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Personality disorder (DSM 5)
Abnormal Psychology (PSY 9)
Pamantasan ng Lungsod ng Valenzuela
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Lesson 11 – Personality Disorders
A personality disorder is an enduring pattern of inner experience and
behavior that deviates markedly from the 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.
General Personality Disorder
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:
- Cognition (i., ways of perceiving and interpreting self, other
people, and events).
- Affectivity (i., the range, intensity, lability, and appropriateness
of emotional response).
Interpersonal functioning.
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., a drug of abuse, a medication) or another medical
condition (e., head trauma).
Cluster A Personality Disorders
People with Cluster A PDs can be described as withdrawn, cold,
suspicious, or irrational.
Paranoid. These people are suspicious and quick to take offense. They
often have few confidants and may read hidden meaning into innocent
remarks.
Schizoid. These patients care little for social relationships, have a
restricted emotional range, and seem indifferent to criticism or praise.
Tending to be solitary, they avoid close (including sexual) relationships.
Schizotypal. Interpersonal relationships are so difficult for these
people that they appear peculiar or strange to others. They lack close
friends and are uncomfortable in social situations. They may show
suspiciousness, unusual perceptions or thinking, eccentric speech, and
inappropriate affect
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:
- Suspects, without sufficient basis, that others are exploiting,
harming, or deceiving him or her.
- Is preoccupied with unjustified doubts about the loyalty or
trustworthiness of friends or associates.
- Is reluctant to confide in others because of unwarranted fear that
the information will be used maliciously against him or her.
- Reads hidden demeaning or threatening meanings into benign
remarks or events.
- Persistently bears grudges (i., is unforgiving of insults, injuries,
or slights).
- Perceives attacks on his or her character or reputation that are
not apparent to others and is quick to react angrily or to
counterattack.
- Has recurrent suspicions, without justification, regarding fidelity
of spouse or sexual partner.
B. Does not occur exclusively during the course of schizophrenia, a
bipolar disorder, or depressive disorder with psychotic features, or
another psychotic disorder and is not attributable to the physiological
effects of another medical condition.
Note: If criteria are met prior to the onset of schizophrenia, add
“premorbid,” i., “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 co-worker as a serious character attack.
Compliments are often misinterpreted (e., a compliment on a new
acquisition is misinterpreted as a criticism for selfishness; a
compliment on an accomplishment is 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., temporal lobe epilepsy) or another
medical condition (Criterion B).
Differential Diagnosis
Other mental disorders with psychotic symptoms.
Paranoid personality disorder can be distinguished from delusional
disorder, persecutory type; schizophrenia; and a bipolar or depressive
disorder with psychotic features because these disorders are all
characterized by a period of persistent psychotic symptoms (e.,
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., 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 attributable to the direct effects of another medical
condition on the central nervous system.
Substance use disorders.
Paranoid personality disorder must be distinguished from symptoms
that may develop in association with persistent substance use.
Paranoid traits associated with physical handicaps.
The disorder must also be distinguished from paranoid traits
associated with the development of physical handicaps (e., 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 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. 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.
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 nticipation
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” may display personality traits that might
be considered schizoid. Only when these traits are inflexible and
maladaptive and cause significant functional impairment or subjective
distress do they constitute schizoid personality disorder.
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:
Ideas of reference (excluding delusions of reference).
Odd beliefs or magical thinking that influences behavior and is
inconsistent with subcultural norms (e., superstitiousness,
belief in clairvoyance, telepathy, or “sixth sense”; in children and
adolescents, bizarre fantasies or preoccupations).
Unusual perceptual experiences, including bodily illusions.
Odd thinking and speech (e., vague, circumstantial,
metaphorical, overelaborate, or stereotyped).
Suspiciousness or paranoid ideation.
Inappropriate or constricted affect.
Behavior or appearance that is odd, eccentric, or peculiar.
Lack of close friends or confidants other than first-degree
relatives.
- 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., “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.
Individuals with schizotypal personality disorder often have ideas of
reference (i., 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., 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.,
walking past a specific object three times to avoid a certain harmful
outcome). Perceptual alterations may be present (e., sensing that
another person is present or hearing a voice murmuring his or her
name) (Criterion A3). Their speech may include unusual or
idiosyncratic phrasing and construction. It is often loose, digressive, or
vague, but 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., 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., 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., 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, 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 ime
in the setting or become more familiar with the other people, because
their anxiety tends to be associated with suspiciousness egarding
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).
