Associated Features Supporting Diagnosis
Depression, irritability, anxiety, obsessive -compulsive symptoms, and apathy are fre-
quently, and psychosis more rarely, associat ed with Huntington’s disease and often pre-
cede the onset of motor symptoms.
Prevalence
Neurocognitive deficits are an eventual ou tcome of Huntington’s disease; the worldwide
prevalence is estimated to be 2.7 per 100,000.  The prevalence of Huntington’s disease in
North America, Europe, and Australia is 5.7 pe r 100,000, with a much lower prevalence of
0.40 per 100,000 in Asia.
Development and Course
The average age at diagnosis of Huntington’s disease is approximately 40 years, although
this varies widely. Age at onset is inversely correlated with CAG expansion length. Juve-
nile Huntington’s disease (ons et before age 20) may present more commonly with brady-
kinesia, dystonia, and rigidity than with the choreic movements characteristic of the adult-
onset disorder. The disease is gradually progre ssive, with median survival approximately
15 years after motor symptom diagnosis.
Phenotypic expression of Huntington’s diseas e varies by presence of motor, cognitive,
and psychiatric symptoms. Psychiatric and co gnitive abnormalities can predate the motor
abnormality by at least 15 years. Initial symp toms requiring care often include irritabity,
anxiety, or depressed mood. Other behavioral  disturbances may include pronounced ap-
athy, disinhibition, impulsivit y, and impaired insight, with apathy often becoming more
progressive over time. Early movement symptoms may involve the appearance of fidget-
iness of the extremitie s as well as mild apraxia  (i.e., difficulty with purposeful movements),


particularly with fine motor tasks. As the disorder progre sses, other motor problems in-
clude impaired gait (ataxia ) and postural instability. Motor impairment eventually affects
speech production ( dysarthria ) such that the speech becomes very difficult to understand,


640 Neurocognitive Disorders
which may result in significant distress resu lting from the communication barrier in the
context of comparatively intact cognition. Advanced motor disease severely affects gait
with progressive ataxia. Eventually individuals become nonambulatory. End-stage motor
disease impairs motor control of eating and swallowing, typically a major contributor to
the death of the individual from aspiration pneumonia.
Risk and Prognostic Factors
Genetic and physiological. The genetic basis of Huntington’s disease is a fully penetrant
autosomal dominant expansion of th e CAG trincleotide, often called a CAG repeat  in the
huntingtin gene. A repeat length of 36 or more  is invariably associated with Huntington’s
disease, with longer repeat lengths associated  with early age at onset. A CAG repeat length
of 36 or more is invariably asso ciated with Huntington’s disease.
Diagnostic Markers
Genetic testing is the primary laboratory test  for the determination of Huntington’s dis-
ease, which is an autosomal dominant disord er with complete penetrance. The trinucleo-
tide CAG is observed to have a repeat ex pansion in the gene that encodes huntingtin
protein on chromosome 4. A di agnosis of Huntington’s disease is not made in the presence
of the gene expansion alone, but the diagno sis is made only after symptoms become man-
ifest. Some individuals with a positive family  history request genetic testing in a presymp-
tomatic stage. Associat ed features may also include neur oimaging changes; volume loss in
the basal ganglia, particularly the caudate nu cleus and putamen, is well known to occur
and progresses over the course of illness. Other structural and functional changes have
been observed in brain imagin g but remain research measures.
Functional Consequences of Major or Mild


Functional Consequences of Major or Mild
Neurocognitive Disorder Du e to Huntington’s Disease
In the prodromal phase of illness and at early diagnosis, occupational decline is most com-
mon, with most individuals repo rting some loss of ability to engage in their typical work.
The emotional, behavioral, and cognitive aspects of Huntington’s disease, such as disin-
hibition and personality changes, are highly associated with functional decline. Cognitive
deficits that contribute most to functional decline may incl ude speed of processing, initi-
ation, and attention rather th an memory impairment. Given that Huntington’s disease on-
set occurs in productive years of life, it may have a very disruptive effect on performance
in the work setting as well as social and fam ily life. As the disease progresses, disability
from problems such as impair ed gait, dysarthria, and impulsive or irritable behaviors may
substantially add to the level of impairment and daily care needs, over and above the care
needs attributable to the cognitive decline.  Severe choreic moveme nts may substantially
interfere with provision of care such  as bathing, dressing, and toileting.
Differential Diagnosis
Other mental disorders. Early symptoms of Huntington’s disease may include instabil-
ity of mood, irritability, or compulsive behaviors that may suggest another mental disor-
der. However, genetic testing or the develo pment of motor symptoms  will distinguish the
presence of Huntington’s disease.
Other neurocognitive disorders. The early symptoms of Huntington’s disease, particu-
larly symptoms of executive dysfunction an d impaired psychomotor speed, may resemble
other neurocognitive disorders (NCDs), such as major or mild vascular NCD.


Major or Mild Neurocognitive Disorder Due to Another Medical Condition 641
Other movement disorders. Huntington’s disease must also be differentiated from other
disorders or conditions associated with chorea, such as Wilson’s disease, drug-induced
tardive dyskinesia, Sydenham’s chorea, systemic  lupus erythematosus, or senile chorea.
Rarely, individuals may present with a course similar to that of Huntington’s disease but
without positive genetic testin g; this is considered to be  a Huntington’s disease pheno-
copy that results from a variet y of potential genetic factors.
Major or Mild Neurocognitive Disorder
 Due to Another Medical Condition
Diagnostic Criteria
A. The criteria are met for major or mild neurocognitive disorder.
B. There is evidence from the history, physical examination, or laboratory findings that the
neurocognitive disorder is the pathophysi ological consequence of another medical
condition.
C. The cognitive deficits are not better explained by another mental disorder or another
specific neurocognitive disorder (e.g., Alzheimer’s disease, HIV infection).
Coding note: For major neurocognitive disorder due  to another medical condition, with
behavioral disturbance, code first the other medical condition, followed by the major neu-
rocognitive disorder due to another medical condition, with behavioral disturbance (e.g.,
340 [G35] multiple sclerosis, 294.11 [F02.81]  major neurocognitive disorder due to multi-
ple sclerosis, with behavioral disturbance). For major neurocognitive disorder due to an-
other medical condition, without behavioral disturbance, code first the other medical
condition, followed by the major neurocognitive disorder due to another medical condition,
without behavioral disturbance (e.g., 340 [G35] multiple sclerosis, 294.10 [F02.80]  major


neurocognitive disorder due to multiple sclerosis, without behavioral disturbance).
For mild neurocognitive disorder due to another medical condition, code 331.83 (G31.84).
(Note:  Do not  use the additional code for the other medical condition. Behavioral distur-
bance cannot be coded but should still be indicated in writing.)
Diagnostic Features
A number of other medical co nditions can cause neurocognitive disorders (NCDs). These
conditions include structural lesions (e.g., primary or secondary brain tumors, subdural
hematoma, slowly progressive or normal-press ure hydrocephalus), hypoxia related to hy-
poperfusion from heart failure, endocrine co nditions (e.g., hypothyroidism, hypercalce-
mia, hypoglycemia), nutritional conditions (e.g., deficiencies of thiamine or niacin), other
infectious conditions (e.g., neurosyphilis, cryptococcosis), im mune disorders (e.g., tempo-
ral arteritis, systemic lupus erythematosus), hepatic or rena l failure, metabolic conditions
(e.g., Kufs’ disease, adrenoleukodystrophy, metachromatic leukodystrophy, other storage
diseases of adulthood and childhood), and ot her neurological conditions (e.g., epilepsy,
multiple sclerosis). Unusual causes of central nervous system injury, such as electrical
shock or intracranial radiation, are generally evident from the history. The temporal asso-
ciation between the onset or exacerbation of  the medical condition and the development of
the cognitive deficit offers the greatest supp ort that the NCD is induced by the medical
condition. Diagnostic certainty regarding this relationship may be increased if the neuro-
cognitive deficits ameliorate partially or stab ilize in the context of treatment of the medical


condition.


642 Neurocognitive Disorders
Development and Course
Typically the course of the NCD progresses in a manner that is commensurate with progres-
sion of the underlying medical disorder. In ci rcumstances where the medical disorder is treat-
able (e.g., hypothyroidism), th e neurocognitive deficit may im prove or at least not progress.
When the medical condition has a deteriorative course (e.g., secondary progressive multiple
sclerosis), the neurocognitive deficits will progre ss along with the tempor al course of illness.
Diagnostic Markers
Associated physical examinatio n and laboratory findings and other clinical features de-
pend on the nature and severity of the medical condition.
Differential Diagnosis
Other major or mild neurocognitive disorder. The presence of an attributable medical
condition does not entirely exclude the possibility of another major or mild NCD. If cog-
nitive deficits persist following successful treatment of an associated medical condition,
then another etiology may be responsible for the cognitive decline.
Major or Mild Neurocognitive Disorder
 Due to Multiple Etiologies
Diagnostic Criteria
A. The criteria are met for major or mild neurocognitive disorder.
B. There is evidence from the history, physical examination, or laboratory findings that the
neurocognitive disorder is the pathophysiological consequence of more than one etio-
logical process, excluding substances (e.g., neurocognitive disorder due to Alzhei-
mer’s disease with subsequent development of vascular neurocognitive disorder).
Note:  Please refer to the diagnostic criteria for the various neurocognitive disorders due
to specific medical conditions for guidance  on establishing the pa rticular etiologies.
C. The cognitive deficits are not better ex plained by another mental disorder and do not
occur exclusively during the course of a delirium.


occur exclusively during the course of a delirium.
Coding note: For major neurocognitive disorder due to multiple etiologies, with behavioral
disturbance, code 294.11 (F02.81) ; for major neurocognitive disorder due to multiple etiolo-
gies, without behavioral disturbance, code 294.10 (F02.80). All of the etiological medical
conditions (with the exception of  vascular disease) should be coded and listed separately
immediately before major neurocognitive diso rder due to multiple etiologies (e.g., 331.0
[G30.9]  Alzheimer’s disease; 331.82 [G31.83]  Lewy body disease; 294.11 [F02.81]  major
neurocognitive disorder due to multiple  etiologies, with behavioral disturbance).
When a cerebrovascular etiology is contributin g to the neurocognitive disorder, the diagno-
sis of vascular neurocognitive disorder should be listed in addition to major neurocognitive
disorder due to multiple etiologies. For example, for a presentation of major neurocognitive
disorder due to both Alzheimer’s disease and va scular disease, with behavioral disturbance,
code the following: 331.0 (G30.9) Alzheimer’s disease; 294.11 (F02.81)  major neurocogni-
tive disorder due to multiple etiologies, with behavioral disturbance; 290.40 (F01.51)  major
vascular neurocognitive disorder, with behavioral disturbance.
For mild neurocognitive disorder due to multiple etiologies, code 331.83 (G31.84).  (Note:
Do not use the additional codes for the etiologies. Behavioral disturbance cannot be coded
but should still be indicated in writing.)


