disorder has also been found to be associated with high rates of
various forms of reported childhood abuse and emotional neglect (Zanarini et al. 1997).
However, reported rates of sexual abuse are higher in inpatients than in outpatients with
this disorder, suggesting that a history of sexual abuse is as much a risk factor for severity
of borderline psychopathology as it is for the disorder itself. In addition, an empirically
based consensus has arisen that suggests that a childhood history of reported sexual abuse
is neither necessary nor sufficient for the development of borderline personality disorder.
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 general population. There is also
an increased familial risk for substance use disorders, anxiety disorders, antisocial
personality disorder, and depressive or bipolar disorders.
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Culture-Related Diagnostic Issues
The pattern of behavior seen in borderline personality disorder has been identified in many
settings around the world. Sociocultural contexts characterized by social demands that
evoke attempts at self-affirmation and acceptance by others, ambiguous or conflictual
relationships with authority figures, or marked uncertainties in adaptation can foster
impulsivity, emotional instability, explosive or aggressive behaviors, and dissociative
experiences that are associated with borderline personality disorder or with transient and
contextual reactions to those environments that can be confused with borderline
personality disorder (Narayanan and Rao 2018; Paris and Lis 2013). Given that
psychodynamic, cognitive, behavioral, and mindfulness aspects of models of mind and self
vary cross-culturally (Hsu and Tseng 1969; Tseng 2001), symptoms or traits that suggest
the presence of borderline personality disorder (e.g., number of sexual partners, shifting
between relationships, substance use) (Narayanan and Rao 2018; Wang et al. 2012) must
be evaluated in light of cultural norms to make a valid diagnosis.
Sex- and Gender-Related Diagnostic Issues
While borderline personality disorder is more common among women than men in clinical
samples, community samples demonstrate no difference in prevalence between men and
women (Bayes and Parker 2017; Grant et al. 2008). This discrepancy may reflect a higher
degree of help-seeking among women, leading them to clinical settings. Clinical
characteristics of men and women with borderline personality disorder appear to be
similar, with potentially a higher degree of externalizing behaviors in boys and men and
internalizing behaviors in girls and women (Bayes and Parker 2017).
Association With Suicidal Thoughts or Behavior
ln a longitudinal study, impulsive and antisocial behaviors of individuals with borderline
personality disorder were associated with increased suicide risk (Soloff and Chiappetta
2012). In a sample of hospitalized patients with borderline personality disorder followed
prospectively for 24 years, around 6% died by suicide, compared with 1.4% in a comparison
sample of individuals with personality disorders other than borderline personality
disorder (Temes et al. 2019). A study of individuals with borderline personality disorder
followed for 10 years found that recurrent suicidal behavior was a defining characteristic of
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borderline personality disorder, associated with declining rates of suicide attempts from
79% to 13% over time (Zanarini et al. 2008).
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 should 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 additional diagnosis of
borderline personality disorder based only on cross-sectional presentation without having
documented that the pattern of behavior had an early onset and a long-standing course.
Separation anxiety disorder in adults
Separation anxiety disorder and borderline personality disorder are characterized by fear of
abandonment by loved ones, but problems in identity, self-direction, interpersonal
functioning, and impulsivity are additionally central to borderline personality disorder.
Other personality disorders
Other personality disorders may be confused with borderline 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
borderline personality disorder, all can be diagnosed. Although histrionic personality
disorder can also be characterized by attention seeking, 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 present in both borderline personality
disorder and schizotypal personality disorder, but these symptoms are more transient,
interpersonally reactive, and responsive to external structuring in borderline personality
disorder. Although paranoid personality disorder and narcissistic 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 physical self-destructiveness, repetitive impulsivity,
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and profound abandonment concerns, distinguishes these disorders from borderline
personality 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 concern of caretakers. 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
emptiness, rage, and demands, 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 disorder must be distinguished from personality change due to
another medical condition, in which the traits that emerge are a direct physiological
consequence of another medical condition.
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. 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, conflicts about sexual orientation, and competing social pressures to
decide on careers.
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Comorbidity
Common co-occurring disorders include depressive and bipolar disorders, substance use
disorders, anxiety disorders (particularly panic disorder and social anxiety disorder)
(McGlashan et al. 2000; Zanarini et al. 2004), eating disorders (notably bulimia nervosa
and binge-eating disorder) (Zanarini et al. 2010), posttraumatic stress disorder, and
attention-deficit/hyperactivity disorder. Borderline personality disorder also frequently co-
occurs with the other personality disorders.
References: Borderline Personality Disorder
Bayes A, Parker G: Borderline personality disorder in men: a literature review and
illustrative case vignettes. Psychiatry Res 257:197–202, 2017
Grant BF, Chou SP, Goldstein RB, et al: Prevalence, correlates, disability, and comorbidity
of DSM-IV borderline personality disorder: results from the Wave 2 National
Epidemiologic Survey on Alcohol and Related Conditions. J Clin Psychiatry 69(4):533–
545, 2008
Gross R, Olfson M, Gameroff M, et al: Borderline personality disorder in primary care.
Arch Intern Med 162(1):53–60, 2002
Gunderson JG, Stout RL, McGlashan TH, et al: Ten-year course of borderline personality
disorder: psychopathology and function from the Collaborative Longitudinal Personality
Disorders study. Arch Gen Psychiatry 68(8):827–837, 2011
Ha C, Balderas JC, Zanarini MC, et al: Psychiatric comorbidity in hospitalized adolescents
with borderline personality disorder. J Clin Psychiatry 75(5):e457–464, 2014
Hsu J, Tseng WS: Chinese culture, personality formation and mental illness. Int J Soc
Psychiatry 16(1):5–14, 1969
Kaess M, von Ceumern-Lindenstjerna IA, Parzer P, et al: Axis I and II comorbidity and
psychosocial functioning in female adolescents with borderline personality disorder.
