668 Personality Disorders
sentimental occasions, having temper tantru ms). However, their emotions often seem to
be turned on and off too quickly to be deeply felt, which may lead others to accuse the in-
dividual of faking these feelings.
Individuals with histrionic pers onality disorder have a high degree of suggestibility (Cri-
terion 7). Their opinions and f eelings are easily influenced by  others and by current fads.
They may be overly trusting, especially of st rong authority figures whom they see as mag-
ically solving their problems. They have a te ndency to play hunches and to adopt convic-
tions quickly. Individuals with  this disorder often consider  relationships more intimate
than they actually are, describing almost every acquaintance as “my dear, dear friend” or
referring to physicians met only once or twice under professional circumstances by their
first names (Criterion 8).
Associated Features Supporting Diagnosis
Individuals with histrionic personality disord er may have difficulty achieving emotional in-
timacy in romantic or sexual relationships. Without being aware of it, they often act out a
role (e.g., “victim” or “princess”) in their rela tionships to others. They  may seek to control
their partner through emotional manipulation or  seductiveness on one level, while display-
ing a marked dependency on them at another level. Individuals with this disorder often
have impaired relationships with same-sex friends because their sexually provocative inter-
personal style may seem a threat  to their friends’ relationsh ips. These individuals may also
alienate friends with demands for constant a ttention. They often become depressed and up-
set when they are not the center of attention.  They may crave novelty, stimulation, and ex-


citement and have a tendency to become bore d with their usual routine. These individuals
are often intolerant of, or frustrated by, situ ations that involve delayed gratification, and
their actions are often directed at obtaining immediate satisfac tion. Although they often ini-
tiate a job or project with great enthusiasm, their interest may lag quickly. Longer-term re-
lationships may be ne glected to make way for the ex citement of new relationships.
The actual risk of suicide is not known, bu t clinical experience suggests that individu-
als with this disorder are at in creased risk for suicidal gestur es and threats to get attention
and coerce better caregiving. Histrionic personality disorder has been associated with
higher rates of somatic symptom disorder, conversion disorder (functional neurological
symptom disorder), and major depressive disord er. Borderline, narcissistic, antisocial, and
dependent personality disorders often co-occur.
Prevalence
Data from the 2001–2002 National Epidemio logic Survey on Alcohol and Related Condi-
tions suggest a prevalence of histrionic personality of 1.84%.
Culture-Related Diagnostic Issues
Norms for interpersonal behavior, personal  appearance, and emotional expressiveness
vary widely across cultures, genders, and age groups. Before considering the various traits
(e.g., emotionality,  seductiveness, dramatic interperso nal style, novelty seeking, sociabil-
ity, charm, impressionability, a tendency to somatization) to be  evidence of histrionic per-
sonality disorder, it is impo rtant to evaluate whether they  cause clinically significant
impairment or distress.
Gender-Related Diagnostic Issues
In clinical settings, this disorder has been di agnosed more frequently in females; however,


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


Narcissistic Personality Disorder 669
Differential Diagnosis
Other personality disorder s and personality traits. Other personality disorders may
be confused with histrionic personality disorder because they have certain features in
common. It is therefore important to distinguish among these disorders based on differ-
ences in their characteristic features. However, if an individual has personality features
that meet criteria for one or more personality disorders in addition to histrionic personal-
ity disorder, all can be diagnosed. Although  borderline personality disorder can also be
characterized by attention seeking, manipulati ve behavior, and rapidly shifting emotions,
it is distinguished by self-destructiveness, angry disruptions in close relationships, and
chronic feelings of deep emptiness and identi ty disturbance. Individuals with antisocial
personality disorder and histrionic personalit y disorder share a tend ency to be impulsive,
superficial, excitement seeking, reckless, seductive, and manipulative, but persons with
histrionic personality disorder tend to be mo re exaggerated in their emotions and do not
characteristically engage in antisocial behavi ors. Individuals with histrionic personality
disorder are manipulative to gain nurturance , whereas those with antisocial personality
disorder are manipulative to gain profit, powe r, or some other material gratification. Al-
though individuals with narcissistic personalit y disorder also crave attention from others,
they usually want praise for their “superiority,” whereas individuals with histrionic per-
sonality disorder are willing to be viewed as frag ile or dependent if this is instrumental in
getting attention. Individuals with narcissistic personality disorder may exaggerate the
intimacy of their relationships with other pe ople, but they are more apt to emphasize the
“VIP” status or wealth of th eir friends. In dependent personality disorder, the individual


“VIP” status or wealth of th eir friends. In dependent personality disorder, the individual
is excessively dependent on othe rs for praise and guidance, but is without the flamboyant,
exaggerated, emotional features of individu als 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 constitu te histrionic personality disorder.
Personality change due to another medical condition. Histrionic personality disorder
must be distinguished from personality ch ange due to another medical condition, in
which the traits that emerge ar e 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 301.81 (F60.81)
A pervasive pattern of grandiosity (in fantasy or behavior), need for admiration, and lack
of empathy, beginning by early adulthood and present in a variety of contexts, as indicated
by five (or more) of the following:
1. Has a grandiose sense of self-importance (e.g., exaggerates achievements and talents,
expects to be recognized as superior without commensurate achievements).
2. Is preoccupied with fantasies of unlimited success, power, brilliance, beauty, or ideal
love.
3. Believes that he or she is “special” and unique and can only be understood by, or
should associate with, other special or high-status people (or institutions).
4. Requires excessive admiration.
5. Has a sense of entitlement (i.e., unreasonable expectations of especially favorable
treatment or automatic compliance with his or her expectations).


670 Personality Disorders
6. Is interpersonally exploitative (i.e., takes advantage of others to achieve his or her own
ends).
7. Lacks empathy: is unwilling to recognize or identify with the feelings and needs of others.
8. Is often envious of others or believes that others are envious of him or her.
9. Shows arrogant, haughty behaviors or attitudes.
Diagnostic Features
The essential feature of narcissistic personality disorder is a pervasive pattern of grandi-
osity, need for admiration, and lack of empathy that begins by early adulthood and is pres-
ent in a variety of contexts.
Individuals with this disorder have a grandiose sense of self-impor tance (Criterion 1).
They routinely overestimate their abilities and in flate their accomplishme nts, often appearing
boastful and pretentious. They may blithely assume that others attribute the same value to
their efforts and may be surprised when the prai se they expect and feel they deserve is not
forthcoming. Often implicit in the inflated ju dgments of their own accomplishments is an un-
derestimation (devaluation) of the contributions of others. Individuals with narcissistic per-
sonality disorder are often preo ccupied with fantasies of unlimit ed success, power, brilliance,
beauty, or ideal love (Criterion 2). They ma y ruminate about “long overdue” admiration and
privilege and compare themselves favora bly with famous or privileged people.
Individuals with narcissistic personality disorder believe that they are superior, spe-
cial, or unique and expect others to recogniz e them as such (Criterion 3). They may feel
that they can only be understood by, and sh ould only associate with, other people who are
special or of high status and may attribute “unique,” “perfect,” or “gifted” qualities to those


with whom they associate. Individuals with th is disorder believe that their needs are spe-
cial and beyond the ken of ordinary people. Their own self-esteem is enhanced (i.e., “mir-
rored”) by the idealized value that they assign  to those with whom they associate. They are
likely to insist on having only the “top” pers on (doctor, lawyer, hair dresser, instructor) or
being affiliated with the “best” institutions but may devalue the credentials of those who dis-
appoint them.
Individuals with this disorder generally require excessiv e admiration (Criterion 4). Their
self-esteem is almost invariably very fragile.  They may be preoccupied with how well they
are doing and how favorably they are regarded by  others. This often takes the form of a need
for constant attention and admira tion. They may expect their arri val to be greeted with great
fanfare and are astonished if others do not c ovet their possessions. Th ey may constantly fish
for compliments, often with great charm. A sens e of entitlement is ev ident in these individ-
uals’ unreasonable expectation of especially fa vorable 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 th eir priorities are so important
that others should defer to them, and then ge t irritated when others fail to assist “in their
very important work.” This sense of entitlement,  combined with a lack of sensitivity to the
wants and needs of others, may result in the conscious or unwitting exploitation of others
(Criterion 6). They expect to be given whatever they want or  feel they need, no matter what
it might mean to others. For example, these individuals may expect great dedication from


it might mean to others. For example, these individuals may expect great dedication from
others and may overwork them wi thout regard for the impact on  their lives. They tend to
form friendships or romantic relationships only if the other person seems likely to advance
their purposes or otherwise enhance their self -esteem. They often usurp special privileges
and extra resources that they believe th ey deserve because they are so special.


their purposes or otherwise enhance their self -esteem. They often usurp special privileges
and extra resources that they believe th ey deserve because they are so special.
Individuals with narcissistic personality disorder generally have a lack of empathy and
have difficulty recognizing the desires, subjective  experiences, and feelings of others (Crite-
rion 7). They may assume that others are tota lly concerned about their welfare. They tend to
discuss their own concerns in inappropriate an d lengthy detail, while failing to recognize
that others also have feelings and needs. They are often contemptuous and impatient with


