Posted: August 6th, 2022

Week 10 _ Assignment: Therapy for Clients With Personality Disorders

See complete instructions on attached document.

Assignment: Therapy for Clients with Personality Disorders

Individuals with personality disorders often find it difficult to overcome the enduring patterns of thought and behavior that they have thus far experienced and functioned with in daily life. Even when patients are aware that personality-related issues are causing significant distress and functional impairment and are open to counseling, treatment can be challenging for both the patient and the therapist. For this Assignment, you examine specific personality disorders and consider therapeutic approaches you might use with clients.

To prepare:

·

Select one of the personality disorders from the DSM-5-TR- See attached PDF document (e.g., paranoid, antisocial, narcissistic, etc.). Then, select a therapy modality (individual, family, or group) that you might use to treat a client with the disorder you selected.

The Assignment _ Instructions

Succinctly, in 2-3 pages, address the following:

· Briefly describe the personality disorder you selected, including the DSM-5-TR diagnostic criteria. ( Use the DSM-5-TR attached PDF document)

· Explain a therapeutic approach and a modality you might use to treat a client presenting with this disorder. Explain why you selected the approach and modality, justifying their appropriateness.

· Next, briefly explain what a therapeutic relationship is in psychiatry. Explain how you would share your diagnosis of this disorder with the client in order to avoid damaging the therapeutic relationship. Compare the differences in how you would share your diagnosis with an individual, a family, and in a group session.

· Support your response with specific examples from this week’s Learning Resources and at least three peer-reviewed, evidence-based sources. Explain why each of your supporting sources is considered scholarly. Attach the PDFs of your sources.

· Use APA7

· At least 5 references – 2 from this week’s Learning Resources (see PDF attachments) and at least three peer-reviewed, evidence-based sources. Attach the PDFs of your sources

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10

Psychotherapies

Psychotherapy for personality disorders (PDs), like any other form of treatment, should be evidence based. For many years, if you wanted to
read about treatment, the only choices you had were to read books describ-

ing the clinical experience of an “expert.” You could also go to workshops

to learn about these ideas. Recommendations were not based on empirical

evidence, however, because there wasn’t any.

Almost all research on the treatment of PDs has studied patients

meeting criteria for borderline PD (BPD), which is also the condition

that most interests clinicians. Starting with the seminal work of Linehan

(1993), a number of innovative methods of treatment have been tested

in clinical trials and shown to be effective. There are now half a dozen

therapies for patients with BPD, each described by an acronym. I am not

convinced, however, that they work in different ways and have different

effects.

http://dx.doi.org/10.1037/14642-011
A Concise Guide to Personality Disorders, by J. Paris
Copyright © 2015 by the American Psychological Association. All rights reserved.

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Three caveats should be considered. First, even if one follows a tested

method of psychotherapy, many decisions still need to be made that

derive from experience and skill. Second, research on the therapy of BPD

does not have the heft of literature on other mental disorders, such as

depression or anxiety. Third, there is no evidence that any one method

that has been tested is better than any other. Any therapy that is well

planned will be better than unstructured treatment as usual (TAU)

because it provides patients with external structures that make up for their

inner chaos.

A further limitation, one that applies to any psychotherapy, is that not

every patient can be expected to benefit from treatment. Even in the most

seriously ill, however, rehabilitation can have partial effects. Yet some are

sicker than others, and those who do best usually have “ego strengths”—

a job, an intimate relationship, or both. These areas of positive function-

ing provide patients with a base on which to build skills in other areas.

Although there are always surprises and some patients who are seriously

ill may recover, the observation that better functioning is predictive of

outcome in psychotherapy is a well-known and consistent finding in

research (Bohart & Greaves-Wade, 2013). If you are treating patients

who have no job, no relationship, and no life to speak of, what is there to

work on? If, on the other hand, patients have a life, then therapy benefits

from a laboratory setting in which people can practice what they learn

in treatment sessions.

Although specialized therapies may not be different from each other,

not all psychotherapies applied in practice are equal. What researchers

call TAU tends to be a mess in which patients talk about their problems

to a sympathetic professional but are not given specific guidance in over-

coming dysfunctional emotions, thoughts, and behaviors. This is why

clinical trials always find that specific methods do better than TAU: It

is not hard to do better. Yet when comparisons are made between two

well-structured approaches, differences usually disappear (McMain et al.,

2009; Zanarini, 2009). Patients need planned and structured forms of

therapy, but the brand name may make no difference.