Psychopathology 46(1):55–62, 2013
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Keuroghlian AS, Frankenburg FR, Zanarini MC: The relationship of chronic medical
illnesses, poor health-related lifestyle choices, and health care utilization to recovery
status in borderline patients over a decade of prospective follow-up. J Psychiatr Res
47:1499–1506, 2013
Lenzenweger MF, Lane MC, Loranger AW, Kessler RC: DSM-IV personality disorders in
the National Comorbidity Survey Replication. Biol Psychiatry 62(6):553–564, 2007
McGlashan TH, Grilo CM, Skodol AE, et al: The Collaborative Longitudinal Personality
Disorders Study: baseline Axis I/II and II/II diagnostic co-occurrence. Acta Psychiatr
Scand 102(4):256–264, 2000
Morgan TA, Zimmerman M: Epidemiology of personality disorders, in Handbook of
Personality Disorders: Theory, Research, and Treatment, 2nd Edition. Edited by Livesley
WJ, Larstone R. New York, Guilford, 2018, pp 173–196
Narayanan G, Rao K: Personality disorders in the Indian culture: reconsidering self-
perceptions, traditional society and values. Psychological Studies 63(1):32–41, 2018
Paris J, Lis E: Can sociocultural and historical mechanisms influence the development of
borderline personality disorder? Transcult Psychiatry 50(1):140–151, 2013
Soloff PH, Chiappetta L: Subtyping borderline personality disorder by suicidal behavior. J
Pers Disord 26(3):468–480, 2012
Temes CM, Frankenburg FR, Fitzmaurice GM, Zanarini MC: Deaths by suicide and other
causes among patients with borderline personality disorder and personality-disordered
comparison subjects over 24 years of prospective follow-up. J Clin Psychiatry
80(1):18m12436, 2019
Tseng WS (ed): Handbook of Cultural Psychiatry. New York, Academic Press, 2001
Wang L, Ross CA, Zhang T, et al: Frequency of borderline personality disorder among
psychiatric outpatients in Shanghai. J Pers Disord 26(3):393–401, 2012
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Widiger TA, Frances AJ: Epidemiology, diagnosis, and comorbidity of borderline
personality disorder, in American Psychiatric Press Review of Psychiatry, Vol 8. Edited by
Tasman A, Hales RE, Frances A. Washington, DC, American Psychiatric Press, 1989, pp
8–24
Zanarini MC, Williams AA, Lewis RE, et al: Reported pathological childhood experiences
associated with the development of borderline personality disorder. Am J Psychiatry
154(8):1101–1106, 1997
Zanarini MC, Frankenburg FR, Hennen J, et al: Axis I comorbidity in patients with
borderline personality disorder: 6-year follow-up and prediction of time to remission. Am
J Psychiatry 161(11):2108–2114, 2004
Zanarini MC, Frankenburg FR, Reich DB, et al: The 10-year course of physically self-
destructive acts reported by borderline patients and Axis II comparison subjects. Acta
Psychiatr Scand 117(3):177–184, 2008
Zanarini MC, Reichman CA, Frankenburg FR, et al: The course of eating disorders in
patients with borderline personality disorder: a 10-year follow-up study. Int J Eat Disord
43(3):226–232, 2010
Zanarini MC, Frankenburg FR, Reich DB, Fitzmaurice G: Attainment and stability of
sustained symptomatic remission and recovery among patients with borderline
personality disorder and Axis II comparison subjects: a 16-year prospective follow-up
study. Am J Psychiatry 169(5):476–483, 2012
Zanarini MC, Frankenburg FR, Reich DB, Fitzmaurice GM: Fluidity of the subsyndromal
phenomenology of borderline personality disorder over 16 years of prospective follow-up.
Am J Psychiatry 173(7):688–694, 2016
Zanarini MC, Temes CM, Magni LR, et al: Prevalence rates of borderline symptoms
reported by adolescent inpatients with BPD, psychiatrically healthy adolescents and adult
inpatients with BPD. Personal Ment Health 11(3):150–156, 2017
Zimmerman M, Chelminski I, Dalrymple K, Rosenstein L: Principal diagnoses in
psychiatric outpatients with borderline personality disorder: implications for screening
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(F60.4)
recommendations. Ann Clin Psychiatry 29(1):54–60, 2017 28207916
Histrionic Personality Disorder
Diagnostic Criteria
A pervasive pattern of excessive emotionality and attention seeking, beginning by early
adulthood 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
emotionality and attention-seeking behavior. This pattern begins by early adulthood and is
present in a variety of contexts.
Individuals with histrionic personality disorder are uncomfortable or feel unappreciated
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
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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, bringing
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 inappropriately
sexually provocative or seductive (Criterion 2). This behavior not only is directed toward
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 appropriate
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 comment 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
rationales 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 qualities
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
individual of faking these feelings.
Individuals with histrionic personality disorder have a high degree of suggestibility
(Criterion 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
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magically solving their problems. They have a tendency to play hunches and to adopt
convictions 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
Impairment in general tends to be lower in histrionic personality disorder than in many
other personality disorders (Bakkevig and Karterud 2010; Cramer et al. 2006; Holzer and
Huang 2019; Ryder et al. 2007; Vaughn et al. 2010a; Zimmerman et al. 2012). However,
the impairment most associated with histrionic personality disorder appears to be
interpersonal in nature. Individuals with histrionic personality disorder have an
interpersonal style characterized by social dominance, which can span a spectrum of
behaviors that include a “warmer dominance” that can be intrusive in nature (e.g., need to
be center of attention; exhibitionistic) to a “colder dominance” that can include arrogant,
controlling, and aggressive behaviors. Romantic relationships appear to be particularly
impaired, with evidence suggesting that individuals with histrionic personality disorder
symptoms are more likely to get divorced or never get married (Disney et al. 2012; Girard
et al. 2017; Røysamb et al. 2011; Wilson et al. 2017). Individuals with histrionic personality
disorder may have difficulty achieving emotional intimacy in romantic or sexual
relationships. Individuals with this disorder often have impaired relationships with same-
sex friends because their sexually provocative interpersonal 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 upset when they are not the center of
attention. They may crave novelty, stimulation, and excitement 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 initiate a job or project
with great enthusiasm, their interest may lag quickly. Longer-term relationships may be
neglected to make way for the excitement of new relationships.
Prevalence
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The estimated prevalence of histrionic personality disorder based on a probability
subsample from Part II of the National Comorbidity Survey Replication was 0.0%
(Lenzenweger et al. 2007).The prevalence of histrionic personality disorder in the National
Epidemiologic Survey on Alcohol and Related Conditions data was 1.8% (Grant et al.
2004). A review of five epidemiological studies (four in the United States) found a median
prevalence of 0.9% (Morgan and Zimmerman 2018).
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, sociability,
charm, impressionability, a tendency to somatization) to be evidence of histrionic
personality disorder, it is important to evaluate whether they cause clinically significant
impairment or distress. The presence of histrionic personality disorder should be
distinguished from reactive and contextual expression of these traits, arising in response to
socialization pressures in competitive peer groups, including the “need to be liked,” that do
not represent pervasive and enduring traits consistent with a personality disorder (Apt and
Hurlburt 1994; Blashfield et al. 2011; Crews et al. 2007; Millon 2011).
Sex- and Gender-Related Diagnostic Issues
In clinical settings, this disorder has been diagnosed more frequently in females; however,
the gender ratio is not significantly different from the gender ratio of females within the
respective clinical setting. In contrast, some studies using structured assessments report
similar prevalence rates among males and females.
Association With Suicidal Thoughts or Behavior
The actual risk of suicide is not known, but clinical experience suggests that individuals
with this disorder may be at increased risk for suicidal gestures and threats (García-Nieto
et al. 2014).
Differential Diagnosis
Other personality disorders and personality traits
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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 differences in their characteristic features. However, if an individual has
personality features that meet criteria for one or more personality disorders in addition to
histrionic personality 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. Although individuals with narcissistic personality disorder also crave
attention from others, they usually want praise for their “superiority,” whereas individuals
with histrionic personality 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 a direct physiological
consequence of another medical condition.
