The Diagnostics and Statistical Manual (DSM) of Psychiatric Disorders is a reference book published by the American Psychiatric Association designed to aid clinicians in establishing diagnoses of mental illness. The third edition was written under Robert Spitzer in 1980, and the revision, which appears here, in 1987. Spitzer was briefly featured in the 2007 BBC TV series The Trap, produced by Adam Curtis, in which he said....
- Paranoid Personality Disorder
- Schizoid Personality Disorder
- Schizotypal Personality Disorder
- Antisocial Personality Disorder
- Borderline Personality Disorder
- Histrionic Personality Disorder
- Narcissistic Personality Disorder
- Avoidant Personality Disorder
- Dependent Personality Disorder
- Obsessive Compulsive Personality Disorder
- Passive Agressive Personality Disorder
- Personality Disorder Not Otherwise Specified
301.00 Paranoid Personality Disorder
The essential feature of this disorder is a pervasive and unwarranted tendency, beginning by early adulthood and present in a variety of contexts, to interpret the actions of people as deliberately demeaning or threatening.
Almost invariably there is a general expectation of being exploited or harmed by others in some way. Frequently a person with this disorder will question, without justification, the loyalty or trustworthiness of friends or associates. Often the person is pathologically jealous, questioning without justification the fidelity of his or her spouse or sexual partner.
Confronted with a new situation, the person may read hidden demeaning or threatening meanings into benign remarks or events, e.g., suspect that a bank has deliberately made a mistake in his account. Often these people are easily slighted and quick to react with anger or counterattack; they may bear grudges for a long time, and never forgive slights, insults, or injuries. They are reluctant to confide in others because of a fear that the information will be used against them. People with this disorder are typically hypervigilant and take precautions against any perceived threat. They tend to avoid blame even when it is warranted. They are often viewed by others as guarded, secretive, devious, and scheming.
When people with this disorder find themselves in a new situation, they intensely and narrowly search for confirmation of their expectations, with no appreciation of the total context. Their final conclusion is usually precisely what they expected in the first place. Often, they have transient ideas of reference, e.g., that others are taking special notice of them, or saying vulgar things about them.
Associated features. People with this disorder are usually argumentative and exaggerate difficulties, "making mountains out of molehills." They often find it difficult to relax, usually appear tense, and have a tendency to counterattack when they perceive any threat. Though they are critical of others, and often litigious, they have great difficulty accepting criticism themselves.
The affectivity of these people is often restricted, and they may appear "cold" to others. They have no true sense of humor and are usually serious. They may pride themselves on always being objective, rational, and unemotional. They usually lack passive, soft, sentimental, and tender feelings.
Occasionally, others see people with this disorder as keen observers who are energetic, ambitious, and capable; but more often they are viewed as hostile, stubborn, and defensive. They tend to be rigid and unwilling to compromise, and may generate uneasiness and fear in others. They often have an inordinate fear of losing their independence or the power to shape events according to their own wishes.
These people usually avoid intimacy except with those in whom they have absolute trust. They display an excessive need to be self-sufficient, to the point of egocentricity and exaggerated self-importance. They avoid participation in group activities unless they are in a dominant position.
People with Paranoid Personality Disorder are often interested in mechanical devices, electronics, and automation. They are generally uninterested in art or aesthetics.
They are keenly aware of power and rank and of who is superior or inferior, and are often envious and jealous of those in positions of power. They disdain people they see as weak, soft, sickly, or defective.
During periods of extreme stress, people with this disorder may experience transient psychotic symptoms, but they are usually of insufficient duration to warrant an additional diagnosis.
Impairment. Because people with Paranoid Personality Disorder generally realize that it is prudent to keep their unusual ideas to themselves, impairment tends to be minimal. However, occupational difficulties are common, especially in relating to authority figures or co-workers. In more severe cases, all relationships are grossly impaired.
Complications. The relationship of this disorder to Delusional Disorder and Schizophrenia, Paranoid Type, is unclear. Certain essential features of Paranoid Personality Disorder, such as suspiciousness and hypersensitivity, may predispose to the development of those other disorders, however.
Predisposing factors. No information.
Prevalence. Since people with this disorder rarely seek help for their personality problems or require hospitalization, the disorder seldom comes to clinical attention.
Because of a tendency of some of them to be moralistic, grandiose, and extrapunitive, people with this disorder may be overrepresented among leaders of cults and other fringe groups.
Sex ratio. This disorder is more commonly diagnosed in men.
Familial pattern. No information.