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SPECIFIC METHODS OF PSYCHOTHERAPY FOR BPD

Dialectical Behavior Therapy

Dialectical behavior therapy (DBT) was the first evidence-based treatment

for BPD. Developed by Marsha Linehan (1993), this was the first psycho-

therapy for BPD to undergo successful clinical trials (Linehan, Armstrong,

Suarez, Allmon, & Heard, 1991; Linehan et al., 2006). The introduction of

DBT was a turning point in the treatment of the disorder, and its principles

lie at the core of all successful therapy in this population. Here, at last, was

a practical approach that targeted the key traits and symptoms of BPD.

Today, DBT remains the leading evidence-based method of therapy

for patients with BPD. It is an adaptation of cognitive behavioral therapy

(CBT), combined with interventions common to other approaches, but

specifically designed to target the emotion dysregulation that characterizes

BPD, and to reduce impulsive behaviors. It applies chain analysis to inci-

dents leading to self-injury and overdoses—that is, showing patients what

emotions lead up to impulsive behaviors and teaching them alternative

ways of handling dysphoric emotions. DBT also emphasizes empathic

responses to distress that provide validation for the inner experience

of patients. The program consists of weekly individual therapy, group

psychoeducation, telephone availability for coaching, as well as support

through consultation for therapists undertaking these procedures. The

method is an eclectic mix of behavior therapy, CBT, mindfulness based

on Zen Buddhism, and original ideas such as radical acceptance (Linehan,

1993). These techniques have been described in some detail (Linehan,

2014; Linehan & Koerner, 2012).

The first published trial (Linehan et al., 1991) compared 1 year of DBT

with TAU and found DBT to be superior, especially in regard to reductions

in self-harm, overdose, and hospitalization. The question was whether it

was too easy to do better than TAU. For this reason, Linehan et al. (2006)

conducted a second clinical trial in which the comparison group was

“treatment by community experts”—therapists who identified themselves

as interested in BPD and experienced in its treatment. The results again

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favored DBT, with reductions in overdoses and subsequent hospitaliza-

tions within a year, although this time there were no differences between

the groups in the frequency of self-harm. Replication studies in other cen-

ters produced similar results, albeit with higher rates of attrition (Linehan

& Koerner, 2012). A meta-analysis (Kliem, Kröger, & Kosfelder, 2010) sup-

ported the conclusion that DBT is an effective and specific method that is

superior to traditional ways of treating BPD patients.

Although several specific methods of therapy designed for BPD

symptoms have been supported by randomized controlled trials (Paris,

2010b), the strongest evidence supports DBT. The method is a clinical

application of psychological research on emotion regulation (Gross, 2013).

The dysregulation in BPD leads to unstable emotions that are abnormal

responses to interpersonal conflict (Koenigsberg, 2010). That conclusion

has been confirmed by studies of BPD patients using ecological momen-

tary assessment, a technology that allows researchers to track emotional

instability more closely by immediate recording of affective and behav-

ioral responses to life events (Russell et al., 2007; Trull et al., 2008). In

DBT, patients are taught better ways of calming down, during and after

emotional storms, which then reduces the frequency of self-harm and

overdoses.

There are some important unanswered questions about DBT. Although

the original cohort received therapy 20 years ago, it has never been fol-

lowed up, so we do not know whether treated samples maintain their

gains and continue to improve beyond a 1-year posttreatment follow-up.

Also, given the resources required to conduct DBT, it needs to be deter-

mined whether this complex program can be dismantled or streamlined

for greater clinical impact. One report found that a 6-month version of

the therapy can also be effective (Stanley, Brodsky, Nelson, & Dulit,

2007). A treatment lasting for a year (and often more) becomes quickly

inaccessible as waiting lists grow and most patients and their families

cannot afford the expense.

Finally, there is the question of whether DBT is a uniquely effica-

cious treatment for BPD or whether other well-structured approaches

can produce the same results. To address this issue, McMain et al. (2009)

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administered DBT for 1 year, with random assignment to a comparison

condition called general psychiatric management, a manualized version of

the American Psychiatric Association (2001) guidelines for the treatment

of BPD. The results of this comparative trial found no differences between

the groups in overdoses, hospitalization, or self-harm. This negative find-

ing had important clinical implications. It suggests that although DBT is

better than most treatments, it can be matched by other therapies that are

designed for this population and that are equally well-structured. Further,

because results were good in both groups, the treatment package used for

the comparison has now been studied on its own, under the name of good

psychiatric management (Gunderson & Links, 2014).

A key question about DBT is whether the results of the treatment are

specific to the method or to the structure. By and large, psychotherapy

research supports a common factors model in which all well-structured

treatments yield similar outcomes (Wampold, 2001). The positive results

of DBT could be due to its high level of structure rather than to its specific

interventions. This supposition was supported by the study by McMain

et al. (2009). So although DBT is clearly better than TAU and somewhat

better than treatment by therapists with experience in treating BPD,

it is not necessarily better than a well-thought-out program of clinical

management.

