THIS section 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 individual’s culture, is pervasive and inflexible, has an onset in adolescence or early adulthood, is stable over time, and leads to distress or impairment. The Personality Disorders included in this section are listed below.

Personality Disorder Not Otherwise Specified is a category provided for two situations: 1) the individual’s personality pattern meets the general criteria for a Personality Disorder and traits of several different Personality Disorders are present, but the criteria for any specific Personality Disorder are not met; or 2) the individual’s personality pattern meets the general criteria for a Personality Disorder, but the individual is considered to have a Personality Disorder that is not included in the Classification (e.g., passive-aggressive personality disorder).

[THREE CLUSTERS]

The Personality Disorders are grouped into three clusters based on descriptive similarities.

Cluster A includes the Paranoid, Schizoid, and Schizotypal Personality Disorders. Individuals with these disorders often appear odd or eccentric.

Cluster B includes the Antisocial, Borderline, Histrionic, and Narcissistic Personality Disorders. Individuals with these disorders often appear dramatic, emotional, or erratic.

Cluster C includes the Avoidant, Dependent, and Obsessive-Compulsive Personality Disorders. Individuals with these disorders often appear anxious or fearful.

It should be noted that this clustering system, although useful in some research and educational situations, has serious limitations and has not been consistently validated. Moreover, individuals frequently present with co-occurring Personality Disorders from different clusters.

DIAGNOSTIC FEATURES

Personality traits are enduring patterns of perceiving, relating to, and thinking about the environment and oneself that are exhibited in a wide range of social and personal contexts. Only when personality traits:

[1] are inflexible and

[2] maladaptive and

[3] cause significant functional impairment or

[4] subjective distress

do they constitute Personality Disorders.

The essential feature of a Personality Disorder is an enduring 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 impulse control (Criterion A).

This enduring pattern is inflexible and pervasive across a broad range of personal and social situations (Criterion B)

and leads to clinically significant distress or impairment in social, occupational, or other important areas of functioning (Criterion C).

The pattern is stable and of long duration, and its onset can be traced back at least to adolescence or early adulthood (Criterion D).

The pattern is not better accounted for as a manifestation or consequence of another mental disorder (Criterion E)

and is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication, exposure to a toxin) or a general medical condition (e.g., head trauma) (Criterion F).

Specific diagnostic criteria are also provided for each of the Personality Disorders included in this section. The items in the criteria sets for each of the specific Personality Disorders are listed in order of decreasing diagnostic importance as measured by relevant data on diagnostic efficiency (when available).

The diagnosis of Personality Disorders requires an evaluation of the individual’s long- term patterns of functioning, and the particular personality features must be evident by early adulthood. The personality traits that define these disorders must also be distinguished from characteristics that emerge in response to specific situational stressors or more transient mental states (e.g., Mood or Anxiety Disorders, Substance Intoxication). The clinician should assess the stability of personality traits over time and across different situations. Although a single interview with the person is sometimes sufficient for making the diagnosis, it is often necessary to conduct more than one interview and to space these over time. Assessment can also be complicated by the fact that the characteristics that define a Personality Disorder may not be considered problematic by the individual (i.e., the traits are often ego-syntonic). To help overcome this difficulty, supplementary information from other informants may be helpful.

RECORDING PROCEDURES

Personality Disorders are coded on Axis II. When (as is often the case) an individual’s pattern of behavior meets criteria for more than one Personality Disorder, the clinician should list all relevant Personality Disorder diagnoses in order of importance. When an Axis I disorder is not the principal diagnosis or the reason for visit, the clinician is encouraged to indicate which Personality Disorder is the principal diagnosis or the reason for visit by noting “Principal Diagnosis” or “Reason for Visit” in parentheses. In most cases, the principal diagnosis or the reason for visit is also the main focus of attention or treatment. Personality Disorder Not Otherwise Specified is the appropriate diagnosis for a “mixed” presentation in which criteria are not met for any single

Personality Disorder but features of several Personality Disorders are present and involve clinically significant impairment.