Substance use disorders
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The disorder must also be distinguished from symptoms that may develop in association
with persistent substance use.
Comorbidity
Histrionic personality disorder has been associated with higher rates of borderline,
narcissistic, paranoid, dependent, and antisocial personality disorders; alcohol and other
substance use and misuse; as well as aggression and violence (Agrawal et al. 2013; Forbes
et al. 2012; Kendler et al. 2008; Kotov et al. 2017; Maclean and French 2014; Pulay et al.
2008; Røysamb et al. 2011; Vaughn et al. 2010b). Histrionic personality disorder is also
thought to be related to somatic symptom disorder, functional neurological symptom
disorder (conversion disorder), and major depressive disorder.
References: Histrionic Personality Disorder
Agrawal A, Narayanan G, Oltmanns TF: Personality pathology and alcohol dependence at
midlife in a community sample. Personal Disord 4(1):55–61, 2013
Apt C, Hurlbert DF: The sexual attitudes, behavior and relationships of women with
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Narcissistic Personality Disorder
Diagnostic Criteria
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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
grandiosity, need for admiration, and lack of empathy that begins by early adulthood and is
present in a variety of contexts.
Individuals with this disorder have a grandiose sense of self-importance, which may be
manifest as an exaggerated or unrealistic sense of superiority, value, or capability
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(Criterion 1). They tend to overestimate their abilities and amplify 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 underestimation or devaluation of the contributions of others.
Individuals with narcissistic personality 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 special or unique and
expect others to recognize them as such (Criterion 3). They can be surprised or even
devastated when the recognition of acclaim they expect and feel they deserve from others is
not forthcoming. They may feel that they can only be understood by, and should only
associate with, people 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 special and beyond the ken of ordinary people. Their own self-esteem is
enhanced (i.e., “mirrored”) 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 disappoint them.
Individuals with this disorder generally require excessive admiration (Criterion 4). Their
self-esteem is almost invariably very fragile, and their struggle with severe internal self-
doubt, self-criticism, and emptiness results in their need to actively seek others’
admiration. They may be preoccupied with how well they are doing and how favorably they
are regarded by others. They may expect their arrival to be greeted with great fanfare and
are astonished if others do not covet their possessions. They may constantly fish for
compliments, often with great charm.
A sense of entitlement, which is rooted in their distorted sense of self-worth, is evident in
these individuals’ 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
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assist “in their very important work.” 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. This sense of entitlement, combined with a lack of understanding and
sensitivity to the wants and needs of others, may result in the conscious or unwitting
exploitation of others (Criterion 6). 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 usurp special privileges and extra resources that they
believe they deserve. Some individuals with narcissistic personality disorder intentionally
and purposefully take advantage of others emotionally, socially, intellectually, or financially
for their own purposes and gains.
Individuals with narcissistic personality disorder generally have a lack of empathy and are
unwilling to recognize or identify with the desires, subjective experiences, and feelings of
others (Criterion 7). They tend to have some degree of cognitive empathy (understanding
another person’s perspective on an intellectual level) but lack emotional empathy (directly
feeling the emotions that another person is feeling) (Ritter et al. 2011). 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 personality disorder typically find an emotional coldness and
lack of reciprocal interest.
These individuals are often envious of others or believe that others 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
contributions 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).
Associated Features
Vulnerability in self-esteem makes individuals with narcissistic personality disorder very
sensitive to criticism or defeat. Although they may not show it outwardly, such experiences
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may leave them feeling ashamed, humiliated, degraded, hollow, and empty. They may react
with disdain, rage, or defiant counterattack. However, such experiences can also lead to
social withdrawal or an appearance of humility that may mask and protect the grandiosity.
Interpersonal relations are typically impaired because of problems related to self-
preoccupation, entitlement, need for admiration, and relative disregard for the sensitivities
of others.
Individuals with narcissistic personality disorder can be competent and high functioning
with professional and social success, while others can have various levels of functional
impairment. Professional capability combined with self-control, stoicism, and
interpersonal distancing with minimal self-disclosure can support sustained life
engagement and even enable marriage and social affiliations. Sometimes ambition and
temporary confidence lead to high achievements, but performance can be disrupted
because of fluctuating self-confidence and intolerance of criticism or defeat. Some
individuals with narcissistic personality disorder have very low vocational functioning,
reflecting an unwillingness to take a risk in competitive or other situations in which failure
or defeat can be possible.
Low self-esteem with inferiority, vulnerability, and sustained feelings of shame, envy, and
humiliation accompanied by self-criticism and insecurity can make individuals with
narcissistic personality disorder susceptible to social withdrawal, emptiness, and depressed
mood. High perfectionist standards are often associated with significant fear of exposure to
imperfection, failure, and overwhelming emotions (Ronningstam and Baskin-Sommers
2013).
Prevalence
The estimated prevalence of narcissistic personality disorder based on a probability
subsample from Part II of the National Comorbidity Survey Replication was 0.0%
(Lenzenweger et al. 2007).The prevalence of narcissistic personality disorder in the
National Epidemiologic Survey on Alcohol and Related Conditions data was 6.2% (Stinson
et al. 2008). A review of five epidemiological studies (four in the United States) found a
median prevalence of 1.6% (Morgan and Zimmerman 2018).
Development and Course
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Narcissistic traits may be particularly common in adolescents but do not necessarily
indicate that the individual will develop narcissistic personality disorder in adulthood.
Predominant narcissistic traits or manifestations of the full disorder may first come to
clinical attention or be exacerbated in the context of unexpected or extremely challenging
life experiences or crises, such as bankruptcies, demotions or loss of work, or divorces. In
addition, individuals with narcissistic personality disorder may have specific difficulties
adjusting to the onset of physical and occupational limitations that are inherent in the
aging process. However, life experiences, such as new durable relationships, real successful
achievements, and tolerable disappointments and setbacks, can all be corrective and
contribute to changes and improvements in individuals with this disorder (Ronningstam et
al. 1995).
Culture-Related Diagnostic Issues
Narcissistic traits may be elevated in sociocultural contexts that emphasize individualism
and personal autonomy over collectivistic goals (Cai et al. 2012; Meisel et al. 2016; Miller et
al. 2015; Vater et al. 2018). Compared with collectivistic contexts, in individualistic
contexts, narcissistic traits may warrant less clinical attention or less frequently lead to
social impairment.
Sex- and Gender-Related Diagnostic Issues
Among adults age 18 and older diagnosed with narcissistic personality disorder, 50%–75%
are men (Grijalva et al. 2015). Gender differences in adults with this disorder include
stronger reactivity in response to stress and compromised empathic processing in men as
opposed to self-focus and withdrawal in women (Hoertel et al. 2018). Culturally based
gender patterns and expectations may also contribute to gender differences in narcissistic
personality disorder traits and patterns.