Narcissistic Personality Disorder 671
others who talk about their ow n problems and concerns. These individuals may be oblivious
to the hurt their remarks may in flict (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 re late to individuals with narcissistic person-
ality disorder typically find an emotional coldness and lack of reciprocal interest.
These individuals are often envious of others or believe that others are envious of them
(Criterion 8). They may begrudge others their su ccesses or possessions, fe eling that they better
deserve those achievements, admiration, or priv ileges. They may harshly devalue the contri-
butions of others, particularly when those individuals have received acknowledgment or
praise for their accomplishments. Arrogant, haug hty behaviors characterize these individuals;
they often display snobbish, disdainful, or patr onizing attitudes (Criterion 9). For example, an
individual with this disorder may complain about  a clumsy waiter’s “rudeness” or “stupidity”
or conclude a medical evaluation with a condescending evaluation of the physician.
Associated Features Supporting Diagnosis
Vulnerability in self-esteem makes individuals with narcissistic personality disorder very
sensitive to “injury” from criticism or defe at. Although they may not show it outwardly,
criticism may haunt these individuals and ma y leave them feeling humiliated, degraded,
hollow, and empty. They may react with disdain, rage, or defiant counterattack. Such ex-
periences often lead to social withdrawal or an appearance of humility that may mask and


periences often lead to social withdrawal or an appearance of humility that may mask and
protect the grandiosity. Interpersonal relation s are typically impaired because of problems
derived from entitlement, the need for admira tion, and the relative disregard for the sen-
sitivities of others. Though overweening ambition and confidence may lead to high
achievement, performance may be disrupted beca use of intolerance of criticism or defeat.
Sometimes vocational functioning can be very low, reflecting an unwillingness to take a
risk in competitive or other situations in wh ich defeat is possible.  Sustained feelings of
shame or humiliation and the attendant self-criticism may be associated with social with-
drawal, depressed mood, and persistent depr essive disorder (dysthymia) or major de-
pressive disorder. In contrast, sustained periods of grandiosity may be associated with a
hypomanic mood. Narcissistic personality disorder is also associated with anorexia ner-
vosa and substance use disorder s (especially related to cocaine). Histrionic, borderline,
antisocial, and paranoid personality disorders may be associated with narcissistic person-
ality disorder.
Prevalence
Prevalence estimates for narcissistic person ality disorder, based on DSM-IV definitions,
range from 0% to 6.2% in community samples.
Development and Course
Narcissistic traits may be particularly comm on in adolescents and do not necessarily in-
dicate that the individual will go on to have narcissistic personality disorder. Individuals
with narcissistic personality disorder may have special difficulties adjusting to the onset of
physical and occupational limitations that  are inherent in the aging process.
Gender-Related Diagnostic Issues
Of those diagnosed with narcissistic personality disorder, 50%–75% are male.
Differential Diagnosis
Other personality disorder s and personality traits. Other personality disorders may


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


672 Personality Disorders
common. It is, therefore, important to distin guish among these disorders based on differ-
ences in their characteristic features. However, if an individual has personality features
that meet criteria for one or more personalit y disorders in addition to narcissistic person-
ality disorder, all can be diagnosed. The most useful feature in discriminating narcissistic
personality disorder from histrionic, antisocial, and borderline personality disorders, in
which the interactive styles are coquettish, callous, and needy, respectively, is the grandi-
osity characteristic of narcissistic personalit y disorder. The relative stability of self-image
as well as the relative lack of self-destruc tiveness, impulsivity, an d abandonment concerns
also help distinguish narcissistic personality disorder from borderline personality disor-
der. Excessive pride in achievements, a relative  lack of emotional display, and disdain for
others’ sensitivities help distinguish narci ssistic personality disorder from histrionic
personality disorder. Although individuals wi th borderline, histrionic, and narcissistic
personality disorders may requir e much attention, those with narcissistic personality dis-
order specifically need that attention to be admiring. Individuals with antisocial and nar-
cissistic personality disorders share a tendency to be tough-minded, glib, superficial,
exploitative, and unempathic. However, narciss istic personality disorder does not neces-
sarily include characteristics of impulsivity, aggression, and deceit. In addition, individu-
als with antisocial personality disorder may not be as needy of the admiration and envy of
others, and persons with narcissistic personal ity disorder usually lack the history of con-
duct disorder in childhood or criminal behavior in adulthood. In both narcissistic person-
ality disorder and obsessive-compulsive personality disorder, the individual may profess


ality disorder and obsessive-compulsive personality disorder, the individual may profess
a commitment to perfectionism and believe that  others cannot do things as well. In con-
trast to the accompanying self-criticism of those with obsessive-compulsive personality
disorder, individuals with narcissistic persona lity disorder are more likely to believe that
they have achieved perfection. Suspiciousness and social withdrawal usually distinguish
those with schizotypal or paranoid personalit y disorder from those with narcissistic per-
sonality disorder. When these qualities are pres ent in individuals with narcissistic person-
ality disorder, they derive primarily from fear s of having imperfections or flaws revealed.
Many highly successful individuals display pe rsonality traits that might be considered
narcissistic. Only when these traits are inflexible, maladaptive, and persisting and cause
significant functional impairment or subjective  distress do they constitute narcissistic per-
sonality disorder.
Mania or hypomania. Grandiosity may emerge as part of manic or 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 a ssociation with persistent substance use.
Cluster C Personality Disorders
Avoidant Personality Disorder
Diagnostic Criteria 301.82 (F60.6)
A pervasive pattern of social inhibition, feelings of inadequacy, and hypersensitivity to neg-
ative evaluation, beginning by early adulthood and present in a variety of contexts, as in-
dicated by four (or more) of the following:
1. Avoids occupational activities that invo lve significant interpersonal contact because of
fears of criticism, disapproval, or rejection.


Avoidant Personality Disorder 673
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 pa ttern of social inhi-
bition, feelings of inadequacy, and hypersensitivity to negative evaluation that begins by
early adulthood and is present in a variety of contexts.
Individuals with avoidant personality disord er avoid work activities that involve sig-
nificant interpersonal contact because of fears of criticism, disapprova l, or rejection (Cri-
terion 1). Offers of job prom otions may be declined because the new responsibilities might
result in criticism from co-workers. These individuals avoid making new friends unless
they are certain they will be liked and accept ed without criticism (Criterion 2). Until they
pass stringent tests proving the contrary, other people are assumed to be critical and dis-
approving. Individuals with this disorder will not join in group activities unless there are
repeated and generous offers of support and nurturance. Inte rpersonal intimacy is often
difficult for these individuals, although they are able to es tablish intimate relationships
when there is assurance of uncritical acceptan ce. They may act with restraint, have diffi-
culty talking about themselves, and withhold intimate feelings for fear of being exposed,
ridiculed, or shamed (Criterion 3).


ridiculed, or shamed (Criterion 3).
Because individuals with this  disorder are preoccupied with being criticized or re-
jected in social situations, they may have a markedly low threshold for detecting such re-
actions (Criterion 4). If someone is even s lightly disapproving or critical, they may feel
extremely hurt. They tend to be shy, quiet, inhibited, and “invisible” because of the fear
that any attention would be degrading or reject ing. They expect that no matter what they
say, others will see it as “wrong,” and so th ey may say nothing at all. They react strongly
to subtle cues that are suggest ive of mockery or derision. Despite their longing to be active
participants in social life, they fear placing their welfare in the hands of others. Individuals
with avoidant personality disorder are inhibi ted in new interpersonal situations because
they feel inadequate and have low self-esteem (Criterion 5). Doubts concerning social
competence and personal appeal become especially manifest in settings involving inter-
actions with strangers. These individuals believe themselves to be socially inept, person-
ally unappealing, or inferior to others (Cri terion 6). They are unusually reluctant to take
personal risks or to engage in any new activities because these may prove embarrassing
(Criterion 7). They are prone to exaggerate the potential dangers of ordinary situations,
and a restricted lifestyle may result from their need for certainty and security. Someone
with this disorder may cancel a job interview for fear of being embarrassed by not dressing
appropriately. Marginal somatic symptoms or  other problems may become the reason for
avoiding new activities.
Associated Features Supporting Diagnosis
Individuals with avoidant personality disorder often vigilantly appr aise the movements
and expressions of those with whom they come  into contact. Their fearful and tense de-


and expressions of those with whom they come  into contact. Their fearful and tense de-
meanor may elicit ridicule an d derision from others, which in turn confirms their self-
doubts. These individuals are very anxious about the possibility that they will react to crit-


meanor may elicit ridicule an d derision from others, which in turn confirms their self-
doubts. These individuals are very anxious about the possibility that they will react to crit-
icism with blushing or crying. They are described by others as being “shy,” “timid,”