Specific maladaptive personality traits that do not meet the threshold for a Personality Disorder may also be listed on Axis II. In such instances, no specific code should be used; for example, the clinician might record “Axis II: V71.09 No diagnosis on Axis II, histrionic personality traits.” The use of particular defense mechanisms may also be indicated on Axis II. For example, a clinician might record “Axis II: 301.6 Dependent Personality Disorder; Frequent use of denial.” Glossary definitions for specific defense mechanisms and the Defensive Functioning Scale appear in Appendix B (See linked section).

When an individual has a chronic Axis I Psychotic Disorder (e.g., Schizophrenia) that was preceded by a preexisting Personality Disorder (e.g., Schizotypal, Schizoid, Paranoid), the Personality Disorder should be recorded on Axis II, followed by “Premorbid” in parentheses. For example: Axis I: 295.30 Schizophrenia, Paranoid Type; Axis II: 301.20 Schizoid Personality Disorder (Premorbid).

SPECIFIC CULTURE, AGE, AND GENDER FEATURES

Judgments about personality functioning must take into account the individual’s ethnic, cultural, and social background. Personality Disorders should not be confused with problems associated with acculturation following immigration or with the expression of habits, customs, or religious and political values professed by the individual’s culture of origin. Especially when evaluating someone from a different background, it is useful for the clinician to obtain additional information from informants who are familiar with the person’s cultural background.

Personality Disorder categories may be applied to children or adolescents in those relatively unusual instances in which the individual’s particular maladaptive personality traits appear to be pervasive, persistent, and unlikely to be limited to a particular developmental stage or an episode of an Axis I disorder. It should be recognized that the traits of a Personality Disorder that appear in childhood will often not persist unchanged into adult life. To diagnose a Personality Disorder in an individual under age 18 years, the features must have been present for at least 1 year. The one exception to this is Antisocial Personality Disorder, which cannot be diagnosed in individuals under age 18 years (See linked section).

Although, by definition, a Personality Disorder requires an onset no later than early adulthood, individuals may not come to clinical attention until relatively late in life. A Personality Disorder may be exacerbated following the loss of significant supporting persons (e.g., a spouse) or previously stabilizing social situations (e.g., a job). However, the development of a change in personality in middle adulthood or later life warrants a thorough evaluation to determine the possible presence of a Personality Change Due to a General Medical Condition or an unrecognized Substance- Related Disorder.

Certain Personality Disorders (e.g., Antisocial Personality Disorder) are diagnosed more frequently in men. Others (e.g., Borderline, Histrionic, and Dependent Personality Disorders) are diagnosed more frequently in women. Although these differences in prevalence probably reflect real gender differences in the presence of such patterns, clinicians must be cautious not to overdiagnose or underdiagnose certain Personality Disorders in females or in males because of social stereotypes about typical gender roles and behaviors.

COURSE

The features of a Personality Disorder usually become recognizable during adolescence or early adult life. By definition, a Personality Disorder is an enduring pattern of thinking, feeling, and behaving that is relatively stable over time. Some types of Personality Disorder (notably, Antisocial and Borderline Personality Disorders) tend to become less evident or to remit with age, whereas this appears to be less true for some other types (e.g., Obsessive-Compulsive and Schizotypal Personality Disorders).

DIFFERENTIAL DIAGNOSIS

Many of the specific criteria for the Personality Disorders describe features (e.g., suspiciousness, dependency, or insensitivity) that are also characteristic of episodes of Axis I mental disorders. A Personality Disorder should be diagnosed only when the defining characteristics appeared before early adulthood, are typical of the individual’s long-term functioning, and do not occur exclusively during an episode of an Axis I disorder. It may be particularly difficult (and not particularly useful) to distinguish Personality Disorders from those Axis I disorders (e.g., Dysthymic Disorder) that have an early onset and a chronic, relatively stable course. Some Personality Disorders may have a “spectrum” relationship to particular Axis I conditions (e.g., Schizotypal Personality Disorder with Schizophrenia; Avoidant Personality Disorder with Social Phobia) based on phenomenological or biological similarities or familial aggregation.