The popularity of DBT depends on its comprehensiveness, as well as

on its commitment to conducting research to demonstrate its efficacy.

DBT is not the only evidence-based therapy on the market, but it is the

only method that has been tested in multiple clinical trials outside the cen-

ter where it was developed, showing that its efficacy cannot be accounted

for by allegiance effects. The ideas behind DBT are fundamental for any

therapist seeing patients with BPD. It is not a narrowly focused form of

treatment that only deals with cognitive schemata; it also provides vali-

dating responses to current emotional upsets and offers education about

emotion regulation.

However, there is a serious problem with DBT: Its expense makes it

inaccessible. This is mainly because of the length of therapy. DBT has been

tested for a year, but even that length of time is beyond most insurance

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policies or the financial resources of most families. Of even more concern,

Linehan (1993) suggested that even this lengthy period may be only the

first phase of a treatment that could go on for several years. I am reminded

of the story of psychoanalysis in which inevitably incomplete results led to

an interminable course of therapy. DBT is effective but is accessible only

to those who can pay for it. Even if it were properly insured, its length

would still make access a problem: Clinics offering the treatment, even for

12 months, often have extensive waiting lists. It is important to shorten

DBT or to make it intermittent (or do both). This is the only way to provide

service to more patients.

We all owe a debt to Marsha Linehan. I have learned an enormous

amount from her and have applied her principles in all the clinics I lead

that treat BPD. Moreover, Linehan’s recent public statements, acknowl-

edging that she herself once suffered from BPD but recovered, were coura-

geous and have done a great deal to reduce the stigma associated with this

disorder. Nonetheless, treatment for BPD suffers from the perception that

DBT is the only brand that works. Therapists should not feel badly if they

are not in a position to provide DBT in a formal way or to refer patients to

a DBT clinic. In the next chapter, I show that its principles can be incor-

porated into normal clinical practice. In my view, brand names are bad for

therapy. As cognitive theory evolves, it has become a more general term for

what might be called simply psychotherapy (Beck & Haigh, 2014). Livesley

(2012) recommended that DBT give up its brand name and incorporate

its best ideas into a general model of treatment for BPD.

Other Evidence-Based Psychotherapies for BPD

Although other methods have been devised, they do not differ from DBT in

any essential way (Paris, in press). We now examine those that have under-

gone clinical trials.

Mentalization-based treatment (MBT; Bateman & Fonagy, 2006) is

rooted in attachment theory, but the method also has a strong cognitive

component. Its assumption is that BPD patients have trouble recognizing

emotions (their own and those of other people), that is, mentalization.

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MBT teaches patients how to do that better. Like most effective programs,

it uses a combination of group and individual therapy. Although devel-

oped by psychoanalysts, it uses a number of cognitive methods similar to

DBT in that patients are taught to recognize their emotions, learn how to

tolerate them, and manage them in more adaptive ways.

MBT was first tested in a randomized controlled trial (RCT) in a day

program lasting 18 months (Bateman & Fonagy, 2001) and found to be

superior to TAU. A second study in a larger sample of outpatients given

18 months of treatment found a decline of both self-reported symptoms

and clinically significant problems, including suicide attempts and hospi-

talization (Bateman & Fonagy, 2009). This is the only method for which

researchers have followed up a cohort for 8 years to determine if the effects

of treatment remain stable, which turned out to be the case (Bateman &

Fonagy, 2004).

MBT needs successful clinical trials in centers outside the hospital where

it originated. Thus far, the only attempt at replication outside the United

Kingdom reported few differences from standard therapy (Jørgensen et al.,

2013). However, Bateman and Fonagy (2008) do not consider MBT as a

“one-and-only” approach but encourage mental health workers to learn

its principles and then apply them in their own clinical settings, without

necessarily following a strict protocol. One can only applaud such open-

mindedness and flexibility. Finally, Bateman and Fonagy (2008) have stated

that the results of their research are not specific to their method but sup-

port any structured approach to psychotherapy. This may be the most con-

sistent finding in this literature (Choi-Kain & Gunderson, 2008).

Transference-focused psychotherapy (TFP; Clarkin, Levy, Lenzenweger,

& Kernberg, 2007) is based on the theories of the psychoanalyst Otto

Kernberg. It differs from other methods in that its focus is on distortions

between therapist and patient in the session, used to illustrate inter-

personal problems elsewhere in the patient’s life. It has thus far under-

gone two clinical trials, one comparing it with DBT, with only minimal

differences (Clarkin, Levy, Lenzenweger, & Kernberg, 2007), and one

comparing it with TAU, to which it was superior (Doering et al., 2010).