Unspecified Neurocognitive Disorder 643
This category is included to cover the clinical presentation of a neurocognitive disorder (NCD)
for which there is evidence that multiple medical conditions have played a probable role in the
development of the NCD. In addition to evidence indicative of the presence of multiple med-
ical conditions that are known to cause NCD (i .e., findings from the hi story and physical ex-
amination, and laboratory findings), it may be he lpful to refer to the diag nostic criteria and text
for the various medical etiologies (e.g., NCD du e to Parkinson’s disease) for more information
on establishing the etiological connection  for that particular medical condition.
Unspecified Neurocognitive Disorder
799.59 (R41.9)
This category applies to presentations in which symptoms characteristic of a neurocogni-
tive 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 neurocognitive diso rders diagnostic class. The unspecified neuro-
cognitive disorder category is used in situations in which the precise etiology cannot be
determined with sufficient certainty to make an etiological attribution.
Coding note:  For unspecified major or mild neurocognitive disorder, code 799.59 (R41.9).
(Note:  Do not use additional codes for any presumed etiological medical conditions. Be-
havioral disturbance cannot be coded but may be indicated in writing.)


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645Personality
 Disorders
This chapter begins  with a general definition of personality disorder that applies
to each of the 10 specific  personality disorders. A personality disorder  is an enduring pattern
of inner experience and behavior  that deviates markedly from the expectations of the in-
dividual’s culture, is pervasive and inflexible , has an onset in adolescence or early adult-
hood, is stable over time, and lead s to distress or impairment.
With any ongoing review process, especially  one of this complexity, different view-
points emerge, and an effort was made to accommodate them. Thus, personality disorders
are included in both Sections II and III. The material in Section II represents an update of
text associated with the same criteria foun d in DSM-IV-TR, whereas Section III includes
the proposed research model for personality disorder diagnosis and conceptualization de-
veloped by the DSM-5 Personality and Persona lity Disorders Work Group. As this field
evolves, it is hoped that both versions will serve clinical practice and research initiatives,
respectively.
The following personality disorders are included in this chapter.
•Paranoid personality disorder  is a pattern of distrust and suspiciousness such that oth-
ers’ motives are interp reted as malevolent.
•Schizoid personality disorder  is a pattern of detachment fr om social relationships and
a restricted range of emotional expression.
•Schizotypal personality disorder  is a pattern of acute discomfort in close relationships,
cognitive or perceptual distortions,  and eccentricities of behavior.
•Antisocial personality disorder  is a pattern of disregard for,  and violation of, the rights
of others.
•Borderline personality disorder  is a pattern of instability in interpersonal relation-
ships, self-image, and affects, and marked impulsivity.


ships, self-image, and affects, and marked impulsivity.
•Histrionic personality disorder  is a pattern of excessive emotionality and attention
seeking.
•Narcissistic personality disorder  is a pattern of grandiosity, need for admiration, and
lack of empathy.
•Avoidant personality disorder  is a pattern of social inhibition, feelings of inadequacy,
and hypersensitivity to negative evaluation.
•Dependent personality disorder is a pattern of submissive and clinging behavior re-
lated to an excessive need  to be taken care of.
•Obsessive-compulsive personality disorder  is a pattern of preoccupation with order-
liness, perfectionism, and control.
•Personality change due to another medical condition  is a persistent personality dis-
turbance that is judged to be due to the direct physiological effects of a medical condi-
tion (e.g., frontal lobe lesion).
•Other specified personality disorder and unspecified personality disorder  is a cate-
gory provided for two situations: 1) the individual’s personality pattern meets the gen-
eral criteria for a personality disorder, an d traits of several different personality
disorders are present, but the criteria for any specific pers onality disorder  are not met;


646 Personality Disorders
or 2) the individual’s personality pattern m eets the general criteria  for a personality dis-
order, but the individual is considered to have a personality disorder that is not in-
cluded in the DSM-5 classification (e.g., passive-aggressive personality disorder).
The personality disorders are grouped into thre e clusters based on descriptive similarities.
Cluster A includes paranoid, schizoid, and schi zotypal personality diso rders. Individuals with
these disorders often appear odd or eccentric. Cluster B includes antisocial, borderline, histri-
onic, and narcissistic personality disorders. In dividuals with these disorders often appear dra-
matic, emotional, or erratic. Cluster C in cludes avoidant, dependent, and obsessive-
compulsive personality disorders. Individuals with these disorders often appear anxious or
fearful. It should be noted that this clustering system, although useful in some research and ed-
ucational situations, has serious limitations and has not been consistently validated.
Moreover, individuals freque ntly present with co-occu rring personality disorders
from different clusters. Prevalence estimates fo r the different clusters suggest 5.7% for dis-
orders in Cluster A, 1.5% for disorders in Cl uster B, 6.0% for disorders in Cluster C, and
9.1% for any personality disorder, indicating frequent co-occurrence of disorders from dif-
ferent clusters. Data from the 2001–2002 National Epidemiologic Survey on Alcohol and
Related Conditions suggest that  approximately 15% of U.S. adults have at least one per-
sonality disorder.
Dimensional Models for Personality Disorders
The diagnostic approach used in this manual  represents the categorical perspective that
personality disorders are qualit atively distinct clinical synd romes. An alternative to the


personality disorders are qualit atively distinct clinical synd romes. An alternative to the
categorical approach is the dimensional perspective that personality disorders represent
maladaptive variants of personality traits that merge imperceptibly into normality and
into one another. See Section III for a full description of a dimensional model for person-
ality disorders. The DSM-IV personality disord er clusters (i.e., odd-eccentric, dramatic-
emotional, and anxious- fearful) may also be viewed as dimensions representing spectra of
personality dysfunction on a continuum with other mental disorders. The alternative di-
mensional models have much in common and together appear to cover the important ar-
eas of personality dysfunction. Their integration, clinical utility, and relationship with the
personality disorder diagnostic categories and various aspects of personality dysfunction
are under active investigation.
General Personality Disorder
Criteria
A. An enduring pattern of inner experience and behavior that deviates markedly from the
expectations of the individual’s culture. This pattern is manifested in two (or more) of
the following areas:
1. Cognition (i.e., ways of perceiving and interpreting self, other people, and events).
2. Affectivity (i.e., the range, intensity, lability, and appropriateness of emotional re-
sponse).
3. Interpersonal functioning.
4. Impulse control.
B. The enduring pattern is inflexible and per vasive across a broad range of personal and
social situations.
C. The enduring pattern leads to clinically signi ficant distress or impairment in social, oc-
cupational, or other important areas of functioning.


General Personality Disorder 647
D. The pattern is stable and of long duration, and its onset can be traced back at least to
adolescence or early adulthood.
E. The enduring pattern is not better explained as a manifestation or consequence of an-
other mental disorder.
F. The enduring pattern is not attributable to the physiological effects of a substance (e.g.,
a drug of abuse, a medication) or another  medical condition (e.g., head trauma).
Diagnostic Features
Personality traits  are enduring patterns of perceiving, relating to, and thinking about the en-
vironment and oneself that are exhibited in a wide range of social and personal contexts.
Only when personality traits are inflexible and maladaptive and cause significant func-
tional impairment or subjective distress do th ey constitute personality disorders. The essen-
tial feature of a personality disorder is an en during pattern of inner experience and behavior
that deviates markedly from the expectations of the individual’s culture and is manifested
in at least two of the following areas: cognition, affectivity, interpersonal functioning, or im-
pulse control (Criterion A). This  enduring pattern is inflexib le and pervasive across a broad
range of personal and social sit uations (Criterion B) and leads to clinically significant dis-
tress or impairment in social, occupational, or  other important areas of functioning (Crite-
rion C). The pattern is stable and of long duration, and its onset can be traced back at least
to adolescence or early adulthood (Criterion D). The pattern is not better explained as a
manifestation or consequence of another mental disorder (Criterion E) and is not attribut-
able to the physiological effects of a substanc e (e.g., a drug of abuse, a medication, exposure
to a toxin) or another medical condition (e.g., head trauma) (Criterion F). Specific diagnostic


criteria are also provided for each of the pe rsonality disorders included in this chapter.
The diagnosis of personality disorders requires an evaluation of the individual’s long-
term patterns of functioning, and the partic ular personality features must be evident by
early adulthood. The personality traits that define these disorders must also be distin-
guished from characteristics th at emerge in response to sp ecific situational stressors or
more transient mental states (e .g., bipolar, depressive, or an xiety disorders; substance in-
toxication). The clinician should assess the stability of pers onality traits over time and
across different situations. Although a single interview with the in dividual is sometimes
sufficient for making the diagnosis, it is of ten necessary to conduct more than one inter-
view and to space these over time. Assessment ca n also be complicated by the fact that the
characteristics that define a personality di sorder may not be considered problematic by
the individual (i.e., the traits are often ego-sy ntonic). To help overcome this difficulty, sup-
plementary information from other informants may be helpful.
Development and Course
The features of a personality disorder usually become recogn izable during adolescence or
early adult life. By definition, a personality disorder is an enduring pattern of thinking,
feeling, and behaving that is relatively stable  over time. Some types of personality disorder
(notably, antisocial and borderli ne personality disorders) tend to become less evident or to
remit with age, whereas this appears to be less true for some other types (e.g., obsessive-
compulsive and schizotypal personality disorders).
Personality disorder categories may be app lied with children or adolescents in those
relatively unusual instances in which the individual’s particular maladaptive personality
traits appear to be pervasive, persistent, an d unlikely to be limited to a particular devel-


traits appear to be pervasive, persistent, an d unlikely to be limited to a particular devel-
opmental stage or another mental disorder. It sh ould be recognized that the traits of a per-


traits appear to be pervasive, persistent, an d unlikely to be limited to a particular devel-
opmental stage or another mental disorder. It sh ould be recognized that the traits of a per-
sonality disorder that appear in childhood will often not persist unchanged into adult life.
For a personality disorder to be diagnosed in an individual younger than 18 years, the fea-
tures must have been present fo r at least 1 year. The one exception to this is antisocial per-