For the three Personality Disorders that may be related to the Psychotic Disorders (i.e., Paranoid, Schizoid, and Schizotypal), there is an exclusion criterion stating that the pattern of behavior must not have occurred exclusively during the course of Schizophrenia, a Mood Disorder With Psychotic Features, or another Psychotic Disorder. When an individual has a chronic Axis I Psychotic Disorder (e.g., Schizophrenia) that was preceded by a preexisting Personality Disorder, the Personality Disorder should also be recorded, on Axis II, followed by “Premorbid” in parentheses.

The clinician must be cautious in diagnosing Personality Disorders during an episode of a Mood Disorder or an Anxiety Disorder because these conditions may have cross- sectional symptom features that mimic personality traits and may make it more difficult to evaluate retrospectively the individual’s long-term patterns of functioning. When personality changes emerge and persist after an individual has been exposed to extreme stress, a diagnosis of Posttraumatic Stress Disorder should be considered (See linked section). When a person has a Substance-Related Disorder, it is important not to make a Personality Disorder diagnosis based solely on behaviors that are consequences of Substance Intoxication or Withdrawal or that are associated with activities in the service of sustaining a dependency (e.g., antisocial behavior). When enduring changes in personality arise as a result of the direct physiological effects of a general medical condition (e.g., brain tumor), a diagnosis of Personality Change Due to a General Medical Condition (See linked section) should be considered.

Personality Disorders must be distinguished from personality traits that do not reach the threshold for a Personality Disorder. Personality traits are diagnosed as a Personality Disorder only when they are inflexible, maladaptive, and persisting and cause significant functional impairment or subjective distress.

 GENERAL DIAGNOSTIC CRITERIA FOR A  PERSONALITY DISORDER

A. An enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual’s culture. This pattern is manifested in two (or more) of the following areas:

1. cognition (i.e., ways of perceiving and interpreting self, other people, and events)

2. affectivity (i.e., the range, intensity, lability, and appropriateness of emotional response)

3. interpersonal functioning

4. impulse control

B. The enduring pattern is inflexible and pervasive across a broad range of personal and social situations.

C. The enduring pattern leads to clinically significant distress or impairment in social, occupational, or other important areas of functioning.

D. The pattern is stable and of long duration, and its onset can be traced back at least to adolescence or early adulthood.

E. The enduring pattern is not better accounted for as a manifestation or consequence of another mental disorder.

F. The enduring pattern is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition (e.g., head trauma).

The diagnostic approach used in this manual represents the categorical perspective that Personality Disorders are qualitatively distinct clinical syndromes. An alternative to the categorical approach is the dimensional perspective that Personality Disorders represent maladaptive variants of personality traits that merge imperceptibly into normality and into one another.

There have been many different attempts to identify the most fundamental dimensions that underlie the entire domain of normal and pathological personality functioning.

One model consists of the following five dimensions:

[1] neuroticism,

[2] introversion versus extroversion,

[3] closedness versus openness to experience,

[4] antagonism versus agreeableness, and

[5] conscientiousness.

Another approach is to describe more specific areas of personality dysfunction, including as many as 15–40 dimensions (e.g.,

[1] affective reactivity,

[2] social apprehensiveness,

[3] cognitive distortion,

[4] impulsivity,

[5] insincerity,

[6] self-centeredness).

Other dimensional models that have been proposed include[:]

positive affectivity, negative affectivity, and constraint;

novelty seeking, reward dependence, harm avoidance, persistence, self-directedness, cooperativeness, and self-transcendence;

power (dominance vs. submission) and affiliation (love vs. hate);

and pleasure seeking versus pain avoidance, passive accommodation versus active modification, and self-propagation versus other nurturance.

The DSM-IV Personality Disorder clusters (i.e., odd-eccentric, dramatic-emotional, and anxious- fearful) may also be viewed as dimensions representing spectra of personality dysfunction on a continuum with Axis I mental disorders. The alternative dimensional models share much in common and together appear to cover the important areas of personality dysfunction. Their integration, clinical utility, and relationship with the Personality Disorder diagnostic categories and various aspects of personality dysfunction are under active investigation.

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