Differential Diagnosis
Other mental disorders with psychotic symptoms.
Schizotypal personality disorder can be distinguished from delusional
disorder, schizophrenia, and a bipolar or depressive disorder with
psychotic features because these disorders are all characterized by a
period of persistent psychotic symptoms (e., 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., 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 attributable to the effects of another medical
condition on the central nervous system.
Substance use disorders.
Schizotypal personality disorder must also be distinguished from
symptoms that may develop in association with persistent substance
use.
Other personality disorders and personality traits.
Other personality disorders may be confused with schizotypal
personality disorder because they have certain features in common. It
is, therefore, important to distinguish among these disorders based on
differences in their characteristic features. However, if an individual
has personality features that meet criteria for one or more personality
disorders 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., intense anger,
anxiety, disappointment) and are usually more dissociative (e.,
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.
Cluster B Personality Disorders
Those with Cluster B PDs tend to be rather theatrical, emotional, and
attention-seeking; their moods are labile and often shallow. They
often have intense interpersonal conflicts.
Antisocial. The irresponsible, often criminal behavior of these people
begins in childhood or early adolescence with truancy, running away,
cruelty, fighting, destructiveness, lying, and theft. In addition to
criminal behavior, as adults they may default on debts or otherwise
behave irresponsibly; act recklessly or impulsively; and show no
remorse for their behavior.
Borderline. These impulsive people engage in behavior harmful to
themselves (sexual adventures, unwise spending, excessive use of
substances or food). Affectively unstable, they often show intense,
inappropriate anger. They feel empty or bored, and they frantically try
to avoid abandonment. They are uncertain about who they are, and
they lack the ability to maintain stable interpersonal relationships.
Differential Diagnosis
The diagnosis of antisocial personality disorder is not given to
individuals younger than 18 years and is given only if there is a history
of some symptoms of conduct disorder 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 consequence of the substance
use disorder (e., 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 personality disorder. Antisocial
personality disorder must be distinguished from criminal behavior
undertaken for gain that is not accompanied by the personality
features characteristic of this disorder. Only when antisocial
personality traits are inflexible, maladaptive, and persistent and cause
significant functional impairment or subjective distress do they
constitute antisocial personality disorder.
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:
- Frantic efforts to avoid real or imagined abandonment. (Note: Do
not include suicidal or self-mutilating behavior covered in Criterion 5.)
- A pattern of unstable and intense interpersonal relationships
characterized by alternating between extremes of idealization and
devaluation.
- Identity disturbance: markedly and persistently unstable self-image
or sense of self.
- Impulsivity in at least two areas that are potentially self-damaging
(e., spending, sex, substance abuse, reckless driving, binge eating).
(Note: Do not include suicidal or selfmutilating behavior covered in
Criterion 5.)
- Recurrent suicidal behavior, gestures, or threats, or self-mutilating
behavior.
- Affective instability due to a marked reactivity of mood (e., intense
episodic dysphoria, irritability, or anxiety usually lasting a few hours
and only rarely more than a few days).
Chronic feelings of emptiness.
Inappropriate, intense anger or difficulty controlling anger (e.,
frequent displays of temper, constant anger, recurrent physical fights).
- 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 when faced with a realistic time-limited
separation or when there are unavoidable changes in plans (e.,
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.
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, characterized by shifting
goals, values, and vocational aspirations. There may be sudden
changes in opinions and plans about career, sexual identity, values,
and types of friends. These individuals may suddenly change from the
role of a needy supplicant for help to that of a righteous avenger of
past mistreatment. Although they usually have a self-image that is
based on being bad or evil, individuals with this disorder may at times
have feelings that they do not exist at all. Such experiences usually
occur in situations in which the individual feels a lack of a meaningful
relationship, nurturing, and support. These individuals may show
worse performance in unstructured work or school situations.
Individuals with borderline personality disorder display impulsivity in
at least two areas that are potentially self-damaging (Criterion 4). They
may gamble, spend money 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). Completed suicide occurs in 8%–10%
of such individuals, and self-mutilative acts (e., cutting or burning)
and suicide threats and attempts are very common. Recurrent
suicidality is often the reason that these individuals present for help.