TFP aims to generalize what happens in therapy to outside relationships.

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Given the long record of failure for psychodynamic therapy in BPD, one

might consider this approach with caution. Nonetheless, at this point TFP

has about as much support as MBT. It shares the advantage of being struc-

tured and well thought out.

Cognitive analytic therapy is based on similar concepts and can be

considered as another psychodynamic–cognitive hybrid. It applies object

relations theory to establish a firmer sense of self in patients. It has been

tested in a population of adolescents (Chanen & McCutcheon, 2013),

where it was effective, albeit not superior, to a manualized version of

“good clinical care.”

Schema-focused therapy (SFT; Young, Klosko, & Weishaar, 2003) is

another mixture of cognitive and psychodynamic approaches that aims

to modify how patients think about their world (i.e., cognitive schemata),

but it also focuses on the distorting effects of negative childhood experiences.

It has undergone one clinical trial comparing it with transference-focused

psychotherapy (Giesen-Bloo et al., 2006), with only minor differences in

outcome and one trial in which it was superior to TAU (Bamelis, Evers,

Spinhoven, & Arntz, 2014). The problem with schema-focused therapy

is that it is designed to last for 3 years, making it even more inaccessible

than DBT.

Standard CBT has been tested in a study conducted in the United

Kingdom (Davidson, Tyrer, Norrie, Palmer, & Tyrer, 2010). After an aver-

age of 26 sessions, BPD patients did better with cognitive therapy than

with TAU. It also seems likely that CBT for BPD is now being conducted

on broader, more flexible principles. When a Cochrane review (Stoffers,

Völlm, et al., 2012) concluded that the data for cognitive therapy were

“promising,” they were not thinking of standard CBT. Linehan had devel-

oped DBT because of her impression that standard CBT was not effective

for BPD. Yet a large RCT (Davidson et al., 2010) found manualized CBT,

modified to target PD symptoms, was superior to TAU for the treatment

of recurrent deliberate self-harm.

It is important to know that therapy lasting for a few months can

be effective. The evidence for this conclusion was recently reviewed by

Davidson and Tran (2014). What was most striking about these findings

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was that the mean length of treatment was 16 sessions. This suggests that

BPD might be treated more rapidly, and less expensively, than by treat-

ments designed to continue for a year or two. Perhaps the most chronic

and severe patients with BPD require several years of therapy, but it makes

no sense to make a long duration the standard of care.

Systems training for emotional predictability and problem solving (STEPPS;

Blum et al., 2008) is a brief and practical program that closely resembles

DBT in its focus on emotion regulation skills. It is designed to supple-

ment TAU, particularly in settings where specialized individual therapies

are not available. STEPPS, based on psychoeducation in groups, has been

supported by clinical trials, with a 1-year follow-up (Blum et al., 2008).

STEPPS is a short-term intervention with psychoeducation conducted

in groups, designed to supplement standard psychotherapy or manage-

ment conducted elsewhere. It is particularly suitable for populations living

in regions where specialized treatment is not available. It is inexpensive

and offers ready accessibility. STEPPS has been subjected to a successful

clinical trial in BPD (Blum et al., 2008), with one replication (Bos, van

der Wel, Appelo, & Verbraak, 2010). It has also undergone one test in

the treatment of antisocial PD (Black, Gunter, Loveless, Allen, & Sieleni,

2010), although one cannot conclude that this makes antisocial PD as

treatable as BPD.

COMMON FACTORS IN THE TREATMENT OF BPD

Although these individual approaches each have useful ideas and tech-

niques, they work through common mechanisms (Paris, in press). A vast

literature shows that the effective factors for outcome in any form of psy-

chotherapy are common rather than specific (Wampold, 2001). Nor is it

necessarily true that patients with BPD can only be seen in specialized

clinics; most benefit from what Gunderson and Links (2014) termed good

psychiatric management. The ideas behind effective therapy are spread-

ing to the wider therapeutic community, and interventions (e.g., teaching

emotion regulation) are becoming part of the armamentarium of thera-

pists of all persuasions.

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It is unfortunate that psychotherapy as a field continues to be defined

by competing methods, many of which use a three-letter acronym. It is

even more unfortunate that clinicians define themselves as practitioners

of any single method. Research can help us get beyond these unnecessary

divisions.

Thus, I agree with Livesley (2012), who suggests that psychotherapy

should be evidence based, not acronym based. Even if some interventions

are partly specific to BPD, we need a single model of therapy to make use

of the best ideas for all sources. To have multiple methods competing for

market share may be good for book sales, but it is not the way to develop

evidence-based practice.