Association With Suicidal Thoughts or Behavior
In the context of severe stress, and given the perfectionism often associated with
narcissistic personality disorder, exposure to imperfection, failure, and overwhelming
emotions can evoke suicidal ideation (Blasco-Fontecilla et al. 2009; Ronningstam 2018;
Ronningstam and Baskin-Sommers 2013). Suicide attempts in individuals with narcissistic
personality disorder tend to be less impulsive and are characterized by higher lethality
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compared with suicide attempts by individuals with other personality disorders (Blasco-
Fontecilla et al. 2009).
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 differences in their characteristic features. However, if an
individual has personality features that meet criteria for one or more personality disorders
in addition to narcissistic personality 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 grandiosity characteristic of narcissistic personality disorder. The
relative stability of self-image and self-control as well as the relative lack of self-
destructiveness, impulsivity, separation insecurity, and emotional hyperreactivity also help
distinguish narcissistic personality disorder from borderline personality disorder (Fossati
et al. 2016).
Excessive pride in achievements, a relative lack of emotional display, and ignorance of or
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 disorder specifically need that attention to be admiring. Individuals with
antisocial and narcissistic personality disorders share a tendency to be tough-minded, glib,
superficial, exploitative, and unempathic. However, narcissistic personality disorder does
not necessarily include characteristics of impulsive aggressivity and deceitfulness. In
addition, individuals with antisocial personality disorder may be more indifferent and less
sensitive to others’ reactions or criticism, and individuals with narcissistic personality
disorder usually lack the history of conduct disorder in childhood or criminal behavior in
adulthood.
In both narcissistic personality disorder and obsessive-compulsive personality disorder, the
individual may profess a commitment to perfectionism and believe that others cannot do
things as well. However, while those with obsessive-compulsive personality disorder tend
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to be more immersed in perfectionism related to order and rigidity, individuals with
narcissistic personality disorder tend to set high perfectionistic standards, especially for
appearance and performance, and to be critically concerned if they are not measuring
up (Smith et al. 2016).
Suspiciousness and social withdrawal usually distinguish those with schizotypal, avoidant,
or paranoid personality disorder from those with narcissistic personality disorder. When
these qualities are present in individuals with narcissistic personality disorder, they derive
primarily from shame and fear of failure, or fear 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
personality disorder.
Mania or hypomania
Grandiosity may emerge as part of manic or hypomanic 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.
Persistent depressive disorder
Experiences that threaten self-esteem can evoke a deep sense of inferiority and sustained
feelings of shame, envy, self-criticism, and insecurity in individuals with narcissistic
personality disorder that can result in persistent negative feelings resembling those seen in
persistent depressive disorder (Tritt et al. 2010). If criteria are also met for persistent
depressive disorder, both conditions can be diagnosed.
Comorbidity
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Narcissistic personality disorder is associated with depressive disorders (persistent
depressive disorder and major depressive disorder), anorexia nervosa, and substance use
disorders (especially related to cocaine). Histrionic, borderline, antisocial, and paranoid
personality disorders may also be associated with narcissistic personality disorder.
References: Narcissistic Personality Disorder
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in patients with narcissistic personality disorder. J Clin Psychiatry 70(11):1583–1587,
2009
Cai H, Kwan VS, Sedikides C: A sociocultural approach to narcissism: the case of modern
China. European Journal of Personality 26(5):529–535, 2012
Fossati A, Somma A, Borroni S, et al: Borderline personality disorder and narcissistic
personality disorder diagnoses from the perspective of the DSM-5 personality traits: a
study on Italian clinical participants. J Nerv Ment Dis 204(12):939–949, 2016
Grijalva E, Newman DA, Tay L, et al: Gender differences in narcissism: a meta-analytic
review. Psychol Bull 141(2):261–310, 2015
Hoertel N, Peyre H, Lavaud P, et al: Examining sex differences in DSM-IV-TR narcissistic
personality disorder symptom expression using Item Response Theory (IRT). Psychiatry
Res 260:500–507, 2018
Lenzenweger MF, Lane MC, Loranger AW, Kessler RC: DSM-IV personality disorders in
the National Comorbidity Survey Replication. Biol Psychiatry 62(6):553–564, 2007
Meisel MK, Ning H, Campbell WK, Goodie AS: Narcissism, overconfidence, and risk
taking in US and Chinese student samples. Journal of Cross-Cultural Psychology
47(3):385–400, 2016
Miller JD, Maples JL, Buffardi L, et al: Narcissism and United States’ culture: the view
from home and around the world. J Pers Soc Psychol 109(6):1068–1089, 2015
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Morgan TA, Zimmerman M: Epidemiology of personality disorders, in Handbook of
Personality Disorders: Theory, Research, and Treatment, 2nd Edition. Edited by Livesley
WJ, Larstone R. New York, Guilford, 2018, pp 173–196
Ritter K, Dziobek I, Preissler S, et al: Lack of empathy in patients with narcissistic
personality disorder. Psychiatry Res 187(1–2):241–247, 2011
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Clinical and Forensic Issues [in Italian]. Edited by Fossati A, Borroni S. Milan, Italy,
Raffaello Cortina Editore, 2018, pp 25–48
Ronningstam E, Baskin-Sommers AR: Fear and decision-making in narcissistic
personality disorder-a link between psychoanalysis and neuroscience. Dialogues Clin
Neurosci 15(2):191–201, 2013
Ronningstam E, Gunderson J, Lyons M: Changes in pathological narcissism. Am J
Psychiatry 152(2):253–257, 1995
Smith MM, Sherry SB, Chen S, et al: Perfectionism and narcissism: a meta-analytic
review. Journal of Research in Personality 64:90–101, 2016
Stinson FS, Dawson DA, Goldstein RB, et al: Prevalence, correlates, disability, and
comorbidity of DSM-IV narcissistic personality disorder: results from the wave 2 National
Epidemiologic Survey on Alcohol and Related Conditions. J Clin Psychiatry 69(7):1033–
1045, 2008
Tritt SM, Ryder AG, Ring AJ, Pincus AL: Pathological narcissism and the depressive
temperament. J Affect Disord 122(3):280–284, 2010
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Cluster C Personality Disorders
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(F60.6)
Avoidant Personality Disorder
Diagnostic Criteria
A pervasive pattern of social inhibition, feelings of inadequacy, and hypersensitivity to
negative evaluation, beginning by early adulthood and present in a variety of contexts,
as indicated 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
inhibition, 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 significant
interpersonal contact because of fears of criticism, disapproval, or rejection (Criterion 1).
Offers of job promotions may be declined because failure to manage the new
responsibilities might result in criticism from coworkers. 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
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to be critical and disapproving. Individuals with this disorder are highly avoidant of group
activities. 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, be reluctant to talk 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 rejected in
social situations, they may have a markedly low threshold for detecting such reactions
(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 critical 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, and may misinterpret a neutral gesture or
statement as critical or rejecting. Despite their longing to be active participants in social
life, they fear placing their psychological 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). These individuals believe
themselves to be socially inept, personally unappealing, or inferior to others (Criterion 6).