648 Personality Disorders
sonality disorder, which cannot be diagnosed in individuals younger than 18 years. Al-
though, by definition, a personality disorder requires an onset no later than early
adulthood, individuals may not come to clinical attention until relatively late in life. A per-
sonality disorder may be exacer bated following the loss of significant supporting persons
(e.g., a spouse) or previously stabilizing social situations (e.g ., a job). However, the devel-
opment of a change in person ality in middle adulthood or later life warrants a thorough
evaluation to determine the possible presence of a personality change due to another med-
ical condition or an unrecogn ized substance use disorder.
Culture-Related Diagnostic Issues
Judgments about personality functioning must take into account the in dividual’s ethnic, cul-
tural, and social background. Personality disord ers should not be confused with problems as-
sociated with acculturation following immigratio n or with the expressi on of habits, customs,
or religious and political values professed by the individual’s culture of origin. It is useful for
the clinician, especially when evaluating some one from a different background, to obtain ad-
ditional information from informants who are fa miliar with the person’s cultural background.
Gender-Related Diagnostic Issues
Certain personality disorders (e.g., antisocial personality disorder) are diagnosed more
frequently in males. Others (e.g., borderline, histrionic, and dependent personality disor-
ders) are diagnosed more freque ntly in females. Although these differences in prevalence
probably reflect real gender differences in the presence of such patterns, clinicians must be
cautious not to overdiagnose or underdiagnos e certain personality disorders in females or
in males because of social stereotypes about typical gender roles and behaviors.
Differential Diagnosis


in males because of social stereotypes about typical gender roles and behaviors.
Differential Diagnosis
Other mental disorders and personality traits. Many of the specific criteria for the per-
sonality disorders describe features (e.g., su spiciousness, dependency, insensitivity) that
are also characteristic of episo des of other mental disorders. A personality disorder should
be diagnosed only when the defining characte ristics appeared before  early adulthood, are
typical of the individual’s long-term function ing, and do not occur exclusively during an
episode of another mental diso rder. It may be particularly difficult (and not particularly
useful) to distinguish personality disorders from persistent mental disorders such as per-
sistent depressive disorder that have an ea rly onset and an enduring, relatively stable
course. Some personality diso rders may have a “spectrum” relationship to other mental
disorders (e.g., schizotypal personality disord er with schizophrenia; avoidant personality
disorder with social anxiety disorder [social phobia]) based on phe nomenological or bio-
logical similarities or familial aggregation.
Personality disorders must be distinguished from personality traits that do not reach
the threshold for a personality disorder. Person ality traits are diagnosed as a personality
disorder only when they are inflexible, maladaptive, and persisting and cause significant
functional impairment or subjective distress.
Psychotic disorders. For the three personality disorders that may be related to the psy-
chotic disorders (i.e., paranoid, schizoid, and schizotypal), there is an exclusion criterion
stating that the pattern of behavior must no t have occurred exclusively during the course
of schizophrenia, a bipolar or depressive disorder with psycho tic features, or another psy-
chotic disorder. When an individual has a pers istent mental disorder  (e.g., schizophrenia)


that was preceded by a preexisting personalit y disorder, the personality disorder should
also be recorded, followed by “premorbid” in parentheses.
Anxiety and depressive disorders. The clinician must be cautious in diagnosing per-


also be recorded, followed by “premorbid” in parentheses.
Anxiety and depressive disorders. The clinician must be cautious in diagnosing per-
sonality disorders during an episode of a depressive disorder or an  anxiety disorder, be-


Paranoid Personality Disorder 649
cause these conditions may have cross-sectio nal symptom features that mimic personality
traits and may make it more difficult to evaluate retrospectively the individual’s long-term
patterns of functioning.
Posttraumatic stress disorder. When personality changes emerge and persist after an
individual has been exposed to  extreme stress, a diagnosis of  posttraumatic stress disorder
should be considered.
Substance use disorders. When an individual has a substance use disorder, it is impor-
tant not to make a personality disorder diag nosis based solely on behaviors that are con-
sequences of substance intoxication or withdraw al or that are associated with activities in
the service of sustaining substance use (e.g., antisocial behavior).
Personality change due to another medical condition. When enduring changes in per-
sonality arise as a result of the physiological effects of another medical condition (e.g.,
brain tumor), a diagnosis of personality chan ge due to another medical condition should
be considered.
Cluster A Personality Disorders
Paranoid Personality Disorder
Diagnostic Criteria 301.0 (F60.0)
A. A pervasive distrust and suspiciousness of others such that their motives are inter-
preted as malevolent, beginning by early adulthood and present in a variety of con-
texts, as indicated by four (or more) of the following:
1. Suspects, without sufficient basis, that others are exploiting, harming, or deceiving
him or her.
2. Is preoccupied with unjustified doubts about the loyalty or trustworthiness of friends
or associates.
3. Is reluctant to confide in others because of unwarranted fear that the information
will be used maliciously against him or her.
4. Reads hidden demeaning or threatening meanings into benign remarks or events.


4. Reads hidden demeaning or threatening meanings into benign remarks or events.
5. Persistently bears grudges (i.e., is unforgiving of insults, injuries, or slights).
6. Perceives attacks on his or her character or reputation that are not apparent to oth-
ers and is quick to react angrily or to counterattack.
7. Has recurrent suspicions, without justification, regarding fidelity of spouse or sexual
partner.
B. Does not occur exclusively during the course of schizophrenia, a bipolar disorder or
depressive disorder with psychotic features, or another psychotic disorder and is not
attributable to the physiological effects of another medical condition.
Note: If criteria are met prior to the onset of schizophrenia, add “premorbid,” i.e., “paranoid
personality disorder (premorbid).”
Diagnostic Features
The essential feature of parano id personality disorder is a pattern of pervasive distrust
and suspiciousness of others such that their motives are interpreted as malevolent. This
pattern begins by early adulthood and is present in a variety of contexts.


650 Personality Disorders
Individuals with this disorder assume that other people will exploit, harm, or deceive
them, even if no evidence exists to support th is expectation (Criterion A1). They suspect on
the basis of little or no eviden ce that others are plotting against them and may attack them
suddenly, at any time and without reason. They often feel that they have been deeply and
irreversibly injured by another person or persons even when there is no objective evidence
for this. They are preoccupied with unjustifie d doubts about the loyalty or trustworthiness
of their friends and associates, whose actions are minutely scrutinize d for evidence of hos-
tile intentions (Criterion A2). Any perceived deviation from trustworthiness or loyalty
serves to support their underlying assumptions. They are so amazed when a friend or as-
sociate shows loyalty that they cannot trust or believe it. If they get into trouble, they ex-
pect that friends and associates w ill either attack or ignore them.
Individuals with paranoid personality disord er are reluctant to confide in or become
close to others because they fear that the information they share will be used against them
(Criterion A3). They may refuse to answer personal questions, saying that the information
is “nobody’s business.” They read hidden meanings that are demeaning and threatening
into benign remarks or events (Criterion A4). For example, an individual with this disor-
der may misinterpret an honest mistake by a store clerk as a deliberate attempt to short-
change, or view a casual humorous remark by  a co-worker as a seri ous character attack.
Compliments are often misinterpreted (e.g.,  a compliment on a new acquisition is mis-
interpreted as a criticism for selfishness; a compliment on an accomplishment is misinter-


interpreted as a criticism for selfishness; a compliment on an accomplishment is misinter-
preted as an attempt to coerce more and better performance). They may view an offer of
help as a criticism that they ar e not doing well enough on their own.
Individuals with this disorder persistently bear grudges and are unwilling to forgive
the insults, injuries, or slights that they th ink they have received (Criterion A5). Minor
slights arouse major hostility, and the hostile f eelings persist for a long time. Because they
are constantly vigilant to the harmful intentions of others, they very often feel that their
character or reputation has been attacked or that they have been slighted in some other
way. They are quick to counterattack and react with anger to perceived insults (Criterion
A6). Individuals with this disorder may be pathologically jealous, often suspecting that
their spouse or sexual partner is unfaithful without any adequate ju stification (Criterion
A7). They may gather trivial and circumstantial  “evidence” to support  their jealous beliefs.
They want to maintain complete control of intimate relationships to avoid being betrayed
and may constantly question and challenge th e whereabouts, actions, intentions, and fi-
delity of their spouse or partner.
Paranoid personality disorder should not be diagnosed if the pattern of behavior oc-
curs exclusively during the course of schizo phrenia, a bipolar disorder or depressive dis-
order with psychotic features, or another psychoti c disorder, or if it is attributable to the
physiological effects of a neurological (e.g., temporal lobe epilepsy) or another medical
condition (Criterion B).
Associated Features Supporting Diagnosis
Individuals with paranoid personality disorder are generally difficult to get along with
and often have problems with close relationsh ips. Their excessive suspiciousness and hos-


and often have problems with close relationsh ips. Their excessive suspiciousness and hos-
tility may be expressed in over t argumentativeness, in recurr ent complaining, or by quiet,
apparently hostile aloofness. Because they ar e hypervigilant for potential threats, they
may act in a guarded, secretive, or devious manner and appear to be “cold” and lacking in
tender feelings. Although they may appear to be objective, rational , and unemotional, they


may act in a guarded, secretive, or devious manner and appear to be “cold” and lacking in
tender feelings. Although they may appear to be objective, rational , and unemotional, they
more often display a labile range of affect, with hostile, stub born, and sarcastic expressions
predominating. Their combative and suspicious  nature may elicit a hostile response in
others, which then serves to conf irm their original expectations.
Because individuals with  paranoid personality disorder lack trust in others, they have
an excessive need to be self-sufficient and a strong sense of autonomy. They also need to