We do not need so many forms of psychotherapy, most of which

resemble each other more in practice than in theory. If therapies based on

so many different ideas and using many different techniques can produce

the same results, they must have a lot in common. One of the main ingre-

dients is structure. Traditional therapies for PD failed because they rely on

unstructured techniques that leave patients adrift. These are not patients

who get better just by being heard and supported. People with BPD also

need specific instruction about emotion regulation, control of impulsiv-

ity, and life skills that can be used to find a job and build a social network.

Although different methods seem to target different aspects of PD, the

failure of comparative trials to find large differences in outcome also sug-

gests that common factors are of crucial importance. Again, consider the

large body of research supporting the view that common factors (also called

nonspecific factors) are the best predictors of results in all forms of psycho-

therapy (Wampold, 2001). By and large, when different forms of therapy are

compared head to head, researchers almost always find equivalent results.

The most important common factors are a strong working alliance, empa-

thy, and a practical problem-solving approach to life problems (Baldwin &

Imel, 2013; Crits-Christoph, Gibbons, & Mukherjee, 2013).

With a complex and challenging disorder like BPD, psychotherapy

needs to maximize these mechanisms and find ways to make them more

specific. The best-validated methods offer a defined structure, focus on

the regulation of emotions, and encourage the solution of interpersonal

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problems through self-observation. Empathy and validation are essential

elements of any therapy but are particularly important for BPD patients,

many of whom are sensitive to the slightest hint of invalidation (Kohut,

1970; Linehan, 1993). In other words, these are patients who can easily feel

that their emotions are being dismissed. They will not listen to anything

else you have to say unless they perceive that their feelings are accepted.

Self-observation is a skill that therapists need to teach all their patients.

When one learns to know feelings better (and not be derailed by them),

one can stand aside from emotional crises or even begin to think about

alternative solutions to problems. Clinicians who provide treatment fol-

lowing these principles do not necessarily need to refer patients to special-

ized programs.

IMPORTANCE OF STRUCTURE IN PSYCHOTHERAPY

Psychotherapy is the backbone of treatment in BPD, but clinicians in the

past were not trained to apply structure to treatment sessions. That is prob-

ably why open-ended therapies have been associated with large dropout

rates (Skodol, Buckley, & Charles, 1983). Moreover, therapies that focus too

much on the past have a way of encouraging patients to regress.

The key to recovery from a PD is to “get a life.” That usually means

finding a job or going back to school to prepare for a job. Without a social

role, recovery from a PD is less likely (Zanarini et al., 2012). Unfortunately,

some of our patients make the mistake of trying to solve their life prob-

lems through an intimate relationship that gives the illusion, for a time, of

unconditional love. In the absence of work, that strategy only makes them

dependent on another person, seriously impeding self-mastery.

Finally, because PDs usually improve with time, therapy aims to hasten

naturalistic recovery. Because patients can get better on their own, deter-

mining whether change is the result of a specific intervention requires test-

ing through RCTs. Thus far, these trials have provided strong support for a

few psychotherapy methods and tentative support for others.

In summary, even if a well-structured approach works well for most

patients, generalized methods might be enough, and patients with BPD

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have done much better since DBT and other methods specific to the dis-

order were developed. We await the day when effective packages of this

kind can be developed for other PDs.

WHAT WORKS, WHAT D OESN’T WORK, AND WHY

Because of their prominent mood symptoms, patients with BPD are often

put on medication and can end up being prescribed four or five different

drugs (Zanarini, Frankenburg, Khera, & Bleichmar, 2001). The review in

Chapter 9 showed that these practices are not evidence based. The role of

pharmacology in BPD treatment is limited and is most effective for short-

term management of insomnia. Because most medications in current use

(antipsychotics, antidepressants, and mood stabilizers) are sedating,

they can “take the edge off ” BPD symptoms through nonspecific effects

on impulsivity. However, as shown by the most recent Cochrane report

(Stoffers, Völlm, et al., 2012), none of these agents have specific effects

on BPD itself. Most patients can be managed with minimal medication

or with no medication at all.

Clinical psychologists treating BPD patients should therefore be cau-

tious about obtaining psychopharmacological consults to “cover them-

selves.” I understand why this happens; these are difficult, scary cases.

However, when you ask for a consult with an MD, your patient may be put

on an aggressive drug regime. If you read the literature, with its conserva-

tive conclusions, it will become clear that although drugs are palliative in

the short term, no pharmacological agent produces remission in BPD. If

you need consultation on difficult cases, I suggest you choose clinicians

with expertise in the psychotherapy of BPD.