Doubts concerning social competence and personal appeal may be most intense for some
individuals in settings involving interactions with strangers. But many others report more
difficulties with repeated interaction, when sharing of personal information would
normally occur, thus, in the individual’s perception, increasing the chances that their
inferiority would be revealed and that they would be rejected. When commencing a new
ongoing social or occupational commitment requiring repeated interpersonal interaction,
individuals may over weeks or months develop a growing conviction that others or
colleagues view them as inferior or lacking worth, resulting in intolerable distress or
anxiety that prompts resignation. Thus, a history of repeated job changes may be present.
Individuals with this disorder 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.
Associated Features
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Individuals with avoidant personality disorder often vigilantly appraise the movements and
expressions of those with whom they come into contact. They are likely to misinterpret
social responses as critical, which in turn confirms their self-doubts. 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 relationships with others. Avoidant behaviors can also adversely
affect occupational functioning 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.
Individuals with avoidant personality disorder have been reported as having insecure
attachment styles characterized by a desire for emotional attachment (which may include a
preoccupation with previous and current relationships), but their fears that others may not
value them or may hurt them may lead them to respond with passivity, anger, or
fear (MacDonald et al. 2013). These attachment patterns have been referred to variously as
“preoccupied” or “fearful” depending on the model employed by researchers.
Prevalence
The estimated prevalence of avoidant personality disorder based on a probability
subsample from Part II of the National Comorbidity Survey Replication was 5.2%
(Lenzenweger et al. 2007). The prevalence of avoidant personality disorder in the National
Epidemiologic Survey on Alcohol and Related Conditions was 2.4% (Grant et al. 2004). A
review of six epidemiological studies (four in the United States) found a median prevalence
of 2.1% (Morgan and Zimmerman 2018).
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 precursor 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 disorder may
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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; the
prevalence in adults older than 65 years has been estimated at 0.8% (Schuster et al. 2013).
This diagnosis should be used with great caution in children and adolescents, 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 migration. In some sociocultural contexts, marked
avoidance might occur following social embarrassment (“loss of face”) or failure to meet
major life goals rather than temperamental shyness (Koyama et al. 2010; Teo et al. 2015).
In these settings, the goal of avoidance includes deliberate minimization of social
interactions in order to preserve social harmony or prevent public offense.
Sex- and Gender-Related Diagnostic Issues
Avoidant personality disorder appears to be more common in women than in men in
community surveys (Cox et al. 2009; Furnham and Trickey 2011; Hasin and Grant 2015;
Lampe and Sunderland 2015; Trull et al. 2010). This gender difference in prevalence is
small but consistently found in large population-based samples (Furnham and Trickey
2011).
Differential Diagnosis
Social anxiety disorder
There appears to be a great deal of overlap between avoidant personality disorder and
social anxiety disorder. It has been suggested that they may represent different
manifestations of similar underlying problems, or avoidant personality disorder may be a
more severe form of social anxiety disorder (Reich 2009). However, differences have also
been described, especially in relation to self-concept (such as self-esteem and the sense of
inferiority in avoidant personality disorder) (Dreessen et al. 1999; Eikenaes et al. 2013;
Hummelen et al. 2007; Lampe 2015; Weinbrecht et al. 2016; Wilson and Rapee 2006); the
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latter is indirect evidence as it shows that negative self-concept in social anxiety disorder
may be unstable and thus less pervasive and entrenched than in avoidant personality
disorder. Additionally, studies have shown that avoidant personality disorder frequently
occurs in the absence of social anxiety disorder (Friborg et al. 2013; Lampe and Malhi
2018), and some separate risk factors have been identified (Torvik et al. 2016), providing
support for retaining two separate diagnostic categories.
Agoraphobia
Avoidance characterizes both avoidant personality disorder and agoraphobia, and they
often co-occur. They can be distinguished by the motivation for the avoidance (e.g., fear of
panic or physical harm in agoraphobia).
Other personality disorders and personality traits
Other personality disorders may be confused with avoidant 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 avoidant personality disorder, all can be diagnosed. Both avoidant
personality disorder and dependent personality disorder are characterized by feelings of
inadequacy, hypersensitivity to criticism, and a need for reassurance. Similar behaviors
(e.g., unassertiveness) and attributes (e.g., low self-esteem and low self-confidence) may be
observed in both dependent personality disorder and avoidant personality disorder,
although other behaviors are notably divergent, such as avoidance of social proximity in
avoidant personality disorder but proximity-seeking in dependent personality disorder.
The motivations behind similar behaviors may be quite different. For example, the
unassertiveness in avoidant personality disorder is described as more closely related to
fears of being rejected or humiliated, whereas in dependent personality disorder it is
motivated by the desire to avoid being left to fend for oneself (Beck et al. 2014; Horowitz
and Wilson 2005; Lampe and Malhi 2018). However, avoidant personality disorder and
dependent personality disorder may be particularly likely to co-occur. Like avoidant
personality disorder, 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
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schizoid or schizotypal personality disorder may be content with and even prefer their
social isolation. Paranoid personality disorder and avoidant personality disorder are both
characterized by a reluctance to confide in others. However, in avoidant personality
disorder, this reluctance is attributable more to a fear of humiliation or being found
inadequate than to a fear of others’ malicious intent.
Many individuals display avoidant personality traits. Only when these traits are inflexible,
maladaptive, and persisting and cause significant functional impairment or subjective
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 a direct physiological
consequence of another medical condition.
Substance use disorders
Avoidant personality disorder must also be distinguished from symptoms that may develop
in association with persistent substance use.
Comorbidity
Other disorders that are commonly diagnosed with avoidant personality disorder include
depressive disorders and anxiety disorders, especially social anxiety disorder. Avoidant
personality disorder also tends to be diagnosed with schizoid personality disorder.
Avoidant personality disorder is associated with increased rates of substance use disorders
at a similar rate to the generalized form of social anxiety disorder.
References: Avoidant Personality Disorder
Beck AT, Davis DD, Freeman A: Cognitive Therapy of Personality Disorders, 3rd Edition.