Paranoid Personality Disorder 651
have a high degree of control over those around them. They are often rigid, critical of oth-
ers, and unable to collaborate, although they  have great difficulty accepting criticism them-
selves. They may blame others for their own shortcomings. Because of their quickness to
counterattack in response to the threats they perceive around them, they may be litigious
and frequently become involved in legal disputes. Individuals with this disorder seek to
confirm their preconceived nega tive notions regarding people or situations they encounter,
attributing malevolent motivati ons to others that are projections of their own fears. They
may exhibit thinly hidden, unrealistic grandios e fantasies, are often attuned to issues of
power and rank, and tend to develop negative  stereotypes of others, particularly those
from population groups distinct from their own. Attracted by simplistic formulations of the
world, they are often wary of  ambiguous situations. They ma y be perceived as “fanatics”
and form tightly knit “cults” or  groups with others who share their paranoid belief systems.
Particularly in response to stress, individu als with this disorder may experience very
brief psychotic episodes (lasting minutes to hour s). In some instances, paranoid personal-
ity disorder may appear as the premorbid ante cedent of delusional disorder or schizo-
phrenia. Individuals with paranoid personal ity disorder may deve lop major depressive
disorder and may be at increased risk fo r agoraphobia and obsessive-compulsive dis-
order. Alcohol and other substance use disord ers frequently occur. The most common co-
occurring personality disorders appear to be schizotypal, schizoid, narcissistic, avoidant,
and borderline.
Prevalence
A prevalence estimate for paranoid personality based on a probability subsample from


Prevalence
A prevalence estimate for paranoid personality based on a probability subsample from
Part II of the National Comorbidity Survey Replication suggests a prevalence of 2.3%,
while the National Epidemiologic Survey on Alcohol and Related Conditions data suggest
a prevalence of paranoid personality disorder of 4.4%.
Development and Course
Paranoid personality disorder may be first apparent in childhood and adolescence with
solitariness, poor peer relationships, social anxiety, underachievement in school, hyper-
sensitivity, peculiar thoughts and language, and idiosyncratic fantasies. These children
may appear to be “odd” or “eccentric” and attr act teasing. In clinical samples, this disorder
appears to be more commonly diagnosed in males.
Risk and Prognostic Factors
Genetic and physiological. There is some evidence for an increased prevalence of par-
anoid personality disorder in relatives of probands with schizophrenia and for a more spe-
cific familial relationship with delusional disorder, persecutory type.
Culture-Related Diagnostic Issues
Some behaviors that are influenced by sociocultural contexts or specific life circumstances
may be erroneously labeled paranoid and may ev en be reinforced by the process of clinical
evaluation. Members of minority groups, immi grants, political and economic refugees, or
individuals of different ethnic backgrounds may display guarded or defensive behaviors
because of unfamiliarity (e.g., language barriers or lack of knowledge of rules and regula-
tions) or in response to the perceived neglect or indifference of the majority society. These
behaviors can, in turn, generate anger and fr ustration in those who deal with these indi-
viduals, thus setting up a vicious cycle of mutual mistrust, which should not be confused
with paranoid personality diso rder. Some ethnic groups also display culturally related be-
haviors that can be misinterpreted as paranoid.


652 Personality Disorders
Differential Diagnosis
Other mental disorders with psychotic symptoms. Paranoid personality disorder can
be distinguished from delusional disorder, pe rsecutory type; schizophrenia; and a bipolar or
depressive disorder with psychotic features be cause these disorders are all characterized by a
period of persistent psychotic symptoms (e.g., delusions and hallucinations). For an additional
diagnosis of paranoid personality disorder to be given, the personal ity disorder must have
been present before the onset of psychotic sy mptoms and must persist when the psychotic
symptoms are in remission. When an individual has another persistent mental disorder (e.g.,
schizophrenia) that was preceded by paranoid personality disorder, paranoid personality dis-
order should also be recorded, follo wed by “premorbid” in parentheses.
Personality change due to another medical condition. Paranoid 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 direct effects of another medical condi-
tion on the central nervous system.
Substance use disorders. Paranoid personality disorder  must be distinguished from
symptoms that may develop in associat ion with persistent substance use.
Paranoid traits associated with physical handicaps. The disorder must also be distin-
guished from paranoid traits associated with  the development of physical handicaps (e.g.,
a hearing impairment).
Other personality disorders and personality traits. Other personality disorders may be
confused with paranoid person ality disorder because they ha ve certain features in common.
It is therefore important to distinguish among these disorders based on differences in their
characteristic features. However, if an individu al has personality features that meet criteria
for one or more personality disorders in additi on to paranoid personality disorder, all can be
diagnosed. Paranoid personality disorder an d schizotypal personality disorder share the


diagnosed. Paranoid personality disorder an d schizotypal personality disorder share the
traits of suspiciousness, interpersonal aloofne ss, and paranoid ideati on, but schizotypal per-
sonality disorder also includes symptoms such as magical thinking, unusual perceptual ex-
periences, and odd thinking and speech. Indivi duals with behaviors th at meet criteria for
schizoid personality disorder ar e often perceived as strange, ec centric, cold, and aloof, but
they do not usually have prominent paranoid ideation. The tendency of individuals with
paranoid personality disorder to react to minor stimuli with anger is also seen in borderline
and histrionic personality disorders. However, these disord ers are not necessarily associ-
ated with pervasive suspiciousness. People with avoidant personality disorder may also be
reluctant to confide in others, but more from fear of being embarrassed or found inadequate
than from fear of others’ malicious intent. Although antisocial behavior may be present in
some individuals with paranoid personality diso rder, it is not usually motivated by a desire
for personal gain or to exploit others as in an tisocial personality diso rder, but rather is more
often attributable to a desire for revenge. In dividuals with narcissistic personality disorder
may occasionally display suspiciousness, social withdrawal, or alienation, but this derives
primarily from fears of having thei r imperfections or flaws revealed.
Paranoid traits may be adaptive, particul arly in threatening environments. Paranoid
personality disorder should be  diagnosed only when these tr aits are inflexible, maladap-
tive, and persisting and cause significant functional impairment or subjective distress.
Schizoid Personality Disorder
Diagnostic Criteria 301.20 (F60.1)
A. A pervasive pattern of detachment from social relationships and a restricted range of


A. A pervasive pattern of detachment from social relationships and a restricted range of
expression of emotions in interpers onal settings, beginning by early adulthood and


A. A pervasive pattern of detachment from social relationships and a restricted range of
expression of emotions in interpers onal settings, beginning by early adulthood and
present in a variety of contexts, as indicated by four (or more) of the following:


Schizoid Personality Disorder 653
1. Neither desires nor enjoys close relationships, including being part of a family.
2. Almost always chooses solitary activities.
3. Has little, if any, interest in having sexual experiences with another person.
4. Takes pleasure in few, if any, activities.
5. Lacks close friends or confidants other than first-degree relatives.
6. Appears indifferent to the praise or criticism of others.
7. Shows emotional coldness, detachment, or flattened affectivity.
B. Does not occur exclusively during the course of schizophrenia, a bipolar disorder or
depressive disorder with psychotic features, another psychotic disorder, or autism
spectrum disorder and is not attributable to the physiological effects of another medical
condition.
Note: If criteria are met prior to the onset of schizophrenia, add “premorbid,” i.e., “schiz-
oid personality disorder (premorbid).”
Diagnostic Features
The essential feature of schizo id personality disorder is a pe rvasive pattern of detachment
from social relationships and a restricted range of expression of emotions in interpersonal
settings. This pattern begins by early adulth ood and is present in a variety of contexts.
Individuals with schizoid personality disord er appear to lack a desire for intimacy,
seem indifferent to opportunities to develop close relationships, and do not seem to derive
much satisfaction from being part of a family or other social group (Criterion A1). They
prefer spending time by themselves, rather than being with other people. They often ap-
pear to be socially isolated or “loners” and al most always choose solitary activities or hob-
bies that do not include interaction with others (Criterion A2). They prefer mechanical or
abstract tasks, such as computer or mathemat ical games. They may have very little interest


abstract tasks, such as computer or mathemat ical games. They may have very little interest
in having sexual experiences with another person (Criterion A3) and take pleasure in few,
if any, activities (Criterion A4). There is usually a reduced experience of pleasure from sen-
sory, bodily, or interpersonal ex periences, such as walking on a beach at sunset or having
sex. These individuals have no  close friends or confidants, except possibly a first-degree
relative (Criterion A5).
Individuals with schizoid personality disord er often seem indifferent to the approval
or criticism of others and do not appear to be bothered by what others may think of them
(Criterion A6). They may be oblivious to the no rmal subtleties of social interaction and of-
ten do not respond appropriately to social cues so that they seem socially inept or super-
ficial and self-absorbed. They usually displa y a “bland” exterior without visible emotional
reactivity and rarely reciprocate gestures or facial expressions, such as smiles or nods (Cri-
terion A7). They claim that they rarely expe rience strong emotions such as anger and joy.
They often display a constricted affect and ap pear cold and aloof. However, in those very
unusual circumstances in which these indivi duals become at least temporarily comfort-
able in revealing themselves, they may ackn owledge having painful feelings, particularly
related to social interactions.
Schizoid personality disorder should not be diagnosed if th e pattern of behavior occurs
exclusively during the course of schizophrenia , a bipolar or depressive disorder with psy-
chotic features, another psychotic disorder, or au tism spectrum disorder, or if it is attrib-
utable to the physiological effects of a neurological (e.g., temporal lobe epilepsy) or another
medical condition (Criterion B).


medical condition (Criterion B).
Associated Features Supporting Diagnosis
Individuals with schizoid personality disord er may have particular difficulty expressing
anger, even in response to direct provocation, which contributes to  the impression that