674 Personality Disorders
“lonely,” and “isolated.” The major problems associated with this disorder occur in social
and occupational functi oning. The low self-esteem and hy persensitivity to rejection are
associated with restricted in terpersonal contacts. These individuals may become relatively
isolated and usually do not have a large social support ne twork that can help them weather
crises. They desire affection and acceptance and may fantasize about idealized relation-
ships with others. The avoidant behaviors can also adversely affect occupational function-
ing because these individuals try to avoid the types of social situations that may be
important for meeting the basic dema nds of the job or for advancement.
Other disorders that are commonly diagnosed with avoidant personality disorder in-
clude depressive, bipolar, and anxiety disorders,  especially social anxiety disorder (social
phobia). Avoidant personality disorder is often diagnosed with dependent personality
disorder, because individuals with avoidant pe rsonality disorder become very attached to
and dependent on those few other people wi th whom they are friends. Avoidant per-
sonality disorder also tends to  be diagnosed with borderline personality disorder and with
the Cluster A personality disorders (i.e., paranoid, schizoid, or schizotypal personality
disorders).
Prevalence
Data from the 2001–2002 National Epidemio logic Survey on Alcohol and Related Condi-
tions suggest a prevalence of about 2.4% for avoidant personality disorder.
Development and Course
The avoidant behavior often st arts in infancy or childhood with shyness, isolation, and
fear of strangers and new situations. Although  shyness in childhood is a common precur-
sor of avoidant personality disorder, in most individuals it tends to gradually dissipate as
they get older. In contrast, individuals who go on  to develop avoidant personality disor-


der may become increasingly shy and avoidant  during adolescence and early adulthood,
when social relationships with new people become especially important. There is some
evidence that in adults, avoi dant personality disorder tend s to become less evident or to
remit with age. This diagnosi s should be used with great caution in children and adoles-
cents, for whom shy and avoidant behavi or may be developmentally appropriate.
Culture-Related Diagnostic Issues
There may be variation in the degree to whic h different cultural and ethnic groups regard
diffidence and avoidance as appropriate. Mo reover, avoidant behavior may be the result
of problems in acculturat ion following immigration.
Gender-Related Diagnostic Issues
Avoidant personality disorder appears to be equally frequent in males and females.
Differential Diagnosis
Anxiety disorders. There appears to be a great deal of  overlap between avoidant person-
ality disorder and social anxiety disorder (s ocial phobia), so much so that they may be
alternative conceptualizations of the same or similar conditions. Avoidance also character-
izes both avoidant personality disorder and agoraphobia, and they often co-occur.
Other personality disorders and personality traits. Other personality disorders may
be confused with avoidant pers onality disorder because they have certain fe atures in com-
mon. It is, therefore, important to distingu ish among these disorder s based on differences
in their characteristic features. However, if  an individual has personality features that
meet criteria for one or more personality diso rders in addition to avoidant personality dis-


Dependent Personality Disorder 675
order, all can be diagnosed. Both avoidant personality disorder and dependent personal-
ity disorder are characterized by  feelings of inadequacy, hypersensitivity to criticism, and
a need for reassurance. Although the primary focus of concern in avoidant personality
disorder is avoidance of humiliation and reject ion, in dependent pers onality disorder the
focus is on being taken care of. However, avoidant personality disorder and dependent
personality disorder are particularly likely to  co-occur. Like avoidant personality disor-
der, schizoid personality disorder and schizotypal personality disorder are characterized
by social isolation. However, individuals with avoidant personality disorder want to have
relationships with others and feel their loneliness deeply, whereas those with schizoid or
schizotypal personality disorder may be conten t with and even prefer  their social isola-
tion. Paranoid personality disorder and avoida nt personality disorder are both character-
ized by a reluctance to confide in others. Ho wever, in avoidant personality disorder, this
reluctance is attributable more to a fear of being embarrassed or being found inadequate
than to a fear of others’ malicious intent.
Many individuals display avoidant personality traits. Only when these traits are in-
flexible, maladaptive, and persisting and caus e significant functional impairment or sub-
jective distress do they constitu te avoidant personality disorder.
Personality change due to another medical condition. Avoidant personality disorder
must be distinguished from personality ch ange due to another medical condition, in
which the traits that emerge ar e 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 a ssociation with persistent substance use.
Dependent Personality Disorder


Dependent Personality Disorder
Diagnostic Criteria 301.6 (F60.7)
A pervasive and excessive need to be taken care of that leads to submissive and clinging
behavior and fears of separation, beginning by early adulthood and present in a variety of
contexts, as indicated by five (or more) of the following:
1. Has difficulty making everyday decisions without an excessive amount of advice and
reassurance from others.
2. Needs others to assume responsibility for most major areas of his or her life.
3. Has difficulty expressing disagreement with others because of fear of loss of support
or approval. ( Note:  Do not include realistic fears of retribution.)
4. Has difficulty initiating projects or doing things on his or her own (because of a lack of
self-confidence in judgment or abilities rather than a lack of motivation or energy).
5. Goes to excessive lengths to obtain nurturance and support from others, to the point
of volunteering to do things that are unpleasant.
6. Feels uncomfortable or helpless when alone because of exaggerated fears of being
unable to care for himself or herself.
7. Urgently seeks another relationship as a source of care and support when a close re-
lationship ends.
8. Is unrealistically preoccupied with fears of being left to take care of himself or herself.
Diagnostic Features
The essential feature of dependent personalit y 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 ad ulthood and is present in a variety of contexts. The dependent


676 Personality Disorders
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 grea t difficulty making every-
day decisions (e.g., what color shirt to wear to work or whether to carry an umbrella) without
an excessive amount of advice and reassurance from others (Criterion 1). These individu-
als tend to be passive and to allow other people  (often a single other person) to take the ini-
tiative and assume responsibility for most majo r areas of their lives (Criterion 2). Adults
with this disorder typically depend on a pa rent 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 spen d their free time, and what school or college
they should attend. This need for others to  assume responsibility goes beyond age-appro-
priate and situation-appropriate requests fo r assistance from others (e.g., the specific
needs of children, elderly persons, and hand icapped persons). Dependent personality dis-
order may occur in an individual who has a serious medical conditio n or disability, but in
such cases the difficulty in taking responsib ility 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 d isagreement with other individuals, especially
those on whom they are dependent (Criterion 3) . These individuals feel so unable to func-
tion alone that they will agree with things that they feel are wrong rather than risk losing


tion alone that they will agree with things that they feel are wrong rather than risk losing
the help of those to whom they look for guidance. They do not get appropriately angry at
others whose support and nurturance they need for fear of alienating them. If the individ-
ual’s concerns regarding the consequences of expressing disagreement are realistic (e.g.,
realistic fears of retribution from an abusiv e spouse), the behavior should not be consid-
ered to be evidence of dependent personality disorder.
Individuals with this disorder have difficulty initiating projects or doing things inde-
pendently (Criterion 4). They lack self-confidence and believe that they need help to begin
and carry through tasks. They will wait for othe rs to start things because they believe that
as a rule others can do them better. These in dividuals are convinced that they are incapable
of functioning independently and present them selves as inept and requiring constant as-
sistance. They are, however, lik ely to function adequately if given the assurance that some-
one else is supervising and approving. There ma y 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 indepen-
dent living, thus perpetuating dependency.
Individuals with dependent personality disord er may go to excessive lengths to obtain
nurturance and support from others, even to  the point of volunteering for unpleasant
tasks if such behavior will bring the care they  need (Criterion 5). They are willing to submit
to what others want, even if the demands are unreasonable. Their need to maintain an im-
portant bond will often re sult in imbalanced or distorted relationships. They may make ex-


traordinary self-sacrifices or tolerate verbal, physical, or sexual abuse.  (It should be noted
that this behavior should be considered evid ence of dependent pers onality disorder only
when it can clearly be established that other options are available to the individual.) Indi-
viduals with this disorder feel uncomfortable or  helpless when alone, because of their ex-


when it can clearly be established that other options are available to the individual.) Indi-
viduals with this disorder feel uncomfortable or  helpless when alone, because of their ex-
aggerated fears of being unable to care for th emselves (Criterion 6). They will “tag along”
with important others just to avoid being alone,  even if they are not interested or involved
in what is happening.
When a close relationship ends (e.g., a breakup with a lover; the death of a caregiver), in-
dividuals with dependent person ality disorder may urgently seek another relationship to
provide the care and support they  need (Criterion 7). Their be lief that they are unable to
function in the absence of a cl ose relationship motivates these individuals to become quickly
and indiscriminately attached to  another individual. Individuals with this disorder are often


Dependent Personality Disorder 677
preoccupied with fears of being left to care fo r 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 ther e are no grounds to justify such fears. To be
considered as evidence of this criterion, the fears must be ex cessive and unrealistic. For ex-
ample, an elderly man with cancer who moves into his son’s household for care is exhibiting
dependent behavior that is appropriate given this person’s life circumstances.
Associated Features Supporting Diagnosis
Individuals with dependent personality diso rder are often charac terized by pessimism
and self-doubt, tend to belittl e their abilities and assets, and may constantly refer to them-
selves as “stupid.” They take criticism and disapproval as proof of their worthlessness and
lose faith in themselves. They may seek ov erprotection and dominance from others. Oc-
cupational functioning may be impaired if in dependent initiative is required. They may
avoid positions of responsibility and become anxious when faced with decisions. Social re-
lations tend to be limited to those few people  on whom the individual is dependent. There
may be an increased risk of depressive disorders, anxiety disorders, and adjustment dis-
orders. Dependent personality disorder often co-occurs with other personality disorders,
especially borderline, avoidant, and histrion ic personality disorders. Chronic physical ill-
ness or separation anxiety disorder in childhood or adolescence may predispose the indi-
vidual to the development of this disorder.
Prevalence
Data from the 2001–2002 National Epidemio logic Survey on Alcohol and Related Condi-
tions yielded an estimated prevalence of depe ndent personality disorder of 0.49%, and de-


pendent personality was estimated, based on a probability subsample from Part II of the
National Comorbidit y Survey Replication, to be 0.6%.
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 dependen t behaviors are considered to be appropriate varies sub-
stantially across different age and sociocultu ral groups. Age and cultural factors need to
be considered in evaluating the diagnostic threshold of each crit erion. Dependent behav-
ior should be considered characteristic of the disorder only when it is clearly in excess of
the individual’s cultural norms or reflects unrealistic concerns. An emphasis on passivity,
politeness, and deferential treatment is characteristic of some societies and may be mis-
interpreted as traits of dependent personality disorder. Similarly, societies may differen-
tially foster and discourage depend ent behavior in males and females.
Gender-Related Diagnostic Issues
In clinical settings, dependent personality d isorder has been diagnosed more frequently in
females, although some studies report simila r prevalence rates among males and females.
Differential Diagnosis
Other mental disorders and medical conditions. Dependent personality disorder must
be distinguished from dependen cy arising as a consequence of  other mental disorders (e.g.,
depressive disorders, panic disorder, agoraphobia) and as a resu lt of other medical conditions.