New York, Guilford, 2014
Cox BJ, Pagura J, Stein MB, Sareen J: The relationship between generalized social phobia
and avoidant personality disorder in a national mental health survey. Depress Anxiety
26(4):354–362, 2009
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Dreessen L, Arntz A, Hendriks T, et al: Avoidant personality disorder and implicit
schema-congruent information processing bias: a pilot study with a pragmatic inference
task. Behav Res Ther 37(7):619–632, 1999 10402687
Eikenaes I, Hummelen B, Abrahamsen G, et al: Personality functioning in patients with
avoidant personality disorder and social phobia. J Pers Disord 27(6):746–763, 2013
Friborg O, Martinussen M, Kaiser S, et al: Comorbidity of personality disorders in anxiety
disorders: a meta-analysis of 30 years of research. J Affect Disord 145(2):143–155, 2013
Furnham A, Trickey G: Sex differences in the dark side traits. Personality and Individual
Differences 50(4):517–522, 2011
Grant BF, Hasin DS, Stinson FS, et al: Prevalence, correlates, and disability of personality
disorders in the United States: results from the National Epidemiologic Survey on Alcohol
and Related Conditions. J Clin Psychiatry 65(7):948–958, 2004
Hasin DS, Grant BF: The National Epidemiologic Survey on Alcohol and Related
Conditions (NESARC) Waves 1 and 2: review and summary of findings. Soc Psychiatry
Psychiatr Epidemiol 50(11):1609–1640, 2015
Horowitz LM, Wilson KR: Interpersonal motives and personality disorders, in Handbook
of Personology and Psychopathology. Edited by Strack S. Hoboken, NJ, Wiley, 2005, pp
495–510
Hummelen B, Wilberg T, Pedersen G, Karterud S: The relationship between avoidant
personality disorder and social phobia. Compr Psychiatry 48(4):348–356, 2007
Koyama A, Miyake Y, Kawakami N, et al; World Mental Health Japan Survey Group:
Lifetime prevalence, psychiatric comorbidity and demographic correlates of “hikikomori”
in a community population in Japan. Psychiatry Res 176(1):69–74, 2010
Lampe L: Social anxiety disorders in clinical practice: differentiating social phobia from
avoidant personality disorder. Australas Psychiatry 23(4):343–346, 2015
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Lampe L, Malhi GS: Avoidant personality disorder: current insights. Psychology Research
and Behavior Management 11:55–66, 2018
Lampe L, Sunderland M: Social phobia and avoidant personality disorder: similar but
different? J Pers Disord 29(1):115–130, 2015
Lenzenweger MF, Lane MC, Loranger AW, Kessler RC: DSM-IV personality disorders in
the National Comorbidity Survey Replication. Biol Psychiatry 62(6):553–564, 2007
MacDonald K, Berlow R, Thomas ML: Attachment, affective temperament, and
personality disorders: a study of their relationships in psychiatric outpatients. J Affect
Disord 151(3):932–941, 2013
Morgan TA, Zimmerman M: Epidemiology of personality disorders, in Handbook of
Personality Disorders: Theory, Research, and Treatment, 2nd Edition. New York,
Guilford, 2018, pp 173–196
Reich J: Avoidant personality disorder and its relationship to social phobia. Curr
Psychiatry Rep 11(1):89–93, 2009
Schuster J-P, Hoertel N, Le Strat YL, et al: Personality disorders in older adults: findings
from the National Epidemiologic Survey on Alcohol and Related Conditions. Am J Geriatr
Psychiatry 21(8):757–768, 2013
Teo AR, Fetters MD, Stufflebam K, et al: Identification of the hikikomori syndrome of
social withdrawal: psychosocial features and treatment preferences in four countries. Int J
Soc Psychiatry 61(1):64–72, 2015
Torvik FA, Welander-Vatn A, Ystrom E, et al: Longitudinal associations between social
anxiety disorder and avoidant personality disorder: a twin study. J Abnorm Psychol
125(1):114–124, 2016
Trull TJ, Jahng S, Tomko RL, et al: Revised NESARC personality disorder diagnoses:
gender, prevalence, and comorbidity with substance dependence disorders. J Pers Disord
24(4):412–426, 2010
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(F60.7)
Weinbrecht A, Schulze L, Boettcher J, Renneberg B: Avoidant personality disorder: a
current review. Curr Psychiatry Rep 18(3):29, 2016
Wilson JK, Rapee RM: Self-concept certainty in social phobia. Behav Res Ther 44(1):113–
136, 2006
Dependent Personality Disorder
Diagnostic Criteria
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
relationship ends.
8. Is unrealistically preoccupied with fears of being left to take care of himself or
herself.
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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 everyday
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 individuals
tend to be passive and to allow other people (often a single other person) to take the
initiative 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-appropriate and
situation-appropriate requests for assistance from others (e.g., the specific needs of
children, elderly persons, and handicapped persons). Dependent personality disorder 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
function 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 express anger toward
others whose support and nurturance they need for fear of alienating them. If the
individual’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
considered to be evidence of dependent personality disorder.
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Individuals with this disorder have difficulty initiating projects or doing things
independently (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 assistance. They are, however, likely to function adequately if given the assurance
that someone 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 loss of
support. Because they rely on others to handle their problems, they often do not learn the
skills of independent 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
important bond will often result in imbalanced or distorted relationships. They may make
extraordinary 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.)
Individuals with this disorder feel uncomfortable or helpless when alone because of their
exaggerated fears of being unable to care for themselves (Criterion 6).
When a close relationship ends (e.g., a breakup with a lover; the death of a caregiver),
individuals 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 losing the support of 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 example, 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.
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Associated Features
Individuals with dependent personality disorder are often characterized by pessimism and
self-doubt and tend to belittle their abilities and assets. They take criticism and disapproval
as proof of their worthlessness and lose faith in themselves. They may seek overprotection
and dominance from others. Occupational functioning may be impaired if independent
initiative is required. They may avoid positions of responsibility and become anxious when
faced with decisions.
Prevalence
The estimated prevalence of dependent personality disorder based on a probability
subsample from Part II of the National Comorbidity Survey Replication was 0.6%
(Lenzenweger et al. 2007). The prevalence of dependent personality disorder in the
National Epidemiologic Survey on Alcohol and Related Conditions was 0.5% (Grant et al.
2004). A review of six epidemiological studies (four in the United States) found a median
prevalence of 0.4% (Morgan and Zimmerman 2018).
Development 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-Related Diagnostic Issues
The degree to which dependent behaviors are considered to be appropriate varies
substantially across different age and sociocultural groups. Age and cultural factors need to
be considered in evaluating the diagnostic threshold of each criterion. Dependent behavior
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
misinterpreted as traits of dependent personality disorder. Similarly, societies may
differentially foster and discourage dependent behavior i n males and females. Individuals
with dependent personality disorder exhibit a pervasive inability to make decisions,
continuous feelings of subjugation, lack of initiative, silence, and social distancing that are
far in excess of usual cultural norms of politeness and purposeful passivity.
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Sex- and Gender-Related Diagnostic Issues
In clinical and community settings, dependent personality disorder has been diagnosed
more frequently in women compared with men (Furnham and Trickey 2011).
Differential Diagnosis
Separation anxiety disorder in adults
Adults with separation anxiety disorder are typically overconcerned about their offspring,
spouses, parents, and pets, and experience marked discomfort when separated from them.
In contrast, individuals with dependent personality disorder feel uncomfortable or helpless
when alone because of exaggerated fears of being unable to take care of themselves.