Differential diagnosis. In Delusional Disorder and Schizophrenia, Paranoid Type, there are persistent psychotic symptoms, such as delusions and hallucinations, that are never part of Paranoid Personality Disorder. However, these disorders may be superimposed on Paranoid Personality Disorder. Antisocial Personality Disorder shares several features with Paranoid Personality Disorders, e.g., difficulty in forming and sustaining close relationships, and poor occupational performance; but except when the two disorders coexist, a lifelong history of antisocial behavior is not present in Paranoid Personality Disorder. People with Schizoid Personality Disorder are often seen as strange and eccentric, cold and aloof, but do not have prominent paranoid ideation
301.20 Schizoid Personality Disorder
The essential feature of this disorder is a pervasive pattern of indifference to social relationships and a restricted range of emotional experience and expression, beginning by early adulthood and present in a variety of contexts.
People with this disorder neither desire nor enjoy close relationships, including being part of a family. They prefer to be "loners," and have no close friends or confidants (or only one) other than first-degree relatives. They almost always choose solitary activities and indicate little if any desire to have sexual experiences with another person. Such people are indifferent to the praise and criticism of others. They claim that they rarely experience strong emotions such as anger and joy, and in fact display a constricted affect. They appear cold and aloof.
Associated features. People with this disorder are often unable to express aggressiveness or hostility. They may seem vague about their goals, indecisive in their actions, self-absorbed, and absentminded. Because of a lack of social skills or desire for sexual experiences, males with this disorder are usually incapable of dating and rarely marry.
Females may passively accept courtship and marry.
Impairment. Social relations are, by definition, severely restricted. Occupational functioning may be impaired, particularly if interpersonal involvement is required. On the other hand, people with this disorder may, in some instances, be capable of high occupational achievement in situations requiring work performance under conditions of social isolation.
Prevalence. The prevalence in clinical settings is low. However, a significant proportion of people working in jobs that involve little or no contact with others, or living in skid-row sections of cities, may have this disorder.
Predisposing factors, sex ratio, and familial pattern. No information.
Differential diagnosis. In Schizotypal Personality Disorder there are eccentricities of communication or behavior. Some people may have both Schizoid and Schizotypal Personality Disorder.
In Avoidant Personality Disorder, social isolation is due to hypersensitivity to rejection, and a desire to enter social relationships is present if there are strong guarantees of uncritical acceptance. In contrast, people with Schizoid Personality Disorder have little desire for social relations.
In Paranoid Personality Disorder, paranoid ideation is a prominent feature.
301.22 Schizotypal Personality Disorder
The essential feature of this disorder is a pervasive pattern of peculiarities of ideation, appearance, and behavior and deficits in interpersonal relatedness, beginning by early adulthood and present in a variety of contexts, that are not severe enough to meet the criteria for Schizophrenia.
The disturbance in the content of thought may include paranoid ideation, suspiciousness, ideas of reference, odd beliefs, and magical thinking that is inconsistent with subcultural norms and influences the person's behavior. Examples include superstitiousness, belief in clairvoyance, telepathy, or "sixth sense," or beliefs that "others can feel my feelings" (when it is not a part of a cultural belief system). In children and adolescents, these thoughts may include bizarre fantasies or preoccupations. Unusual perceptual experiences may include illusions and sensing the presence of a force or person not actually present (e.g., "I felt an evil presence in the room"). Often speech shows marked peculiarities, but never to the point of loosening of associations or incoherence. Speech may be impoverished, digressive, vague, or inappropriately abstract. Concepts may be expressed unclearly or oddly, or words may be used in an unusual way. People with this disorder often appear odd and eccentric in behavior and appearance. For example, they are often unkempt, display unusual mannerisms, and talk to themselves.
Interpersonal relatedness is invariably impaired in these people. They display inappropriate or constricted affect, appearing silly and aloof and rarely reciprocating gestures or facial expressions, such as smiling or nodding. They have no close friends or confidants (or only one) other than first-degree relatives, and are extremely anxious in social situations involving unfamiliar people.
Associated features. Varying mixtures of anxiety, depression, and other dysphoric moods are common. Features of Borderline Personality Disorder are often present, and in some cases both diagnoses may be warranted. During periods of extreme stress, people with this disorder may experience transient psychotic symptoms, but they are usually insufficient in duration to warrant an additional diagnosis. Because of peculiarities in thinking, people with Schizotypal Personality Disorder are prone to eccentric convictions.
Impairment. Some interference with social or occupational functioning is common.
Prevalence. Recent studies, using DSM-III criteria, indicate that approximately 3% of the population have this disorder.
Sex ratio. No information.
Familial pattern. There is some evidence that people with Schizotypal Personality Disorder are more common among the first-degree biologic relatives of people with Schizophrenia than among the general population.