These self-destructive acts are usually precipitated by threats of
separation or rejection or by expectations that the individual assumes
increased responsibility. Self-mutilation may occur during dissociative
experiences and often brings relief by reaffirming the ability to feel or
by expiating the individual’s sense of being evil.
Individuals with borderline personality disorder may display affective
instability that is due to a marked reactivity of mood (e., 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 (Criterion 7). Easily bored, they may constantly
seek something to do. 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., 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, lasting
minutes or hours. The real or perceived return of the caregiver’s
nurturance may result in a remission of symptoms.
Differential Diagnosis
Depressive and bipolar disorders.
Borderline personality disorder often co-occurs with depressive or
bipolar disorders, and when criteria for both are met, both may be
diagnosed. Because the cross-sectional presentation of borderline
personality disorder can be mimicked by an episode of depressive or
bipolar disorder, the clinician should avoid giving an 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 longstanding course.
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
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 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).
Differential Diagnosis
Other personality disorders and personality traits.
Other personality disorders may be confused with histrionic
personality disorder because they have certain features in common. It
is therefore important to distinguish among these disorders based on
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 attributable to the effects of another medical condition on
the central nervous system.
Substance use disorders.
The disorder must also be distinguished from symptoms that may
develop in association with persistent substance use.
Narcissistic Personality Disorder
Diagnostic Criteria
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:
- Has a grandiose sense of self-importance (e., exaggerates
achievements and talents, expects to be recognized as superior
without commensurate achievements).
- Is preoccupied with fantasies of unlimited success, power, brilliance,
beauty, or ideal love.
- 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).
Requires excessive admiration.
Has a sense of entitlement (i., unreasonable expectations of
especially favorable treatment or automatic compliance with his or her
expectations).
- Is interpersonally exploitative (i., takes advantage of others to
achieve his or her own ends).
- Lacks empathy: is unwilling to recognize or identify with the feelings
and needs of others.
- Is often envious of others or believes that others are envious of him
or her.
- Shows arrogant, haughty behaviors or attitudes.
Diagnostic Features
Other personality disorders and personality traits. Other personality
disorders may be confused with histrionic personality disorder
because they have certain features in common. It is therefore
important to distinguish among these disorders based on 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
attributable to the effects of another medical condition on the central
nervous system. Substance use disorders. The disorder must also be
distinguished from symptoms that may develop in association with
persistent substance use.
Differntial 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 as
well as the relative lack of self-destructiveness, impulsivity, and
abandonment concerns also help distinguish narcissistic personality
disorder from borderline personality disorder. Excessive pride in
achievements, a relative lack of emotional display, and disdain for
others’ sensitivities help distinguish narcissistic personality disorder
from histrionic personality disorder. Although individuals with
borderline, histrionic, and narcissistic personality disorders may
require much attention, those with narcissistic personality 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 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. 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. In contrast to the accompanying
self-criticism of those with obsessive-compulsive personality disorder,
individuals with narcissistic personality disorder are more likely to
believe that they have achieved perfection. Suspiciousness and social
withdrawal usually distinguish those with schizotypal or paranoid
personality disorder from those with narcissistic personality disorder.
When these qualities are present in individuals with narcissistic
personality disorder, they derive primarily from fears of having
imperfections or flaws revealed. Many highly successful individuals
display personality traits that might be considered narcissistic. Only
when these traits are inflexible, maladaptive, and persisting and cause
significant functional impairment or subjective distress do they
constitute narcissistic 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.
Cluster C Personality Disorders
Someone with a Cluster C PD will tend to be anxious and tense, often
overcontrolled.
Avoidant. These timid people are so easily wounded by criticism that
they hesitate to become involved with others. They may fear the
embarrassment of showing emotion or of saying things that seem
foolish. They may have no close friends, and they exaggerate the risks
of undertaking pursuits outside their usual routines
Dependent. These people so much need the approval of others that
they have trouble making independent decisions or starting projects;
they may even agree with others whom they know to be wrong. They
fear abandonment, feel helpless when they are alone, and are
miserable when relationships end. They are easily hurt by criticism and
will even volunteer for unpleasant tasks to gain the favor of others
Obsessive–Compulsive . Perfectionism and rigidity characterize these
people. They are often workaholics, and they tend to be indecisive,
excessively scrupulous, and preoccupied with detail They insist that
others do things their way. They have trouble expressing affection,
tend to lack generosity, and may even resist throwing away worthless
objects they no longer need
Avoidant personality disorder must be distinguished from personality
change due to another medical condition, in which the traits that
emerge are attributable to the effects of another medical condition on
the central nervous system.