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 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
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 submissive and clinging behavior and by the person’s
self-perception of not being able to function adequately without the help and support of
others (Bornstein 2012). 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 emptiness, rage, and
demands, 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 a typical pattern of unstable and
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intense relationships. Individuals with histrionic personality disorder, like those with
dependent personality disorder, have a strong need for reassurance and approval and may
appear childlike and clinging. However, unlike dependent personality disorder, which is
characterized by self-effacing and docile behavior, histrionic personality disorder is
characterized by gregarious flamboyance with active demands for attention. Moreover,
individuals with histrionic personality disorder typically have less insight regarding their
underlying dependency needs than do people with dependent personality
disorder (Bornstein 1998). Both dependent personality disorder and avoidant personality
disorder are characterized by feelings of inadequacy, 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 dependent personality disorder have a pattern of
seeking and maintaining connections to important others, rather than avoiding and
withdrawing from relationships.
Many individuals display dependent personality traits. Only when these traits are
inflexible, maladaptive, and persisting and cause significant functional impairment or
subjective distress do they constitute dependent personality disorder.
Personality change due to another medical condition
Dependent personality disorder must be distinguished from personality change due to
another medical condition, in which the traits that emerge are a direct physiological
consequence of another medical condition.
Substance use disorders
Dependent personality disorder must also be distinguished from symptoms that may
develop in association with persistent substance use.
Comorbidity
There may be an increased risk of depressive disorders, anxiety disorders, and adjustment
disorders. Dependent personality disorder often co-occurs with other personality disorders,
especially borderline, avoidant, and histrionic personality disorders. Chronic physical
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(F60.5)
illness or persistent separation anxiety disorder in childhood or adolescence may
predispose the individual to the development of this disorder.
References: Dependent Personality Disorder
Bornstein RF: Implicit and self‐attributed dependency needs in dependent and histrionic
personality disorders. J Pers Assess 71(1):1–14, 1998
Bornstein RF: From dysfunction to adaptation: an interactionist model of dependency.
Annu Rev Clin Psychol 8:291–316, 2012
Furnham A, Trickey G: Sex differences in the dark side traits. Personality and Individual
Differences 50(4):517–522, 2011
Grant BF, Hasin DS, Stinson FS, et al: Prevalence, correlates, and disability of personality
disorders in the United States: results from the National Epidemiologic Survey on Alcohol
and Related Conditions. J Clin Psychiatry 65(7):948–958, 2004
Lenzenweger MF, Lane MC, Loranger AW, Kessler RC: DSM-IV personality disorders in
the National Comorbidity Survey Replication. Biol Psychiatry 62(6):553–564, 2007
Morgan TA, Zimmerman M: Epidemiology of personality disorders, in Handbook of
Personality Disorders: Theory, Research, and Treatment, 2nd Edition. Edited by Livesley
WJ, Larstone R. New York, Guilford, 2018, pp 173–196
Obsessive-Compulsive Personality Disorder
Diagnostic Criteria
A pervasive pattern of preoccupation with orderliness, perfectionism, and mental and
interpersonal 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.
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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, losing track of time in the process. 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 trying their best to
recreate it from memory and proceeding to accomplish the tasks. They dismiss the fact that
other people tend to become very annoyed at the delays and inconveniences that result
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from this behavior because they preferentially respond to either their anxiety about making
a mistake or their insistence on how things should be done. Time is poorly allocated, and
the most important tasks are left to the last moment. The perfectionism 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 routinely missed or the individual has a pattern of exerting
extraordinary effort (e.g., working through the night, skipping meals) in order to make the
deadline at the last moment, and aspects of the individual’s life that are not the current
focus of activity may fall into disarray (Pinto 2020).
Individuals with obsessive-compulsive personality disorder display excessive devotion to
work and productivity to the exclusion or devaluing 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 reluctantly take time for leisure activities or vacations, they are
very uncomfortable unless 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 formally organized activity (e.g., sports). Hobbies or
recreational activities are approached as serious tasks or with methodical intensity,
requiring careful organization and hard work to master. The emphasis is on perfect
performance. These individuals turn play into a structured work-like task (e.g., correcting
an infant for not putting rings on the post in the right order; telling a toddler to ride their
tricycle in a straight line; turning a baseball game into a harsh “lesson”).
Individuals with obsessive-compulsive personality disorder may be excessively
conscientious, scrupulous, and inflexible about matters of morality, ethics, or values
(Criterion 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 or harshly judgmental of others’ moral or ethical missteps. Individuals with
this disorder are rigidly deferential to authority and rules and insist on quite literal
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compliance, with no rule bending for extenuating circumstances. For example, the
individual will not lend a dollar to a friend who is short of the fare needed to get on a bus
because “neither a borrower nor a lender be” or because it would be “bad” for the friend’s
character. These qualities should not be accounted for by the individual’s cultural 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 admit to
being “pack rats.” They regard discarding objects as wasteful because “you never know
when you might need something.” The clutter may also result from an accumulation of
partially read learning material or unfinished projects that the individual intends to get to
someday but that have been sidelined because of procrastination and/or a meticulous yet
slow work style. These individuals 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, piles of reading material, broken appliances, and so on (Pinto
2020).
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, load the dishwasher, build a doghouse),
even to the point of micromanaging others, 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 (having difficulty spending money
on both themselves and others) 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 to these plans or their usual routines. Totally wrapped up in their own perspective,
they have difficulty acknowledging the viewpoints of others. Friends and colleagues may
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become frustrated by this constant rigidity. Even when individuals with obsessive-
compulsive 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
When rules and established procedures do not dictate the correct answer, decision-making
may become a time-consuming, often painful process (e.g., exhaustively researching
options before making a purchase). Individuals with obsessive-compulsive personality
disorder may have such difficulty deciding which tasks take priority 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 anger is typically not expressed
directly. For example, an individual may be angry when service in a restaurant is poor, but
instead of complaining to the management, the individual ruminates about how much to
leave as a tip. On 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 have difficulty relating to and sharing emotions. For
example, they may express affection in a highly controlled or stilted fashion and may be
very uncomfortable in the presence of others who are emotionally expressive. 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 displays of emotion in
others. They often have difficulty expressing tender feelings, rarely paying compliments.
Individuals with this disorder may experience occupational difficulties and distress,
particularly when confronted with new situations that demand flexibility and compromise.
Prevalence
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The estimated prevalence of obsessive-compulsive personality disorder based on a
probability subsample from Part II of the National Comorbidity Survey Replication was
2.4% (Lenzenweger et al. 2007). The prevalence of obsessive-compulsive personality
disorder in the National Epidemiologic Survey on Alcohol and Related Conditions was
7.9% (Grant et al. 2004). A review of five epidemiological studies (three in the United
States) found a median prevalence of 4.7% (Morgan and Zimmerman 2018).