It must be acknowledged that psychotherapy for these patients has

not always had a good reputation. More than 75 years ago, Stern (1938)

described BPD as treatment-resistant (i.e., it didn’t respond to psycho-

analysis). Ever since, therapists have struggled with the obstacles the

disorder presents. It is not easy to manage people who don’t follow your

advice, don’t always come to appointments, and frequently threaten

suicide.

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Even so, many problems can also be understood as artifacts of well-

meaning but insufficiently structured therapy. TAU is often the com-

parison point in research studies, but it might be better described as

“the usual mess.” Patients with BPD don’t fit well into normal practice,

in either clinics or offices. They need therapists trained to provide more

specific interventions.

Yet even when therapy is based on a theory, it can still falter. In the

past, patients with BPD were offered regressive psychoanalytic approaches

that were unproductive or counterproductive. In BPD, therapy fails when

too much time is spent talking about the past. Of course, if childhood was

marked by trauma, life histories need to be validated and understood, but

patients need to move on and deal with their current problems in relation-

ships and work.

Standard methods of behavioral therapy and CBT may also run into

difficulties in this population. Linehan (1993) developed DBT because

standard CBT did not seem to be effective for treatment of BPD. For exam-

ple, patients with BPD are not always willing to do the homework that CBT

requires. Linehan’s discovery was that therapy works best when offering

specific strategies for emotion regulation. This was the great breakthrough

that has made BPD a treatable disorder.

Moreover, the “supportive” techniques used in TAU (sessions that

review the week and provide nonspecific encouragement) are not evidence

based. Research on therapy for BPD shows that almost any specific method

is better than TAU, underlining the limitations inherent in the reality of

all these “usual” clinical practices. Yet, as more therapists become aware of

more specific methods, TAU itself may be changing for the better.

Being an effective therapist for these patients may not depend that

much on your theory about BPD. It is more important to understand

people whose communication style can be difficult and problematic, to be

comfortable with knowing that you cannot prevent suicide. If you want to

treat BPD, the first requirement is a thick skin.

Yet psychotherapies designed for BPD have a stronger evidence base

than any form of pharmacotherapy. As noted earlier, medications have

never been shown to lead to the sustained remissions documented for

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A C O N C I S E G U I D E TO P E R S O NA L I T Y D I S O R D E R S

132

psychological treatments. However, not “any old” psychotherapy will do.

In the past, mistaken methods leading to poor results have given therapy

for patients with BPD a difficult reputation.

Although no research has specifically examined TAU, it is not difficult

to see why it doesn’t work. Patients come to their sessions and tell stories

about stressful events that have occurred over the week. Therapists vali-

date feelings, but by itself, that does little for patients who misunderstand

and distort their interpersonal environment. The danger is that patients

will perceive that their therapists agree with them—that other people are

to blame and that they are victims.

Empathy has to be linked to tactful confrontations to help patients

learn new ways of understanding and dealing with problems, what

Bateman and Fonagy (2006) called the capacity to mentalize (similar to the

concept of mindfulness). Thus, using what Linehan (1993) called a dia-

lectical approach, one must validate as one teaches new skills. The absence

of such an approach is why supportive therapy has limited value. The aim

must be to have a strong enough alliance with patients that they are willing

to see their problems in a different light.

These principles help us to understand why classical psychodynamic

therapy was often ineffective for BPD. Patients who cannot mentalize and

who are constantly in the throes of emotion dysregulation cannot make

use of procedures such as free association with a relatively silent therapist

who only intervenes to make “interpretations.” Moreover, when therapy

focuses on the past rather than the present, patients are more likely to be

mired down in their grievances than to move on (this is what Linehan

meant by radical acceptance). People move on more easily when they feel

understood, independent of a therapist’s theories (Strupp, Fox, & Lesser,

1969). Reexperiencing traumatic events from childhood can be par-

ticularly counterproductive. A neuroimaging study helps to show why.

Koenigsberg (2010) found that patients with BPD do not habituate to stress-

ful thoughts but become increasingly activated and disturbed. Thus, thera-

pies that focus on trauma produce regression and increase symptom levels.

In summary, therapies that are present oriented, have a strong cognitive

component, balance acceptance and change, offer a predictable structure,

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P S YC H OT H E R A P I E S

133

and in which therapists are active and engaged are most likely to succeed.

We need to place more importance on the present than the past to help

patients to get a life. In most cases this means getting a job or an education.

It can also mean raising a family. For some people, it may involve hobbies

or volunteer work. In whatever form, one must engage with the world to

get better. Patients also need to be told that they have to work on getting a

life now, not wait for therapy to somehow make doing so easier.