654 Personality Disorders
they lack emotion. Their lives sometimes se em directionless, an d they may appear to
“drift” in their goals. Such individuals ofte n react passively to adverse circumstances and
have difficulty responding appropriately to im portant life events. Because of their lack of
social skills and lack of desire for sexual experiences, individuals with this disorder have
few friendships, date infreque ntly, and often do not marry. Occupational functioning may
be impaired, particularly if interpersonal involvement is required, but individuals with
this disorder may do well when they work un der conditions of soci al isolation. Particu-
larly in response to stress, individuals with this disorder may experience very brief psy-
chotic episodes (lasting minutes to hours) . In some instances, schizoid personality
disorder may appear as the pr emorbid antecedent of delusional disorder or schizophre-
nia. Individuals with this disorder may so metimes develop major depressive disorder.
Schizoid personality disorder most often co-occurs with schi zotypal, paranoid, and avoid-
ant personality disorders.
Prevalence
Schizoid personality disorder is uncommon in clinical settings. A prevalence estimate for
schizoid personality based on a probability su bsample from Part II of the National Co-
morbidity Survey Replication suggests a pr evalence of 4.9%. Data from the 2001–2002
National Epidemiologic Survey on Alcohol and Related Conditions suggest a prevalence of
3.1%.
Development and Course
Schizoid personality disorder may be first apparent in childhood  and adolescence with
solitariness, poor peer relationships, and underachievement in school, which mark these
children or adolescents as different and make them subject to teasing.
Risk and Prognostic Factors
Genetic and physiological. Schizoid personality disorder may have increased preva-


Genetic and physiological. Schizoid personality disorder may have increased preva-
lence in the relatives of individuals with schizophrenia or schizotypa l personality disorder.
Culture-Related Diagnostic Issues
Individuals from a variety of cultural bac kgrounds sometimes exhibit defensive behaviors
and interpersonal styles that may be erroneously labeled as “schizoid.” For example, those
who have moved from rural to metropolitan  environments may react with “emotional
freezing” that may last for several months and manifest as solitary activities, constricted
affect, and other deficits in communication. Immigrants from other countries are some-
times mistakenly perceived as cold, hostile, or indifferent.
Gender-Related Diagnostic Issues
Schizoid personality disorder is diagnosed slightly more often in males and may cause
more impairment in them.
Differential Diagnosis
Other mental disorders with psychotic symptoms. Schizoid persona lity disorder can
be distinguished from delusional disorder, sc hizophrenia, and a bipolar or depressive dis-
order with psychotic features because these d isorders are all characterized by a period of
persistent psychotic symptoms (e .g., delusions and hallucinations). To give an additional
diagnosis of schizoid personality disorder, the personality disorder must have been present
before the onset of psychotic symptoms an d must persist when the psychotic symptoms


Schizotypal Personality Disorder 655
are in remission. When an individual has a pe rsistent psychotic diso rder (e.g., schizophre-
nia) that was preceded by schizoid person ality disorder, schizoid personality disorder
should also be recorded, followe d by “premorbid” in parentheses.
Autism spectrum disorder. There may be great difficulty di fferentiating individuals with
schizoid personality disorder from those with milder forms of autism spectrum disorder,
which may be differentiated by more severely  impaired social inte raction and stereotyped
behaviors and interests.
Personality change due to another medical condition. Schizoid 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. Schizoid personality disorder must also be distinguished
from symptoms that may develop in a ssociation with persistent substance use.
Other personality disorder s and personality traits. Other personality disorders may be
confused with schizoid personality disorder because they have certain features in com-
mon. It is, therefore, import ant to distinguish among these disorders based on differences
in their characteristic features. However, if an individual has personality features that
meet criteria for one or  more personality disorders in addition to schizoid personality dis-
order, all can be diagnosed. Although characteri stics of social isolation and restricted af-
fectivity are common to schizoid, schizotypal, and paranoid personality disorders,
schizoid personality disorder can be distin guished from schizotypa l personality disorder
by the lack of cognitive and perceptual dist ortions and from paranoid personality disorder
by the lack of suspiciousness and paranoid ideation. The social isolation of schizoid per-


sonality disorder can be distinguished from th at of avoidant personality disorder, which is
attributable to fear of being embarrassed or  found inadequate and excessive anticipation
of rejection. In contrast, people with schizoid personality disorder have a more pervasive
detachment and limited desire for social in timacy. Individuals with obsessive-compulsive
personality disorder may also show an apparent social detachment stemming from devo-
tion to work and discomfort wi th emotions, but they do have  an underlying capacity for
intimacy.
Individuals who are “loners” may display pe rsonality traits that might be considered
schizoid. Only when these trai ts are inflexible and maladaptive and cause significant func-
tional impairment or subjective distress do they constitute schizoid personality disorder.
Schizotypal Personality Disorder
Diagnostic Criteria 301.22 (F21)
A. A pervasive pattern of social and interpersonal deficits marked by acute discomfort
with, and reduced capacity for, close relationships as well as by cognitive or perceptual
distortions and eccentricities of behavior, beginning by early adulthood and present in
a variety of contexts, as indicated by five (or more) of the following:
1. Ideas of reference (excluding delusions of reference).
2. Odd beliefs or magical thinking that influences behavior and is inconsistent with
subcultural norms (e.g., superstitiousness, belief in clairvoyance, telepathy, or
“sixth sense”; in children and adolescents,  bizarre fantasies or preoccupations).
3. Unusual perceptual experiences, including bodily illusions.
4. Odd thinking and speech (e.g., vague, circumstantial, metaphorical, overelaborate,
or stereotyped).
5. Suspiciousness or paranoid ideation.


656 Personality Disorders
6. Inappropriate or constricted affect.
7. Behavior or appearance that is odd, eccentric, or peculiar.
8. Lack of close friends or confidants other than first-degree relatives.
9. Excessive social anxiety that does not diminish with familiarity and tends to be as-
sociated with paranoid fears rather than negative judgments about self.
B. Does not occur exclusively during the course of schizophrenia, a bipolar disorder or
depressive disorder with psychotic features, another psychotic disorder, or autism
spectrum disorder.
Note:  If criteria are met prior to the onset of schizophrenia, add “premorbid,” e.g., “schizo-
typal personality disorder (premorbid).”
Diagnostic Features
The essential feature of schizo typal personality disorder is a pervasive pattern of social
and interpersonal deficits ma rked by acute discomfort with, and reduced capacity for,
close relationships as well as by cognitive or pe rceptual distortions and eccentricities of be-
havior. This pattern begins by early adulthoo d and is present in a variety of contexts.
Individuals with schizotypal personality disord er often have ideas of reference (i.e., in-
correct interpretations of casual incidents and external events as having a particular and
unusual meaning specifically for the person ) (Criterion A1). Th ese should be distin-
guished from delusions of reference, in whic h the beliefs are held with delusional convic-
tion. These individuals may be superstitiou s or preoccupied with paranormal phenomena
that are outside the norms of their subculture (Criterion A2). They may feel that they have
special powers to sense events before they happen or to read others’ thoughts. They may
believe that they have magical control over  others, which can be implemented directly


believe that they have magical control over  others, which can be implemented directly
(e.g., believing that their spouse’s taking the do g out for a walk is the direct result of think-
ing an hour earlier it should be done) or in directly through compli ance with magical rit-
uals (e.g., walking past a specific object three times to avoid a certain harmful outcome).
Perceptual alterations may be present (e.g., se nsing that another person is present or hear-
ing a voice murmuring his or her name) (Criterion A3). Their speech may include unusual
or idiosyncratic phrasing and construction. It is often loose, digressive, or vague, but with-
out actual derailment or incoherence (Criteri on A4). Responses can be either overly con-
crete or overly abstract, and words or conc epts are sometimes applied in unusual ways
(e.g., the individual may state that he  or she was not “talkable” at work).
Individuals with this disorder are often suspicious and may have paranoid ideation
(e.g., believing their colleagues at work ar e intent on undermining their reputation with
the boss) (Criterion A5). They are usually not able to negotiate the fu ll range of affects and
interpersonal cuing required fo r successful relationships and thus often appear to interact
with others in an inappropriate, stiff, or constricted fashion (Criterion A6). These individ-
uals are often considered to be odd or ecce ntric because of unusual mannerisms, an often
unkempt manner of dress that does not quite “fit together,” and inattention to the usual
social conventions (e.g., the in dividual may avoid eye contact, wear clothes that are ink
stained and ill-fitting, and be unable to join in the give-and-take banter of co-workers)


(Criterion A7).
Individuals with schizotypal personality di sorder experience in terpersonal related-
ness as problematic and are uncomfortable relating to other people. Although they may
express unhappiness about their lack of relationships, their behavior suggests a decreased
desire for intimate contacts. As a result, they  usually have no or few close friends or con-
fidants other than a first-degree relative (Cri terion A8). They are anxious in social situa-
tions, particularly those invo lving unfamiliar people (Crite rion A9). They will interact


fidants other than a first-degree relative (Cri terion A8). They are anxious in social situa-
tions, particularly those invo lving unfamiliar people (Crite rion A9). They will interact
with other individuals when they have to but prefer to keep to themselves because they
feel that they are different and just do not “fit  in.” Their social anxiety does not easily abate,