Differential diagnosis. In Schizophrenia, Residual Type, there is a history of an active phase of Schizophrenia with psychotic symptoms. When psychotic symptoms occur in Schizotypal Personality Disorder, they are transient and not as severe. In Schizoid Personality Disorder and Avoidant Personality Disorder, there are no oddities of behavior, thinking, perception, and speech, such as are present in Schizotypal Personality Disorder. Frequently, people with Borderline Personality Disorder also meet the criteria for Schizotypal Personality Disorder; in such instances, both diagnoses should be recorded. Suspiciousness and paranoid ideation may be present in Paranoid Personality Disorder, but other oddities of thought or behavior are not.
301.70 Antisocial Personality Disorder
The essential feature of this disorder is a pattern of irresponsible and antisocial behavior beginning in childhood or early adolescence and continuing into adulthood. For this diagnosis to be given, the person must be at least 18 years of age and have a history of Conduct Disorder before the age of 15.
Lying, stealing, truancy, vandalism, initiating fights, running away from home, and physical cruelty are typical childhood signs. In adulthood the antisocial pattern continues, and may include failure to honor financial obligations, to function as a responsible parent or to plan ahead, and an inability to sustain consistent work behavior. These people fail to conform to social norms and repeatedly perform antisocial acts that are grounds for arrest, such as destroying property, harassing others, stealing, and having an illegal occupation.
People with Antisocial Personality Disorder tend to be irritable and aggressive and to get repeatedly into physical fights and assaults, including spouse- or child-beating.
Reckless behavior without regard to personal safety is common, as indicated by frequently driving while intoxicated or getting speeding tickets. Typically, these people are promiscuous (defined as never having sustained a monogamous relationship for more than a year). Finally, they generally have no remorse about the effects of their behavior on others; they may even feel justified in having hurt or mistreated others.
After age 30, the more flagrantly antisocial behavior may diminish, particularly sexual promiscuity, fighting, and criminality.
Associated features. In early adolescence these people characteristically use tobacco, alcohol, and other drugs and engage in voluntary sexual intercourse unusually early for their peer group. Psychoactive Substance Use Disorders are commonly associated diagnoses. Less commonly, Somatization Disorder may be present. Despite the stereotype of a normal mental status in this disorder, frequently there are signs of personal distress, including complaints of tension, inability to tolerate boredom, depression, and the conviction (often correct) that others are hostile toward them. The interpersonal difficulties and dysphoria tend to persist into late adult life even when the more flagrant antisocial behavior has diminished. Almost invariably there is a markedly impaired capacity to sustain lasting, close, warm, and responsible relationships with family, friends, or sexual partners.
Age at onset. By definition the Conduct Disorder symptoms begin before the age of 15. The first symptoms of Conduct Disorder in females who develop Antisocial Personality Disorder usually appear in puberty, whereas in males the Conduct Disorder is generally obvious in early childhood.
Impairment. The disorder is often extremely incapacitating, resulting in failure to become an independent, self-supporting adult and giving rise to many years of institutionalization, more commonly penal than medical. (Some people who have several features of the disorder achieve political and economic success; but these people virtually never present the full picture of the disorder, lacking, in particular, the early onset in childhood that usually interferes with educational achievement and precludes most public careers.)
Complications. People with this disorder are more likely than people in the general population to die prematurely by violent means.
Predisposing factors. Predisposing factors are Attention-deficit Hyperactivity Disorder and Conduct Disorder during prepuberty. The absence of consistent parental discipline apparently increases the likelihood that Conduct Disorder will develop into Antisocial Personality Disorder. Other predisposing factors include abuse as a child, removal from the home, and growing up without parental figures of both sexes.
Prevalence. The estimate of the prevalence of Antisocial Personality Disorder among American males is about 3%, and for American females, less than 1 %. The disorder is more common in lower-class populations, partly because it is associated with impaired earning capacity and partly because fathers of those with the disorder frequently have the disorder themselves, and consequently their children often grow up in impoverished homes.
Sex ratio. The disorder is much more common in males than in females.
Familial pattern. Antisocial Personality Disorder is five times more common among first-degree biologic relatives of males with the disorder than among the general population.
The risk to the first-degree biologic relatives of females with the disorder is nearly ten times that of the general population. There is also an increased risk of Somatization Disorder and Psychoactive Substance Use Disorders in the relatives of males and females with the disorder. Within a family that has a member with Antisocial Personality Disorder, males more often have Antisocial Personality Disorder and Psychoactive Substance Use Disorders, whereas females more often have Somatization Disorder; but there is an increase in all of these disorders in both males and females compared with the general population. Adoption studies show that both genetic and environmental factors contribute to the risk of this group of disorders, because parents with Antisocial Personality Disorder increase the risk of Antisocial Personality Disorder, Somatization Disorder, and Psychoactive Substance Use Disorders in both their adopted and biologic children.