INTEGRATED BPD TREATMENT

Although evidence-based treatments for BPD have emerged from spe-

cialized treatment programs, these clinics tend to be too expensive or

inaccessible. Yet even though these are not the settings where most ther-

apists work, the same principles can be applied to ordinary practice.

An example is the use of group therapy to teach patients behavioral

and cognitive skills, which is part of the package offered by the methods

that have been most systematically tested. Most clinicians in practice do

not carry out this kind of treatment. This is why the STEPPS program

was developed: to augment individual therapies conducted by therapists

in the community by providing a group setting based on the principles

of psychoeducation. Yet because few communities have access to STEPPS,

therapists should consider doing more group therapy in their own prac-

tices or in group practices. Another example is the use of psychoeducation

to teach life skills and emotion management. CBT has been doing this for

decades. These methods can also be transferred to the setting of individual

therapy.

Another implication of research on BPD treatment is that therapists

need to move out of the primarily receptive mode they may have been

taught to adopt. There is no contradiction between empathic listening

and therapeutic activity.

Psychotherapy for BPD is being held back by the existence of mul-

tiple competing methods, each with a three-letter acronym. The results

of these methods tend to be overinterpreted by therapists with allegiance

to one or another of them. Yet although all well-structured methods are

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134

superior to TAU, none is clearly superior. There should be only one kind

of psychotherapy for PD: the one that works. An integrated method would

use the best ideas from everyone and put them together into one package

(Livesley, 2012).

This conclusion, consistent with research on common factors in all

therapies, should be reassuring. Therapists need not be overly concerned

that they haven’t been trained in the latest method or the latest twist on

existing methods. Psychotherapy is placed in a bad light by the endless

competition between approaches. In medicine, there is no such thing as

a school of treatment specific to any drug; therapeutic agents are used

when appropriate and when they complement other interventions. Even

so, treatment of BPD cannot be generic but needs to be more specific. For

some clinical problems, such as severe substance abuse (W. R. Miller &

Rollnick, 2013), new and different methods have been developed. Several

of the therapies developed for BPD offer unique interventions that go

beyond what clinicians do for most of their patients.

Linehan unlocked a crucial door by placing emphasis on skills for

emotion regulation. BPD patients do not recognize their emotions or

know how to deal with them, nor do they know how to self-soothe when

experiencing difficult feelings. They often do not even know they have

had an emotion and move directly to impulsive actions to get rid of a bad

or uncomfortable feeling. That is why reviewing the sequence of events

before a cut or an overdose is so crucial. Also, even though mindfulness

is a difficult technique for most people to learn, even the simplest forms

of self-observation can be useful. STEPPS offers a practical method, with

down-to-earth pictograms of boiling pots to help people rate the inten-

sity of their emotions. MBT also teaches people to recognize what they

feel, but adds an emphasis on the need to recognize what other people

are feeling.

Radical acceptance is another important element that is common to

all effective therapies. Patients are not encouraged to feel like victims but to

come to terms with the past. Most will have had difficult childhoods with

adverse events of various kinds. Yet they need to accept the hand that life has

dealt them and to accept themselves with all their flaws. Radical acceptance

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P S YC H OT H E R A P I E S

135

is similar to the famous motto of Alcoholics Anonymous, which advises

people to accept what they cannot change.

Rather like the proverbial tale of the blind men and the elephant, each

of the specific methods developed to treat these patients looks at the prob-

lem of BPD from a different angle, and all have some degree of validity.

One can combine the management of emotion dysregulation emphasized

by DBT, the ability to observe feelings emphasized by MBT, and the focus

on negative thought patterns that characterizes SFT, together with a lim-

ited level of exploration and understanding of life histories. These tools

are all part of a broad therapeutic armamentarium, nested in an empathic

and practical approach, aimed at maximizing the common factors that

produce success.

APPLYING EVIDENCE-BASED PRACTICE TO
PD TREATMENT AS A WHOLE

When specific methods are developed for the other PDs, they will prob-

ably follow many of the same principles described for BPD. What is

needed is to define trait domains that can be modified by psychological

interventions and to develop interventions that can be used to increase

interpersonal skills and reduce negative patterns of behavior. For exam-

ple, a treatment package that had an effective way of modifying gran-

diosity could open the door to effective treatment of narcissistic PD.

Similarly, a package modifying perfectionism would be the key to treat-

ing obsessive–compulsive PD. It is known that CBT programs for treat-

ing social anxiety have some effect on avoidant PD (Ahmed et al., 2012),

but they have not been extensively tested.