678 Personality Disorders
Other personality disorders and personality traits. Other personality disorders may be
confused with dependent personality disorder because they ha ve certain features in com-
mon. It is therefore important to distinguis h among these disorders based on differences in
their characteristic features. However, if an individual has personality features that meet cri-
teria for one or more personality disorders in addition to dependent personality disorder, all
can be diagnosed. Although many personality disorders are characterized by dependent
features, dependent personality disorder can be distinguished by its predominantly submis-
sive, reactive, and clinging be havior. Both dependent person ality disorder and borderline
personality disorder are characterized by fe ar of abandonment; however, the individual
with borderline personality disorder reacts to  abandonment with feelings of emotional emp-
tiness, rage, and demands, whereas the individual with dependent personality disorder re-
acts with increasing appeasement and submissiveness and urgently seeks a replacement
relationship to provide caregiving and suppor t. Borderline personalit y disorder can further
be distinguished from dependen t personality disorder by a ty pical pattern of unstable and
intense relationships. Individual s with histrionic personality disorder, like those with de-
pendent personality disorder, ha ve a strong need for reassu rance and approval and may ap-
pear childlike and clinging. However, unli ke dependent personality disorder, which is
characterized by self-effacing and docile behavior, histrionic personality disorder is charac-
terized by gregarious flamboyance with acti ve demands for attention. Both dependent
personality disorder and avoidant personality di sorder are characterized by feelings of in-
adequacy, hypersensitivity to criticism, and a need for reassurance; however, individuals
with avoidant personality disorder have such a strong fear of humiliation and rejection that


with avoidant personality disorder have such a strong fear of humiliation and rejection that
they withdraw until they are certain they will be accepted. In  contrast, individuals with de-
pendent personality disorder have a pattern of  seeking and maintaining connections to im-
portant others, rather than avoiding  and withdrawing fr om relationships.
Many individuals display dependent personalit y traits. Only when these traits are in-
flexible, maladaptive, and persisting and caus e significant functional impairment or sub-
jective distress do they constitute  dependent personality disorder.
Personality change due to another medical condition. Dependent personality disor-
der must be distinguished from personality change due to another medical condition, in
which the traits that emerge ar e 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 a ssociation with persistent substance use.
Obsessive-Compulsive Personality Disorder
Diagnostic Criteria 301.4 (F60.5)
A pervasive pattern of preoccupation with orderliness, perfectionism, and mental and in-
terpersonal control, at the expense of flexibility, openness, and efficiency, beginning by
early adulthood and present in a variety of contexts, as indicated by four (or more) of the
following:
1. Is preoccupied with details, rules, lists, order, organization, or schedules to the extent
that the major point of the activity is lost.
2. Shows perfectionism that interferes with task completion (e.g., is unable to complete a
project because his or her own over ly 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).


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).


Obsessive-Compulsive Personality Disorder 679
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 obse ssive-compulsive personality disorder is a preoccupation
with orderliness, perfectionism, and mental and interpersonal control, at the expense of
flexibility, openness, and efficiency. This patt ern begins by early adulthood and is present
in a variety of contexts.
Individuals with obse ssive-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 repetiti on, paying extraordinary attention to detail
and repeatedly checking for possible mistakes. They are oblivious to the fact that other
people tend to become very annoyed at the de lays and inconveniences that result from this
behavior. For example, when such individuals misplace a list of things to be done, they
will spend an inordinate amount  of time looking for the list  rather than spending a few
moments re-creating it from memory and proceeding to accomplish the tasks. Time is
poorly allocated, and the most important tasks are left to the last moment. The perfection-
ism and self-imposed high standards of performance cause significant dysfunction and
distress in these individuals. They may beco me so involved in maki ng every detail of a


project absolutely perfect that the project is never finished (Criterion 2). For example, the
completion of a written report is delayed by  numerous time-consuming rewrites that all
come up short of “perfection.” Deadlines are missed, and aspects of the individual’s life
that are not the current focus of activity may fall into disarray.
Individuals with obsessive-compulsive pers onality disorder display excessive devotion
to work and productivity to th e exclusion of leisure activities and friendships (Criterion 3).
This behavior is not accounted for by economic necessity. They often f eel that they do not
have time to take an evening or a weekend day of f to go on an outing or to just relax. They
may keep postponing a pleasurable activity, such as a vacation, so that it may never occur.
When they do take time for leisure activities or vacations, they are very uncomfortable un-
less they have taken along some thing to work on so they do not “waste time.” There may be
a great concentration on househ old chores (e.g., repeated excessive cleaning so that “one
could eat off the floor”). If they spend time with friends, it is likely to be in some kind of for-
mally organized activity (e.g., sports). Hobbies  or recreational activities are approached as
serious tasks requiring careful organization and hard work to master. The emphasis is on
perfect performance. These individuals turn play  into a structured task (e.g., correcting an
infant for not putting ring s on the post in the right order; tell ing a toddler to ride his or her tri-
cycle in a straight line; turning a baseball game into a harsh “lesson”).
Individuals with obsessive-co mpulsive personality disord er may be excessively con-
scientious, scrupulous, and infl exible about matters of moralit y, ethics, or values (Crite-


rion 4). They may force themselves and othe rs to follow rigid moral principles and very
strict standards of performance. They may al so be mercilessly self-c ritical about their own
mistakes. Individuals with this disorder are rigidly deferential to authority and rules and
insist on quite literal compliance, with no ru le bending for extenuating circumstances. For


mistakes. Individuals with this disorder are rigidly deferential to authority and rules and
insist on quite literal compliance, with no ru le bending for extenuating circumstances. For
example, the individual will not lend a quarte r to a friend who needs one to make a tele-
phone call because “neither a borrower nor a le nder be” or because it  would be “bad” for


680 Personality Disorders
the person’s character. These qualities should not be accounted for by the individual’s cul-
tural or religious identification.
Individuals with this disorder may be unable to discard worn-out or worthless objects,
even when they have no sentimental value (C riterion 5). Often these individuals will ad-
mit to being “pack rats.” They regard discar ding objects as wastef ul because “you never
know when you might need something” and will become upset if someone tries to get rid of
the things they have saved. Their spouses or roommates may complain about the amount of
space taken up by old parts, magazines, broken appliances, and so on.
Individuals with obsessive-compulsive pers onality 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 detaile d instructions about how things should be done (e.g., there is one
and only one way to mow the lawn, wash the dishes, build a doghouse) and are surprised
and irritated if others suggest creative alternat ives. At other times they may reject offers of
help even when behind schedule because th ey believe no one else can do it right.
Individuals with this disorder may be miserly and stingy and maintain a standard of
living far below what they can afford, believing that spending must be tightly controlled to
provide for future catastrophes (Criterion 7) . Obsessive-compulsive personality disorder
is characterized by rigidity and stubbornness (Criterion 8). Individuals with this disorder
are so concerned about having things done the one “correct” way that they have trouble
going along with anyone else’s ideas. These individuals plan ahead in meticulous detail


going along with anyone else’s ideas. These individuals plan ahead in meticulous detail
and are unwilling to consider changes. Totally  wrapped up in their own perspective, they
have difficulty acknowledging the viewpoints of others. Friends and colleagues may be-
come frustrated by this constant rigidity. Even when individuals with obsessive-compul-
sive personality disorder recognize that it may be in their interest to compromise, they
may stubbornly refuse to do  so, arguing that it is “t he principle of the thing.”
Associated Features Supporting Diagnosis
When rules and established procedures do not dictate the correct answer, decision making
may become a time-consuming, often painfu l process. Individuals with obsessive-
compulsive personality disorder may have such difficulty deciding which tasks take pri-
ority or what is the best way of doing some pa rticular task that they may never get started
on anything. They are prone to become upset or angry in situations in which they are not
able to maintain control of their physical or interpersonal environment, although the an-
ger is typically not expressed di rectly. For example, an individual may be angry when ser-
vice in a restaurant is poor, but instead of complaining to the management, the individual
ruminates about how much to leave as a tip. 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 au thority they respect and excessive resistance
to authority they do not respect.
Individuals with this disorder usually expres s affection in a highly  controlled or stilted
fashion and may be very uncomfortable in the presence of others who are emotionally ex-
pressive. Their everyday relationships have a formal and serious quality, and they may be


pressive. Their everyday relationships have a formal and serious quality, and they may be
stiff in situations in which others would smile  and be happy (e.g., greeting a lover at the
airport). They carefully hold th emselves back until they are sure that whatever they say
will be perfect. They may be preoccupied with  logic and intellect, and intolerant of affec-


airport). They carefully hold th emselves back until they are sure that whatever they say
will be perfect. They may be preoccupied with  logic and intellect, and intolerant of affec-
tive behavior in others. They often have diffi culty expressing tender feelings, rarely pay-
ing compliments. Individuals with this disord er may experience occupational difficulties
and distress, particularly when confronted with new situat ions that demand flexibility
and compromise.
Individuals with anxiety disorders, including generalized anxiety disorder, social anx-
iety disorder (social phobia), and specific pho bias, and obsessive-compulsive disorder (OCD)