Differential diagnosis. Conduct Disorder consists of the typical childhood signs of Antisocial Personality Disorder. Since such behavior may terminate spontaneously or evolve into other disorders such as Schizophrenia, a diagnosis of Antisocial Personality Disorder should not be made in children; it is reserved for adults (18 or over), who have had time to show the full longitudinal pattern.
Adult Antisocial Behavior, in the category Conditions Not Attributable to a Mental Disorder, should be considered when criminal or other aggressive or antisocial behavior occurs in people who do not meet the full criteria for Antisocial Personality Disorder and whose antisocial behavior cannot be attributed to any other mental disorder.
When Psychoactive Substance Abuse and antisocial behavior begin in childhood and continue into adult life, both Psychoactive Substance Use Disorder and Antisocial Personality Disorder should be diagnosed if the criteria for each disorder are met, regardless of the extent to which some of the antisocial behavior may be a consequence of the Psychoactive Substance Use Disorder, e.g., illegal selling of drugs, or the assaultive behavior associated with Alcohol Intoxication. When antisocial behavior in an adult is associated with a Psychoactive Substance Use Disorder, the diagnosis of Antisocial Personality Disorder is not made unless the childhood signs of Antisocial Personality Disorder were also present and continued into adult life.
Mental Retardation and Schizophrenia may present with some of the features of Antisocial Personality Disorder, such as impairment in occupational functioning and parenting; but the additional diagnosis of Antisocial Personality Disorder should be made only if there is a clear pattern of antisocial behavior.
Manic Episodes may be associated with antisocial behavior. However, the absence of Conduct Disorder in childhood and the episodic nature of the antisocial behavior preclude the additional diagnosis of Antisocial Personality Disorder.
301.83 Borderline Personality Disorder
The essential feature of this disorder is a pervasive pattern of instability of self-image, interpersonal relationships, and mood, beginning by early adulthood and present in a variety of contexts.
A marked and persistent identity disturbance is almost invariably present. This is often pervasive, and is manifested by uncertainty about several life issues, such as selfimage, sexual orientation, long-term goals or career choice, types of friends or lovers to have, or which values to adopt. The person often experiences this instability of selfimage as chronic feelings of emptiness or boredom.
Interpersonal relationships are usually unstable and intense, and may be characterized by alternation of the extremes of overidealization and devaluation. These people have difficulty tolerating being alone, and will make frantic efforts to avoid real or imagined abandonment.
Affective instability is common. This may be evidenced by marked mood shifts from baseline mood to depression, irritability, or anxiety, usually lasting a few hours or, only rarely, more than a few days. In addition, these people often have inappropriately intense anger or lack of control of their anger, with frequent displays of temper or recurrent physical fights. They tend to be impulsive, particularly in activities that are potentially self-damaging, such as shopping sprees, psychoactive substance abuse, reckless driving, casual sex, shoplifting, and binge eating.
Recurrent suicidal threats, gestures, or behavior and other self-mutilating behavior (e.g., wrist-scratching) are common in the more severe forms of the disorder. This behavior may serve to manipulate others, may be a result of intense anger, or may counteract feelings of "numbness" and depersonalization that arise during periods of extreme stress.
Some conceptualize this disorder as a level of personality organization rather than as a specific Personality Disorder.
Associated features. Frequently this disorder is accompanied by many features of other Personality Disorders, such as Schizotypal, Histrionic, Narcissistic, and Antisocial Personality Disorders. In many cases more than one diagnosis is warranted. Quite often social contrariness and a generally pessimistic outlook are observed. Alternation between dependency and self-assertion is common. During periods of extreme stress, transient psychotic symptoms may occur, but they are generally of insufficient severity or duration to warrant an additional diagnosis.
Impairment. Often there is considerable interference with social or occupational functioning.
Complications. Possible complications include Dysthymia, Major Depression, Psychoactive Substance Abuse, and psychotic disorders such as Brief Reactive Psychosis.
Premature death may result from suicide.
Sex ratio. The disorder is more commonly diagnosed in females.
Prevalence. Borderline Personality Disorder is apparently common.
Predisposing factors and familial pattern. No information.
Differential diagnosis. In Identity Disorder there is a similar clinical picture, but Borderline Personality Disorder preempts the diagnosis of Identity Disorder if the criteria for the Personality Disorder are met, the disturbance is sufficiently pervasive and persistent, and it is unlikely that it will be limited to a developmental stage. In Cyclothymia there is also affective instability, but in Borderline Personality Disorder (without a coexisting Mood Disorder) there are no Hypomanic Episodes. In some cases, however, both disorders may be present.