Substance use disorders
Avoidant personality disorder must also be distinguished from
symptoms that may develop in association with persistent substance
use.
Dependent Personality Disorder
Diagnostic Criteria
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:
- Has difficulty making everyday decisions without an excessive
amount of advice and reassurance from others.
- Needs others to assume responsibility for most major areas of his or
her life.
- Has difficulty expressing disagreement with others because of fear
of loss of support or approval. (Note: Do not include realistic fears of
retribution.)
- 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).
- Goes to excessive lengths to obtain nurturance and support from
others, to the point of volunteering to do things that are unpleasant.
- Feels uncomfortable or helpless when alone because of exaggerated
fears of being unable to care for himself or herself.
- Urgently seeks another relationship as a source of care and support
when a close relationship ends.
- Is unrealistically preoccupied with fears of being left to take care of
himself or herself.
Diagnostic Features
The essential feature of dependent personality disorder is a pervasive
and excessive need to be taken care of that leads to submissive and
clinging behavior and fears of separation. This pattern begins by early
adulthood and is present in a variety of contexts. The dependent and
submissive behaviors are designed to elicit caregiving and arise from a
self-perception of being unable to function adequately without the
help of others.
Individuals with dependent personality disorder have great difficulty
making everyday decisions (e., 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., 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 get appropriately angry at 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., realistic fears of retribution from an
abusive spouse), the behavior should not be considered to be evidence
of dependent personality disorder.
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 abandonment. 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). They will “tag
along” with important others just to avoid being alone, even if they are
not interested or involved in what is happening.
When a close relationship ends (e., 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 being abandoned by that person when there are
no grounds to justify such fears. To be considered as evidence of this
criterion, the fears must be excessive and unrealistic. For 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.
Differential Diagnosis
Other mental disorders and medical conditions.
Dependent personality disorder must be distinguished from
dependency arising as a consequence of other mental disorders (e.,
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, reactive, and clinging
behavior. Both dependent personality disorder and borderline
personality disorder are characterized by fear of abandonment;
however, the individual with borderline personality disorder reacts to
abandonment with feelings of emotional 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
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. 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 attributable to the effects of another medical
condition on the central nervous system.
Substance use disorders.
Dependent personality disorder must also be distinguished from
symptoms that may develop in association with persistent substance
use.
Obsessive-Compulsive Personality Disorder
Diagnostic Criteria
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:
- Is preoccupied with details, rules, lists, order, organization, or
schedules to the extent that the major point of the activity is lost.
- Shows perfectionism that interferes with task completion (e., is
unable to complete a project because his or her own overly strict
standards are not met).
- Is excessively devoted to work and productivity to the exclusion of
leisure activities and friendships (not accounted for by obvious
economic necessity).
- Is overconscientious, scrupulous, and inflexible about matters of
morality, ethics, or values (not accounted for by cultural or religious
identification).
- Is unable to discard worn-out or worthless objects even when they
have no sentimental value.
- Is reluctant to delegate tasks or to work with others unless they
submit to exactly his or her way of doing things.
- Adopts a miserly spending style toward both self and others; money
is viewed as something to be hoarded for future catastrophes.
- Shows rigidity and stubbornness.
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 emerge attributable to the effects of another medical condition
on the central nervous system.
Substance use disorders.
Obsessive-compulsive personality disorder must also be distinguished
from symptoms that may develop in association with persistent
substance use.
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.
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.,
310 [F07] personality change due to temporal lobe epilepsy). The
other medical condition should be coded and listed separately
immediately before the personality disorder due to another medical
condition (e., 345 [G40] temporal lobe epilepsy; 310.
[F07] personality change due to temporal lobe epilepsy).
Personality disorder (DSM 5)
Course: Abnormal Psychology (PSY 9)
University: Pamantasan ng Lungsod ng Valenzuela
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