In many ways, psychotherapy for PDs is just beginning. BPD, because

of its great clinical burden, will continue to take precedence. However,

other PDs, common in clinical and community settings, need specific

interventions of their own. Inspired by the success of treatment for BPD,

such programs are bound to be developed in the coming decades.

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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

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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

histrionic personality disorder. J Sex Marital Ther 20(2):125–133, 1994

Bakkevig JF, Karterud S: Is the Diagnostic and Statistical Manual of Mental Disorders,

Fourth Edition, histrionic personality disorder category a valid construct? Compr

Psychiatry 51(5):462–470, 2010

Blashfield RK, Reynolds SM, Stennett B: The death of histrionic personality disorder, in

The Oxford Handbook of Personality Disorders. Edited by Widiger TA. New York, Oxford

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Cramer V, Torgersen S, Kringlen E: Personality disorders and quality of life: a population

study. Compr Psychiatry 47(3):178–184, 2006

Crews M, Moran P, Bhugra D: Personality disorders and culture, in Textbook of Cultural

Psychiatry. Edited by Bhugra D, Bhui K. Cambridge, UK, Cambridge University Press,

2007, pp 272–281

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Disney KL, Weinstein Y, Oltmanns TF: Personality disorder symptoms are differentially

related to divorce frequency. J Fam Psychol 26(6):959–965, 2012

Forbes MK, Kotov R, Ruggero CJ, et al: Delineating the joint hierarchical structure of

clinical and personality disorders in an outpatient psychiatric sample. Compr Psychiatry

79:19–30, 2012

García-Nieto R, Blasco-Fontecilla H, de León-Martinez V, Baca-García E: Clinical features

associated with suicide attempts versus suicide gestures in an inpatient sample. Arch

Suicide Res 18(4):419–431, 2014

Girard JM, Wright AGC, Beeney JE, et al: Interpersonal problems across levels of the

psychopathology hierarchy. Compr Psychiatry 79:53–69, 2017

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

Holzer KJ, Huang J: Physical health–related quality of life among older adults with

personality disorders. Aging Ment Health 23(8):1031–1040, 2019

Kendler KS, Aggen SH, Czajkowski N, et al: The structure of genetic and environmental

risk factors for DSM-IV personality disorders: a multivariate twin study. Arch Gen

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(HiTOP): a dimensional alternative to traditional nosologies. J Abnorm Psychol

126(4):454–477, 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

Maclean JC, French MT: Personality disorders, alcohol use, and alcohol misuse. Soc Sci

Med 120:286–300, 2014

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(F60.81)

Millon T: Sociable styles, pleasuring types, histrionic disorders: the SPH spectrum

(Chapter 7), in Disorders of Personality: Introducing a DSM/ICD Spectrum From Normal

to Abnormal. Hoboken, NJ, Wiley, 2011, pp 330–374

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

Pulay AJ, Dawson DA, Hasin DS, et al: Violent behavior and DSM-IV psychiatric

disorders: results from the National Epidemiologic Survey on Alcohol and Related

Conditions. J Clin Psychiatry 69(1):12–22, 2008

Røysamb E, Kendler KS, Tambs K, et al: The joint structure of DSM-IV Axis I and Axis II

disorders. J Abnorm Psychol 120(1):198–209, 2011

Ryder AG, Costa PT, Bagby RM: Evaluation of the SCID-II personality disorder traits for

DSM-IV: coherence, discrimination, relations with general personality traits, and

functional impairment. J Pers Disord 21(6):626–637, 2007 18072864

Vaughn MG, Fu Q, Beaver D, et al: Are personality disorders associated with social

welfare burden in the United States? J Pers Disord 24(6):709–720, 2010a

Vaughn MG, Fu Q, Bender K, et al: Psychiatric correlates of bullying in the United States:

findings from a national sample. Psychiatr Q 81(3):183–195, 2010b

Wilson S, Stroud CB, Durbin CE: Interpersonal dysfunction in personality disorders: a

meta-analytic review. Psychol Bull 143(7):677–734, 2017 28447827

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most strongly associated with indices of psychosocial morbidity in psychiatric

outpatients? Compr Psychiatry 53(7):940–945, 2012

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

Blasco-Fontecilla H, Baca-Garcia E, Dervic K, et al: Specific features of suicidal behavior

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

Ronningstam E: Narcissistic trauma and suicide [in Italian], in Pathological Narcissism.

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

Vater A, Moritz S, Roepke S: Does a narcissism epidemic exist in modern western

societies? Comparing narcissism and self-esteem in East and West Germany. PloS One

13(1):e0188287, 2018 (correction: PloS One 13(5):e0198386, 2018 29813123)

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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