Obsessive-Compulsive Personality Disorder 681
have an increased likelihood of having a person ality disturbance that meets criteria for ob-
sessive-compulsive personality disorder. Even so , it appears that the majority of individ-
uals with OCD do not have a pattern of behavior that meets criteria for this personality
disorder. Many of the features  of obsessive-compulsive pers onality disorder overlap with
“type A” personality characteristics (e.g., pr eoccupation with work, competitiveness, time
urgency), and these features may be present in  people at risk for myocardial infarction.
There may be an association between obsessiv e-compulsive personality disorder and de-
pressive and bipolar disorders and eating disorders.
Prevalence
Obsessive-compulsive personalit y disorder is one of the mo st prevalent personality dis-
orders in the general population, with estimated prevalence ranging from 2.1% to 7.9%.
Culture-Related Diagnostic Issues
In assessing an individual for obsessive-com pulsive personality disorder, the clinician
should not include those behaviors that reflect habits, customs, or interpersonal styles that
are culturally sanctioned by the individual’s  reference group. Certain cultures place sub-
stantial emphasis on work and productivity; the resulting behaviors in members of those
societies need not be considered indications of obsessive-compulsive personality disorder.
Gender-Related Diagnostic Issues
In systematic studies, obsessiv e-compulsive personality disord er appears to be diagnosed
about twice as often among males.
Differential Diagnosis
Obsessive-compulsive disorder. Despite the similarity in names, OCD is usually easily
distinguished from obsessive-comp ulsive personality disorder by  the presence of true ob-
sessions and compulsions in OCD. When crit eria for both obsessive-compulsive person-
ality disorder and OCD are met, bo th diagnoses should be recorded.


ality disorder and OCD are met, bo th diagnoses should be recorded.
Hoarding disorder. A diagnosis of hoarding disorder should be considered especially
when hoarding is extreme (e.g., accumulated st acks of worthless objects present a fire haz-
ard and make it difficult for others to walk through the house). When criteria for both ob-
sessive-compulsive personality disorder and ho arding disorder are met, both diagnoses
should be recorded.
Other personality disorder s and personality traits. Other personality disorders may
be confused with obsessive-compulsive person ality disorder because they have certain
features in common. It is, therefore, important to distingu ish among these disorders based
on differences in their characteristic features. However, if an individual has personality
features that meet criteria for one or more personality disorders in addition to obsessive-
compulsive personality disorder, all can be diagnosed. Individuals with narcissistic per-
sonality disorder may also profess a commitmen t 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 obse ssive-compulsive personality disorder are
usually self-critical. Individuals with narcissi stic or antisocial personality disorder lack
generosity but will indulge themselves, wher eas those with obsessive-compulsive person-
ality disorder adopt a miserly spending style toward both self and others. Both schizoid
personality disorder and obsessive-compulsive  personality disorder may be characterized
by an apparent formality and social detachme nt. In obsessive-compulsive personality dis-
order, this stems from discomfort with emot ions and excessive devotion to work, whereas
in schizoid personality disorder there is a fundamental lack of capacity for intimacy.


682 Personality Disorders
Obsessive-compulsive personality traits in moderation may be espe cially adaptive, par-
ticularly in situations that reward high perfor mance. Only when these traits are inflexible,
maladaptive, and persisting and cause significa nt functional impairment or subjective dis-
tress do they constitute obsessive-compulsive personality disorder.
Personality change due to another medical condition. Obsessive-compulsive person-
ality disorder must be distin guished from personality change due to another medical con-
dition, in which the traits emerge attributable to the effects of another medical condition
on the central nervous system.
Substance use disorders. Obsessive-compulsive personality disorder must also be dis-
tinguished from symptoms that may develop in  association with persistent substance use.
Other Personality Disorders
Personality Change
 Due to Another Medical Condition
Diagnostic Criteria 310.1 (F07.0)
A. A persistent personality disturbance that represents a change from the individual’s pre-
vious characteristic personality pattern.
Note:  In children, the disturbance involves a marked deviation from normal devel-
opment or a significant change in the child’s usual behavior patterns, lasting at least
1 year.
B. There is evidence from the history, physical examination, or laboratory findings that the
disturbance is the direct pathophysiological consequence of another medical condition.
C. The disturbance is not better explained by another mental disorder (including another
mental disorder due to another medical condition).
D. The disturbance does not occur exclusively during the course of a delirium.
E. The disturbance causes clinically significant distress or impairment in social, occupa-
tional, or other important areas of functioning.
Specify whether:
Labile type:  If the predominant feature is affective lability.
Disinhibited type:  If the predominant feature is poor impulse control as evidenced by


Disinhibited type:  If the predominant feature is poor impulse control as evidenced by
sexual indiscretions, etc.
Aggressive type:  If the predominant feature is aggressive behavior.
Apathetic type:  If the predominant feature is marked apathy and indifference.
Paranoid type:  If the predominant feature is suspiciousness or paranoid ideation.
Other type: If the presentation is not characterized by any of the above subtypes.
Combined type:  If more than one feature predominates in the clinical picture.
Unspecified type
Coding note:  Include the name of the other medical condition (e.g., 310.1 [F07.0] person-
ality change due to temporal lobe epilepsy). The other medical condition should be coded
and listed separately immediately before the personality disorder due to another medical
condition (e.g., 345.40 [G40.209] temporal lobe epilepsy; 310.1 [F07.0] personality
change due to temporal lobe epilepsy).


Personality Change Due to Another Medical Condition 683
Subtypes
The particular personality change can be sp ecified by indicating the symptom presenta-
tion that predominates in the clinical presentation.
Diagnostic Features
The essential feature of a personality change due to another medical condition is a persis-
tent personality disturbance that is judged to  be due to the direct pathophysiological ef-
fects of a medical condition. The personality disturbance represents a change from the
individual’s previous characteristic personalit y pattern. In children , this condition may be
manifested as a marked deviat ion from normal development rather than as a change in a
stable personality pattern (Criterion A). There must be evidence from the history, physical
examination, or laboratory findings that the personality change is the direct physiological
consequence of another medical condition (Crite rion B). The diagnosis is not given if the
disturbance is better explained by another ment al 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 ca use 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, ou tbursts of aggression or rage grossly out of proportion to any precipi-
tating psychosocial stressor, marked apathy , suspiciousness, or paranoid ideation. The
phenomenology of the change is indicated using the subtypes listed in the criteria set. An
individual with the disorder is often characte rized by others as “not himself [or herself].”
Although it shares the term “personality” with  the other personality disorders, this diag-
nosis is distinct by virtue of its specific et iology, different phenome nology, and more vari-


able onset and course.
The clinical presentation in a given individual may depend on the nature and localiza-
tion of the pathological process. For example, injury to the frontal lobes may yield symp-
toms such as lack of judgment or foresight, facetiousness, disinhibition, and euphoria.
Right hemisphere strokes have often been shown to evoke personal ity changes in asso-
ciation with unilateral spatial neglect, anos ognosia (i.e., inability of the individual to
recognize a bodily or functional deficit, such as the existence of hemiparesis), motor im-
persistence, and other ne urological deficits.
Associated Features Supporting Diagnosis
A variety of neurological and other medica l conditions may cause personality changes,
including central nervous system neoplasm s, head trauma, cerebrovascular disease,
Huntington’s disease, epilepsy, infectious conditions with central nervous system in-
volvement (e.g., HIV), endocrine conditions (e.g., hypothyroidism, hypo- and hyperadre-
nocorticism), and autoimmune conditions with central nerv ous system involvement (e.g.,
systemic lupus erythematosus). The associat ed physical examination findings, laboratory
findings, and patterns of preval ence and onset reflec t those of the neurological or other
medical condition involved.
Differential Diagnosis
Chronic medical conditions associ ated with pain and disability. Chronic medical con-
ditions associated with pain and disability can also be associated with changes in person-
ality. The diagnosis of personality change du e 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 psycholo gical adjustment or response to another med-
ical condition (e.g., dependent behaviors that result from a need for the assistance of others


ical condition (e.g., dependent behaviors that result from a need for the assistance of others
following a severe head trauma, card iovascular disease , or dementia).