301.50 Histrionic Personality Disorder
The essential feature of this disorder is a pervasive pattern of excessive emotionality and attention-seeking, beginning by early adulthood and present in a variety of contexts.
In other classifications this category is termed Hysterical Personality.
People with this disorder constantly seek or demand reassurance, approval, or praise from others and are uncomfortable in situations in which they are not the center of attention. They characteristically display rapidly shifting and shallow expression of emotions. Their behavior is overly reactive and intensely expressed; minor stimuli give rise to emotional excitability. Emotions are often expressed with inappropriate exaggeration, for example, the person may appear much more sad, angry, or delighted than would seem to be warranted. People with this disorder tend to be very self-centered, with little or no tolerance for the frustration of delayed gratification. Their actions are directed to obtaining immediate satisfaction.
These people are typically attractive and seductive, often to the point of looking flamboyant and acting inappropriately. They are typically overly concerned with physical attractiveness. In addition, their style of speech tends to be expressionistic and lacking in detail. For example, a person may describe his vacation as "Just fantastic!" without being able to be more specific.
Associated features. People with this disorder are lively and dramatic and are always drawing attention to themselves. They are prone to exaggeration in their interpersonal relations and often act out a role such as that of "victim" or "princess" without being aware of it. They crave novelty, stimulation, and excitement and quickly become bored with normal routine. Others frequently perceive them as superficially charming and appealing, but lacking genuineness. They are often quick to form friendships, but once a relationship is established, can become egocentric and inconsiderate.
They may constantly demand reassurance because of feelings of helplessness and dependency. Their actions are often inconsistent, and may be misinterpreted by others.
In relationships they attempt to control the opposite sex or to enter into a dependent relationship. Flights into romantic fantasy are common. The actual quality of their sexual relationships is variable. Some are promiscuous; others, naive and sexually unresponsive; and still others, apparently normal in their sexual adjustment.
Usually these people show little interest in intellectual achievement and careful, analytic thinking, but they are often creative and imaginative.
People with this disorder tend to be impressionable and easily influenced by others or by fads. They are apt to be overly trusting of others and suggestible, and to show an initially positive response to any strong authority figure who, they think, can provide a magical solution for their problems. Though they adopt convictions strongly and readily, their judgment is not firmly rooted, and they often play hunches.
Frequent complaints of poor health, such as weakness or headaches, or subjective feelings of depersonalization may be present. During periods of extreme stress, people with this disorder may experience transient psychotic symptoms, but they are generally of insufficient severity or duration to warrant an additional diagnosis.
Impairment. Interpersonal relations are usually stormy and ungratifying.
Complications. Complications include Brief Reactive Psychosis, Conversion Disorder, and Somatization Disorder.
Predisposing factors. No information.
Prevalence and sex ratio. The disorder is apparently common, and is diagnosed much more frequently in females than in males.
Familial pattern. The disorder is apparently more common among first-degree biologic relatives of people with this disorder than among the general population.
Differential diagnosis. In Somatization Disorder, complaints of physical illness dominate the clinical picture, although histrionic features are common. In many cases Somatization Disorder and Histrionic Personality Disorder coexist. Borderline Personality Disorder is also often present; in such cases both diagnoses should be made.
In Dependent Personality Disorder, the person similarly is excessively dependent on others for praise and guidance, but is without the flamboyant, exaggerated, emotional features of Histrionic Personality Disorder. People with Narcissistic Personality Disorder are similarly excessively self-centered, but are usually preoccupied with a grandiose sense of self and with intense envy.
301.81 Narcissistic Personality Disorder
The essential feature of this disorder is a pervasive pattern of grandiosity (in fantasy or behavior), hypersensitivity to the evaluation of others, and lack of empathy that begins by early adulthood and is present in a variety of contexts.
People with this disorder have a grandiose sense of self-importance. They tend to exaggerate their accomplishments and talents, and expect to be noticed as "special" even without appropriate achievement. They often feel that because of their "specialness," their problems are unique, and can be understood only by other special people.
Frequently this sense of self-importance alternates with feelings of special unworthiness.
For example, a student who ordinarily expects an A and receives a grade of A minus may, at that moment, express the view that he or she is thus revealed to all as a failure. Conversely, having gotten an A, the student may feel fraudulent, and unable to take genuine pleasure in a real achievement.
These people are preoccupied with fantasies of unlimited success, power, brilliance, beauty, or ideal love, and with chronic feelings of envy for those whom they perceive as being more successful than they are. Although these fantasies frequently substitute for realistic activity, when such goals are actually pursued, it is often with a driven, pleasureless quality and an ambition that cannot be satisfied.