Schizotypal Personality Disorder 657
even when they spend more time in the setti ng or become more fa miliar with the other
people, because their anxiety tends to be assoc iated with suspiciousness regarding others’
motivations. For example, when attending a dinner party, the individual with schizotypal
personality disorder will not become more rela xed as time goes on, but rather may become
increasingly tense and suspicious.
Schizotypal personality disorder should not be diagnosed if the pattern of behavior oc-
curs exclusively during the course of schizo phrenia, a bipolar or de pressive disorder with
psychotic features, another psychotic disorder, or autism spectrum disorder (Criterion B).
Associated Features Supporting Diagnosis
Individuals with schizotypal personality diso rder often seek treatment for the associated
symptoms of anxiety or depression rather than for the personality disorder features per se.
Particularly in response to stress, individual s with this disorder may experience transient
psychotic episodes (lasting minutes to hours), although they usually are insufficient in du-
ration to warrant an additional diagnosis such  as brief psychotic disorder or schizophreni-
form disorder. In some cases, clinically sig nificant psychotic symptoms may develop that
meet criteria for brief psychotic disorder, sc hizophreniform disorder, delusional disorder,
or schizophrenia. Over half may have a hist ory of at least one ma jor depressive episode.
From 30% to 50% of individuals diagnosed with  this disorder have a concurrent diagnosis
of major depressive disorder when admitted to  a clinical setting. There is considerable co-
occurrence with schizoid, paranoid, avoi dant, and borderline personality disorders.
Prevalence
In community studies of schizotypal personality disorder, reported rates range from 0.6%


in Norwegian samples to 4.6% in a U.S. commu nity sample. The prevalence of schizotypal
personality disorder in clinical populations seems to be infrequent (0%–1.9%), with a
higher estimated prevalence in the general population (3.9%) found in the National Epi-
demiologic Survey on Alco hol and Related Conditions.
Development and Course
Schizotypal personality disorder has a relative ly stable course, with only a small propor-
tion of individuals going on to develop sc hizophrenia or another psychotic disorder.
Schizotypal personality disorder may be firs t apparent in childhood and adolescence with
solitariness, poor peer relationships, social anxiety, underachievement in school, hyper-
sensitivity, peculiar thoughts and language, an d bizarre fantasies. These children may ap-
pear “odd” or “eccentric” and attract teasing.
Risk and Prognostic Factors
Genetic and physiological. Schizotypal personality disord er appears to aggregate fa-
milially and is more prevalent among the firs t-degree biological relatives of individuals
with schizophrenia than among the general po pulation. There may also be a modest in-
crease in schizophrenia and other psychotic disorders in the relatives of probands with
schizotypal personality disorder.
Cultural-Related Diagnostic Issues
Cognitive and perceptual distortions must be evaluated in the context of the individual’s
cultural milieu. Pervasive cultur ally determined characteristic s, particularly those regard-
ing religious beliefs and rituals, can appear to be schizotypal to the uninformed outsider
(e.g., voodoo, speaking in tongues, life beyo nd death, shamanism, mind reading, sixth
sense, evil eye, magical beliefs related to health and illness).


658 Personality Disorders
Gender-Related Diagnostic Issues
Schizotypal personality disorder may be slightly more common in males.
Differential Diagnosis
Other mental disorders with psychotic symptoms. Schizotypal personality disorder
can be distinguished from de lusional disorder, schizophrenia , and a bipolar or depressive
disorder with psychotic features because thes e disorders are all characterized by a period
of persistent psychotic symptoms (e.g., delu sions and hallucinations). To give an addi-
tional diagnosis of schizotypal personality disorder, the personality disorder must have
been present before the onset of psychoti c symptoms and persis t when the psychotic
symptoms are in remission. Wh en an individual has a persist ent psychotic disorder (e.g.,
schizophrenia) that was preceded by schizo typal personality disorder, schizotypal per-
sonality disorder should also  be recorded, followed by “premorbid” in parentheses.
Neurodevelopmental disorders. There may be great difficulty differentiating children
with schizotypal personality disorder from the heterogeneous group of solitary, odd chil-
dren whose behavior is characterized by mark ed social isolation, eccentricity, or peculiar-
ities of language and whose diagnoses woul d probably include milder forms of autism
spectrum disorder or language communicat ion disorders. Commun ication disorders may
be differentiated by the primacy and severity of the disorder in language and by the char-
acteristic features of impaired language found in a specialized language assessment.
Milder forms of autism spectrum disorder are differentiated by the even greater lack of so-
cial awareness and emotional reciprocity and stereotyped behaviors and interests.
Personality change due to another medical condition. Schizotypal personality disor-
der must be distinguished from personality change due to another medical condition, in


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. Schizotypal personality disorder  must also be distinguished
from symptoms that may develop in a ssociation with persistent substance use.
Other personality disorders and personality traits. Other personality disorders may
be confused with schizotypal personality diso rder because they have certain features in
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 personality disorders in addition to schizotypal person-
ality disorder, all can be diagnosed. Although paranoid and schizoid personality disor-
ders may also be characterized by social de tachment and restricted affect, schizotypal
personality disorder can be distinguished fr om these two diagnoses by the presence of
cognitive or perceptual distortions and marked eccentricity or oddn ess. Close relation-
ships are limited in both schizotypal person ality disorder and avoidant personality dis-
order; however, in avoidant personality disorder an active desire for relationships is
constrained by a fear of rejection, whereas in schizotypal personality disorder there is
a lack of desire for relationships and persis tent detachment. Indivi duals with narcissistic
personality disorder may also display suspic iousness, social withdrawal, or alienation,
but in narcissistic personality disorder these qualities derive primarily from fears of hav-
ing imperfections or flaws revealed. Individu als with borderline personality disorder may
also have transient, psychotic-like symptoms, but these are usually more closely related to


also have transient, psychotic-like symptoms, but these are usually more closely related to
affective shifts in response to  stress (e.g., intense anger, anxiety, disappointment) and are
usually more dissociative (e.g., derealization, depersonalization). In contrast, individuals
with schizotypal personality disorder are more likely to have enduring psychotic-like symp-


usually more dissociative (e.g., derealization, depersonalization). In contrast, individuals
with schizotypal personality disorder are more likely to have enduring psychotic-like symp-
toms that may worsen under stress but are less  likely to be invariably associated with pro-
nounced affective symptoms. Although social isolation may occur in borderline personality


Antisocial Personality Disorder 659
disorder, it is usually secondary to repeated  interpersonal failures due to angry outbursts
and frequent mood shifts, rather than a result of a persistent lack of social contacts and de-
sire for intimacy. Furt hermore, individuals with schizoty pal personality disorder do not
usually demonstrate the impulsiv e or manipulative behaviors of the individual with bor-
derline personality diso rder. However, there is a high ra te of co-occurren ce between the
two disorders, so that making such distinctions is not always  feasible. Schizotypal features
during adolescence may be reflective of transi ent emotional turmoil, rather than an endur-
ing personality disorder.
Cluster B Personality Disorders
Antisocial Personality Disorder
Diagnostic Criteria 301.7 (F60.2)
A. A pervasive pattern of disregard for and violation of the rights of others, occurring since
age 15 years, as indicated by three (or more) of the following:
1. Failure to conform to social norms with respect to lawful behaviors, as indicated by
repeatedly performing acts that are grounds for arrest.
2. Deceitfulness, as indicated by repeated lying, use of aliases, or conning others for
personal profit or pleasure.
3. Impulsivity or failure to plan ahead.
4. Irritability and aggressiveness, as indicated by repeated physical fights or assaults.
5. Reckless disregard for safety of self or others.
6. Consistent irresponsibility, as indicated by repeated failure to sustain consistent
work behavior or honor financial obligations.
7. Lack of remorse, as indicated by being indifferent to or rationalizing having hurt,
mistreated, or stolen from another.
B. The individual is at least age 18 years.


B. The individual is at least age 18 years.
C. There is evidence of conduct disorder with onset before age 15 years.
D. The occurrence of antisocial behavior is not exclusively during the course of schizo-
phrenia or bipolar disorder.
Diagnostic Features
The essential feature of antisocial personality disorder is a pervasive pattern of disregard
for, and violation of, the rights of others that  begins in childhood or early adolescence and
continues into adulthood. This pattern  has also been referred to as psychopathy, sociopathy,
or dyssocial personality disorder.  Because deceit and manipulation are central features of an-
tisocial personality disorder, it  may be especially helpful to  integrate information acquired
from systematic clinical assessment with information collected from collateral sources.
For this diagnosis to be given, the individual  must be at least age 18 years (Criterion B)
and must have had a history of some symptoms of conduct disorder before age 15 years
(Criterion C). Conduct disorder involves a repe titive and persistent pattern of behavior in
which the basic rights of othe rs or major age-appropriate societal norms or rules are vio-
lated. The specific behaviors characteristic of  conduct disorder fall into one of four cate-
gories: aggression to people and animals, destruction of proper ty, deceitfulness or theft, or
serious violation of rules.


660 Personality Disorders
The pattern of antisocial behavior continues into adulthood. Indi viduals with antiso-
cial personality disorder fail to conform to social norms with respect to lawful behavior
(Criterion A1). They may repeatedly perfor m acts that are grounds for arrest (whether
they are arrested or not), such as destroying  property, harassing ot hers, stealing, or pur-
suing illegal occupations. Persons with this di sorder disregard the wishes, rights, or feel-
ings of others. They are freq uently deceitful and manipulative in order to gain personal
profit or pleasure (e.g., to obtain money, sex,  or power) (Criterion A2). They may repeat-
edly lie, use an alias, con others, or malinger. A pattern of impulsiv ity may be manifested
by a failure to plan ahead (Criterion A3). Decisions are made on the spur of the moment,
without forethought and without consideration fo r the consequences to self or others; this
may lead to sudden changes of jobs, residences , or relationships. Individuals with antiso-
cial personality disorder tend to be irrita ble and aggressive and may repeatedly get into
physical fights or commit acts of physical assau lt (including spouse beating or child beat-
ing) (Criterion A4). (Aggressive acts that are required to defend oneself or someone else
are not considered to be evidence for this it em.) These individuals also display a reckless
disregard for the safety of themselves or othe rs (Criterion A5). This may be evidenced in
their driving behavior (i.e., recurrent speedi ng, driving while intoxicated, multiple acci-
dents). They may engage in sexual behavior or  substance use that has a high risk for harm-
ful consequences. They may neglec t or fail to care for a child in a way that puts the child in
danger.