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


change from baseline personality functioning and the presence of a specific etiological
medical condition.
Other Specified Personality Disorder
301.89 (F60.89)
This category applies to presentations in 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 diagno stic class. The other specified personality
disorder category is used in situations in which the clinician chooses to communicate the
specific reason that the presentation does not meet the criteria for any specific personality
disorder. This is done by recording “other specified personality disorder” followed by the
specific reason (e.g., “mixed personality features”).
Unspecified Personality Disorder
301.9 (F60.9)
This category applies to presentations in which symptoms characteristic of a personality
disorder that cause clinically significant distress or impairment in social, occupational, or
other important areas of functioning predominate but do not meet the full criteria for any of
the disorders in the personality disorders diagnostic class. The unspecified personality
disorder category is used in situations in which the clinician chooses not to specify the rea-
son that the criteria are not met for a specific personality disorder, and includes presenta-
tions in which there is insufficient information to make a more specific diagnosis.


685Paraphilic
 Disorders
Paraphilic disorders  included in this manual are voyeuristic disorder (spying on
others in private activities), exhibitionisti c disorder (exposing th e genitals), frotteuristic
disorder (touching or rubbin g against a nonconsenting individual), sexual masochism
disorder (undergoing humiliation , bondage, or suffering), se xual sadism disorder (inflict-
ing humiliation, bondage, or suffering), pedophilic disorder (sexual focus on children), fe-
tishistic disorder (using nonliv ing objects or having a highly specific focus on nongenital
body parts), and transvestic disorder (engaging in sexua lly arousing cross-dressing).
These disorders have tr aditionally been selected for specific listing and assignment of ex-
plicit diagnostic criteria in DSM for two main  reasons: they are relatively common, in re-
lation to other paraphilic disorders, and some  of them entail actions for their satisfaction
that, because of their noxiousness or potentia l harm to others, are classed as criminal of-
fenses. The eight listed disorders do not exha ust the list of possible  paraphilic disorders.
Many dozens of distinct paraphilias have be en identified and named, and almost any of
them could, by virtue of its negative consequences for the individual or for others, rise to
the level of a paraphilic disorder. The diagno ses of the other specified and unspecified
paraphilic disorders are therefore indispensable and will be required in many cases.
In this chapter, the order of  presentation of the listed paraphilic disorders generally
corresponds to common classification scheme s for these conditions. The first group of
disorders is based on anomalous activi ty preferences.  These disorders are subdivided into


disorders is based on anomalous activi ty preferences.  These disorders are subdivided into
courtship disorders,  which resemble distorted components of human courtship behavior
(voyeuristic disorder, exhibitionistic di sorder, and frotteuristic disorder), and algolagnic
disorders,  which involve pain and suffering (sexual masochism disorder and sexual sadism
disorder). The second group of disorders is based on anomalous target preferences.  These
disorders include one directed at other hu mans (pedophilic disorder) and two directed
elsewhere (fetishistic  disorder and tran svestic disorder).
The term paraphilia  denotes any intense and persistent sexual interest other than sexual
interest in genital stimulation or preparator y fondling with phenotypically normal, phys-
ically mature, consenting human partners. In some circumstances, the criteria “intense
and persistent” may be difficult to apply, su ch as in the assessment of persons who are
very old or medically ill and who may not have  “intense” sexual interests of any kind. In
such circumstances, the term paraphilia  may be defined as any sexual interest greater than
or equal to normophilic sexual interests. There are also spec ific paraphilias that are gen-
erally better described as preferential  sexual interests than as intense sexual interests.
Some paraphilias primarily concern the indivi dual’s erotic activities, and others pri-
marily concern the individual’s erotic targets. Examples of  the former would include in-
tense and persistent interests in spanking, whipping, cutting, binding, or strangulating
another person, or an interest in these activiti es that equals or exceeds the individual’s in-
terest in copulation or equivalent interaction with another person. Examples of the latter


terest in copulation or equivalent interaction with another person. Examples of the latter
would include intense or preferential sexual in terest in children, corp ses, or amputees (as
a class), as well as intense or preferential in terest in nonhuman animals, such as horses or
dogs, or in inanimate obje cts, such as shoes or articles made of rubber.
A paraphilic disorder  is a paraphilia that is currently causing distress or impairment to the
individual or a paraphilia whose satisfaction has entailed personal harm, or risk of harm, to


686 Paraphilic Disorders
others. A paraphilia is a necessary but not a sufficient condition for having a paraphilic dis-
order, and a paraphilia by itself does not nece ssarily justify or require clinical intervention.
In the diagnostic criteria set for each of the listed paraphilic disorder s, Criterion A specifies
the qualitative nature of the paraphilia (e.g., an erotic focus on children or on exposing the gen-
itals to strangers), and Criterio n B specifies the negative conseq uences of the paraphilia (i.e.,
distress, impairment, or harm to  others). In keeping with the distinction between paraphilias
and paraphilic disorders, the term diagnosis  should be reserved for individuals who meet both
Criteria A and B (i.e., individuals who have a pa raphilic disorder). If an individual meets Cri-
terion A but not Criterion B for a particular paraphilia—a circumstance that might arise when
a benign paraphilia is discovered during the clinical investigation of some other condition—
then the individual may be said to have that paraphilia but not a paraphilic disorder.
It is not rare for an individual to manifest tw o or more paraphilias. In some cases, the para-
philic foci are closely related and the connectio n between the paraphilias is intuitively com-
prehensible (e.g., foot fetishism and shoe fetish ism). In other cases, th e connection between the
paraphilias is not obvious, and the presence of mu ltiple paraphilias may be coincidental or else
related to some generalized vulnerability to an omalies of psychosexual development. In any
event, comorbid diagnoses of separate paraphil ic disorders may be warranted if more than
one paraphilia is causing suffering to the individual or harm to others.


one paraphilia is causing suffering to the individual or harm to others.
Because of the two-pronged nature of diag nosing paraphilic disorders, clinician-rated
or self-rated measures and se verity assessments could addre ss either the strength of the
paraphilia itself or the seriousness of its co nsequences. Although the distress and impair-
ment stipulated in the Criterio n B are special in being the im mediate or ultimate result of
the paraphilia and not primarily the result of some other factor, the phenomena of reactive
depression, anxiety, guilt, poor work history, impaired social relations, and so on are not
unique in themselves and may be quantified  with multipurpose measures of psychosocial
functioning or quality of life.
The most widely applicable framework for assessing the strength of a paraphilia itself
is one in which examinees’ paraphilic sexual fa ntasies, urges, or beha viors are evaluated in
relation to their normophilic sexual interests and behaviors. In a clinical interview or on
self-administered questionnair es, examinees can be asked whether their paraphilic sexual
fantasies, urges, or behaviors are weaker th an, approximately equal to, or stronger than
their normophilic sexual intere sts and behaviors. This same type of comparison can be,
and usually is, employed in psychophysiological  measures of sexual interest, such as pe-
nile plethysmography in males or viewing time in males and females.
Voyeuristic Disorder
Diagnostic Criteria 302.82 (F65.3)
A. Over a period of at least 6 months, recurrent and intense sexual arousal from observ-
ing an unsuspecting person who is naked, in the process of disrobing, or engaging in
sexual activity, as manifested by fantasies, urges, or behaviors.


sexual activity, as manifested by fantasies, urges, or behaviors.
B. The individual has acted on these sexual urges with a nonconsenting person, or the
sexual urges or fantasies cause clinically significant distress or impairment in social,
occupational, or other important areas of functioning.
C. The individual experiencing the arousal and/or acting on the urges is at least 18 years
of age.
Specify if:
In a controlled environment:  This specifier is primarily applicable to individuals living
in institutional or other settings where opportunities to engage in voyeuristic behavior
are restricted.