Self-esteem is almost invariably very fragile; the person may be preoccupied with how well he or she is doing and how well he or she is regarded by others. This often takes the form of an almost exhibitionistic need for constant attention and admiration.
The person may constantly fish for compliments, often with great charm. In response to criticism, he or she may react with rage, shame, or humiliation, but mask these feelings with an aura of cool indifference.
Interpersonal relationships are invariably disturbed. A lack of empathy (inability to recognize and experience how others feel) is common. For example, the person may be unable to understand why a friend whose father has just died does not want to go to a party. A sense of entitlement, an unreasonable expectation of especially favorable treatment, is usually present. For example, such a person may assume that he or she does not have to wait in line when others must. Interpersonal exploitativeness, in which others are taken advantage of in order to achieve one's ends, or for selfaggrandizement, is common. Friendships are often made only after the person considers how he or she can profit from them. In romantic relationships, the partner is often treated as an object to be used to bolster the person's self-esteem.
Associated features. Frequently, many of the features of Histrionic, Borderline, and Antisocial Personality Disorders are present; in some cases more than one diagnosis may be warranted.
Depressed mood is extremely common. Often the person is painfully self-conscious and preoccupied with grooming and remaining youthful. Personal deficits, defeats, or irresponsible behavior may be justified by rationalization or lying. Feelings may be faked in order to impress others.
Impairment. Some impairment in interpersonal relations is inevitable. Occupational functioning may be impeded by depressed mood, interpersonal difficulties, or the pursuit of unrealistic goals. In other cases, occupational functioning may be enhanced by an unquenchable thirst for success.
Complications. Dysthymia and psychotic disorders such as Brief Reactive Psychosis are possible complications. Major Depression can occur as the person approaches middle age and becomes distressed by awareness of the physical and occupational limitations that become apparent at this stage of life.
Prevalence. This disorder appears to be more common recently than in the past, but this may be due only to more professional interest in it.
Predisposing factors, sex ratio, and familial pattern. No information.
Differential diagnosis. Borderline, Histrionic, and Antisocial Personality Disorders are often also present; in such instances, multiple diagnoses should be given.
However, in comparison with people with Antisocial Personality Disorder, people with Narcissistic Personality Disorder tend to be less impulsive, and their exploitation is more for the promotion of feelings of entitlement and power than for material gain.
They display less emotional exaggeration than people with Histrionic Personality Disorder, and are less intensely involved with, or dependent on, others. People with Narcissistic Personality Disorder also tend to have a more cohesive identity and to be less impulsive and emotional than people with Borderline Personality Disorder.
301.82 Avoidant Personality Disorder
The essential feature of this disorder is a pervasive pattern of social discomfort, fear of negative evaluation, and timidity, beginning by early adulthood and present in a variety of contexts.
Most people are somewhat concerned about how others assess them, but those with this disorder are easily hurt by criticism and are devastated by the slightest hint of disapproval. They generally are unwilling to enter into relationships unless given an unusally strong guarantee of uncritical acceptance; consequently, they often have no close friends or confidants (or only one) other than first-degree relatives.
Social or occupational activities that involve significant interpersonal contact tend to be avoided. For example, a promotion that will increase social demands may be refused. In social situations, these people are reticent because of a fear of saying something inappropriate or foolish, or of being unable to answer a question. They fear being embarrassed by blushing, crying, or showing signs of anxiety before other people.
Generalized timidity produces resistance to doing anything that will deviate from the person's normal routine. Often the potential difficulties, physical dangers, or risks involved in doing something ordinary, but outside the person's usual activities, are exaggerated. For example, the person may cancel an important trip because of a remote possibility that heavy rain will make driving dangerous.
Unlike people with Schizoid Personality Disorder, who are socially isolated, but have no desire for social relations, those with Avoidant Personality Disorder yearn for affection and acceptance. They are distressed by their lack of ability to relate comfortably to others.
Associated features. Depression, anxiety, and anger at oneself for failing to develop social relations are commonly experienced. Specific phobias may also be present.
Impairment. Social relations are, by definition, severely restricted. Occupational functioning may be impaired, particularly if interpersonal involvement is required.
Complications. Social Phobia may be a complication of this disorder.
Predisposing factors. Avoidant Disorder of Childhood or Adolescence predisposes to the development of this disorder. In addition, disfiguring physical illness may predispose to its development.
Prevalence. Avoidant Personality Disorder is apparently common.
Familial pattern. No information.
Differential diagnosis. In Schizoid Personality Disorder there is also social isolation, but little or no desire for social involvement and an indifference to criticism.