danger.
Individuals with antisocial personality disord er also tend to be consistently and ex-
tremely irresponsible (Criterion A6). Irrespon sible work behavior may be indicated by sig-
nificant periods of unemployme nt despite available job opportunities, or by abandonment
of several jobs without a realistic plan for ge tting another job. There may also be a pattern
of repeated absences fr om work that are not explained by illness either in themselves or in
their family. Financial irresponsibility is indicated by acts such as defaulting on debts, fail-
ing to provide child support, or  failing to support other dependents on a regular basis. In-
dividuals with antisocial personality disorder  show little remorse for the consequences of
their acts (Criterion A7). They  may be indifferent to, or provide a superficial rationaliza-
tion for, having hurt, mistreated, or stolen from someone (e.g., “life’s unfair,” “losers de-
serve to lose”). These individuals may blame the victims for being foolish, helpless, or
deserving their fate (e.g., “he had it coming  anyway”); they may minimize the harmful
consequences of their actions; or they may simply indicate complete indifference. They
generally fail to compensate or make amends  for their behavior. They may believe that
everyone is out to “help number one” and that  one should stop at nothing to avoid being
pushed around.
The antisocial behavior must not occur excl usively during the course of schizophrenia
or bipolar disorder (Criterion D).
Associated Features Supporting Diagnosis
Individuals with antisocial personality disord er frequently lack empathy and tend to be
callous, cynical, and contempt uous of the feelings, rights, and sufferings of others. They


may have an inflated and arrogant self-appraisa l (e.g., feel that ordinary work is beneath
them or lack a realistic concern about their current problems or th eir future) and may be
excessively opinionated, self-assured, or coc ky. They may display a glib, superficial charm
and can be quite voluble and verbally facile (e.g., using technical terms or jargon that
might impress someone who is unfamiliar with th e topic). Lack of empathy, inflated self-


and can be quite voluble and verbally facile (e.g., using technical terms or jargon that
might impress someone who is unfamiliar with th e topic). Lack of empathy, inflated self-
appraisal, and superficial charm are features that have been commonly included in tradi-
tional conceptions of psychopathy that may be  particularly distinguishing of the disorder
and more predictive of recidivism in prison  or forensic settings, where criminal, delin-
quent, or aggressive acts are likely to be no nspecific. These individuals may also be irre-
sponsible and exploitative in their sexual re lationships. They may have a history of many


Antisocial Personality Disorder 661
sexual partners and may never have sustained a monogamous relationship. They may be
irresponsible as parents, as evidenced by maln utrition of a child, an illness in the child re-
sulting from a lack of minimal hygiene, a ch ild’s dependence on neighbors or nonresident
relatives for food or shelter, a failure to arrange for a caretaker for a young child when the
individual is away from home, or repeated squandering of money required for household
necessities. These individuals may receive di shonorable discharges from the armed ser-
vices, may fail to be self-supporting, may be come impoverished or even homeless, or may
spend many years in penal institutions. Indi viduals with antisocial personality disorder
are more likely than people in the general po pulation to die prematurely by violent means
(e.g., suicide, accidents, homicides).
Individuals with antisocial personality disorder may also experience dysphoria, in-
cluding complaints of tension, inability to  tolerate boredom, and depressed mood. They
may have associated anxiety disorders, depressive disorders, substa nce use disorders, so-
matic symptom disorder, gambli ng disorder, and other disord ers of impulse control. In-
dividuals with antisocial personality disorder  also often have personality features that
meet criteria for other personality disorders,  particularly borderline, histrionic, and nar-
cissistic personality disorders. The likelihood  of developing antisocial personality disor-
der in adult life is increased if the indivi dual experienced childhood onset of conduct
disorder (before age 10 years) and accompanyi ng attention-deficit/hyperactivity disorder.
Child abuse or neglect, unstable or erratic parenting, or inconsistent parental discipline
may increase the likelihood that conduct disord er will evolve into antisocial personality
disorder.


may increase the likelihood that conduct disord er will evolve into antisocial personality
disorder.
Prevalence
Twelve-month prevalence rates of antisocial personality diso rder, using criteria from pre-
vious DSMs, are between 0.2% and 3.3%. The highest prevalence of antisocial personality
disorder (greater than 70%) is among most se vere samples of males with alcohol use dis-
order and from substance abuse clinics, prison s, or other forensic settings. Prevalence is
higher in samples affected by adverse socioeconomic (i.e., poverty) or sociocultural (i.e.,
migration) factors.
Development and Course
Antisocial personality disorder has a chronic course but may become less evident or remit
as the individual grows older, particularly by the fourth deca de of life. Although this re-
mission tends to be particularly evident with respect to engaging in criminal behavior,
there is likely to be a decrease in the full spectrum of antisocial behaviors and substance
use. By definition, antisocial personalit y cannot be diagnosed before age 18 years.
Risk and Prognostic Factors
Genetic and physiological. Antisocial personality disorder  is more common among the
first-degree biological relatives of those with the disorder than in the general population.
The risk to biological relatives of females with  the disorder tends to be higher than the risk
to biological relatives of males with the disorder. Biological  relatives of individuals with
this disorder are also at in creased risk for somatic symptom disorder and substance use
disorders. Within a family that has a member with antisocial personality disorder, males
more often have antisocial personality disord er and substance use disorders, whereas fe-
males more often have somatic symptom disorder. However, in such families, there is an


males more often have somatic symptom disorder. However, in such families, there is an
increase in prevalence of al l of these disorders in both males and females compared with
the general population. Adoption studies indi cate that both genetic and environmental
factors contribute to the risk of developing antisocial personality disorder. Both adopted
and biological children of parents with antisocial personality disorder have an increased


662 Personality Disorders
risk of developing antisocial personality disorder, somatic symptom disorder, and sub-
stance use disorders. Adopted-away children resemble their biological parents more than
their adoptive parents,  but the adoptive family environm ent influences the risk of devel-
oping a personality disorder and related psychopathology.
Culture-Related Diagnostic Issues
Antisocial personality disorder appears to be associated with low socioeconomic status
and urban settings. Concerns have been raised  that the diagnosis may at times be misap-
plied to individuals in settings in which seemingly antisocial behavior may be part of a
protective survival stra tegy. In assessing antisocial traits, it is helpful for the clinician to
consider the social and economic co ntext in which the behaviors occur.
Gender-Related Diagnostic Issues
Antisocial personality disorder is much more common in males than in females. There has
been some concern that antisocial persona lity disorder may be underdiagnosed in fe-
males, particularly because of the emphasis on  aggressive items in the definition of con-
duct disorder.
Differential Diagnosis
The diagnosis of antisocial personality disorder is not given to individuals younger than
18 years and is given only if there is a histor y of some symptoms of conduct disorder be-
fore age 15 years. For individuals older than 18 years, a diagnosis of conduct disorder is
given only if the criteria for antiso cial personality disorder are not met.
Substance use disorders. When antisocial behavior in an adult is associated with a
substance use disorder, the diagnosis of antisoci al personality disorder is not made unless
the signs of antisocial personality disorder were also present in childhood and have con-
tinued into adulthood. When substance use and antisocial behavior both began in childhood
and continued into adulthood, both a substance use disorder  and antisocial personality


and continued into adulthood, both a substance use disorder  and antisocial personality
disorder should be diagnosed if the criteria fo r both are met, even though some antisocial
acts may be a consequence of the substance us e disorder (e.g., illegal selling of drugs, thefts
to obtain money for drugs).
Schizophrenia and bipolar disorders. Antisocial behavior that  occurs exclusively dur-
ing the course of schizophrenia or a bipolar disorder should not be diagnosed as antisocial
personality disorder.
Other personality disorders. Other personality disorders may be confused with antiso-
cial personality disorder because they have certain features in common. It is therefore im-
portant to distinguish among these disorders based on differences in their characteristic
features. However, if an indivi dual has personality features that meet criteria for one or
more personality disorders in addition to antisocial personality disorder, all can be diag-
nosed. Individuals with antisocial personalit y disorder and narcissistic personality disor-
der share a tendency to be tough-minded, glib , superficial, exploitative, and lack empathy.
However, narcissistic personality disorder does not include ch aracteristics of impulsivity,
aggression, and deceit. In addition, individuals with antisocial personality disorder may
not be as needy of the admiration and envy of others, and persons with narcissistic per-
sonality disorder usually lack the history of  conduct disorder in childhood or criminal
behavior in adulthood. Indivi duals with antisocial personality disorder and histrionic
personality disorder share a tendency to be impulsive, superficial,  excitement seeking,
reckless, seductive, and manipulative, but pe rsons with histrionic personality disorder
tend to be more exaggerated in their emotions  and do not characteristically engage in an-
tisocial behaviors. Individuals with histrion ic and borderline pers onality disorders are


Borderline Personality Disorder 663
manipulative to gain nurturance, whereas thos e with antisocial personality disorder are
manipulative to gain profit, po wer, or some other material gratification. Individuals with
antisocial personality disorder tend to be less emotionally unstable and more aggressive
than those with borderline personality disorder. Although antisocial behavior may be
present in some individuals with paranoid pe rsonality disorder, it is not usually moti-
vated by a desire for personal gain  or to exploit others as in antisocial personality disorder,
but rather is more often attributable to a desire for revenge.
Criminal behavior not associated  with a personality disorder. Antisocial personality
disorder must be distinguished from criminal behavior undertaken for gain that is not ac-
companied by the personality features characteristic of this disorder. Only when antisocial
personality traits are inflexible, maladaptive, and persistent and cause significant func-
tional impairment or subjective distress do th ey constitute antisocial personality disorder.
Borderline Personality Disorder
Diagnostic Criteria 301.83 (F60.3)
A pervasive pattern of instability of interpersonal relationships, self-image, and affects,
and marked impulsivity, beginning by early adulthood and present in a variety of contexts,
as indicated by five (or more) of the following:
1. Frantic efforts to avoid real or imagined abandonment. ( Note:  Do not include suicidal
or self-mutilating behavior covered in Criterion 5.)
2. A pattern of unstable and intense interpersonal relationships characterized by alternat-
ing between extremes of idealization and devaluation.
3. Identity disturbance: markedly and persistently unstable self-image or sense of self.
4. Impulsivity in at least two areas that are potentially self-damaging (e.g., spending, sex,


substance abuse, reckless driving, binge eating). ( Note:  Do not include suicidal or self-
mutilating behavior covered in Criterion 5.)
5. Recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior.
6. Affective instability due to a marked reactivity of mood (e.g., intense episodic dysphoria,
irritability, or anxiety usually lasting a few hours and only rarely more than a few days).
7. Chronic feelings of emptiness.
8. Inappropriate, intense anger or difficulty controlling anger (e.g., frequent displays of
temper, constant anger, recurrent physical fights).
9. Transient, stress-related paranoid ideation or severe dissociative symptoms.
Diagnostic Features
The essential feature of  borderline personality disorder is  a pervasive pattern of instability
of interpersonal relationships, self-image, an d affects, and marked impulsivity that begins
by early adulthood and is present in a variety of contexts.
Individuals with borderline pe rsonality disorder make fran tic efforts to avoid real or
imagined abandonment (Criterion 1). The perception of impending separation or rejection,
or the loss of external structure, can lead to profound changes in sel f-image, affect, cognition,
and behavior. These individuals are very sensitive to environmental circumstances. They ex-
perience intense abandonment fears and inappropriate anger even when  faced with a real-
istic time-limited separation or when there are unavoidable changes in plans (e.g., sudden
despair in reaction to a clinician’s announcing the end of the hour; panic or fury when some-
one important to them is just a few minutes la te or must cancel an appointment). They may
believe that this “abandonment” implies they  are “bad.” These abandonment fears are re-
lated to an intolerance of being alone and a need  to have other people with them. Their frantic