Voyeuristic Disorder 687
In full remission:  The individual has not acted on the urges with a nonconsenting per-
son, and there has been no distress or impairment in social, occupational, or other ar-
eas of functioning, for at least 5 years while in an uncontrolled environment.
Specifiers
The “in full remission” specifier does not address the continued presence or absence of
voyeurism per se, which may still be present af ter behaviors and dist ress have remitted.
Diagnostic Features
The diagnostic criteria for voyeuristic disorder can apply both to individuals who more or less
freely disclose this paraphilic interest and to those who categorically deny any sexual arousal
from observing an unsuspecting person who is na ked, disrobing, or engaged in sexual activity
despite substantial objective evidence to the cont rary. If disclosing individuals also report dis-
tress or psychosocial problems because of thei r voyeuristic sexual pref erences, they could be
diagnosed with voyeuristic disorder. On the ot her hand, if they declare no distress, demon-
strated by lack of anxiety, obse ssions, guilt, or shame, about these paraphilic impulses and are
not impaired in other im portant areas of functioning because of this sexual interest, and their
psychiatric or legal histories indicate that they  do not act on it, they could be ascertained as
having voyeuristic sexual interest but should not  be diagnosed with voyeuristic disorder.
Nondisclosing individuals include, for example, individuals known to have been spy-
ing repeatedly on unsuspecting persons who ar e naked or engaging in sexual activity on
separate occasions but who deny any urges or fantasies concerning such sexual behavior,
and who may report that known episodes of wa tching unsuspecting naked or sexually ac-


and who may report that known episodes of wa tching unsuspecting naked or sexually ac-
tive persons were all accidental and nonsexual. Others may disclose past episodes of ob-
serving unsuspecting naked or sexually ac tive persons but contest any significant or
sustained sexual interest in this behavior. Since these individuals deny having fantasies or
impulses about watching others nude or involv ed in sexual activity, it follows that they
would also reject feeling subjectively distressed  or socially impaired by such impulses. De-
spite their nondisclosing stance, such individuals may be diagnosed with voyeuristic dis-
order. Recurrent voyeuristic behavior cons titutes sufficient suppo rt for voyeurism (by
fulfilling Criterion A) and simult aneously demonstrates that this paraphilically motivated
behavior is causing harm to ot hers (by fulfilling Criterion B).
“Recurrent” spying on unsuspecting persons who are naked or engaging in sexual ac-
tivity (i.e., multiple victims, each on a separate oc casion) may, as a general rule, be inter-
preted as three or more victim s on separate occasions. Fewer victims can be interpreted as
satisfying this criterion if there were multiple  occasions of watching the same victim or if
there is corroborating evidence of a distinct or preferential interest in secret watching of
naked or sexually acti ve unsuspecting persons. Note th at multiple victims, as suggested
earlier, are a sufficient but not a necessary cond ition for diagnosis; the criteria may also be
met if the individual acknowledges intense voyeuristic sexual interest.
The Criterion A time frame, indicating that  signs or symptoms of voyeurism must have
persisted for at least 6 months , should also be understood as a general guideline, not a
strict threshold, to ensure that the sexual in terest in secretly watching unsuspecting naked


strict threshold, to ensure that the sexual in terest in secretly watching unsuspecting naked
or sexually active others is not merely transient.
Adolescence and puberty generally increase sexual curiosity and activity. To alleviate
the risk of pathologizing normative sexual in terest and behavior during pubertal adoles-
cence, the minimum age for the diagnosis of voye uristic disorder is 18 years (Criterion C).
Prevalence
Voyeuristic acts are the most common of pote ntially law-breaking sexual behaviors. The


cence, the minimum age for the diagnosis of voye uristic disorder is 18 years (Criterion C).
Prevalence
Voyeuristic acts are the most common of pote ntially law-breaking sexual behaviors. The
population prevalence of voyeuristic disorder  is unknown. However, based on voyeuris-


688 Paraphilic Disorders
tic sexual acts in nonclinical samples, the highest possible lifetime prevalence for voyeuris-
tic disorder is approximately 12% in males and 4% in females.
Development and Course
Adult males with voyeuristic disorder often first become aware of their sexual interest in
secretly watching unsuspecti ng persons during adolescence. However, the minimum age
for a diagnosis of voyeuristic disorder is 18 years because there is substantial difficulty in
differentiating it from age-appropriate pubert y-related sexual curiosity and activity. The
persistence of voyeurism over time is unclear. Voyeuristic disorder, however, per defini-
tion requires one or more contributing factors that may change over time with or without
treatment: subjective distress (e.g., guilt, sh ame, intense sexual fr ustration, loneliness),
psychiatric morbidity, hypersex uality, and sexual impulsivit y; psychosocial impairment;
and/or the propensity to act out sexually by spying on unsuspecting naked or sexually ac-
tive persons. Therefore, the course of voyeuristic disorder is likely to vary with age.
Risk and Prognostic Factors
Temperamental. Voyeurism is a necessary precondition  for voyeuristic disorder; hence,
risk factors for voyeurism sh ould also increase the rate of voyeuristic disorder.
Environmental. Childhood sexual abuse, substance misuse, and sexual preoccupation/
hypersexuality have been suggested as risk fa ctors, although the causal relationship to
voyeurism is uncertain and the specificity unclear.
Gender-Related Diagnostic Issues
Voyeuristic disorder is very uncommon among females in clinical settings, while the male-
to-female ratio for single sexually ar ousing voyeuristic acts might be 3:1.
Differential Diagnosis
Conduct disorder and antiso cial personality disorder. Conduct disorder in adolescents


Differential Diagnosis
Conduct disorder and antiso cial personality disorder. Conduct disorder in adolescents
and antisocial personality disorder would be  characterized by additional norm-breaking
and antisocial behaviors, and the specific sexual interest in secretly watching unsuspect-
ing others who are naked or engaging in  sexual activity should be lacking.
Substance use disorders. Substance use disorders might involve single voyeuristic ep-
isodes by intoxicated individuals but should no t involve the typical sexual interest in se-
cretly watching unsuspecting persons being na ked or engaging in sexual activity. Hence,
recurrent voyeuristic sexual fantasies, urges, or behaviors that occu r also when the indi-
vidual is not intoxicated suggest that voyeuristic disorder might be present.
Comorbidity
Known comorbidities in voyeur istic disorder are largely b ased on research with males
suspected of or convicted for acts involving the secret watching of unsuspecting nude or
sexually active persons. Hence, these comorb idities might not apply to all individuals with
voyeuristic disorder. Conditions  that occur comorbidly with voyeuristic disorder include
hypersexuality and other paraphilic disorders, particularly exhibitionistic disorder. De-
pressive, bipolar, anxiety, an d substance use disorders; a ttention-deficit/hyperactivity
disorder; and conduct disorder and antisocial personality disorder ar e also frequent co-
morbid conditions.


Exhibitionistic Disorder 689
Exhibitionistic Disorder
Diagnostic Criteria 302.4 (F65.2)
A. Over a period of at least 6 months, recurrent and intense sexual arousal from the ex-
posure of one’s genitals to an unsuspecting person, as manifested by fantasies, urges,
or behaviors.
B. The individual has acted on these sexual  urges with a nonconsenting person, or the
sexual urges or fantasies cause clinically significant distress or impairment in social,
occupational, or other important areas of functioning.
Specify whether:
Sexually aroused by exposing ge nitals to prepubertal children
Sexually aroused by exposing genitals  to physically mature individuals
Sexually aroused by exposing genitals to prepubertal children and to physically
mature individuals
Specify if:
In a controlled environment:  This specifier is primarily applicable to individuals living in
institutional or other settings where opportunities to expose one’s genitals are restricted.
In full remission:  The individual has not acted on the urges with a nonconsenting per-
son, and there has been no distress or impairment in social, occupational, or other ar-
eas of functioning, for at least 5 years while in an uncontrolled environment.
Subtypes
The subtypes for exhibitionistic disorder are ba sed on the age or physical maturity of the non-
consenting individuals to whom the individual prefers to expose his or her genitals. The non-
consenting individuals could be prepubescent children, adults, or both. This specifier should
help draw adequate attention to  characteristics of victims of individuals with exhibitionistic
disorder to prevent co-occurring pedophilic di sorder from be ing overlooked. However, indi-
cations that the individual with exhibitionistic disorder is sexually attracted to exposing his or


cations that the individual with exhibitionistic disorder is sexually attracted to exposing his or
her genitals to children should not preclude a diagnosis of pedophilic disorder.
Specifiers
The “in full remission” specifier does not addr ess the continued presence or absence of ex-
hibitionism per se, which may still be present after behaviors and distress have remitted.
Diagnostic Features
The diagnostic criteria for exhibitionistic diso rder can apply both to individuals who more or
less freely disclose this paraphilia and to those who categorically deny any sexual attraction to
exposing their genitals to unsuspecting persons despite substantial objective evidence to the
contrary. If disclosing individuals also report ps ychosocial difficulties because of their sexual
attractions or preferences for exposing, they ma y be diagnosed with exhibitionistic disorder. In
contrast, if they declare no distress (exemplified by absence of anxiety, obsessions, and guilt or
shame about these paraphilic impulses) and are not impaired by this sexual interest in other
important areas of functioning, and their self-rep orted, psychiatric, or legal histories indicate
that they do not act on them, they could be asce rtained as having exhibi tionistic sexual interest
but not be diagnosed with exhibitionistic disorder.
Examples of nondisclosing individuals in clude those who have exposed themselves
repeatedly to unsuspecting persons on separa te occasions but who deny any urges or fan-


690 Paraphilic Disorders
tasies about such sexual behavior and who re port that known episodes of exposure were
all accidental and nonsexual. Others may disclo se past episodes of sexual behavior involv-
ing genital exposure but refute any significant or sustained sexual interest in such behav-
ior. Since these individuals deny having urge s or fantasies involving genital exposure, it
follows that they would also deny feeling subjectively distressed or socially impaired by
such impulses. Such individuals may be diagnosed with exhibitionistic disorder despite
their negative self-report. Re current exhibitionistic behavior constitutes sufficient support
for exhibitionism (Criterion A)  and simultaneously demonstrat es that this paraphilically
motivated behavior is causing harm to others (Criterion B).
“Recurrent” genital exposure to unsuspecting others (i.e., multiple victims, each on a
separate occasion) may, as a ge neral rule, be interpreted as three or more victims on sep-
arate occasions. Fewer victims can be interpreted as satisfying this criterion if there were
multiple occasions of exposure to the same victim, or if th ere is corroborating evidence of
a strong or preferential interest in genital exposure to unsuspecting persons. Note that
multiple victims, as suggested earlier, are a sufficient but not a necessary condition for di-
agnosis, as criteria may be met by an indi vidual’s acknowledging intense exhibitionistic
sexual interest with distress and/or impairment.
The Criterion A time frame, indicating that signs or sy mptoms of exhibitionism must
have persisted for at least 6 months, should also be understo od as a general guideline, not
a strict threshold, to ensure that the sexual interest in exposing one’s genitals to unsuspect-
ing others is not merely transient. This migh t be expressed in clear evidence of repeated
behaviors or distress ov er a nontransient period  shorter than 6 months.