People with Avoidant Personality Disorder may sometimes appear dependent, since once they have been able to form a relationship, they tend to be very clinging and fearful of losing it.
In Social Phobias humiliation is a concern; but usually a specific situation, such as public speaking, is avoided rather than personal relationships. However, as noted in Complications, these disorders may coexist. When Agoraphobia is present, avoidant behavior may be relatively pervasive, but is due to a fear of being in places or situations where help may not be available.
In Avoidant Disorder of Childhood or Adolescence, there is a similar clinical picture, but Avoidant Personality Disorder preempts this diagnosis if the criteria for the Personality Disorder are met, the disturbance is sufficiently pervasive and persistent, and it is unlikely that it will be limited to a developmental stage.
301.60 Dependent Personality Disorder
The essential feature of this disorder is a pervasive pattern of dependent and submissive behavior beginning by early adulthood and present in a variety of contexts.
People with this disorder are unable to make everyday decisions without an excessive amount of advice and reassurance from others, and will even allow others to make most of their important decisions. For example, an adult with this disorder will typically assume a passive role and allow his or her spouse to decide where they should live, what kind of job he or she should have, and with which neighbors they should be friendly. A child or adolescent with this disorder may allow his or her parent(s) to decide
what he or she should wear, with whom to associate, how to spend free time, and what school or college to attend.
This excessive dependence on others leads to difficulty in initiating projects or doing things on one's own. People with this disorder tend to feel uncomfortable or helpless when alone, and will go to great lengths to avoid being alone. They are devastated when close relationships end, and tend to be preoccupied with fears of being abandoned.
These people are easily hurt by criticism and disapproval, and tend to subordinate themselves to others, agreeing with people even when they believe them to be wrong, for fear of being rejected. They will volunteer to do things that are unpleasant or demeaning in order to get others to like them.
Associated features. Frequently another Personality Disorder is present, such as Histrionic, Schizotypal, Narcissistic, or Avoidant Personality Disorder. Anxiety and depression are common.
People with this disorder invariably lack self-confidence. They tend to belittle their abilities and assets. For example, a person with this disorder may constantly refer to himself or herself as "stupid." They may at times seek, or stimulate, overprotection and dominance in others.
Impairment. Occupational functioning may be impaired if the job requires independence.
Social relations tend to be limited to those with the few people on whom the person is dependent.
Complications. Dysthymic Disorder and Major Depression are common complications.
Predisposing factors. Chronic physical illness may predispose to the development of this disorder in children and adolescents. Some believe that Separation Anxiety Disorder predisposes to the development of Dependent Personality Disorder.
Prevalence and sex ratio. The disorder is apparently common, and is diagnosed more frequently in females.
Familial pattern. No information.
Differential diagnosis. Dependent behavior is common in Agoraphobia, but the person is more likely to actively insist that others assume responsibility, whereas in Dependent Personality Disorder, the person passively maintains a dependent relationship.
301.40 Obsessive Compulsive Personality Disorder
The essential feature of this disorder is a pervasive pattern of perfectionism and inflexibility, beginning by early adulthood and present in a variety of contexts.
These people constantly strive for perfection, but this adherence to their own overly strict and often unattainable standards frequently interferes with actual completion of tasks and projects. No matter how good an accomplishment, it often does not seem "good enough." Preoccupation with rules, efficiency, trivial details, procedures, or form interferes with the ability to take a broad view of things. For example, such a person, having misplaced a list of things to be done, will spend an inordinate amount of time looking for the list rather than spend a few moments re-creating the list from memory and proceed with accomplishing the tasks. Time is poorly allocated, the most important tasks being left to the last moment.
People with this disorder are always mindful of their relative status in dominancesubmission relationships. Although they resist the authority of others, they stubbornly and unreasonably insist that people conform to their way of doing things.
Work and productivity are prized to the exclusion of pleasure and interpersonal relationships. Often there is preoccupation with logic and intellect and intolerance of affective behavior in others. When pleasure is considered, it is something to be planned and worked for. However, the person usually keeps postponing the pleasurable activity, such as a vacation, so that it may never occur.
Decision making is avoided, postponed, or protracted, perhaps because of an inordinate fear of making a mistake. For example, assignments cannot be completed on time because the person is ruminating about priorities. This indecisiveness may cause the person to retain worn or worthless objects even when they have no sentimental value.
People with this disorder tend to be excessively conscientious, moralistic, scrupulous, and judgmental of self and others—for example, considering it "sinful" for a neighbor to leave her child's bicycle out in the rain.