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 cultural communities
place substantial emphasis on work and productivity, and some members of sociocultural
groups (e.g., certain religious groups, professions, migrants) may at times rigidly embrace
codes of conduct; work demands; restrictive social environments; rules of behavior; or
standards that emphasize overconscientiousness, moral scrupulosity, and striving for
perfectionism that may be reinforced by norms of the cultural group (Alarcón et al. 1998).
Such behaviors should not on their own be considered indications of obsessive-compulsive
personality disorder.
Sex- and Gender-Related Diagnostic Issues
In large population-based studies, obsessive-compulsive personality disorder appears to be
equally prevalent in men and women (Furnham and Trickey 2011; Grant et al. 2012;
Lenzenweger et al. 2007).
Differential Diagnosis
Obsessive-compulsive disorder (OCD)
Despite the similarity in names, OCD is usually easily distinguished from obsessive-
compulsive personality disorder by the presence of true obsessions and compulsions in
OCD. When criteria for both obsessive-compulsive personality disorder and OCD are met,
both diagnoses should be recorded.
Hoarding disorder
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A diagnosis of hoarding disorder should be considered especially when hoarding is extreme
(e.g., accumulated stacks of worthless objects present a fire hazard and make it difficult for
others to walk through the house). When criteria for both obsessive-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 personality 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 personality disorder are usually self-critical. Individuals with
narcissistic or antisocial personality disorder lack generosity but will indulge themselves,
whereas those with obsessive-compulsive personality 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 disorder, 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,
particularly in situations that reward high performance. Only when these traits are
inflexible, maladaptive, and persisting and cause significant functional impairment or
subjective distress do they constitute obsessive-compulsive personality disorder.
Personality change due to another medical condition
Obsessive-compulsive personality disorder must be distinguished from personality change
due to another medical condition, in which the traits are a direct physiological consequence
of another medical condition.
Substance use disorders
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Obsessive-compulsive personality disorder must also be distinguished from symptoms that
may develop in association with persistent substance use.
Comorbidity
Individuals with anxiety disorders (e.g., generalized anxiety disorder, separation anxiety
disorder, social anxiety disorder, specific phobias) and OCD have an increased likelihood of
having a personality disturbance that meets criteria for obsessive-compulsive personality
disorder. Even so, it appears that the majority of individuals 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 individuals at risk for myocardial infarction. There may be an association
between obsessive-compulsive personality disorder and depressive and bipolar disorders
and eating disorders.
References: Obsessive-Compulsive Personality Disorder
Alarcón RD, Foulks EF, Vakkur M: Culture and the depathologization of personality
disorders (Chapter 8), in Personality Disorders and Culture: Clinical and Conceptual
Interactions. New York, Wiley, 1998, pp 175–202
Furnham A, Trickey G: Sex differences in the dark side traits. Personality and Individual
Differences 50(4):517–522, 2011
Grant BF, Stinson FS, Dawson DA, et al: Co-occurrence of 12-month alcohol and drug use
disorders and personality disorders in the United States: results from the National
Epidemiologic Survey on Alcohol and Related Conditions. Arch Gen Psychiatry
61(4):361–368, 2004
Grant JE, Mooney ME, Kushner MG: Prevalence, correlates, and comorbidity of DSM-IV
obsessive-compulsive personality disorder: results from the National Epidemiologic
Survey on Alcohol and Related Conditions. J Psychiatr Res 46(4):469–475, 2012
Lenzenweger MF, Lane MC, Loranger AW, Kessler RC: DSM-IV personality disorders in
the National Comorbidity Survey Replication. Biol Psychiatry 62(6):553–564, 2007
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(F07.0)
Morgan TA, Zimmerman M: Epidemiology of personality disorders, in Handbook of
Personality Disorders: Theory, Research, and Treatment, 2nd Edition. Edited by Livesley
WJ, Larstone R. New York, Guilford, 2018, pp 173–196
Pinto A: Psychotherapy for obsessive-compulsive personality disorder, in Obsessive-
Compulsive Personality Disorder. Edited by Grant JE, Chamberlain SR. Washington, DC,
American Psychiatric Association Publishing, 2020, pp 143–177
Other Personality Disorders
Personality Change Due to Another Medical Condition
Diagnostic Criteria
A. A persistent personality disturbance that represents a change from the
individual’s previous characteristic personality pattern.
Note: In children, the disturbance involves a marked deviation from normal
development 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,
occupational, or other important areas of functioning.
Specify whether:
Labile type: If the predominant feature is affective lability.
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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., F07.0
personality change due to temporal lobe epilepsy). The other medical condition
should be coded and listed separately immediately before the personality change
due to another medical condition (e.g., G40.209 temporal lobe epilepsy; F07.0
personality change due to temporal lobe epilepsy).
Subtypes
The particular personality change can be specified by indicating the symptom presentation
that predominates in the clinical presentation.
Diagnostic Features
The essential feature of a personality change due to another medical condition is a
persistent personality disturbance that is judged to be a physiological consequence of
another 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
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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
precipitating 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 diagnosis is distinct by virtue of its specific etiology, different phenomenology, and
more variable onset and course.
The clinical presentation in a given individual may depend on the nature and localization of
the pathological process. For example, injury to the frontal lobes may yield symptoms such
as lack of judgment or foresight, facetiousness, disinhibition, and euphoria. In this
example, the diagnosis of personality change due to frontal lobe injury would be made if a
persistent personality disturbance is a deviation from the individual’s previous
characteristic personality pattern prior to the injury (Criterion A). Right hemisphere
strokes have often been shown to evoke personality changes in association 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 impersistence, and other
neurological deficits.
Associated Features
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
involvement (e.g., HIV), endocrine conditions (e.g., hypothyroidism, hypo- and
hyperadrenocorticism), and autoimmune conditions with central nervous system
involvement (e.g., systemic lupus erythematosus). The associated physical examination
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findings, laboratory findings, and patterns of prevalence and onset reflect those of the
neurological or other medical condition involved.
Differential Diagnosis
Chronic medical conditions associated with pain and disability
Chronic medical conditions associated with pain and disability can also be associated with
changes in personality. 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 medical 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 personality 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 another medical condition may be given in addition
to the diagnosis of major neurocognitive disorder if the personality change is judged to be a
physiological consequence of the pathological process causing the neurocognitive disorder
and if the personality change is a prominent part of the clinical presentation.
Another mental disorder due to another medical condition
The diagnosis of personality change due to another medical condition is not given if the
disturbance is better explained 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 relationship
between the personality change and substance use, the other specified category for the
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(F60.89)
(F60.9)
specific substance can be used (e.g., other specified stimulant-related disorder with
personality change).
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 conduct disorders; panic
disorder). However, in these disorders, no specific physiological factor 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 Speci�ed Personality Disorder
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
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”).
Unspeci�ed Personality Disorder
This category applies to presentations in which symptoms characteristic of a
personality disorder that cause clinically significant distress or impairment in social,
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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 reason that the criteria are not met for a specific personality
disorder and includes presentations in which there is insufficient information to make
a more specific diagnosis.
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