behaviors or distress ov er a nontransient period  shorter than 6 months.
Prevalence
The prevalence of exhibitionistic disorder is unknown. However, based on exhibitionistic
sexual acts in nonclinical or general populati ons, the highest possible prevalence for exhi-
bitionistic disorder in the male population is 2%–4%. The prevalence of exhibitionistic dis-
order in females is even more uncertain but is  generally believed to be much lower than in
males.
Development and Course
Adult males with exhibitionistic disorder often report that they first became aware of sex-
ual interest in exposing their genitals to unsuspecting persons during adolescence, at a
somewhat later time than the typical development of normative sexual interest in women
or men. Although there is no minimum age re quirement for the diagno sis of exhibitionis-
tic disorder, it may be difficult to different iate exhibitionistic be haviors from age-appro-
priate sexual curiosity in adolescents. Wher eas exhibitionistic impulses appear to emerge
in adolescence or early adulthood, very little is known about persistence over time. By def-
inition, exhibitionistic disord er requires one or more contributing factors, which may
change over time with or without treatment; subjective distress (e.g., guilt, shame, intense
sexual frustration, lo neliness), mental disorder comorb idity, hypersexuality, and sexual
impulsivity; psychosocial impair ment; and/or the propensity to act out sexually by expos-
ing the genitals to unsuspecting persons. Ther efore, the course of exhibitionistic disorder
is likely to vary with age. As with other sexual preferences, advancing age may be associ-
ated with decreasing exhibitionistic  sexual preferences and behavior.
Risk and Prognostic Factors
Temperamental. Since exhibitionism is a necessary pr econdition for exhibitionistic dis-


Temperamental. Since exhibitionism is a necessary pr econdition for exhibitionistic dis-
order, risk factors for exhibiti onism should also increase the rate of exhibitionistic disor-
der. Antisocial history, antisocial person ality disorder, alcohol misuse, and pedophilic
sexual preference might increase risk of se xual recidivism in ex hibitionistic offenders.


Frotteuristic Disorder 691
Hence, antisocial personality disorder, alco hol use disorder, and pedophilic interest may
be considered risk factors for exhibitionistic disorder in males with exhibitionistic sexual
preferences.
Environmental. Childhood sexual and emotional abus e and sexual preoccupation/hyper-
sexuality have been suggested as risk factor s for exhibitionism, al though the causal rela-
tionship to exhibitionism is unce rtain and the specificity unclear.
Gender-Related Diagnostic Issues
Exhibitionistic disorder is highly unusual in females, whereas single sexually arousing ex-
hibitionistic acts might occur up to half as often among women compared with men.
Functional Consequences of  Exhibitionistic Disorder
The functional consequences of exhibitionisti c disorder have not been addressed in re-
search involving individuals who have not acte d out sexually by exposing their genitals to
unsuspecting strangers but who fulfill Criterio n B by experiencing intense emotional dis-
tress over these preferences.
Differential Diagnosis
Potential differential diagnose s for exhibitionistic disorder sometimes occur also as co-
morbid disorders. Therefore, it is generally necessary to evaluate the evidence for exhibi-
tionistic disorder and ot her possible conditions as separate questions.
Conduct disorder and antisocial personality disorder. Conduct disorder in adolescents
and antisocial personality disorder would be characterized by additional norm-breaking and
antisocial behaviors, and the specific sexual interest in exposing the genitals should be lacking.
Substance use disorders. Alcohol and substance use di sorders might involve single
exhibitionistic episodes by intoxicated individuals but should not involve the typical sex-
ual interest in exposing the genitals to unsusp ecting persons. Hence, recurrent exhibition-
istic sexual fantasies, urges, or behaviors that occur also when the individual is not
intoxicated suggest that exhibitionistic disorder might be present.
Comorbidity


intoxicated suggest that exhibitionistic disorder might be present.
Comorbidity
Known comorbidities in exhibitionistic disorder are largely based on research with indi-
viduals (almost all males) convicted for criminal acts involving genital exposure to non-
consenting individuals. Hence,  these comorbidities might not apply to all individuals who
qualify for a diagnosis of exhibitionistic diso rder. Conditions that occur comorbidly with
exhibitionistic disorder at high rates includ e depressive, bipolar, anxiety, and substance
use disorders; hypersexuality; attention-deficit/hyperactiv ity disorder; other paraphilic
disorders; and antisocial  personality disorder.
Frotteuristic Disorder
Diagnostic Criteria 302.89 (F65.81)
A. Over a period of at least 6 months, recurrent and intense sexual arousal from touching
or rubbing against a nonconsenting person, as manifested by fantasies, urges, or be-
haviors.
B. The individual has acted on these sexual  urges with a nonconsenting person, or the
sexual urges or fantasies cause clinically significant distress or impairment in social,
occupational, or other important areas of functioning.


692 Paraphilic Disorders
Specify if:
In a controlled environment:  This specifier is primarily applicable to individuals living
in institutional or other settings where opportunities to touch or rub against a noncon-
senting person are restricted.
In full remission:  The individual has not acted on the urges with a nonconsenting per-
son, and there has been no distress or impairment in social, occupational, or other ar-
eas of functioning, for at least 5 years while in an uncontrolled environment.
Specifiers
The “in remission” specifier does not address the continued presence or absence of frot-
teurism per se, which may still be present af ter behaviors and distress have remitted.
Diagnostic Features
The diagnostic criteria for frotteuristic disord er can apply both to in dividuals who relatively
freely disclose this paraphilia and to those wh o firmly deny any sexual attraction from touch-
ing or rubbing against a nonconsenting individual regardless of considerable objective evi-
dence to the contrary. If disclo sing individuals also report psychosocial impairment due to
their sexual preferences for touching or ru bbing against a nonconsenting individual, they
could be diagnosed with frotteuristic disorder. In  contrast, if they declare no distress (demon-
strated by lack of anxiety, ob sessions, guilt, or shame) about these paraphilic impulses and are
not impaired in other im portant areas of functioning because of this sexual interest, and their
psychiatric or legal histories indicate that they  do not act on it, they could be ascertained as
having frotteuristic sexual interest but should not  be diagnosed with frotteuristic disorder.
Nondisclosing individuals include, for in stance, individuals known to have been
touching or rubbing against nonconsenting individuals on separate occasions but who


touching or rubbing against nonconsenting individuals on separate occasions but who
contest any urges or fantasies concerning such  sexual behavior. Such individuals may re-
port that identified episodes of touching or rubbing against an unwilling individual were
all unintentional and nonsexual. Others may disc lose past episodes of touching or rubbing
against nonconsenting individuals but contest any major or persistent  sexual interest in
this. Since these individuals deny having fant asies or impulses about touching or rubbing,
they would consequently reject feeling dist ressed or psychosocially impaired by such
impulses. Despite their nondisclosing position, such individuals may be diagnosed with
frotteuristic disorder. Recurrent  frotteuristic behavior constitutes satisfactory support for
frotteurism (by fulfilling Criterion A) and co ncurrently demonstrates that this paraphili-
cally motivated behavior is causing harm  to others (by fulfilling Criterion B).
“Recurrent” touching or rubbing against a no nconsenting individual (i.e., multiple vic-
tims, each on a separate occasion) may, as a ge neral rule, be interpreted as three or more vic-
tims on separate occasions. Fewer victims can be interpreted as satisfying this criterion if
there were multiple occasions of touching or rubbing agains t the same unwilling individ-
ual, or corroborating evidence of a strong or preferential interest in touching or rubbing
against nonconsenting individuals. Note that mu ltiple victims are a sufficient but not a nec-
essary condition for diagnosis; criteria may also be met if the individual acknowledges in-
tense frotteuristic sexual inte rest with clinically significant distress and/or impairment.
The Criterion A time frame, indicating that si gns or symptoms of frotteurism must persist
for at least 6 months, should also  be interpreted as a general guid eline, not a strict threshold, to


ensure that the sexual interest in touching or rubbing against a nonconsenting individual is not
transient. Hence, the duration part of Criterion A may also be met if there is clear evidence of
recurrent behaviors or distress over a shorter but nontrans ient time period.
Prevalence


transient. Hence, the duration part of Criterion A may also be met if there is clear evidence of
recurrent behaviors or distress over a shorter but nontrans ient time period.
Prevalence
Frotteuristic acts, including the uninvited sexu al touching of or rubbing against another
individual, may occur in up to 30% of adult males in the general population. Approximately