People with this disorder are stingy with their emotions and material possessions. They tend not to express their feelings, and rarely give compliments or gifts. Everyday relationships have a conventional, formal, and serious quality. Others often perceive these people as stilted or "stiff."
Associated features. People with this disorder may complain of difficulty expressing tender feelings. They may experience considerable distress because of their indecisiveness and general ineffectiveness. Their speech may be circumstantial. Depressed mood is common. These people have an unusually strong need to be in control. When they are unable to control others, a situation, or their environment, they often ruminate about the situation and become angry, although the anger is usually not expressed directly. (For example, a man may be angry when service in a restaurant is poor, but instead of complaining to the management, ruminates about how much he will leave as a tip.) Frequently there is extreme sensitivity to social criticism, especially if it comes from someone with considerable status or authority.
Impairment. This disorder frequently is quite incapacitating, particularly in its effect on occupational functioning.
Complications. Obsessive Compulsive Disorder, Hypochondriasis, Major Depression, and Dysthymia may be complications. Many of the features of Obsessive Compulsive Personality Disorder are apparently present in people who develop myocardial infarction, particularly those with overlapping "Type A" personality traits of time urgency, hostility-aggressiveness, and exaggerated competitiveness.
Predisposing factors. No information.
Prevalence and sex ratio. The disorder seems to be common, and is more frequently diagnosed in males.
Familial pattern. The disorder is apparently more common among first-degree biologic relatives of people with this disorder than among the general population.
Differential diagnosis. In Obsessive Compulsive Disorder there are, by definition, true obsessions and compulsions, which are not present in Obsessive Compulsive Personality Disorder. However, if the criteria for both disorders are met, both diagnoses should be recorded.
301.84 Passive Aggressive Personality Disorder
The essential feature of this disorder is a pervasive pattern of passive resistance to demands for adequate social and occupational performance, beginning by early adulthood and present in a variety of contexts. The resistance is expressed indirectly rather than directly, and results in pervasive and persistent social and occupational ineffectiveness even when more self-assertive and effective behavior is possible. The name of this disorder is based on the assumption that such people are passively expressing covert aggression.
People with this disorder habitually resent and oppose demands to increase or maintain a given level of functioning. This occurs most clearly in work situations, but is also evident in social functioning. The resistance is expressed indirectly through such maneuvers as procrastination, dawdling, stubbornness, intentional inefficiency, and "forgetfulness." These people obstruct the efforts of others by failing to do their share of the work. For example, when an executive gives a subordinate some material to review for a meeting the next morning, rather than complain that he has no time to do the work, the subordinate may misplace or misfile the material and thus attain his goal by passively resisting the demand on him.
These people become sulky, irritable, or argumentative when asked to do something they do not want to do. They often protest to others about how unreasonable the demands being made on them are, and resent useful suggestions from others concerning how to be more productive. As a result of their resentment of demands, they unreasonably criticize or scorn the people in authority who are making the demands.
Associated features. Often people with this disorder are dependent and lack selfconfidence.
Typically, they are pessimistic about the future, but have no realization that their behavior is responsible for their difficulties.
Impairment. These people are ineffective both socially and occupationally because of their passive aggressive behavior. For example, because of their intentional inefficiency, job promotions are not offered them. A housewife with the disorder may fail to do the laundry or to stock the kitchen with food because of procrastination and dawdling.
Complications. Frequent complications include Major Depression, Dysthymia, and Alcohol Abuse or Dependence.
Predisposing factors. Oppositional Defiant Disorder in childhood or adolescence apparently predisposes to the development of this disorder.
Prevalence, sex ratio, and familial pattern. No information.
Differential diagnosis. In Oppositional Defiant Disorder, the clinical picture may be similar, and this diagnosis preempts the diagnosis of Passive Aggressive Personality Disorder if the person is under 18.
Passive aggressive maneuvers that are used in certain situations in which assertive behavior is discouraged, or actually punished, and that are not part of a pervasive pattern of personality functioning do not warrant this diagnosis.
301.90 Personality Disorder Not Otherwise Specified
Disorders of personality functioning that are not classifiable as a specific Personality Disorder. An example is features of more than one specific Personality Disorder that do not meet the full criteria for any one, yet cause significant impairment in social or occupational functioning, or subjective distress. In DSM-III, this was called Mixed Personality Disorder.
This category can also be used when the clinician judges that a specific Personality Disorder not included in this classification is appropriate, such as Impulsive Personality Disorder, Immature Personality Disorder, Self-defeating Personality Disorder (see p. 371), or Sadistic Personality Disorder (see p. 369). In such instances the clinician should note the specific personality disorder in parentheses, e.g., Personality Disorder NOS (Self-defeating Personality Disorder).