664 Personality Disorders
efforts to avoid abandonment may include impulsive actions such as self-mutilating or sui-
cidal behaviors, which are described separately in Criterion 5.
Individuals with borderline personality disord er have a pattern of unstable and intense
relationships (Criterion 2). They may idealize potential caregivers or lovers at the first or
second meeting, demand to spend a lot of time  together, and share the most intimate details
early in a relationship. Howeve r, they may switch quickly from idealizing other people to
devaluing them, feeling that the other person does not care enough, does not give enough,
or is not “there” enough. These individuals can empathize with and nurture other people,
but only with the expectation th at the other person will “be ther e” in return to meet their
own needs on demand. These indi viduals are prone to sudden and dramatic shifts in their
view of others, who may alternatively be seen as beneficent supports or as cruelly punitive.
Such shifts often reflect disillusionment with a caregiver whose nurturing qualities had
been idealized or whose rejectio n or abandonment is expected.
There may be an identity disturbance charac terized by markedly and persistently un-
stable self-image or sense of self (Criterion 3). There are sudden and dramatic shifts in self-
image, characterized by shifting goals, values, and vocational aspirations. There may be
sudden changes in opinions and plans about ca reer, sexual identity, values, and types of
friends. These individuals may suddenly chan ge from the role of a needy supplicant for
help to that of a righteous av enger of past mistreat ment. Although they usually have a self-
image that is based on being bad or evil, individuals with this disorder may at times have


image that is based on being bad or evil, individuals with this disorder may at times have
feelings that they do not exist at all. Such experiences usually occur in situations in which
the individual feels a lack of a meaningful relationship, nurturing, and support. These in-
dividuals may show worse performance in unstructured work or school situations.
Individuals with borderline pe rsonality disorder display impulsivity in at least two areas
that are potentially self-damaging (Criterion  4). They may gamble, spend money irrespon-
sibly, binge eat, abuse substanc es, engage in unsafe sex, or  drive recklessly. Individuals
with this disorder display recurrent suicidal behavior, gestures, or threats, or self-mutilat-
ing behavior (Criterion 5). Completed suicide occurs in 8%–10% of such individuals, and
self-mutilative acts (e.g., cutting or burnin g) and suicide threats and attempts are very
common. Recurrent suicidality is often the reason that these individuals present for help.
These self-destructive acts are usually precipit ated by threats of separation or rejection or
by expectations that the individual assumes increased responsibility. Self-mutilation may
occur during dissociative experiences and often brings relief by reaffirming the ability to
feel or by expiating the individual’s sense of being evil.
Individuals with borderline personality disorder may display affective instability that
is due to a marked reactivity of  mood (e.g., intense episodic dysphoria, irritability, or anx-
iety usually lasting a few hours and only rarely more than a few days) (Criterion 6). The
basic dysphoric mood of those with borderline personality disorder is often disrupted by
periods of anger, panic, or de spair and is rarely relieved by periods of well-being or satis-


faction. These episodes may reflect the indivi dual’s extreme reactivity to interpersonal
stresses. Individuals with borderline personalit y disorder may be troubled by chronic feel-
ings of emptiness (Criterion 7). Easily bored,  they may constantly seek something to do.
Individuals with this disorder frequently expr ess inappropriate, intense anger or have dif-
ficulty controlling their anger (Criterion 8) . They may display extreme sarcasm, enduring


Individuals with this disorder frequently expr ess inappropriate, intense anger or have dif-
ficulty controlling their anger (Criterion 8) . They may display extreme sarcasm, enduring
bitterness, or verbal outbursts. The anger is often elicited when  a caregiver or lover is seen
as neglectful, withholding, uncaring, or abandoning. Such expressions of anger are often
followed by shame and guilt and contribute to the feeling they have of being evil. During
periods of extreme stress , transient paranoid ideation or dissociative symptoms (e.g., de-
personalization) may occur (Criterion 9), but th ese are generally of insufficient severity or
duration to warrant an addition al diagnosis. These episodes occur most frequently in re-
sponse to a real or imagined abandonment. Symptoms tend to be transient, lasting min-
utes or hours. The real or perceived return of the caregiver’s nurturance may result in a
remission of symptoms.


Borderline Personality Disorder 665
Associated Features Supporting Diagnosis
Individuals with borderline personality disorder may have a pattern of undermining
themselves at the moment a goal is about to be realized (e.g., dropping out of school just
before graduation; regressing se verely after a discussion of ho w well therapy is going; de-
stroying a good relationship just when it is clear that the relationship could last). Some in-
dividuals develop psychotic-like symptoms (e.g ., hallucinations, body-image distortions,
ideas of reference, hypnagogic phenomena) du ring times of stress. Individuals with this
disorder may feel more secure with transition al objects (i.e., a pet or inanimate possession)
than in interpersonal relationships. Prematur e death from suicide may occur in individu-
als with this disorder, especially in those with co-occurring depressive disorders or sub-
stance use disorders. Physical handicaps may result from self-inflicted abuse behaviors or
failed suicide attempts. Recurrent job losses, in terrupted education, and separation or di-
vorce are common. Physical and sexual abuse, neglect, hostile conflict, and early parental
loss are more common in the childhood histor ies of those with borderline personality dis-
order. Common co-occurring disorders include depressive and bipolar disorders, sub-
stance use disorders, eating disorders (not ably bulimia nervosa), posttraumatic stress
disorder, and attention-defici t/hyperactivity disorder. Bo rderline personality disorder
also frequently co-occurs with the other personality disorders.
Prevalence
The median population prevalence of border line personality disorder is estimated to be
1.6% but may be as high as 5.9%. The preval ence of borderline personality disorder is


about 6% in primary care sett ings, about 10% among individual s seen in outpatient mental
health clinics, and about 20% among psychiat ric inpatients. The prevalence of borderline
personality disorder may decrease in older age groups.
Development and Course
There is considerable variability in the course of borderline personality disorder. The most
common pattern is one of chronic instability in early adulthoo d, with episodes of serious
affective and impulsive dyscontrol and high levels of use of health and mental health re-
sources. The impairment from the disorder and the risk of suicide are greatest in the
young-adult years and gradually wane with advancing age. Although the tendency to-
ward intense emotions, impulsivity, and intens ity in relationships is often lifelong, indi-
viduals who engage in therapeutic interv ention often show improvement beginning
sometime during the first year. During their 30s and 40s, the majority of individuals with
this disorder attain greater stability in their relationships and vocational functioning. Fol-
low-up studies of individuals identified thr ough outpatient mental health clinics indicate
that after about 10 years, as many as half of the individuals no longer  have a pattern of be-
havior that meets full criteria for borderline personality disorder.
Risk and Prognostic Factors
Genetic and physiological. Borderline personality disorder is about five times more
common among first-degree biological relatives of those with the disorder than in the gen-
eral population. There is  also an increased familial risk for substance use disorders, anti-
social personality disorder, and depressive or bipolar disorders.
Culture-Related Diagnostic Issues
The pattern of behavior seen in  borderline personality disorder  has been identified in many
settings around the world. Adolescents and youn g adults with identity  problems (especially
when accompanied by substance use) may transiently display behaviors that misleadingly


666 Personality Disorders
give the impression of borderline personality disorder. Such situations are characterized by
emotional instability, “existential” dilemmas, uncertainty, anxiety- provoking choices, con-
flicts about sexual orientation, and competing social pressures to decide on careers.
Gender-Related Diagnostic Issues
Borderline personality disord er is diagnosed predominantly (about 75%) in females.
Differential Diagnosis
Depressive and bipolar disorders. Borderline personality disorder often co-occurs with
depressive or bipolar disorders, and when criteria for both are met, both may be diagnosed.
Because the cross-sectional presentation of bo rderline personality disorder can be mimicked
by an episode of depressive or bipolar disord er, the clinician should avoid giving an addi-
tional diagnosis of borderline personality diso rder based only on cr oss-sectional presenta-
tion without having documented that the pattern of behavior had an early onset and a long-
standing course.
Other personality disorders. Other personality disorders ma y be confused with border-
line personality disorder because they have certain features in  common. It is therefore im-
portant to distinguish among these disorders based on differences in their characteristic
features. However, if an individual has person ality features that meet criteria for one or
more personality disorders in addition to bord erline personality disorder, all can be diag-
nosed. Although histrionic personality disorder can also be characterized by attention seek-
ing, manipulative behavior, an d rapidly shifting emotions, borderline personality disorder
is distinguished by self-destructiveness, an gry disruptions in close relationships, and
chronic feelings of deep emptiness and loneline ss. Paranoid ideas or illusions may be pres-
ent in both borderline personality disorder an d schizotypal personality disorder, but these
symptoms are more transient, in terpersonally reactive, and responsive to external structur-